Bankstown Hospital - Grand Rounds - Further Reading

Welcome to the Grand Rounds Further Reading List.

This library guide is to help support you in your professional development.

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"The wrong patient"

 Psychosis in the elderly 

Djosci Coêlho de Sá, H., et al. (2024). "LATE ONSET PSYCHOSIS IN THE ELDERLY: DIFFERENTIAL DIAGNOSIS AND THE IMPACT OF BRAIN AGING." Health and Society 4(05): 188 - 198  https://periodicojs.com.br/index.php/hs/article/view/2262 PDF @ Link

Late-onset psychosis in the elderly is a condition characterized by the onset of psychotic symptoms, such as hallucinations and delusions, after the age of 60. Although psychosis at younger ages is often associated with primary psychiatric disorders such as schizophrenia, diagnosis in the elderly is more complex, as it involves the need to differentiate between various conditions that can affect the brain and behavior, such as dementias, neurological disorders and factors related to brain aging. The impact of brain aging, such as diminished cognitive abilities and changes in brain structure, also plays an important role in the development and course of psychosis in this age group. The aim of this work is to analyze the differential diagnosis of late onset psychosis in the elderly, exploring the conditions that can mimic psychotic symptoms and the impact of brain aging on this process. It also aims to assess the implications of this diagnosis for clinical management and patients’ quality of life. This study uses a systematic review to investigate late onset psychosis in the elderly, its relationship with neurodegenerative diseases, differential diagnoses with dementias and therapeutic approaches, both pharmacological and non-pharmacological. The search was carried out in databases such as SciELO, PubMed, LILACS and Journal of Neurosciences, and included analysis of critical reviews, empirical studies and clinical guidelines. Additional data was obtained from population studies and clinical analyses involving geriatric patients with psychosis. The differential diagnosis of late onset psychosis is challenging, as it involves distinguishing between primary and secondary psychiatric causes. Neurodegenerative disorders, such as Alzheimer’s disease and dementia with Lewy bodies, are often associated with psychotic symptoms in the elderly. Likewise, disorders such as major depression with psychotic features and delirium can present with similar symptoms, and a detailed clinical assessment is essential. The exclusion of underlying medical factors, such as infections, metabolic disorders and adverse effects of medication, is crucial to ensure an accurate diagnosis. Brain aging, in turn, plays a key role in the vulnerability of the elderly to psychosis. With age, structural and functional changes occur in the brain, such as cortical atrophy, reduced neuronal density and alterations in dopaminergic pathways, which can predispose to the emergence of psychotic symptoms. These changes make the brain more susceptible to stress factors, inflammation and sensory deficits, which can precipitate psychotic episodes. Thus, the treatment of late onset psychosis involves a careful approach, given the sensitivity of the elderly to antipsychotics and the increased risk of side effects. The choice of treatment must balance efficacy in controlling symptoms with minimizing risks, and the use of low doses and constant monitoring are recommended to avoid complications. It is therefore concluded that late onset psychosis in the elderly presents significant diagnostic challenges, requiring a multifactorial approach that takes into account brain aging and the various medical conditions that can mimic or contribute to psychotic symptoms. Differential diagnosis is essential to ensure appropriate treatment, which, when properly targeted, can substantially improve patients’ quality of life. The impact of brain ageing on vulnerability to psychosis highlights the need for detailed clinical assessment and individualized therapeutic strategies for this population group.

Fischer, C. E. and L. Agüera-Ortiz (2018). "Psychosis and dementia: risk factor, prodrome, or cause?" International Psychogeriatrics 30(2): 209-219 Cambridge Core https://www.cambridge.org/core/product/65F67FCEF7B4F7BA98128DE9DAA14FEA ARTICLE REQUEST FORM

                Background: Progression of dementia is often associated with the emergence of neuropsychiatric symptoms (NPS), though there is recent evidence that NPS may occur in prodromal dementia (PrD) and impact clinical course. Mood and anxiety symptoms are the NPS that tend to occur most frequently in PrD and thus have been most extensively studied. Comparatively, there has been little focus on psychotic symptoms in PrD. Methods: The authors review the existing literature on psychosis in PrD, including the functional psychosis of early and late onset, with a focus on epidemiology, phenomenology, and clinical course and treatment considerations. Results: Patients with psychotic disorders at baseline such as schizophrenia may be more at risk for developing dementia over time, although this is not completely clear. Psychotic symptoms are likely more common in PrD than previously understood based on factor analysis studies, although they are much more common in established dementia. Variability in findings may reflect the heterogeneous nature of PrD studies to date and the lack of inclusion of patients with late onset psychosis in most clinical studies. The presence of psychosis in patients with PrD may be associated with a worse prognosis in terms of mortality and conversion to dementia. Conclusions: Research to date suggests that psychosis in PrD may be more common than previously thought and impact clinical course negatively. Future studies incorporating patients with late onset psychotic disorders and focusing on the impact of early recognition and treatment, are required to more fully understand the role of psychosis in PrD.

Gallier-Birt, I., et al. (2024). "Risk Factors in the Development of Very Late-Onset Schizophrenia-Like Psychosis: A Scoping Review." BJPsych Open 10(S1): S34-S35 Cambridge. https://www.cambridge.org/core/journals/bjpsych-open/article/risk-factors-in-the-development-of-very-lateonset-schizophrenialike-psychosis-a-scoping-review/14AB1F13DB2A6C7C3BA6066634BF1C82 ARTICLE REQUEST FORM

                Aims: Very Late-Onset Schizophrenia-Like Psychosis (VLOSLP) is a condition resembling schizophrenia, which has a first onset in individuals at age 60 or later. Understanding the risk factors associated with the development of this condition is crucial, given the increasing ageing population and the elevated mortality rate in VLOSLP patients compared with the general population. This scoping review aims to explore and map the risk factors associated with VLOSLP development and begin to identify potential mechanisms linking these factors through comprehensive literature searching, screening and data extraction.MethodsConducted as a scoping review; MEDLINE, Embase and APA PsycInfo were searched using the terms: “Very-Late Onset Schizophrenia-Like Psychosis”, “VLOSLP”, “Geriatric Psychosis” and “Geriatric Schizophrenia”. Inclusion criteria focused on psychosis with onset at 60 years or older and the identification of at least one potential risk factor. Studies were excluded which did not specifically refer to age of onset or concerned psychosis with an attributable organic cause. Thematic analysis was used to categorise risk factors into biological and psychosocial themes, followed by further organisation into specific subthemes.ResultsOut of 326 initial results, 41 studies met inclusion criteria and underwent data analysis. Key risk factors included female gender, sensory impairment, social isolation, and migration, with potential interconnections identified between factors. Postulated mechanisms for the role of a risk factor in VLOSLP development recorded in the literature were included in the review. Mechanisms showed potential co-linkage between subthemes of risk factor. Migration status was also shown to impact gender as a risk factor, with male migrants experiencing higher rates of VLOSLP than their female counterparts. Thematic analysis highlighted how social isolation, a prominent risk factor, might be linked to, or reinforced by, sensory impairment, trauma, bereavement, and premorbid personality traits.ConclusionThe scoping review revealed that risk factors for VLOSLP span across biological, social, and psychological domains, with the findings contributing to the broader understanding of schizophrenia-like psychoses in the elderly population. Social isolation emerged as a widely-cited factor, reiterating the importance of managing risk factors for VLOSLP in vulnerable individuals via a holistic and multidisciplinary approach. Results bring attention to the bi-directional relationships between risk factors and psychotic illness, with perceived risk factors a potential consequence of the psychosis. In response to this, future work may involve large-cohort longitudinal studies to outline temporal relationships between risk factors and symptom development.

Huang, S. S. (2025). "Challenges in the management of visual and tactile hallucinations in elderly people." World J Psychiatry 15(1): 101946   2220-3206 https://pmc.ncbi.nlm.nih.gov/articles/PMC11684211/  Article @ Link

                This letter provides a concise review of the pertinent literature on visual and tactile hallucinations in elderly patients. The discussion addresses differential diagnoses and potential underlying mechanisms, as well as the psychopathology associated with tactile hallucinations, and emphasizes the necessity for investigation into the possibility of coexisting delusional infestation (parasitosis). These symptoms frequently manifest in patients with primary psychotic disorders, organic mental disorders, and substance use disorders. The proposed pathophysiological mechanisms may involve dopaminergic imbalances and dysfunction of the striatal dopamine transporter.

Moraiti, V. and G. N. Porfyri (2024). "Schizophrenia and Risk of Dementia: A Literature Review." European Psychiatry 67(S1): S760-S761 Cambridge Core https://www.cambridge.org/core/product/CC68F2DD2327F77F10FC853F3D63222C

  ARTICLE REQUEST FORM

Introduction; Dementia is a clinical syndrome affecting 1-2% of the population under the age of 65, while at older ages the frequency doubles every five years. The clinical manifestations include memory loss, communication deficits, agnosia, apraxia and executive dysfunction. Schizophrenia is a complex, chronic mental disorder affecting approximately 1% of the population, presenting with disturbances in perception, thought and behavior. Objectives: To investigate the relationship between schizophrenia and later-onset dementia; more specifically to explore whether schizophrenia increases the dementia risk.MethodsA review of 35 articles -from 2010 to 2023- on PubMed and Google Scholar regarding patients with schizophrenia or other type of psychosis, who later presented dementia. Results: Patients with a history of schizophrenia, schizotypal disorder, or delusional disorder are more likely to develop dementia. The greatest risk is presented in patients showing the shortest duration of psychotic symptoms (5 years or less), while at 5-10 years the probability of developing dementia decreases. The most common types of dementia occurring in psychotic patients are Alzheimer’s disease (50-70%),vascular dementia (30%) and unspecified dementia (15%).Chronic patients (10+ years of symptomatology) are less likely to develop dementia. Psychotic patients over the age of 65 are more likely to develop dementia later in life, while individuals who develop schizophrenia after their 40s are three to four times more likely to present dementia compared to patients carrying a schizophrenia diagnosis before their 40s.Females with Late-Onset Schizophrenia have an increased dementia risk compared to males carrying the same diagnosis and compared to healthy females of the same age. Physical conditions implicated in the onset of dementia in schizophrenic patients include cardiovascular diseases, lung disease, substance and alcohol use, head injuries and diabetes. Conclusions: According to data, there is a strong correlation between schizophrenia and dementia. However, the related studies are limited in number, while their results require further investigation because of limitations (small sample sizes, co-morbidities, selection of chronic elderly patients). Furthermore, most of these studies were conducted in Western countries, highlighting the necessity of pursuing additional research. Disclosure of Interest None Declared.

Pustam, L., et al. (2024). "Antipsychotics Use in the Elderly: Balancing the Risks and Benefits." Advances in Psychiatry and Behavioral Health 4(1): 167-175  https://doi.org/10.1016/j.ypsc.2024.05.012

https://www.advancesinpsychiatryandbehavioralhealth.com/article/S2667-3827(24)00020-6/abstract

ARTICLE REQUEST FORM

                Antipsychotic use in the elderly patient population has been increasing, and as life expectancy grows longer there is a need for standardizing this treatment option. Much debate exists on the use of antipsychotics, but nevertheless they are still prescribed, whether or not approved by the U.S. Food and Drug Administration, for dementia, delirium, psychosis, and mood disorders. The authors explore the evidence supporting the use of antipsychotics in the elderly population, while also highlighting the risks and liabilities. The authors also review different guidelines which can aid providers when prescribing antipsychotics for the geriatric population.

Psychology & Behavioral Sciences Collection  is an essential full-text database for psychologists, counselors, researchers and students. It provides hundreds of full-text psychology journals, including many indexed in APA PsycInfo. It offers particularly strong coverage in child and adolescent psychology and counseling. Available via Bankstown Hospital Clinical Library's myAthens website. Register for access.