Abstract
Psychosis in the elderly represents a frequent and challenging feature, with a prevalence of psychotic symptoms that may reach 10–63% in the hospitalized population. However, both the diagnosis and the treatment of psychotic symptoms in the elder population may present many problems.
In the present chapter, we debate the differential diagnosis between the causes of psychosis in the elderly and how to deal with them. The first cause of psychosis in this population is represented by dementia. Psychiatric symptoms may be present not only in the last phases of neurodegenerative disorders but also in the early stages or at onset, more frequently in specific subtypes of dementia, such as frontotemporal dementia. The second most common cause of psychosis in the geriatric population is depression, while delirium is the third. Delirium, differently from the other described diagnoses, is characterized by an acute change in mental status, disturbances of consciousness, and clouded sensorium and may be caused by several circumstances, ranging from infections to inappropriate medication use.
Considering the background of the present literature, we report the case of a 66-year-old man who was referred to our inpatient clinic for a manic episode with delusions. We investigated the differential diagnostic processes, which encompass a comprehensive clinical evaluation, a very accurate anamnestic interview, blood tests, and eventually brain imaging. Another major issue of concern is treatment, which might be guided by a multidisciplinary endeavor, including pharmacological and non-pharmacological interventions.
This is a preview of subscription content, log in via an institution.
Buying options
Tax calculation will be finalised at checkout
Purchases are for personal use only
Learn about institutional subscriptionsReferences
Mintzer J, Targum S. Psychosis in elderly patients: classification and pharmacotherapy. J Geriatr Psychiatry Neurol. 2003;16:199–206.
Broadway J, Mintzer J. The many faces of psychosis in the elderly. Curr Opin Psychiatry. 2007;20(6):551–8. [Review]
Ostling S, Borjesson-Hanson A, Skoog I. Psychotic symptoms and paranoid ideation in a population-based sample of 95-year-olds. Am J Geriatr Psychiatry. 2007;15:999–1004.
Kyomen HH, Whitfield TH. Psychosis in the elderly. Am J Psychiatry. 2009;166(2):146–50.
Bennett S, Thomas AJ. Depression and dementia: cause, consequence or coincidence? Maturitas. 2014;79(2):184–90.
Murray PS, Kumar S, Demichele-Sweet MAA, Sweet RA. Psychosis in Alzheimer’s disease. Biol Psychiatry. 2014;75(7):542–52.
Grau-Rivera O, Gelpi E, Carballido-López E, Sánchez-Valle R, López-Villegas MD. Rapidly progressive dementia with psychotic onset in a patient with the C9ORF72 mutation. Clin Neuropathol. 2015;34(5):294–7.
Gossink FT, Vijverberg EG, Krudop W, Scheltens P, Stek ML, Pijnenburg YA, Dols A. Psychosis in behavioral variant frontotemporal dementia. Neuropsychiatr Dis Treat. 2017;13:1099–106.
Galimberti D, Dell'Osso B, Altamura AC, Scarpini E. Psychiatric symptoms in frontotemporal dementia: epidemiology, phenotypes, and differential diagnosis. Biol Psychiatry. 2015;78(10):684–92.
Hall D, Finger EC. Psychotic symptoms in frontotemporal dementia. Curr Neurol Neurosci Rep. 2015;15(7):46.
Shinagawa S, Nakajima S, Plitman E, Graff-Guerrero A, Mimura M, Nakayama K, Miller BL. Psychosis in frontotemporal dementia. J Alzheimers Dis. 2014;42(2):485–99.
Mulsant BH, Ganguli M. Epidemiology and diagnosis of depression in late life. J Clin Psychiatry. 1999;20:9–15.
Wohlreich MM, Mallinckrodt CH, Watkin JG, et al. Duloxetine for the long-term management of major depressive disorder in patients aged 65 and older: an open-label study. BMC Geriatr. 2004;4:11.
Gournellis R, Lykouras L, Fortos A, Oulis P, Roumbos V, Christodoulou GN. Psychotic (delusional) major depression in late life: a clinical study. Int J Geriatr Psychiatry. 2001;16(11):1085–91.
Kessing L. Differences in diagnostic subtypes among patients with late and early onset of a single depressive episode. Int J Geriatr Psychiatry. 2006;21:1127–31.
Heser K, Tebarth F, Wiese B, Eisele M, Bickel H, Köhler M, Mösch E, Weyerer S, Werle J, König HH, Leicht H, Pentzek M, Fuchs A, Riedel-Heller SG, Luppa M, Prokein J, Scherer M, Maier W. Wagner M; age CoDe study group. Age of major depression onset, depressive symptoms, and risk for subsequent dementia: results of the German study on ageing, cognition, and dementia in primary care patients (AgeCoDe). Psychol Med. 2013;43(8):1597–610.
Kukreja D, Günther U, Popp J. Delirium in the elderly: current problems with increasing geriatric age. Indian J Med Res. 2015;142(6):655–62.
Morandi A, Di Santo SG, Cherubini A, Mossello E, Meagher D, Mazzone A, Bianchetti A, Ferrara N, Ferrari A, Musicco M, Trabucchi M, Bellelli G, ISGoD Group. Clinical features associated with delirium motor subtypes in older inpatients: results of a Multicenter study. Am J Geriatr Psychiatry. 2017;25(10):1064–71.
Inouye SK, Westendorp RG, Saczynski JS. Delirium in elderly people. Lancet. 2014;383:911–22.
By the American Geriatrics Society 2015 Beers Criteria Update Expert Panel. American Geriatrics Society 2015 updated beers criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2015;63(11):2227–46.
Fong TG, Davis D, Growdon ME, Albuquerque A, Inouye SK. The interface between delirium and dementia in elderly adults. Lancet Neurol. 2015;14(8):823–32.
Gavazzi G, Delerce E, Cambau E, François P, Corroyer B, de Wazières B, Fougère B, Paccalin M, Gaillat J. Diagnostic criteria for urinary tract infection in hospitalized elderly patients over 75 years of age: a multicenter cross-sectional study. Med Mal Infect. 2013;43(5):189–94.
Barthel H, Schroeter ML, Hoffmann KT, Sabri O. PET/MR in dementia and other neurodegenerative diseases. Semin Nucl Med. 2015;45(3):224–33.
Linjakumpu T, Hartikainen S, Klaukka T, et al. Use of medications and polypharmacy are increasing among the elderly. J Clin Epidemiol. 2002;55:809–17.
Rovera C, Mauri MC, Bertin E, Di Pace C, Paletta S, Reggiori A, De Gaspari IF, Cattaneo D, Mari D, Altamura AC. Duloxetine in elderly major depression disorder: effectiveness and drug plasma level evaluation. Hum Psychopharmacol. 2016;31(5):349–55.
Bellivier F, Golmard JL, Rietschel M, Schulze TG, Malafosse A, Preisig M, McKeon P, Mynett-Johnson L, Henry C, Leboyer M. Age at onset in bipolar I affective disorder: further evidence for three subgroups. Am J Psychiatry. 2003;160(5):999–1001.
Carlino AR, Stinnett JL, Kim DR. New onset of bipolar disorder in late life. Psychosomatics. 2013 Jan–Feb;54(1):94–7.
Besga A, Gonzalez I, Echeburua E, Savio A, Ayerdi B, Chyzhyk D, Madrigal JL, Leza JC, Graña M, Gonzalez-Pinto AM. Discrimination between Alzheimer's disease and late onset bipolar disorder using multivariate analysis. Front Aging Neurosci. 2015;7:231.
Hahn C, Lim HK, Lee CU. Neuroimaging findings in late-onset schizophrenia and bipolar disorder. J Geriatr Psychiatry Neurol. 2014;27(1):56–62.
Kales HC, Gitlin LN, Lyketsos CG. Assessment and management of behavioral and psychological symptoms of dementia. BMJ. 2015;350:h369.
Besga A, Chyzhyk D, Gonzalez-Ortega I, Echeveste J, Graña-Lecuona M, Graña M, Gonzalez-Pinto A. White matter tract integrity in Alzheimer's disease vs. late onset bipolar disorder and its correlation with systemic inflammation and oxidative stress biomarkers. Front Aging Neurosci. 2017;9:179.
Galimberti D, Prunas C, Paoli RA, Dell'Osso B, Fenoglio C, Villa C, Palazzo C, Cigliobianco M, Camuri G, Serpente M, Scarpini E, Altamura AC. Progranulin gene variability influences the risk for bipolar I disorder, but not bipolar II disorder. Bipolar Disord. 2014a;16(7):769–72.
Galimberti D, Reif A, Dell'Osso B, Palazzo C, Villa C, Fenoglio C, Kittel-Schneider S, Leonhard C, Olmes DG, Serpente M, Paoli RA, Altamura AC, Scarpini E. C9ORF72 hexanucleotide repeat expansion as a rare cause of bipolar disorder. Bipolar Disord. 2014b;16(4):448–9.
Rubino E, Vacca A, Gallone S, Govone F, Zucca M, Gai A, Ferrero P, Fenoglio P, Giordana MT, Rainero I. Late onset bipolar disorder and frontotemporal dementia with mutation in progranulin gene: a case report. Amyotroph Lateral Scler Frontotemporal Degener. 2017;18:1–3.
Stern Y. What is cognitive reserve? Theory and research application of the reserve concept. J Int Neuropsychol Soc. 2002;8(3):448–60.
Cheng ST. Cognitive reserve and the prevention of dementia: the role of physical and cognitive activities. Curr Psychiatry Rep. 2016;18(9):85.
Goodwin GM, Abbar M, Schlaepfer TE, Grunze H, Licht RW, Bellivier F, Fountoulakis KN, Altamura AC, Pitchot W, Ågren H, Holsboer-Trachsler E, Vieta E. Aripiprazole in patients with bipolar mania and beyond: an update of practical guidance. Curr Med Res Opin. 2011;27(12):2285–99.
Wu CS, Hsieh MH, Tang CH, Chang CJ. Comparative effectiveness of long-acting injectable risperidone vs. long-acting injectable first-generation antipsychotics in bipolar disorder. J Affect Disord. 2016;197:189–95.
Kishi T, Oya K, Iwata N. Long-acting injectable antipsychotics for prevention of relapse in bipolar disorder: a systematic review and meta-analyses of randomized controlled trials. Int J Neuropsychopharmacol. 2016;19(9)
Author information
Authors and Affiliations
Editor information
Editors and Affiliations
Self-Assessment Questionnaire
Self-Assessment Questionnaire
-
1.
What is the best therapeutic option for the stabilization of late-onset bipolar disorder?
-
(A) Lithium
-
(B) Valproic acid
-
(C) Lamotrigine
-
(D) Antipsychotic
-
-
2.
What is the most frequent differential diagnosis that could be confusing in an elderly person presenting psychotic symptoms?
-
(A) Dementia
-
(B) Unipolar depression
-
(C) Delirium
-
(D) Brain neoplasia
-
-
3.
What is the most frequent volumetric difference found between late-onset bipolar disorder and early-onset bipolar disorder?
-
(A) Frontal and temporal regions and white matter hyperintensities
-
(B) Cerebellum
-
(C) Basal ganglia
-
(D) Specifically prefrontal cortex
-
-
4.
Which is the most reliable clinical scale evaluation for psychotic symptoms in bipolar disorder?
-
(A) PANSS
-
(B) YMRS
-
(C) BPRS
-
(D) WHO DAS
-
-
5.
Which is the most important clinical domain among the following for evaluation in the follow-up after the clinical stabilization of the patient?
-
(A) Cardiological aspect
-
(B) Cognition
-
(C) Plasma level
-
(D) Endocrinological aspect
-
Rights and permissions
Copyright information
© 2019 Springer International Publishing AG, part of Springer Nature
About this chapter
Cite this chapter
Rovera, C., Pigoni, A. (2019). Psychosis in the Elderly. In: Altamura, A., Brambilla, P. (eds) Clinical Cases in Psychiatry: Integrating Translational Neuroscience Approaches. Springer, Cham. https://doi.org/10.1007/978-3-319-91557-9_3
Download citation
DOI: https://doi.org/10.1007/978-3-319-91557-9_3
Published:
Publisher Name: Springer, Cham
Print ISBN: 978-3-319-91556-2
Online ISBN: 978-3-319-91557-9
eBook Packages: MedicineMedicine (R0)