NEWSLETTER

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LATE ONSET SCHIZOPHRENIA & other RELATED PSYCHOSIS

Pierre Lesly Francois, M.D.

Geriatric Psychiatrist

04/07/07

 Late Onset Schizophrenia and other related psychosis.

Pierre Lesly Francois M.D.  Geriatric Psychiatrist

Variation in Terminology.

Although the literature on Late Onset  Schizophrenia and related psychosis dates back to the early 1900s, there are several confounding problems with his interpretation. Variously referred to as paraphrenia, late paraphrenia, paranoia, and involutional paranoid disorder, there has been no consensus about the terminology. The term paraphrenia has been popular in the European Literature, whereas Late Onset Psychosis has gained acceptance in the recent American Literature. 

Age of Onset.

There has been no general agreement on the definition of late onset. Some studies chose 40 years of age as the cutoff, whereas others defined late onset as onset after 45, 60, and 65 of age. The presence of premorbid paranoid and schizoid personality traits may further confuse the issue, and older patients with psychotic symptoms may be thought to have organic mental syndromes, mood disorders or simple sensory deficits.

Diagnostic Criteria For Late Onset Schizophrenia.

To diagnose Late Onset Schizophrenia, the patient should meet DSM IV Criteria for schizophrenia ( including duration of at least six months), with the additional requirement that the onset of symptoms ( including the prodrome) be at or after age 45. The prototypical patient is a middle-aged or elderly person who functioned moderately well through early adulthood (despite some premorbid schizoid or paranoid personality traits) and who exhibits persecutory delusions and auditory hallucinations and shows some improvement in positive symptoms with low-dose neuroleptic therapy, yet has a chronic course.

Psychopathology of Late Onset Schizophrenia.

Late-Onset Schizophrenia is often characterized by bizarre delusions, which have a predominantly persecutory flavor. Auditory hallucinations are the second most prominent psychotic symptom. Systematized delusions of physical or mental influence are seen in many of the patients. Grandiose, erotic, or somatic delusions may occur in some cases. Schneiderian first-rank symptoms, such as thought broadcasting or two voices arguing with each other, are less common but are not rare. Depressive symptoms are reported by a number of these patients. In contrast, looseness of association and inappropriateness of affect are less common than in younger schizophrenic patients.

Clinical Evaluation.

Whenever an older patient presents with psychotic symptoms, organic pathology must first be ruled out. A complete history, followed by a careful neurological evaluation, other physical examination, and appropriate laboratory tests ( including tests of thyroid function tests, toxicology screening, and serologic tests for syphilis), are usually part of the assessment, Computed Tomography ( CT) or magnetic resonance imaging ( MRI) may be needed to identify cases where structural brain abnormalities are suspected.

Differential Diagnosis.

Given the relatively high incidence of paranoia in geriatric patients, diagnostic specificity becomes imperative. Two important conditions in the differential of Late Onset Psychosis are mood disorders with psychotic features and delusional disorder. These diagnoses are more likely to have onset during middle age or old age than during early adulthood. Mood disorders with psychotic features may present for the first time after age 45, and they can be confused with late onset psychosis. A diagnosis of schizophrenia is made when the total duration of all mood symptoms has been brief relative to that of the primary psychotic symptoms. Delusional disorder may mimic Late Onset Psychosis, but the later diagnosis is more likely in the presence of bizarre delusions or prominent auditory hallucinations. Delusional disorder is distinguished from Late Onset Psychosis by the presence of non bizarre delusions and the absence of prominent auditory or visual hallucinations, disorganized speech, negative symptoms and functional impairment outside the area of delusions.

Differentiation from Early Onset Psychosis.

Similar to Early Onset Psychosis, there is an insidious deterioration of personal and social adjustment. A sizable proportion of Late Onset Schizophrenia patients have abnormal premorbid personality traits of a paranoid or schizoid nature. Some patients have never been married and have been previously considered by acquaintances to be eccentric, reserved and suspicious. Nevertheless, when compared to Early Onset Schizophrenia subjects, patients with late Onset Schizophrenia were more likely to have been married, to have held a job, and to have had better adjustment during adolescence and early adulthood. In patients with suspected Late Onset Schizophrenia, it is important to establish an absence of prodromal symptoms before age 45 to exclude the diagnosis of Early Onset Schizophrenia. Late Onset Schizophrenia shows a female predominance not found among Early Onset Schizophrenia.

Course of Late Onset Schizophrenia.

Many schizophrenic patients survive into old age, yet comparatively little is known about the long term course of late Onset Schizophrenia. A review of the Literature on the course of schizophrenia in general suggests that a majority of patients either undergo remission or are left with mild symptoms over the long term. The more positive , dramatic symptoms of schizophrenia seem to lessen in severity with the passage of time.

Pharmacological Management Of late Onset Schizophrenia

Neuroleptics have been shown to be the most effective treatment modality for schizophrenia, although pharmacotherapy in the older patient is complicated by alterations in both the pharmacokinetic and pharmacodynamic responses. With the possible exception of Clozapine, the available data suggest that the commonly prescribed antipsychotic medications are equally efficacious. Therefore selection of an antipsychotic for use in the elderly should be based primarily on the following: a) the side effect profile of the particular drug; b) the potential adverse consequences of the additional antipsychotic medication to preexisting medication regimen or a concomitant physical illness; and c) a history of a patient’s previous therapeutic response to a specific neuroleptic.

Side Effects.

An important consideration is the higher incidence of side effects seen in elderly patients, as compared to younger patients, upon administration of a given amount of neuroleptic. Usually, small doses of neuroleptic are sufficient for improvement in older patients. The side effects profiles of individual neuroleptic differ considerably and such differences may be important in prescribing a particular medication to a patient for a whom the occurrence of a particular side effect might prove dangerous. Finally, an agent that previously produced a positive response in that patient or in a blood relative may be tried first, whereas an agent that led to an unfavorable reaction may be avoided.

Neuroleptic Dosage in Late Onset Schizophrenia.

The neuroleptic dose correlated significantly with current age, age at onset of illness, severity of negative symptoms, and impairment on a variety of neuropsychological test measures such as The Halstead Reitan average Impairment Rating, Story and Figure learning and psychomotor speed. The association of later age at onset of prognosis than Early Onset schizophrenia with lower dosages may also be consistent with suggestion that Late Onset psychosis has a better prognosis than Early onset schizophrenia.

Non Pharmacologic Treatment.

The results of controlled research on psychological treatment suggest that intervention may improve the outcome of schizophrenia, although many patients require long term treatment due to the chronic nature of the illness. A widely studied psychological intervention for schizophrenia is social skills training, although cognitive retraining and didactic family counseling have also shown positive effects.

Clinical Implications:

The following conclusions can be made with at least some degree of certainty:

1. - Schizophrenia can have onset after age 45, although such late onset of schizophrenia is much less common than onset prior to age 45.

2. - Delusional disorder and psychotic depression are more likely to have onset during middle age and old age than during early adulthood.

3.- Late Onset Psychotic disorder may be fundamentally similar to their early-onset counterparts in the underlying neurobiologic predisposition. Certain specific protective factors may however prevent an early breakdown, whereas other aging related precipitants may be responsible for the onset of symptoms during later life.

4. - Late-Onset Psychosis patients have neuroleptic responsiveness that is qualitatively similar to that of younger patients. The Late-Onset patients, however need and tolerate much lower dosages than do the early-onset patients.

5. - Late-Onset schizophrenia and other related psychosis must be considered in any comprehensive theories of psychosis especially schizophrenia.