Psychosomatics 47:356-359, July-August 2006
doi: 10.1176/appi.psy.47.4.356
© 2006 Academy of Psychosomatic Medicine
Onset of Schizophrenia at Age 100
Ana Natasha Cervantes, M.D.,
Peter V. Rabins, M.D., M.P.H., and
Phillip R. Slavney, M.D.
Received July 26, 2005; revised August 30, 2005; accepted September 29, 2005. From the Dept. of Psychiatry, Johns Hopkins Hospital, Baltimore, MD. Address correspondence and reprint requests to Ana Natasha Cervantes, M.D., Clifton T. Perkins Hospital Center, 8450 Dorsey Run Road, Jessup, MD 20794. e-mail: ancervan1{at}yahoo.com
|
ABSTRACT
|
Schizophrenia is generally regarded as a disease starting in adolescence and early adulthood. Cases beginning after the age of 60 are rare. The authors present the case of a woman who, at the age of 100, developed an illness marked by delusions and hallucinations and who was diagnosed with schizophrenia, paranoid type. Authors discuss the differential diagnosis of psychotic symptoms presenting late in life.
|
INTRODUCTION
|
For many years, there has been a certain reluctance to diagnose schizophrenia when the onset of the illness is after age 60. Thus, for example, a recent international consensus suggested using the term "late-onset schizophrenia" for illnesses starting between the ages of 40 and 60, but "very-late-onset schizophrenia-like psychosis" for illnesses beginning after the age of 60.1 Such diagnostic caution is prudent, given that delusional and hallucinating elderly patients are more likely to have delirium, dementia, or an affective disorder than they are to have schizophrenia. This is particularly true of hospitalized patients who are evaluated by a psychiatry consultation service. Still, it seems to us that, once other conditions have been excluded, an illness whose manifestations are characteristic of schizophrenia should be diagnosed as schizophrenia, even when the patient is over age 60. We believe that the following case description illustrates the onset of schizophrenia at age 100.
|
Case Report
|
"Mrs. A," a 100-year-old Caucasian woman, was referred to the Johns Hopkins Emergency Department by her internist for evaluation of auditory hallucinations and persecutory delusions.
According to Mrs. A, she had begun hearing male voices some 10 months before, shortly after her 100th birthday. The voices, which she attributed to "The Imps of Satan," sang and cursed. Mrs. A was convinced that other people could hear the "Imps" and became angry with her daughter when the latter said she could not hear them.
According to Mrs. A’s family, in the 3 weeks before admission, the patient became increasingly preoccupied with the "Imps" and increasingly suspicious and fearful. On the day before admission, Mrs. A frantically telephoned her granddaughter to say that people in her house were trying to kill her. In reality, the only people in the house were Mrs. A’s long-time home aides, whom she seemed unable to recognize. When Mrs. A’s granddaughter arrived at the house with her husband, Mrs. A accused her granddaughter’s husband of 20 years of being an imposter. Mrs. A then became combative and said there was a conspiracy against her. The granddaughter called the patient’s internist, and Mrs. A was brought to the Emergency Department. There, laboratory studies revealed a possible urinary tract infection (UTI), and the patient was admitted to the Dept. of Medicine with a provisional diagnosis of delirium.
Family and personal history Mrs. A had no family history of psychiatric illness, including dementia. She completed high school and 6 months of training as a librarian, but was a homemaker for most of her life. She was married at age 24 and widowed at age 56. She and her husband had five children, and for the last 13 years, she had been living with one of her daughters. Mrs. A had always been very religious and was a member of the Church of Christ. She had not used tobacco, alcohol, or drugs, and had never been arrested. According to her family, Mrs. A was an independent, intelligent, and pleasant person who had never been suspicious. There was no previous history of psychiatric illness, odd beliefs, or memory problems.
Medical and surgical history Mrs. A had a 20-year history of bilateral hearing loss but did not use hearing aids because she did not like how they looked. She also had long-standing cataracts and macular degeneration, but the former had not been corrected because of the latter.
Mrs. A had chronic mild hypothyroidism, treated with levothyroxine 75 mcg daily, and mild hypertension, treated with metoprolol 25 mg bid and sustained-release nifedipine 60 mg daily. Five years before admission, Mrs. A had had two hospitalizations for dehydration, both of which occurred in the setting of initiating diuretics for treatment of the hypertension. She also had osteoarthritis, which was treated with rofecoxib 12.5 mg daily.
Mrs. A’s surgical history included breast cancer, which had been diagnosed 14 years before admission and treated with a lumpectomy. She had had several local recurrences excised, and, after the last recurrence, 2 years before admission, she was treated with tamoxifen. Since then, there had been no evidence of recurrences or metastases. Mrs. A also had a history of a lumbar schwannoma, which had been removed 11 years before admission. After that operation, she developed urinary incontinence, which was being treated with extended-release oxybutinin chloride. There had been no recent changes in any of her medications.
On review of systems, Mrs. A reported increased urinary frequency, poor hearing, and poor vision. The two latter complaints were unchanged from their baselines before the onset of her hallucinations and delusions.
Evaluation and treatment on medical unit Mrs. A’s admission urinalysis revealed many bacteria and a few WBCs, and the urine culture grew out >100,000 colonies/ml of Escherichia coli. Her basic metabolic panel, liver function tests, ammonia level, CBC, thyroid-function tests, lipid panel, vitamin B12 level, and folate level were all within normal limits. A rapid plasma reagin and a urine screen for drugs of abuse were negative.
Computerized tomography (CT) of the brain, without contrast, showed prominent ventricles, sulci, and cisterns, compatible with parenchymal volume loss, as well as moderate periventricular white-matter hypodensities and scattered subcortical hypodensities in both frontal regions and the left temporal region, consistent with chronic small-vessel ischemic changes.
Evaluation by the psychiatry consultation service The psychiatry consultation service was contacted on the day after Mrs. A’s admission to the Dept. of Medicine, after basic laboratory tests and a CT scan of the brain had been obtained. In addition to considering a diagnosis of delirium due to a urinary tract infection (urine culture results were still pending), the Medicine team had considered the diagnosis of dementia. However, the intern had performed a Mini-Mental State Exam (MMSE), with spelling "world" backward, rather than serial subtractions, as the test of concentration, and Mrs. A had scored 28/30, with points lost for reading the phrase and copying the interlocking pentagons—tasks she could not complete because of her poor vision. The Medicine team questioned whether Mrs. A’s performance on the MMSE was consistent with dementia. Furthermore, according to the medical intern, the patient had been suspicious and guarded, and complained of hearing the "Imps of Satan." The Medicine team requested a psychiatric consultation to help clarify the nature of Mrs. A’s illness and to recommend how it might best be treated.
At the time of the psychiatric evaluation, Mrs. A was alert, cooperative, and made good eye contact, though she was very hard of hearing. She had no psychomotor abnormalities and appeared younger than her actual age. Mrs. A’s speech was prompt, fluent, and slightly circumstantial at times, but there was no evidence of formal thought disorder or aphasia. She described her mood as "good" and it appeared to be neutral. Her affect was appropriate to the content of her speech. Mrs. A’s self-attitude was intact, and she was hopeful. She denied passive death wishes, suicidal thoughts, and homicidal thoughts. Mrs. A also denied persecutory delusions and the belief that her granddaughter’s husband was an imposter, but she acknowledged hearing the "Imps of Satan." She described these auditory hallucinations as several male voices that she heard through her ears. They cursed and sang, but did not talk about her, comment on her actions, or repeat her thoughts. Mrs. A said that she had been hearing the "Imps" for several months, and she believed that people throughout Baltimore were also hearing them. She denied hallucinations in other sensory modalities and also denied obsessions, compulsions, and phobias. The patient had a good fund of general information, including major news events and the upcoming anniversary of September 11th, but she had no insight into her psychiatric illness. Mrs. A reluctantly agreed to take another MMSE and this time scored 19/30, losing 2 points for orientation to the hospital building and floor, 3 points for serial subtractions, 3 points for recall, 1 point for writing a sentence, 1 point for reading the phrase, and 1 point for copying the interlocking pentagons. When spelling "world" backward was substituted for serial subtractions, Mrs. A’s score rose to 22/30.
According to the daughter with whom Mrs. A lived, the patient had not experienced any recent decline in her cognitive or functional abilities. Although Mrs. A was frail, she was able to wash herself, brush and floss her teeth, feed herself, and accurately relay phone messages to her daughter from memory.
Both Mrs. A’s daughter and granddaughter thought that the patient’s short-term and long-term recall were unchanged of late and that her ability to use language was intact. Mrs. A had not written checks or paid bills in 3 years, but that was because of her deteriorating vision. Mrs. A’s visual loss and frailty had also led her daughter to hire home aides 4 hours per day to cook and clean and to assist the patient with tub-bathing. Mrs. A’s prescribed medications were given to her by her daughter because the patient could not see well enough to differentiate the pills, but Mrs. A kept her own supply of acetaminophen to take on an as-needed basis and did so appropriately.
The psychiatry consultation team thought that Mrs. A had schizophrenia and that her poor performance on the second MMSE was due to poor cooperation due to delirium secondary to the UTI, rather than to dementia, for the patient had no history of cognitive decline in the months before admission. On the basis of this diagnostic formulation, and because the psychiatry consultation team and the Medicine team believed that Mrs. A’s psychiatric illness would best be treated on a psychiatric service, the patient was transferred to a psychiatric inpatient unit.
Evaluation and treatment on the psychiatry unit The inpatient psychiatry team prescribed quetiapine, 12.5 mg at bedtime, but for the first few days after transfer, Mrs. A continued to experience auditory hallucinations of the "Imps" and was convinced that staff members were accomplices of the "Imps" or were trying to "damn [her] immortal soul." The patient completed a 5-day course of gatifloxacin for her UTI, but the resolution of the infection had no impact on her hallucinations and delusions.
Mrs. A agreed to have a combined MRI and magnetic resonance angiographic (MRA) study of her brain and an EEG. The MRI/MRA confirmed the results of the CT (i.e., cerebral atrophy and bilateral small-vessel ischemic changes), but was otherwise normal. The only noteworthy feature on the EEG was slowing (3 Hz–6 Hz) of the posterior basic rhythm, consistent with the patient’s age.
Although the patient agreed to these tests, she refused another MMSE until the day before she was discharged, and even then she was not completely cooperative. On that occasion, Mrs. A scored 22/30, losing 1 point for orientation to the hospital floor, 2 points for serial subtractions, 2 points for recall, 1 point for writing a sentence, 1 point for reading the phrase, and 1 point for copying the interlocking pentagons.
In the second week of her hospitalization, on 12.5 mg of quetiapine, Mrs. A denied hallucinations and delusions and had no evidence of them in her speech or behavior. Her daughter felt that the patient would benefit from more help than it was possible to give her at home, and so she was discharged to an assisted-living facility. The inpatient psychiatry team diagnosed her illness as psychosis, not otherwise specified, resolved.
Post-hospital course The first author of this article was able to evaluate Mrs. A on two occasions in the assisted-living facility. The patient’s auditory hallucinations recurred shortly after her discharge from the hospital. Now she heard not only the "Imps," but also the voices of people outside her room swearing at her. She denied hallucinations in other modalities. Mrs. A’s persecutory delusions also returned (e.g., she believed that her granddaughter’s family was going to kill her), and she was convinced that "the Imps" were transmitting "electrolysis currents" through the floor, even though she did not feel them.
Mrs. A showed no evidence of cognitive or functional decline. Two months after her admission to the assisted-living facility and 3 weeks before her death, the patient scored 27/30 on the MMSE, losing 1 point for serial subtractions, 1 point for reading the phrase, and 1 point for copying the interlocking pentagons. On that occasion, she also completed the Trails B test without error and demonstrated her verbal fluency by naming, in 1 minute, 22 items found in a grocery store.
Despite an increase in the dose of quetiapine to 75 mg bid, Mrs. A’s hallucinations and delusions never completely resolved. She became agitated on occasion, but never to the extent that psychiatric hospitalization was needed. Except for these periods of agitation, the patient’s mood was neutral overall. Some 3 months after admission to the assisted-living facility, Mrs. A died of complications of influenza, at age 101. No autopsy was performed.
|
Discussion
|
In the case we have described, the patient experienced the new onset of auditory hallucinations and persecutory delusions at age 100. These phenomena, which occurred without cognitive deterioration or a persistent mood disturbance, had lasted over 9 months before they worsened in the setting of delirium caused by a urinary tract infection. Eradication of that infection did not lead to a complete resolution of the hallucinations and delusions, although subsequent treatment with quetiapine did, if only for a few weeks. The hallucinations and delusions then returned and persisted, again without cognitive deterioration or a persistent mood disturbance, until the patient’s death some 3 months later. We believe that her illness before and after the delirium was typical of schizophrenia and that there was no need to defer that diagnosis in this case. The involvement of a psychiatry consultation team early on in the care of this patient was important, because the diagnosis of schizophrenia had not been considered before the psychiatric evaluation.
Given the patient’s age and her hallucinations and delusions, dementia had to be considered in the differential diagnosis. The central argument against dementia is that the patient had no evidence of cognitive deterioration, except when she showed delirium. Furthermore, although hallucinations and delusions can occur in dementia, they are rarely the presenting complaints.2 In the one type of dementia in which hallucinations appear early (Lewy-body dementia), the hallucinations are visual in type, and parkinsonian phenomena are prominent.
Because affective disorders are more common in elderly people than is schizophrenia, mania and depression (perhaps due to stroke) also had to be included in the differential diagnosis. Here, the central argument against such disorders is that the patient had no sustained change in mood. It must also be noted that, although she had small-vessel ischemic changes on an MRI, there was no evidence of a recent stroke.
Given the nature of the patient’s hallucinations and delusions, substance abuse should also be considered as the cause of her illness. Against this possibility is that the patient, who was a very religious woman, without a history of substance abuse, had a negative urine toxicology screen.
It is also possible, in theory, to understand her illness as a complication of macular degeneration and visual impairment—the Charles Bonnet syndrome—or as a result of a cerebral tumor, either primary or metastatic. Charles Bonnet syndrome can be dismissed because her hallucinations were auditory, not visual, and a cerebral tumor is most unlikely because there was no evidence of one on brain CT, MRI, or MRA.
Although the patient’s chronic hearing loss cannot be regarded as the cause of her illness, it is noteworthy that deafness has been identified as a risk factor for late-onset schizophrenia. The role of deafness in the pathophysiology of the illness is unclear, but impaired hearing is more common in patients with late-onset schizophrenia than in elderly patients with affective disorders,3 patients previously diagnosed with schizophrenia who have grown old,4 and normal-control subjects.5,6
The signs and symptoms of late-onset schizophrenia are, in general, like those of early-onset schizophrenia1—an observation supported by this case. We believe that the patient’s chronic auditory hallucinations and persecutory delusions are typical of schizophrenia and that they cannot be explained by another disorder. Even though her illness began when she was 100 years old, the most appropriate diagnosis for this illness is schizophrenia.
|
REFERENCES
|
- Howard RJ, Rabins PV, Seeman MV, et al, and The International Late-Onset Schizophrenia Group: Late-onset schizophrenia and very-late-onset schizophrenia-like psychosis: an international consensus. Am J Psychiatry 2000; 157:172–178[Abstract/Free Full Text]
- Bassiony MM, Lyketsos CG: Delusions and hallucinations in Alzheimer’s disease: review of the brain decade. Psychosomatics 2003; 44:388–401[Abstract/Free Full Text]
- Howard RJ, Rabins PV, Castle DJ: Late-onset schizophrenia. Taylor and Frances Group, 1999, pp 28-43
- Pearlson GD, Kreger L, Rabins PV, et al: A chart-review study of late-onset and early-onset schizophrenia. Am J Psychiatry 1989; 146:1568–1574[Abstract/Free Full Text]
- Levy R, Naguib M, Hymas N: Late paraphrenia (letter). Br J Psychiatry 1987; 151:702[Medline]
- Howard RJ, Rabins PV, Castle D: Late-onset schizophrenia. Taylor and Frances Group, 1999, pp 29-43
- Almeida OP, Howard RJ, Levy R, et al: Psychotic states arising in late life: the role of risk factors. Br J Psychiatry 1995; 166:215–228[Abstract/Free Full Text]
This article has been cited by other articles:
|
|
|
|
 
C. Harrington
Onset of Schizophrenia at Age 100--or Psychosis as the Presenting Symptom of a Cognitive Disorder?
Psychosomatics,
August 1, 2007;
48(4):
360 - 361.
[Full Text]
[PDF]
|
|
|
Get information about faster international access.
Privacy Policy
Copyright © 2006
Academy of Psychosomatic Medicine.
All rights reserved.
Home
| Search
| Current Issue
| Past Issues
| Subscribe
| All APPI Journals
| Help
| Contact Us
|
TOP
ABSTRACT
INTRODUCTION
