The older person with psychotic symptoms

Chapter 22 THE OLDER PERSON WITH PSYCHOTIC SYMPTOMS



INTRODUCTION


Psychotic symptoms in older people are highly prevalent and occur in many different mental health problems, including delirium, dementia, mood disorders and psychotic disorders. Some otherwise normal older people experience hallucinations in the context of sensory impairment such as low vision or poor hearing. However, this chapter will focus on the older person with a psychotic disorder.



CASE VIGNETTE


The police liaison officer to the local health district referred Mrs GH, an 83-year-old single woman, to the older persons’ mental health service (OPMHS). Mrs GH had been repeatedly telephoning the local police station over the past 4 months complaining about the behaviour of her neighbours. She claimed that her neighbours had installed a powerful electrical machine in their lounge room that they were using to send beams of radiation into her house. Mrs GH said that this radiation was causing her refrigerator to malfunction and was causing an odd sensation in her knee joints that made it difficult for her to walk. She had responded to these alleged attacks by turning off her refrigerator and by wrapping her knees in cardboard. According to the police officer, Mrs GH had angrily confronted her neighbours a few days earlier and her neighbours had lodged an official complaint with the police. The police had investigated Mrs GH’s claims and found them to be baseless.



EPIDEMIOLOGY


Psychotic symptoms occur commonly among older people. Henderson et al (1998) surveyed 935 residents of Canberra and Queanbeyan aged 70 years and over living in the community or in supported accommodation and found that 42 (4.49%) reported hallucinations and 26 (2.78%) had delusions. Overall, the estimated prevalence of at least one psychotic symptom was 5.7% for those living in the community and 7.5% for those living in supported accommodation. People with dementia or cognitive impairment were more likely to have psychotic symptoms. When these investigators resurveyed the same people 3.6 years later, there were 35 new cases of psychotic symptoms among the 581 who did not have psychotic symptoms at baseline. Thus, the incidence (new cases) of psychotic symptoms over 3.6 years was 6.0%.


The best evidence on the prevalence of psychotic disorders in older people comes from a Finnish study (Perala et al 2007). Despite the emphasis given to young people with schizophrenia both in the mass media and within mental health services, the findings from this study indicate that psychotic disorders are actually more common in older people than in young or middle-aged people. The prevalence of non-affective psychotic disorders (schizophrenia, schizoaffective disorder, schizophreniform disorder, delusional disorder, brief psychotic disorder, and psychotic disorder not otherwise specified) in people aged 65 years and over was 2.32% (95% CI = 1.67–3.21), whereas the prevalence in people aged 30–44 years was 1.27% (95% CI = 0.89–1.82). In contrast, the prevalence of affective psychoses (bipolar I disorder and major depression with psychotic features) was very similar in middle-aged and older people: 0.57% (95% CI = 0.32–1.01) in people aged 65 years and over and 0.52% (95% CI = 0.32–0.87) in people aged 30–44 years.



CLINICAL FEATURES


The primary psychotic disorders such as schizophrenia are characterised by positive symptoms (hallucinations, delusions and formal thought disorder), negative symptoms (impaired volition, personality change, social impairment and communication difficulties) and cognitive impairment (principally frontal executive dysfunction). However, late-onset psychotic disorders are often characterised more by positive symptoms, rather than by negative symptoms and thought disorder.



Illusions and hallucinations


Perceptual abnormalities including illusions and hallucinations occur in normal people and in many different mental health problems. This means that the presence of these symptoms does not always mean that the person is suffering from a mental health problem. Hallucinations may be defined as perceptions without objects. In other words, the person experiences the perception in the absence of any external sensory stimulus. Hallucinations may occur in any sensory modality—vision (visual), hearing (auditory), smell (olfactory), taste (gustatory), touch (tactile) and bodily movement (kinaesthetic).


Auditory hallucinations are common in psychotic disorders. These may be complex, involving voices speaking to or about the person, or simple, including tones, clicks, buzzes or other noises. Hallucinatory music is not uncommon. Hallucinatory voices may sometimes give instructions or commands to the person. Visual hallucinations can suggest the presence of delirium, but can also occur in the Charles Bonnet syndrome in which a person with impaired eyesight (usually due to macular degeneration or glaucoma) develops visual hallucinations in the absence of cognitive impairment or symptoms of mental illness.


Hypnagogic and hypnopompic hallucinations occur when going to sleep and waking from sleep, respectively. Similar hallucinations occur in situations of sensory deprivation, including the white noise generated by heavy rain or a bathroom shower. Strong suggestion or expectation due to mental set may also lead to simple hallucinations in normal people. Hallucinations should be distinguished from illusions, in which there is a stimulus, and from visual images, which are conscious products of the imagination.



Delusions, overvalued ideas and marked preoccupations


The presence of delusions is always indicative of mental health problems, so care must be taken in their detection. Delusions are false, unshakeable beliefs of morbid origin, which are out of keeping with the person’s social, cultural and educational background. By chance, some delusions turn out to be true. For instance, delusional infidelity may turn out to be true because of the high background prevalence of marital infidelity. It is sometimes difficult to distinguish delusions from unusual religious beliefs, and care should be taken when attempting to do this. The assistance of transcultural mental health workers is likely to be essential when dealing with people from other cultural or language groups.


Overvalued ideas are strongly held beliefs that dominate a person’s life, but are not delusions or obsessions. Such beliefs involve non-bizarre subjects. At interview, the person with the overvalued idea will sometimes express doubt about their belief.


Delusions are said to be mood congruent when they are in keeping with the person’s predominant mood. Thus, delusions of guilt, poverty and hypochondriasis are said to be mood congruent with depression, and delusions of power, beauty and boundless wealth are mood congruent with mania.


Bizarre delusions involve things that could not possibly be true, although the definition of what could not possibly be true changes with advances in science and technology. Non-bizarre delusions include things that could be true, such as being followed or being bugged. Bizarre delusions include things that could not be true, such as the neighbour beaming rays into the person’s home to cause arthritis in their knees.


The content of delusions varies a lot. Delusions commonly involve themes of control, persecution, jealousy, guilt or sin, grandiosity, religion or love. Somatic delusions involve the idea that the body is diseased or changed in some way. One common type is delusional parasitosis in which the person believes that they are infested with parasites. Nihilistic delusions involve the bizarre belief that some part of the self, or some part of others or the world, no longer exists.


Partition delusions and phantom boarders are other delusions commonly seen in older people. Partition delusions refer to the belief that there are people, animals or other living things in the ceiling, beneath the floorboards or behind the walls. Some older people believe that these people or animals can move through solid walls at will. Partition delusions occur in both late-onset psychotic disorders and in dementia. The phantom boarders’ delusion involves the belief that other people are living in the house. The person will refer to the other people and may take them into account when preparing meals or setting the table for dinner. In the author’s experience, this delusion generally occurs in people with dementia.



Passivity phenomena and other psychotic symptoms


The main category of passivity phenomena is thought alienation, which includes thought insertion, thought withdrawal and thought broadcasting. In thought insertion the person experiences thoughts inserted into their mind by an outside agency, whereas in thought withdrawal thoughts are removed from their mind by an outside agency. In thought broadcasting, the person is unable to contain their thoughts within their mind and has the belief that everyone else can hear their thoughts spoken aloud. Thought withdrawal is experienced by some people as thought blocking, or the sudden cessation of a train of thought.


Somatic passivity phenomena include the experience of bodily sensations generated by outside forces. It is generally considered to be a delusion of control. Such phenomena are often accompanied by hallucinatory sensations. Examples include physical sensations that the person experiences as being produced by the effects of beams of radiation or similar outside influences.


Formal thought disorder reflects abnormalities in the form rather than the content of thinking. In formal thought disorder, the person’s speech and writing are less intelligible than normal to others. There may be loose or tangential associations between successive thoughts or derailing in which a thought comes off the tracks altogether. Thinking may become woolly or excessively allusive. Neologisms (new words) may be invented by the person and existing words may be given new meanings. Formal thought disorder may occur in both ‘functional’ disorders such as schizophrenia and in ‘organic’ disorders such as dementia. However, it is quite uncommon in late-onset psychotic disorders.


Disorganised thinking and behaviour are common features of psychotic disorders in young people and may persist into later life in older people with chronic psychotic disorders. However, late-onset psychotic disorders are not usually characterised by marked disorganisation of thought or behaviour in the absence of cognitive impairment.


Catatonia is an uncommon motor disturbance that may occur in psychotic disorders, mood disorders and neurological conditions. The person with catatonia may have markedly reduced or markedly increased motor behaviour. In the rigid form of catatonia the person may hold postures for hours. Catatonia needs to be distinguished from neuroleptic malignant syndrome.

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Aug 6, 2016 | Posted by in GERIATRICS | Comments Off on The older person with psychotic symptoms

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