Diagnosing and Treating Psychotic Disorders in Late Life.

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Author: Rajesh R. Tampi
Date: Aug. 2021
From: Psychiatric Times(Vol. 38, Issue 8)
Publisher: Intellisphere, LLC
Document Type: Article
Length: 2,141 words
Lexile Measure: 2600L

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Although psychosis often emerges relatively early in life, it can also appear for the first time in older patients. These cases raise special challenges. The morbidity and mortality rates for psychosis in late life are significantly greater when compared with those for psychosis among younger individuals. (1) Furthermore, greater incidence of adverse effects is noted when antipsychotic medications are prescribed to older adults. (2) But once clinicians determine the root of the problem, they have an array of potentially effective treatment options.

Primary and Secondary Disorders

In identifying psychotic disorders in late life, a distinction must be made between primary psychotic disorders and secondary psychotic disorders. (3) The term primary psychotic disorders describes conditions in which the psychotic symptoms are the main clinical presentation of the illness. Primary psychotic disorders include illnesses along the schizophrenia spectrum, major depressive disorder (MDD), and bipolar disorder with psychotic features.

The term secondary psychotic disorders refers to illnesses in which psychosis is the secondary or associated symptom, not the core clinical feature of the disorder. Examples of secondary psychotic disorders including delirium, neurocognitive disorders, psychosis due to drugs of abuse or prescribed medications, or psychosis due to medical or neurological disorders. (4) Available evidence indicates that among older adults, approximately 60% of the cases are secondary disorders. (4,5)

Diagnosis

A thorough history, including information from collateral sources, can help differentiate between primary and secondary causes. (6) Acute or subacute onset of symptoms might suggest the occurrence of delirium or of substance- or medication-induced psychosis. Insidious onset of symptoms may suggest a primary psychotic disorder, such as a schizophrenia spectrum disorder.

Features suggestive of a secondary psychotic disorder include an atypical age of onset of symptoms, visual hallucinations presenting independently of auditory hallucinations, the occurrence of psychotic symptoms in an individual with no previous psychiatric history or no family history, the presence of abnormal findings on physical examinations, or evidence of the use of prescribed medications or abuse of illicit substances. (7) The Figure describes a workup for psychotic disorders in late life.

Exploring Treatment Strategies

For secondary psychotic disorders, the initial treatment involves addressing possible causes, including the discontinuation of offending medications or drugs of abuse or the treatment of underlying medical or neurological causes. (8) For psychotic symptoms that are unresponsive to these strategies, pharmacological treatment becomes essential. (5,8) Antipsychotic medications should be prescribed to older adults cautiously, as their long-term use may cause significant adverse effects. (9,10) Available guidelines recommend the short-term use of antipsychotics to treat the psychotic symptoms. (2) Before initiating treatment with antipsychotic medications, clinicians should always perform a risk-benefit analysis, keeping in mind the individual's physical condition and comorbid medical disorders. (2,11) Starting medication at a lower dose (one-fourth to half the starting dose for adults) and gradually titrating to the optimal dose may reduce the incidence of ad medication combination. (18) In a systematic review of meta-analyses that evaluated the use of antipsychotics among individuals with dementia, the investigators found that antipsychotics had modest efficacy in treating...

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