Recognition of Psychotic Symptoms among Older Adults
Psychotic symptoms, hallucinations, and delusions, arising de novo in older adults, represent a major risk factor for the development of dementia, illness, delirium, functional impairment and death. These symptoms and associated behavioural manifestations overlap with depressive disorders and may be signs of cognitive impairment or dementia. Symptoms may be vague or legitimized so that the psychosis is unrecognized by family and physicians. Specific queries regarding the nature of the symptoms and the impact on function will provide diagnostic clues. Several brief assessment tools can be used in primary care, specifically the NPI-Q and Blessed Dementia Scale.
Key words: psychosis, hallucinations, delusions, dementia, depression.
Introduction
Case Study
SM is an 89-year-old man who presented to the emergency room stating that he wanted to die. His wife, distressed by his complaints, reported that he was consumed with the desire to die because of his physical complaints (vertigo, tinnitus, reflux, and weight loss) and a pervasive concern about finances. He was started on an antidepressant four weeks prior without benefit. Both the patient and his wife denied that he had memory problems. Review of the medical record documented evaluation of multiple somatic complaints and lack of response to medication or reassurance. Significant functional impairment was noted.
This scenario highlights some of the diagnostic uncertainty associated with recognition of psychotic symptoms among older adults.
Symptoms in Older Adults
The incidence of new psychotic symptoms among nondemented older adults may be significantly higher than generally recognized, with one study reporting an incidence of 19.8% in individuals over the age of 85.1
Most psychotic symptoms in older adults present as visual hallucinations, delusions, and delusional misinterpretations. Although there is considerable clinical overlap, these appear to represent discrete clinical entities and may have different diagnostic and prognostic significance.1,3
Hallucinations
Hallucinations are usually visual and may be complex4 and well formed (such as seeing people that talk).
Hallucinations often involve seeing family members, alive or deceased. They may involve children or people unknown to the person. Hallucinations are usually nonthreatening. Even when individuals recognize that the hallucinatory episode is not real, they may see it in a positive way, such as the ability to communicate with a deceased relative. Hallucinations occur more commonly when the person is alone and family members may interpret the episode as a dream (or nightmare).
Delusions
Delusions are typically well organized and relate to ordinary events. The delusions often have sufficient plausibility so that relatives are uncertain whether they are delusions or not. The conviction that something has been stolen, often with accusations directed at a family member, may cause serious emotional distress and family discord unless identified as delusional. Individuals suffering from delusions may even call the police, who may not recognize the claims as a medical problem unless there are repeated episodes. Complaints about finances may seem plausible, but if individuals are delusional, they will not be mollified by explanation or reassurance. Paranoid delusions (for example, “my spouse is having an affair” or “my family is going to put me in a home”) may occur in isolation and may be difficult to distinguish from appropriate concern. Individuals have been reported to respond to delusional thinking by brandishing guns, obviously representing a significant threat.5 Arising in the night, dressing, and leaving for “work” is common and may lead to caregiver fatigue. The distinguishing feature of delusions is their persistence despite facts, explanations, and reassurances.
Delusional Misinterpretation
Among individuals with dementia, misinterpretations and illusions