Psychosis in the Elderly
At admission, Ms. A’s responses to questions were largely irrational or irrelevant to the topic at hand. In a more lucid moment, Ms. A conveyed that she had pain, gesturing to her stomach. Her vital signs were stable; she was afebrile and normotensive. Initial mental status examination revealed Ms. A to be an unkempt, distraught, elderly woman with poor eye contact and poor attention span. She was restless and would intermittently grasp imaginary objects in the air, uttering brief phrases or nonspecific sounds in response to questions. Her thought processes were disorganized as she conveyed vague thoughts with themes of fears of dying and of being harmed. She was irritable and had a labile affect and clouded sensorium that fluctuated between periods of lucidity and of obtundation. Her insight and judgment were severely impaired.
Ms. A’s psychotropic medications at the time of admission included 400 mg of quetiapine daily in divided doses for delusions, hallucinations, and agitation; 500 mg of divalproex daily for mood instability and agitation; 100 mg of sertraline daily for depression and agitation; and 4–6 mg of lorazepam daily in divided doses for anxiety and agitation. Her medical history was significant for hypothyroidism, coronary artery disease, atrial fibrillation, hypertension, hypercholesterolemia, and gastroesophageal reflux disease. For these conditions, she was taking 25 mg of levothyroxine daily, 0.125 mg of digoxin daily, 40 mg of enoxaparin daily, 325 mg of aspirin daily, 50 mg of metoprolol twice daily, 40 mg of simvastatin daily, and 40 mg of pantoprazole daily. Ms. A also had a history of recurrent urinary tract infections, chronic constipation, frequent falls, and osteoporosis. She had no known drug allergies.
From the initial interview and mental status examination, we can judge that there were three leading conditions that may have been contributing to Ms. A’s presentation of paranoid delusions, visual hallucinations, restlessness, and difficulty in being redirected: delirium; major depressive disorder, recurrent, severe with psychotic features; and dementia with delusions, depressed mood, and behavioral disturbance. Ms. A suffered from medical conditions that could predispose her to a delirium or a psychotic disorder due to a general medical condition. Because she presented with a clouded sensorium, which supported a diagnosis of delirium, a diagnosis of a psychotic disorder due to a general medical condition could not be fully supported at initial presentation.
There may be interactions among delirium, depression, and dementia. Elderly patients with dementia may have a lower threshold for delirium, and delirium has been associated with the development of dementia (1) . Similarly, depression may be a risk factor for developing dementia or be a prodrome of dementia (2) .
According to her son, Ms. A had a history of “strange thoughts” since early adulthood, raising the question of a possible primary psychotic disorder, such as schizophrenia, schizoaffective disorder, or delusional disorder, as part of her differential diagnosis. However, her premorbid social/occupational functioning and her course of illness did not support these diagnoses. It was judged that Ms. A’s “strange thoughts” were in fact unique overvalued ideas that were unlikely to have been truly psychotic in nature. Because she had not abused alcohol or other illicit substances in the past, and these were not accessible to her recently, substance abuse or dependence was not considered a likely cause of Ms. A’s psychotic symptoms. Alcohol and prescription drugs seem to be the main substances of abuse in the elderly, although illicit recreational drug abuse or dependence may become more prevalent with the aging of the baby boomers, who have an overall increased prevalence of illicit drug abuse that persists as this generation ages (3) .
Misuse or abuse of potentially addictive prescription drugs (benzodiazepines, opiates, and the like) and other drugs cited in the updated Beers criteria (4) for potentially inappropriate medication use in the elderly is of growing concern, as many elderly hospital admissions may be related to medications or toxic effects of medications. Inappropriate use of or withdrawal from centrally active prescriptions, over-the-counter and alternative medications, alcohol, and other psychoactive substances may trigger psychotic symptoms.
Ms. A’s urinalysis with cultures and sensitivities revealed an Escherichia coli urinary tract infection. Consistent with infection, the CBC with differential showed an elevated WBC count with left shift, and the erythrocyte sedimentation rate and C-reactive protein levels were elevated. Free T 4 and total T 3 were low, with an elevated thyroid-stimulating hormone level. EEG showed nonspecific generalized slowing, and a brain scan revealed mild age-related atrophy and no acute intracranial process. A chest x-ray showed cardiomegaly, hypoinflation, and no acute changes. ECG showed atrial fibrillation with a ventricular response rate of 95. Echocardiogram revealed left ventricle inferior wall hypokinesis with an ejection fraction of 50%. Mini-Mental State Examination and neuropsychological testing were attempted but could not be completed because of Ms. A’s poor attention and concentration abilities. Occupational therapy functional assessment showed that Ms. A needed total assistance with activities of daily living. The neurologist diagnosed an acute confusional state, and an internal medicine evaluation revealed constipation but no other acute physical findings. Pertinent findings are discussed in conjunction with associated interventions in the next section.
Pharmacologic interventions for psychosis in the elderly include conventional or atypical antipsychotic medications; in acutely agitated elderly patients, there may be a role for benzodiazepines as well (5 , 6) . For those with Alzheimer’s type dementia, antipsychotics seem to be more effective for paranoia, anger, and aggression (5) . Cognitive enhancers such as cholinesterase inhibitors also have been reported to be helpful (6) . The choice and dosing of medications for elderly patients is guided not only by efficacy but primarily by potential adverse interactions with other medications or illnesses, susceptibility to unwanted side effects, and the usefulness of some side effects for certain patients (for example, an antipsychotic that increases appetite may be desirable for a patient with weight loss due to anorexia). It is recommended that doses be titrated up or down slowly, according to clinical response and the development of side effects. Once a patient starts to show a positive response to a medication, it may be best to hold the dosage steady and monitor the patient for further improvement before attempting to change the dose to a recommended therapeutic dosage. Medication starting doses for the elderly are commonly one-fifth to one-quarter of those recommended for younger adult patients (7) . Ease of use (e.g., once-a-day dosing) and insurance coverage for medications are practical concerns that may influence treatment adherence.
Nonpharmacologic interventions include individual, group, couples, and family psychotherapies; behavioral and milieu management; occupational therapies; expressive therapies, such as music and art therapies; and case management. Emphasizing nonpharmacologic interventions may allow patients to receive maximum benefits from minimal effective dosages of medication and avoid side effects that can be more prominent as medication dosages increase.
Ms. A was worked up and treated for conditions that can cause delirium, such as inappropriate drug use, withdrawal from drugs, infection, urinary retention, constipation, physiologic abnormalities, cardiovascular problems, intracranial strokes, seizures or hemorrhages, and sensory deprivation.
The medications that Ms. A was taking at the time of admission were reviewed. Because of modest efficacy and minimal effectiveness of most psychotropic agents in managing behavioral disturbances, multiple drugs are often used in the hope that there will be some combined efficacy. This all too often has the unintended consequence of exacerbating behavioral difficulties. For Ms. A, it was noted that sedative, antipsychotic, anticonvulsant, and antidepressant medications (lorazepam, quetiapine, divalproex, and sertraline) had been prescribed in relatively large doses for agitation, anxiety, delusions, hallucinations, mood instability, and depression. At high doses and in combination, they were judged to be adding to her acute confusional state. Thus, a psychotropic “drug holiday” was initiated. Psychotropic medications were tapered down in dose and then discontinued, despite Ms. A’s history of major depression with psychosis and Alzheimer’s type dementia with behavioral disturbance. Ms. A would then be monitored for emergent psychiatric signs and symptoms as her delirium cleared, and psychotropic medications would be reintroduced sequentially if clinically appropriate as her delirium resolved.
Ms. A also was found to have an E. coli urinary tract infection and constipation, both of which may contribute to delirium, especially in elderly persons with dementia. To treat the infection, Ms. A received antibiotics according to the results of the urine culture antibiotic sensitivities. Fluid intake was encouraged, and she was started on a probiotic. For constipation, a bowel regimen with a high-fiber diet, increased oral fluids, a bulk former, a stool softener, and an intestinal stimulant was initiated.
Her levels of free T 4 and total T 3 were low, and the thyroid-stimulating hormone level was elevated, suggesting that Ms. A had not been taking adequate doses of her thyroid medication. A hypothyroid state can cause a delirium and resemble a dementia. Endocrinologic consultation was obtained and levothyroxine dosages were readjusted.
In her more lucid moments, Ms. A conveyed that she had pain, which can contribute to delirium. She gestured on separate occasions to her stomach. In the light of such cardiac risk factors as chronic atrial fibrillation, hypertension, and hypercholesterolemia, aspirin had been prescribed to prevent ministrokes. After reviewing Ms. A’s clinical condition and medications further, it was judged that the aspirin might be causing her abdominal discomfort, despite the use of medication for gastroesophageal reflux disease. In her current situation, it was judged that the risks outweighed the benefits of continuing on aspirin therapy, and the aspirin was discontinued. Within a few days, her complaints of abdominal distress declined. Reducing pharmacologic treatments when appropriate may be more helpful than adding more medication.
Ms. A’s sensorium continued to clear, and she had fewer episodes of psychosis and purposeless hyperactivity. When such episodes occurred, they were intermittent and consisted of brief periods of delusions with pacing, during which times she was redirectable. She was more responsive to interactive and milieu interventions, occupational therapy, and physical therapy.
Nonpharmacologic approaches included individual, group, and family psychotherapies, expressive therapies such as art and music therapy, behavioral and milieu interventions, and case management (14 , 15) . Appropriate family members were included as part of the treatment team to encourage communication and cooperation from those serving as patient surrogates. ECT, considered a treatment of choice for depression with psychosis, was not pursued because the potential risks, such as increased confusion, outweighed the potential benefits, especially since Ms. A responded well to low dosages of antidepressant and antipsychotic medications.
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