Psychosis in the elderly: is it different?

How to recognize the symptoms

Marta Coromina Sadurní

Psychiatrist. Assistant to the Mental Health Department

Parc Sanitari Sant Joan de Déu

When, for the first time in life, psychotic symptoms appear in older people, they may be the first manifestation of an organic illness.

Sometimes psychotic symptoms appear before fever or pain.

In this sense, it is important that primary and community care can take a good clinical history, make a good diagnosis and request complementary tests that help identify if there is an organic cause that explains the presence of psychotic symptoms. Only by making a good diagnosis can good treatment be given.

Depression in older people

Therefore, when faced with the presence of psychotic symptoms in the elderly, first of all it is necessary to rule out that they are a consequence or secondary to a disease or medication, in these cases it is said that the psychosis is organic. Only when this has been ruled out can we speak of primary psychosis, that is to say that the psychotic symptoms cannot be explained by another cause.

Depending on the origin of the psychosis, we speak of primary or organic psychosis.

When we should suspect an organic cause in the presence of psychotic symptoms in an elderly person:

The presence of alterations in consciousness or fluctuating changes in consciousness with moments of confusion and others of lucidity.
The presence of temporal or spatial disorientation
The presence of visual hallucinations.
The presence of other symptoms such as fever or pain
When there is a sudden change in health status
They often appear in hospitalized or polymedicated elderly people.

In addition, it must be borne in mind that:

A person with sensory deficits (hearing, sight) is more likely to present psychotic symptoms.
The presence of cognitive impairment. Psychotic symptoms are common in advanced stages of dementia.

It should be noted that psychotic symptoms usually resolve if the origin of the condition that causes them is treated (when an infection improves).

Psychosis is usually primary when:

When the symptoms are not explained by any other health problem or clinical situation.
When the onset of symptoms is insidious or slow and is accompanied by previous changes in the way that person is or functions.
When there is a previous history of psychosis. It should be noted that psychosis usually first appears between adolescence and early adulthood. People with early-onset psychosis may continue to have psychotic symptoms into adulthood.

However, there are primary psychoses that begin at a later age. Approximately 25% of psychoses begin after the age of 45.

It should be noted that women tend to have a later onset of psychosis, sometimes after menopause.

How do older people with psychosis evolve?

Improved healthcare and the emergence of effective treatments have meant that the prognosis for schizophrenia and other psychotic disorders has improved greatly in recent years and life expectancy has increased.

Thus, the evolution of people with psychosis as they grow older can be characterized by:

A decrease in positive symptoms (hallucinations, delusions, etc.) is common and these have less interference with daily life.
Predominance of negative symptoms such as affective flattening, disconnection with the environment, etc. Especially more frequent in schizophrenia.
There are usually fewer and fewer acute crises.
The appearance of affective symptoms and depression in people with psychosis is more frequent than in the general population. These are symptoms that often go unnoticed and attention must be paid to early diagnosis.
People with psychosis may experience age-related cognitive decline, just like the rest of the population.
Appearance of more health problems, in relation to the general population. Greater prevalence of neurological, cardiovascular or respiratory diseases. In the case of schizophrenia, there is also a greater risk of suicide.

The increased life expectancy and improved quality of life of people with psychosis as they grow older are also accompanied by new needs. One of the challenges for the future is the need to have specific resources for older people with psychosis with which to address comorbidity. To this lack of resources, we must add the fact that many resources in the mental health and social network are for people under 65 years of age. This means that older people are excluded , as is the case, for example, in homes with mental health support, day hospitals, community rehabilitation services or social clubs. Therefore, a review of the inclusion criteria in these resources should be carried out.