Understanding Psychosis in Older Adults

Neurocognitive and Sensory-Related Psychosis

In older adults, psychosis is frequently intertwined with neurodegenerative diseases or sensory impairments.

Dementia and Lewy Body Dementia

Psychosis is a common feature of various disease states, most notably Lewy body dementia, which is often associated with a rapid decline in cognitive function.

Delirium and Sensory Perceptions

Delirium is a critical state to identify because it often presents with specific types of perceptual disturbances:

• Hallucinations: These are primarily visual in nature during delirium. They can also be tactile (touch) or olfactory (smell).
• Illusions: These are misperceptions of actual visual stimuli (e.g., seeing a coat on a rack and perceiving it as a person).
• Paranoid Delusions: These tend to be "simple" in content, such as the belief that people are following them or stealing from them.

Charles Bonnet Syndrome

Another important consideration is Charles Bonnet Syndrome, a condition where individuals with significant vision loss experience complex visual hallucinations.

Comprehensive Assessment Strategies

Because the underlying cause of psychosis in an older adult can be anything from a psychiatric break to a life-threatening infection, a comprehensive assessment is mandatory.

1. Rule Out Physical and Medical Triggers

Before concluding that a patient has a primary psychiatric disorder, clinicians must rule out medical causes. This includes:

• Infections (e.g., Urinary Tract Infections are common triggers).
• Polypharmacy (the use of multiple medications that may interact).
• Substance use or abuse.
• Sensory impairments (vision or hearing loss).
• Metabolic/Endocrine issues (e.g., thyroid disease).
• Trauma.

Clinicians should utilize bloodwork and imaging to investigate these possibilities.

2. Clinical History and Observation

• Onset: Was the onset sudden? A sudden onset often points toward delirium or a medical trigger rather than a chronic psychiatric disorder.
• History: Obtain a thorough history of previous episodes of psychosis, depression, or bipolar illness, as well as past hospitalizations and current cognitive function.
• Collateral Information: Involve family members and caregivers, as they can provide vital context regarding the patient's baseline behavior and the timing of changes.

Exam Tip: If a patient presents with sudden-onset visual hallucinations, always prioritize ruling out delirium and medical triggers (like infection or polypharmacy) before diagnosing a primary psychotic disorder.

Treatment and Management

Treatment decisions should be driven by the patient's distress and safety. Clinicians must ask: Are the symptoms distressing to the patient? Do the symptoms pose a risk to the patient or others?.

Pharmacological Interventions

If medication is necessary, antipsychotic agents (both typical and atypical) may be used. However, prescribing in the elderly requires extreme caution:

• Dosing: Use lower doses than would be prescribed for younger adults due to physiological changes associated with aging.
• Indications: Medications may be used for short-term management of psychosis related to depression, mania, or substance-induced states.
• Risks: Be mindful of increased fall risks, potential interactions with other medications, and the patient's overall physical status.
• Dementia Caution: Use antipsychotics with particular caution in patients with dementia.
• Monitoring: Closely monitor adherence and effectiveness. If a medication is not effective, it may suggest that the psychosis is driven by an underlying physical cause; in such cases, the ineffective medication should not be continued.

Holistic and Ongoing Care

Effective management extends beyond medication. It is essential to:

• Develop a strong therapeutic relationship with the client.
• Provide services at the individual, family, and community levels.
• Recognize that assessments and interventions must be ongoing, as the patient's condition can change rapidly.