Psychosomatics 49:90-91, January-February 2008
doi: 10.1176/appi.psy.49.1.90
© 2008 Academy of Psychosomatic Medicine
Psychosis in the Elderly
Edited by Anne Hassett, M.D., David Ames, M.D., and Edmond Chiu, M.D., Abingdon, UK, Taylor & Francis, 2005, 259 pages, ISBN 1-84184-394-6, $89.95
Laura A. Stanton, M.D.
Psychotic symptoms in the elderly population present a challenge for psychiatrists in inpatient, consultation/liaison, and nursing home settings. The study of psychosis in elderly patients has received little attention, despite the fact that it is a very real and serious clinical concern. The resulting behavioral problems cause distress to both patients and caregivers. Such behavior can contribute to the institutionalization of the elderly patient.
This book provides a window into the world of psychosis in the geriatric population. It reviews much of the research about psychosis in the elderly population. It covers late-onset schizophrenia (LOS), depression, bipolar affective disorder, delirium, dementia, and the basal-ganglia diseases.
Chapter authors, experts in the field of geriatric psychiatry, provide a complete list of references at the end of each chapter, and there are several tables throughout the book that compare and contrast the psychotic symptoms of each of the above disorders, providing the reader with a concise summary of a vast subject and easy tools for arriving at a differential diagnosis.
Chapters 1 and 2 cover the historical perspective of the classification and definition of psychosis in elderly patients. The authors review the history of Kraepelin’s "dementia praecox" and Roth’s "late paraphrenia." These terms were a source of controversy at the Leeds Castle Meeting in 1998. At the meeting, a distinction between late-onset schizophrenia (LOS) and very-late-onset schizophrenia (VLOS) was made, and a new framework in which to view these disorders was developed. The authors discuss the distinctions between early-onset schizophrenia (EOS) and LOS, such as the relative lack of negative symptoms in LOS, as well as the "partition delusions" experienced in LOS, in the context of the epidemiology of psychotic disorders in the geriatric population. They acknowledge, however, that much remains to be defined and clarified with regard to these conditions.
The next several chapters review the epidemiology, clinical features, and treatment of LOS. There are several excellent tables that compare EOS and LOS. Chapter 4 reviews neuroimaging in LOS, a rarely-studied and fascinating topic, and the chapter provides images of some specific cases. Chapter 5 covers the neuropsychology of LOS, and Chapter 6 reviews the use of antipsychotics in the treatment of LOS.
Although there is much literature addressing the use of pharmacotherapy for psychosis, our practice guidelines are based on studies of younger populations, and there is a limited evidence-base for the use of antipsychotics in the geriatric population. Thus, an excellent table that summarizes the evidence to-date on the use of atypical antipsychotics for elderly patients is particularly welcome; it includes specific drugs, authors, and the study design. The remaining sections on schizophrenia present non-pharmacologic interventions for elderly patients with EOS and LOS; these include chapters on psychosocial rehabilitation, a multi-disciplinary approach, and goals for residential care.
Chapter 11 covers psychosis and delirium. It is estimated that psychotic symptoms occur in up to half of patients with delirium, and delirium is one of the most common causes of psychosis in elderly patients. The chapter reviews the different characteristics of psychotic symptoms that occur in delirium, dementia, LOS, and Parkinson’s disease, touching briefly on the management of these symptoms. Haloperidol has been the drug of choice for the treatment of psychosis in delirium, but there is a growing body of research suggesting that atypical antipsychotics may be effective in alleviating symptoms. Unfortunately, there is little research on the subject.
Chapters 12 and 13 review the psychotic symptoms of depression and bipolar disorders. The authors review the possible etiologies of late-life depression and discuss the relative benefits of electroconvulsive therapy (ECT) and antidepressant medication in its treatment. ECT is an excellent treatment for psychotic depression among geriatric patients because of its low side-effect profile and high response rate. The authors also address the high risk of suicide in elderly patients who suffer from psychotic depression, even though the current data focus mostly on a younger population.
Chapter 14 summarizes the psychotic symptoms of dementia, with an emphasis on Alzheimer’s dementia. There is a well-organized table that summarizes the standard studies looking at psychotic symptoms in patients with dementia and a brief discussion about dementia with Lewy bodies. Treatment options are discussed, but it is evident that there are scarce data on this topic. Most studies focus on the use of antipsychotics to control agitation and aggression among patients with dementia and do not focus specifically on psychotic symptoms. The authors do mention the use of cholinesterase inhibitors to alleviate psychotic symptoms.
The remaining chapters review psychotic symptoms and stress, substance abuse, the basal ganglia diseases, and iatrogenic causes of psychosis in elderly patients. The book concludes with a summary of the current research and the future directions for research on these psychoses.
Although this book provides a comprehensive overview of psychosis in elderly patients, almost half of the book focuses on schizophrenia, especially LOS. It would have been useful to have greater emphasis on the more prevalent disorders, such as delirium and dementia. Nevertheless, this book enhances the understanding of psychosis in elderly patients, and it will be useful for clinicians. There are complete references at the end of each chapter and excellent tables that allow the reader to explore various aspects of these psychotic symptoms in greater depth. Psychosis in elderly patients is a subject that warrants greater research, and we would hope to see our knowledge-base expand in the future.
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FOOTNOTES
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Laura A. Stanton, M.D., is a resident in Psychiatry at Brown University Hospitals, Providence, RI.
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