Thoughts on elderly patient with sudden onset psychosis

[BiscoDisco]

60 something female with no previous psych history per reliable family (including husband). About 6 months ago became more paranoid, suspicious of family. Fearful of food - only prepares her own. Two psych hospitalizations since then for paranoia, hearing voices. Most recently hospitalized because she attempted to stab husband - thinks family is evil. Labs so far normal, awaiting head ct. Neuro saw her and thinks it is primary psych, doubts dementia as do I given the sudden onset. Any thoughts here?

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[splik]

Differential diagnosis is broad. These cases are usually primary psychiatric disorder, but other neurological and degenerative causes must be considered. Differential includes MDD w/ psychosis, late paraphrenia, very late onset schizophrenia, late onset bipolar, delirious mania, cerebrovascular disease, Alzheimer's, bvFTD, DLB, corticobasal syndrome, TBI, HAND, syphilis, alcoholic paranoia, drug induced, nutritional (e.g. Wernicke, pellagra), neoplastic, paraneoplastic, autoimmune, infectious, epileptic, heavy metal toxicity.

Even if secondary to another condition, you still want to formulate the presentation based on what the psychiatric phenotype is, i.e. what syndrome is this most closely like - depressive psychosis, manic psychosis, catatonia, delirium, delusional disorder etc and treat accordingly. If truly sudden onset (unlikely), one would consider affective, delirious, drug induced (including withdrawal), vascular, epileptic and infectious causes.

 

[Psych Person]

60 something female with no previous psych history per reliable family (including husband). About 6 months ago became more paranoid, suspicious of family. Fearful of food - only prepares her own. Two psych hospitalizations since then for paranoia, hearing voices. Most recently hospitalized because she attempted to stab husband - thinks family is evil. Labs so far normal, awaiting head ct. Neuro saw her and thinks it is primary psych, doubts dementia as do I given the sudden onset. Any thoughts here?

Post-menopausal development of primary psychotic disorders, such as delusional disorder and schizophrenia, is a well-recognized, established phenomenon in females.

For females, they have two points commonly for developing primary psychosis, the late 20’s/early 30’s and the immediate post-menopausal years, most often 55-60 years old (maybe a little broader than this). The proportion of females developing their first break is, of course, much, much smaller in the post-menopausal period compared to the classic early in life period, but it absolutely happens a lot more frequently than in males at the same late middle-age years. Women have two peaks in life for developing primary psychotic disorders whereas males really only have one (the adolescence/early adulthood one).

The development of psychosis post-menopausally is intimately tied to lower estrogen levels for females. The depletion/dramatic lowering of estrogen in menopause is directly tied to psychosis developing. This is why Tamoxifen is actually efficacious in treating psychosis in post-menopausal females (this is not a recommendation to treat post-menopausal females with psychosis with Tamoxifen).

With all of this being said, because the patient is older, you have to do a very thorough workup, including neurocognitive, medical, substance abuse, before declaring schizophrenia for the first time in a 55-60 year old. Also, try and get a good collateral history about the person and see what she was like throughout life. Was the person perhaps always a bit on the unusual side, perhaps leaning Schizotypal in certain ways? Also, Major Depressive Disorder with Psychotic Features is A LOT more common in older folks, so make sure there wasn’t a depression that preceded the psychosis, I’m sure there was more of a gradual progression into frank psychosis as opposed to a sudden change as families so often like to pretend. Grandma was usually a bit odd for a while. Good luck. God bless.

 

[annoyedpsychiatrist]

I dont think its delusional disorder as she also has AH and she seems like she has fairly severe symptoms. I have a decent number of older patients with delusional disorder that are still fairly functional despite dealing with it. If you do a full medical workup and everything is negative, autoimmune, infection, neurological, etc (basically everything mentioned above) then I would be suspicious of late onset schizophrenia (which is rare but can happen) or a neurocog disorder, again as mentioned above. These two would be high on my differential. Collateral is very important here, how she was at her baseline, things that changed in her life when the symptoms started, and how the symptoms progressed.

 

[Styrene]

60 something female with no previous psych history per reliable family (including husband). About 6 months ago became more paranoid, suspicious of family. Fearful of food - only prepares her own. Two psych hospitalizations since then for paranoia, hearing voices. Most recently hospitalized because she attempted to stab husband - thinks family is evil. Labs so far normal, awaiting head ct. Neuro saw her and thinks it is primary psych, doubts dementia as do I given the sudden onset. Any thoughts here?

Paraphrenia or very late onset schizophrenia

 

[Stagg737]

This is interesting as I was about to post a somewhat similar case in a separate thread, but patient is in her 80's. What's her functional level? Neuropsych testing (even just a SLUMS OR MOCA)? I've had a few cases like this (usually with women) which have almost uniformly ended up being a neuro issue that neuro kept saying was psych or an autoimmune/rheum case. When you say "labs so far are normal", what labs? Also, any major medical co-morbidities (RA, h/o cancer, IBS/Crohns, etc)?

 

[annoyedpsychiatrist]

These are pretty extreme symptoms for an onset of only 6mo- i suspect there was more going on for a longer duration but it went unnoticed.

In the absence of any medical explanation such as endocrine/autoimmune/etc i suspect late onset schizophrenia.

 

[PsyDr]

I've seen a subset of elderly female patients, with osteoarthritis, who develop UTIs, get hyperammonemic or hyperuremic, and then have sudden onset of neuropsychiatric symptoms.

 

[nexus73]

Why isn't paraphrenia in the DSM?

 

[clausewitz2]

Why isn't paraphrenia in the DSM?

Historical accident. There really isn't a deeper explanation.

 

[TheRightMedication]

I'm intensely curious as to the cognitive exam. Also in my opinion we can take MDD with psychosis off the table - she doesn't have delusions of poverty or condemnation with neurovegetative signs. She's running around shanking people.

 

[Jules A]

I'm intensely curious as to the cognitive exam.

Me too and brain imaging. When medical causes are sufficiently ruled out I tend to think these cases are likely dementia. Families tend to be really lousy historians and intelligent, high functioning people can confabulate their way through years.

 

[mistafab]

As above, parse out the cognitive functioning. Additionally, get nitty gritty with behaviors during that duration of symptoms as well. Make sure you know clearly if the positive symptoms presented with additional behavioral disturbances (new onset violence, impulsive gambling, prostitution, etc). One such case turned out to be pramipexole induced.

Also, very closely examine the medication list. Do the due diligence to evaluate potential iatrogenic-psychotic or deliriogenic states. Several consults for this I personally worked on turned out to be tacrolimus or prednisone (to name a few).

Imaging is warranted in my book for this age group. They say it can be warranted with any FEP, however in the 60+ group I think that it actually is warranted. One such case turned out to be clear FTD.

So again, it could be primary psych. But old people in general you should work through the differential and make sure you can convince yourself it is truly psych primary. Otherwise, you may be engaging in the black box treatment, and doom these folks to die sooner.

 

[Celexa]

Late onset and sudden onset are two completely different things.

If the patient had slow development of symptoms over months, that is not sudden onset. In an older pt as others have pointed out while you need to do a thorough medical workup, dementia and primary psych disorders are both going to be high on your list.

True sudden or subacute onset (psychosis developing over days or in a few weeks) is a different animal and the differential is much more weighted towards medical causes.

In my experience older folks with new gradual onset of delusions of infidelity are almost always due to dementia.

 

[Ceke2002]

Me too and brain imaging. When medical causes are sufficiently ruled out I tend to think these cases are likely dementia. Families tend to be really lousy historians and intelligent, high functioning people can confabulate their way through years.

This was the situation with my Mum, except it was months not years. Biggest problem was her baseline state included anxiety & depression plus suspected histrionic and BPD, so it wasn't completely out of the norm for her to become emotionally disregulated & forget things like names and places; made it really hard to spot any early warning signs of dementia As it turned out her diagnosing Doctors & Geriatrician in hospital did come to the conclusion that there were no early warning signs, and that there had been a rapid onset.

First inkling that something might be wrong was loss of appetite, weight loss & signs of clinical depression. She had just lost one of her sisters to brain cancer, so the depression was understandable at that stage. A few weeks later she was indicating signs of mental confusion & paranoid ideation, but she claimed to be aware that her thoughts were abnormal, told me her GP was monitoring her closely, had allegedly agreed to try medication & was supposedly seeing a Therapist who specialised in grief states and depression in the elderly. She went so far as to call me once a week with updates on how well her therapy was going, with detailed conversations on what they talked about, what her therapist was like, how much she thought the therapy was helping, her GP was happy with her progress, she was managing to get out and socialise more, etc etc. Then her other sister rang me and blew the lid off everything - she wasn't seeing a therapist, she was lying to her GP, lying to friends & family members, and lying to me. Before we had a chance to arrange a proper assessment she went into a delirium, lost all contact with reality, and ended up being sectioned under the mental health act. The delirium was eventually resolved, the psychotic symptoms weren't, cue the fast track into a residential care facility. She died less than a year later.

It still amazes me though how convincingly she was able to lie about her condition, right up until her hospitalisation.

 

[Jules A]

This was the situation with my Mum, except it was months not years. Biggest problem was her baseline state included anxiety & depression plus suspected histrionic and BPD, so it wasn't completely out of the norm for her to become emotionally disregulated & forget things like names and places; made it really hard to spot any early warning signs of dementia As it turned out her diagnosing Doctors & Geriatrician in hospital did come to the conclusion that there were no early warning signs, and that there had been a rapid onset.

First inkling that something might be wrong was loss of appetite, weight loss & signs of clinical depression. She had just lost one of her sisters to brain cancer, so the depression was understandable at that stage. A few weeks later she was indicating signs of mental confusion & paranoid ideation, but she claimed to be aware that her thoughts were abnormal, told me her GP was monitoring her closely, had allegedly agreed to try medication & was supposedly seeing a Therapist who specialised in grief states and depression in the elderly. She went so far as to call me once a week with updates on how well her therapy was going, with detailed conversations on what they talked about, what her therapist was like, how much she thought the therapy was helping, her GP was happy with her progress, she was managing to get out and socialise more, etc etc. Then her other sister rang me and blew the lid off everything - she wasn't seeing a therapist, she was lying to her GP, lying to friends & family members, and lying to me. Before we had a chance to arrange a proper assessment she went into a delirium, lost all contact with reality, and ended up being sectioned under the mental health act. The delirium was eventually resolved, the psychotic symptoms weren't, cue the fast track into a residential care facility. She died less than a year later.

It still amazes me though how convincingly she was able to lie about her condition, right up until her hospitalisation.

I’m really sorry your Mum and family had that experience. Generally speaking unless family are actually living with the person it is difficult to know the nuances of their recent state of functioning.

 

[Ceke2002]

I’m really sorry your Mum and family had that experience. Generally speaking unless family are actually living with the person it is difficult to know the nuances of their recent state of functioning.

Thank you, and yes I tend to agree.