Muzumel A. Chaudhary, MD, Psychiatry Resident, University of British Columbia, Vancouver, BC.
Kiran Rabheru, MD, CCFP, FRCP, ABPN, Clinical Associate Professor, Department of Psychiatry, University of British Columbia; Geriatric Psychiatrist, Vancouver General, University of British Columbia, and Riverview Hospitals, Vancouver, BC.

New-onset paranoid symptoms are common among older individuals. They can signify an acute mental status change owing to medical illness, correspond to behavioural and psychological symptoms of dementia, or equate to an underlying affective or primary psychotic mental disorder. The implications of paranoid symptoms are considerable and affect patients, families, and caregivers alike. Accurate identification, diagnosis, and treatment of late-life paranoid symptoms present a unique clinical challenge as issues of morbidity and mortality are inherent both to the illness state and available treatment approaches.
Key words: paranoia, delusions, etiology, older adults, atypical antipsychotic.

A. Mark Clarfield, MD

I had almost been convinced by Mrs. C. that her friend Sarah, after 50 years of friendship, had actually turned on her. On the surface, the story presented by my patient, who appeared well-groomed and intelligent, was certainly quite believable. I had read far more incredible tales in the Toronto Globe and Mail.

Apparently, the friendship between the two ladies went back many years. They had been born in the same little poverty-stricken Jewish shtetl (farming village) in Poland just after the turn of the century. They had both moved to Montreal where they married and brought up their respective families. The two ladies and their families shared summer holidays "at the lake," as well as their children's birthdays, baseball games and graduation celebrations and weddings.

Later in life, after both were widowed, the two women moved into separate but adjacent apartments in a subsidized seniors' home. They exchanged keys so that each could look after the other's apartment when the need arose.

It was just last year, my patient informed me, "that of all people"; Sarah had started stealing from her. First it was just little things, such as a quart of milk. But lately, as the stakes got higher and jewelry began to go missing, my patient became concerned. She confronted her friend Sarah who "blew her stack.

Thomas Tsirakis, BA

Attempting a home visit on a paranoid patient often presents the clinician with a number of difficult challenges. These include: gaining and maintaining the patient's trust, addressing the patient's concerns without reinforcing their suspicions or delusions, attempting to physically examine the patient, the avoidance of becoming incorporated into a patient's delusion(s) and avoiding personal injury when confronted with a potentially violent patient.

The term paranoid describes those individuals who display "fixed suspicions, delusions of reference, jealousy, or persecution, dominant ideas or grandiose trends, which are logically elaborated with due regard for reality once a false premise has been accepted." It is important to remember that paranoia is only a symptom of an underlying pathology and is not a diagnosis. Thus, if the patient is unknown to the clinician, it is important to determine (via family or the patient's physician) whether the paranoia is of acute onset or chronic in nature and whether it has already been medically addressed.

There are a number of factors (some reversible) which may generate paranoid reactions in the elderly, and should be completely ruled out (see Table 1).