Skip to main content

Late-Life Psychosis: Diagnosis and Treatment

Current Psychiatry Reports volume 17, Article number: 1 (2015) Cite this article

Abstract

Psychosis is one of the most common conditions in later life with a lifetime risk of 23 %. Despite its high prevalence, late-onset psychosis remains a diagnostic and treatment dilemma. There are no reliable pathognomonic signs to distinguish primary or secondary psychosis. Primary psychosis is a diagnosis of exclusion and the clinician must rule out secondary causes. Approximately 60 % of older patients with newly incident psychosis have a secondary psychosis. In this article, we review current, evidence-based diagnostic and treatment approaches for this heterogeneous condition, emphasizing a thorough evaluation for the “six d’s” of late-life psychosis (delirium, disease, drugs dementia, depression, delusions). Treatment is geared towards the specific cause of psychosis and tailored based on comorbid conditions. Frequently, environmental and psychosocial interventions are first-line treatments with the judicious use of pharmacotherapy as needed. There is an enormous gap between the prevalence of psychotic disorders in older adults and the availability of evidence-based treatment. The dramatic growth in the elderly population over the first half of this century creates a compelling need to address this gap.

This is a preview of subscription content, access via your institution.

Access options

Buy single article

Instant access to the full article PDF.

USD 39.95

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Burgy M. The concept of psychosis: historical and phenomenological aspects. Schizophr Bull. 2008;34:1200–10.

    PubMed Central  PubMed  Google Scholar 

  2. World Health Organization. The ICD-10 classification of mental and behavioural disorders: clinical descriptions and diagnostic guidelines. 1992.

  3. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th edition. Arlington (VA): American Psychiatric Association. 2013. The newly published and updated version of the Diagnostic and Statistical Manual of the American Psychiatric Association.

  4. Holroyd S, Laurie S. Correlates of psychotic symptoms among elderly outpatients. Int J Geriatr Psychiatry. 1999;14:379–84.

    CAS  PubMed  Google Scholar 

  5. Webster J, Grossberg GT. Late-life onset of psychotic symptoms. Am J Geriatr Psychiatry. 1998;6(3):196–202.

    CAS  PubMed  Google Scholar 

  6. Javadpour A, Sehatpour M, Mani A, Sahraian A. Assessing diagnosis and symptoms profiles of late-life psychosis. J Gerontopsychol Geriatr Psychiatry. 2013;26(4):205–9. A study of 201 elderly people with psychosis indicating the heterogeneous etiologies of late-life psychosis.

    Google Scholar 

  7. Freudenreich O. Differential diagnosis of psychotic symptoms: medical mimics. Psychiatr Times. 2010;27(12):56–61.

    Google Scholar 

  8. Brunelle S, Cole MG, Elie M. Risk factors for the late-onset psychoses: a systematic review of cohort studies. Int J Geriatr Psychiatry. 2012;27(3):240–52. A recent systematic review of the risk factors for late-onset psychosis, indicating positive associations with history of psychotic symptoms, cognitive problems, poor health status, visual impairment, and negative life events. No association was found with female gender.

    PubMed  Google Scholar 

  9. Marsh CM. Psychiatric presentations of medical illness. Psychiatr Clin N Am. 1997;20(1):181–204.

    CAS  Google Scholar 

  10. Freudenreich O, Charles Schulz S, Goff DC. Initial medical work-up of first-episode psychosis: a conceptual review. Early Interv Psychiatry. 2009;3(1):10–8.

    PubMed  Google Scholar 

  11. Inouye SK, Westendorp RG, Saczynski JS. Delirium in elderly people. Lancet. 2014;383(9920):911–22. An up-to-date of review covering the state of delirium risk, diagnosis, prognosis, and treatment.

    PubMed  Google Scholar 

  12. Witlox J, Eurelings LS, de Jonghe JF, Kalisvaart KJ, Eikelenboom P, Van Gool WA. Delirium in elderly patients and the risk of postdischarge mortality, institutionalization, and dementia: a meta-analysis. JAMA. 2010;304(4):443–51.

    CAS  PubMed  Google Scholar 

  13. Boettger S, Breitbart W. Phenomenology of the subtypes of delirium: phenomenological differences between hyperactive and hypoactive delirium. Palliat Support Care. 2011;9(02):129–35. A study indicating a much higher prevalence of perceptual disturbances and delusions in hypoactive delirium than had previously been reported.

    PubMed  Google Scholar 

  14. Meagher DJ, Moran M, Raju B, Gibbons D, Donnelly S, Saunders J, et al. Phenomenology of delirium: assessment of 100 adult cases using standardised measures. Br J Psychiatry. 2007;190(2):135–41.

    PubMed  Google Scholar 

  15. Webster R, Holroyd S. Prevalence of psychotic symptoms in delirium. Psychosomatics. 2000;41(6):519–22.

    CAS  PubMed  Google Scholar 

  16. Rahkonen T, Luukkainen-Markkula R, Paanila S, Sivenius J, Sulkava R. Delirium episode as a sign of undetected dementia among community dwelling elderly subjects: a 2 year follow up study. J Neurol Neurosurg Psychiatry. 2000;69(4):519–21.

    CAS  PubMed Central  PubMed  Google Scholar 

  17. Inouye SK, van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Ann Intern Med. 1990;113:941–8.

    CAS  PubMed  Google Scholar 

  18. Inouye SK, Kosar CM, Tommet D, Schmitt EM, Puelle MR, Saczynski JS, et al. The CAM-S: development and validation of a new scoring system for delirium severity in 2 cohorts. Ann Intern Med. 2014;160(8):526–33. Results from the development and validation of a new severity measure for delirium (CAM-S), showing that as severity scores increased, length of stay, nursing home admissions, and mortality also increased.

    PubMed  Google Scholar 

  19. Jacobson S, Jerrier H. EEG in delirium. Semin Clin Neuropsychiatry. 2000;5:86–92.

    CAS  PubMed  Google Scholar 

  20. Desai AK, Grossberg GT. Differential diagnosis of psychotic disorders in the elderly. In: Cohen CI, editor. Schizophrenia into later life. Washington: American Psychiatric Publishing; 2003.

    Google Scholar 

  21. National Institute for Health and Care Excellence. Dementia. CG103. London: National Institute for Health and Care Excellence. 2010.

  22. Trzepacz, P., Breitbart, W., Franklin, J., Levenson, J., Martini, D. R., & Wang, P. Practice guideline for the treatment of patients with delirium. American Journal of Psychiatry, 1999;156.

  23. Cook, I. Guideline watch: practice guideline for the treatment of patients with delirium. APA Practice Guidelines. American Psychiatric Publishing, Inc. 2010.

  24. Siddiqi N, House AO, Holmes JD. Occurrence and outcome of delirium in medical in-patients: a systematic literature review. Age Ageing. 2006;35(4):350–64.

    PubMed  Google Scholar 

  25. Clegg A, Young JB. Which medications to avoid in people at risk of delirium: a systematic review. Age Ageing. 2011;40(1):23–9. A systematic review of medications associated with delirium; revealing statistically significant increased risk for: opioids, benzodiazepines, dihydropyridines, and possibly antihistamines; no increased risk was found with digoxin and neuroleptics. Uncertain change of risk status was found H2 antagonists, tricyclic antidepressants, antiparkinson medications, steroids, non-steroidal anti-inflammatory drugs and antimuscarinics. Conclusions are limited by the relatively small number of included studies (14), having eliminated 18,753 other studies uncovered by their search method.

    PubMed  Google Scholar 

  26. Johnstone EC, Cooling NJ, Frith CD, et al. Phenomenology of organic and functional psychoses and the overlap between them. Br J Psychiatry. 1988;153:770–6.

    CAS  PubMed  Google Scholar 

  27. Cardinal RN, Bullmore ET. The diagnosis of psychosis. New York: Cambridge University Press; 2011. A comprehensive textbook on the diagnosis of psychosis across the life span. Provides an extensive differential diagnosis of potential conditions associated with secondary psychosis.

    Google Scholar 

  28. Alexopoulos GS, Streim JE, Carpenter D. Expert consensus guidelines for using antipsychotic agents in older patients. J Clin Psychiatry. 2004;65:5–99.

    PubMed  Google Scholar 

  29. Atkinson RM. Aging and alcohol use disorders: diagnostic issues in the elderly. Int Psychogeriatr. 1990;2(1):55–72.

    CAS  PubMed  Google Scholar 

  30. Substance Abuse and Mental Health Services Administration. Results from the 2012 National Survey on Drug Use and Health: summary of national findings. NSDUH Series H-46, HHS Publication No. (SMA) 13–4795. Rockville (MD): Substance Abuse and Mental Health Services Administration. 2013. The most recent national survey on drug use and health.

  31. Han B, Gfroerer JC, Colliver JD, Penne MA. Substance use disorder among older adults in the United States in 2020. Addiction. 2009;104:88–96.

    PubMed  Google Scholar 

  32. Brown RL, Rounds LA. Conjoint screening questionnaires for alcohol and other drug abuse. Wis Med J. 1995;94:135–40.

    CAS  PubMed  Google Scholar 

  33. Kuerbis AN, Sacco P. A review of existing treatments for substance abuse among the elderly and recommendations for future directions. Subst Abus. 2013;7:13–37. A review of the current literature on late-life substance abuse and treatments. Continued study is urgently needed and the review notes that like their younger counterparts, treatment response is heterogeneous.

    Google Scholar 

  34. Brunelle S, Cole MG, Elie M. Risk factors for the late-onset psychoses: a systematic review of cohort studies. Int J Geriatr Psychiatry. 2012;27(3):240–52. A systematic review of cohort studies, revealing limitations of all studies included but some evidence that a history of psychotic symptoms, cognitive problems, poor physical health, visual impairment, and negative life events are risk factors for late-onset psychosis.

    PubMed  Google Scholar 

  35. Paulsen JS et al. Incidence of and risk factors for hallucinations and delusions in patients with probable AD. Neurology. 2000;54(10):1965–71.

    CAS  PubMed  Google Scholar 

  36. Ropacki SA, Jeste DV. Epidemiology of and risk factors for psychosis of Alzheimer’s disease: a review of 55 studies published from 1990 to 2003. Am J Psychiatry. 2005;162:2022–30.

    PubMed  Google Scholar 

  37. Ostling S, Gustafson D, Blennow K, Borjesson-Hanson A, Waern M. Psychotic symptoms in a population-based sample of 85-year-old individuals with dementia. J Geriatr Psychiatry Neurol. 2011;24(1):3–8. A large population based study (n = 495) of Swedish adults aged 85 and over diagnosed with dementia showing a prevalence of psychotic symptoms ranging from 36% (Alzheimer’s Disease) and 54% (vascular dementia). Increasing prevalence of psychosis was noted to correlate with increasing severity of dementia.

    PubMed  Google Scholar 

  38. Bassiony MM, Steinberg MS, Warren A, et al. Delusions and hallucinations in Alzheimer’s disease: prevalence and clinical correlates. Int J Geriatr Psychiatry. 2000;15:99–107.

    CAS  PubMed  Google Scholar 

  39. Broadway J, Mintzer J. The many faces of psychosis in the elderly. Curr Opin Psychiatry. 2007;20:551–8.

    PubMed  Google Scholar 

  40. Panza F, Frisardi V, Seripa D, D’Onofrio G, Santamato A, Masullo C, et al. Apolipoprotein E genotypes and neuropsychiatric symptoms and syndromes in late-onset Alzheimer’s disease. Ageing Res Rev. 2012;11(1):87–103. A review of the current literature regarding a putative association between apolipoprotein-E genotypes and neuropsychiatric symptoms.

    CAS  PubMed  Google Scholar 

  41. Tighe SK, Oishi K, Mori S, Smith GS, Albert M, Lyketsos CG, et al. Diffusion tensor imaging of neuropsychiatric symptoms in mild cognitive impairment and Alzheimer’s dementia. J Neuropsychiatry Clin Neurosci. 2012;24(4):484–8. A study using diffusion tensor imaging to measure functional anisotropy (FA) in AD and MCI. Low anterior cingulate FA was associated with increased odds of irritability in mild AD and MCI participants.

    PubMed Central  PubMed  Google Scholar 

  42. Balthazar MLF, Pereira FRS, Lopes TM, da Silva EL, Coan AC, Campos BM, et al. Neuropsychiatric symptoms in Alzheimer’s disease are related to functional connectivity alterations in the salience network. Hum Brain Mapp. 2014;35:1237–46. A brain network connectivity study of (n = 20) AD patients showing a correlation between increased connectivity in anterior cingulate cortex and right insula areas of the SN and hyperactivity syndrome.

    PubMed  Google Scholar 

  43. Leroi I, Voulgari A, Breitner JC, Lyketsos CG. The epidemiology of psychosis in dementia. Am J Geriatr Psychiatry. 2003;11(1):83–91.

    PubMed  Google Scholar 

  44. Nagahama Y, Okina T, Suzuki N, Matsuda M, Fukao K, Murai T. Classification of psychotic symptoms in dementia with Lewy bodies. Am J Geriatr Psychiatry. 2007;15(11):961–7.

    PubMed  Google Scholar 

  45. Ballard C, Holmes C, McKeith I, Neill D, O’Brien J, Cairns N, et al. Psychiatric morbidity in dementia with Lewy bodies: a prospective clinical and neuropathological comparative study with Alzheimer’s disease. Am J Psychiatr. 1999;156(7):1039–45.

    CAS  PubMed  Google Scholar 

  46. Ballard CG, Saad K, Patel A, Gahir M, Solis M, Coope B, et al. The prevalence and phenomenology of psychotic symptoms in dementia sufferers. Int J Geriatr Psychiatry. 1995;10(6):477–85.

    Google Scholar 

  47. Ballard CG et al. A prospective study of dementia with Lewy bodies. Age Ageing. 1998;27(5):631–6.

    CAS  PubMed  Google Scholar 

  48. Forsaa EB, Larsen JP, Wentzel-Larsen T, et al. A 12-year population-based study of psychosis in Parkinson disease. Arch Neurol. 2010;67:996–1001.

    PubMed  Google Scholar 

  49. Aarsland D, Larsen JP, Tandberg E, et al. Predictors of nursing home placement in Parkinson’s disease: a population-based, prospective study. J Am Geriatr Soc. 2000;48:938–42.

    CAS  PubMed  Google Scholar 

  50. Marsh L, Williams JR, Rocco M, et al. Psychiatric comorbidities in patients with Parkinson disease and psychosis. Neurology. 2004;63:293–300.

    CAS  PubMed  Google Scholar 

  51. Wang LY, Borisovskaya A, Maxwell AL, Pascualy M. Common psychiatric problems in cognitively impaired older patients. Clin Geriatr Med. 2014;30(3):443–67. A thorough review of the myriad of psychiatric disorders and neuropsychiatric symptoms facing adults with neurocognitive disorders and their treatment.

    CAS  PubMed  Google Scholar 

  52. Iglewicz A, Meeks TW, Jeste DV. New wine in old bottle: late-life psychosis. Psychiatr Clin N Am. 2011;34(2):295–318. A comprehensive review of late-life schizophrenia and psychosis in the context of neurocognitive disorders.

    Google Scholar 

  53. Gauthier S, Wirth Y, Mobius HJ. Effects of memantine on behavioural symptoms in Alzheimer’s disease patients: an analysis of the Neuropsychiatric Inventory (NPI) data of two randomised, controlled studies. Int J Geriatr Psychiatry. 2005;20(5):459–64.

    CAS  PubMed  Google Scholar 

  54. Rodda J, Morgan S, Walker Z. Are cholinesterase inhibitors effective in the management of the behavioral and psychological symptoms of dementia in Alzheimer’s disease? A systematic review of randomized, placebo-controlled trials of donepezil, rivastigmine and galantamine. Int Psychogeriatr. 2009;21(5):813–24.

    PubMed  Google Scholar 

  55. Lachaine J, Beauchemin C, Crochard A, et al. The impact of memantine and cholinesterase inhibitor initiation for Alzheimer disease on the use of antipsychotic agents: analysis using the Regie de l’Assurance Maladie du Quebec database. Can J Psychiatry. 2013;58(4):195–200. A study of AD patients in the Quebec provincial health system noting a decreased initiation of antipsychotic medication following memantine prescription but not acetylcholinesterase inhibitors.

    PubMed  Google Scholar 

  56. Schneider LS, Dagerman KS, Insel P. Risk of death with atypical antipsychotic drug treatment for dementia: meta-analysis of randomized placebo-controlled trials. JAMA. 2005;294(15):1934–43.

    CAS  PubMed  Google Scholar 

  57. Schneider LS, Dagerman K, Insel PS. Efficacy and adverse effects of atypical antipsychotics for dementia: meta-analysis of randomized, placebo-controlled trials. Am J Geriatr Psychiatry. 2006;14(3):191–210.

    PubMed  Google Scholar 

  58. Rossom RC, Rector TS, Lederle FA, Dysken MW. Are all commonly prescribed antipsychotics associated with greater mortality in elderly male veterans with dementia? J Am Geriatr Soc. 2010;58(6):1027–34.

    PubMed  Google Scholar 

  59. Huybrechts KF, Gerhard T, Crystal S, Olfson M, Avorn J, Levin R, et al. Differential risk of death in older residents in nursing homes prescribed specific antipsychotic drugs: population based cohort study. Br Med J. 2012;344:e977. A large, population based study of nursing home patients (n = 75,445), >65 years old, newly started on antipsychotic medication, indicating an increase risk of mortality for haloperidol in this population (compared to risperidone) and a relative decreased risk of mortality with the use of quetiapine.

    CAS  Google Scholar 

  60. Vigen CL, Mack WJ, Keefe RS, Sano M, Sultzer DL, Stroup TS, et al. Cognitive effects of atypical antipsychotic medications in patients with Alzheimer’s disease: outcomes from CATIE-AD. Am J Psychiatry. 2011;168(8):831–9. A publication from the CATIE-AD trial indicating a more pronounced decline in cognitive function in patients treated with antipsychotic medications than those treated with placebo.

    PubMed Central  PubMed  Google Scholar 

  61. Ballard C., Waite J. The effectiveness of atypical antipsychotics for the treatment of aggression and psychosis in Alzheimer’s disease. Cochrane Database Syst Rev. (1): 2006

  62. Rabins PV, Blacker D, et al. APA work group on Alzheimer’s disease and other dementias. American Psychiatric Association practice guideline for the treatment of patients with Alzheimer’s disease and other dementias. Second edition. Am J Psychiatry. 2007;164 Suppl 12:5–56.

    PubMed  Google Scholar 

  63. Lyketsos CG, Colenda CC, Beck C, et al. Position statement of the American Association for Geriatric Psychiatry regarding principles of care for patients with dementia resulting from Alzheimer disease. Am J Geriatr Psychiatry. 2006;14(7):561–72.

    PubMed  Google Scholar 

  64. National Institute for Health and Care Excellence. Dementia. CG42. London: National Institute for Health and Care Excellence. 2006

  65. Sultzer DL, Davis SM, Tariot PN, Dagerman KS, Lebowitz BD, Lyketsos CG, et al. Clinical symptom responses to atypical antipsychotic medications in Alzheimer’s disease: phase 1 outcomes from the CATIE-AD effectiveness trial. Am J Psychiatry. 2008;165(7):844–54.

    PubMed Central  PubMed  Google Scholar 

  66. Meeks TW, Jeste DV. Beyond the black box: what is the role for antipsychotics in dementia? Curr Psychiatry. 2008;7(6):50–65.

    Google Scholar 

  67. Maher AR, Maglione M, Bagley S, et al. Efficacy and comparative effectiveness of atypical antipsychotic medications for off-label uses in adults: a systematic review and meta-analysis. JAMA. 2011;306(12):1359–69. A systematic review of off-label atypical antipsychotic use showing a small but significant improvement in global behavioral scores in dementia patients.

    CAS  PubMed  Google Scholar 

  68. Seitz DP, Adunuri N, Gill SS, Gruneir A, Herrmann N, Rochon P. Antidepressants for agitation and psychosis in dementia. Cochrane Database Syst Rev. 2011;16(2):CD008191. The most current Cochrane review of the use of antidepressants in the treatment of agitation and psychosis in dementia. Indicates an association between reduction of agitation and treatment with sertraline and citalopram. Further controlled studies are needed to verify this association.

    Google Scholar 

  69. Tariot PN, Erb R, Leibovici A, et al. Carbamazepine treatment of agitation in nursing home patients with dementia: a preliminary study. J Am Geriatr Soc. 1994;42(11):1160–6.

    CAS  PubMed  Google Scholar 

  70. Tariot PN, Erb R, Podgorski CA, et al. Efficacy and tolerability of carbamazepine for agitation and aggression in dementia. Am J Psychiatry. 1998;155(1):54–61.

    CAS  PubMed  Google Scholar 

  71. Wang LY, Shofer JB, Rohde K, Hart KL, Hoff DJ, McFall YH, et al. Prazosin for the treatment of behavioral symptoms in patients with Alzheimer disease with agitation and aggression. Am J Geriatr Psychiatry. 2009;17(9):744–51.

    PubMed Central  PubMed  Google Scholar 

  72. Diederich NJ, Fénelon G, Stebbins G, Goetz CG. Hallucinations in Parkinson disease. Nat Rev Neurol. 2009;5(6):331–42.

    CAS  PubMed  Google Scholar 

  73. Connolly BS, Lang AE. Pharmacological treatment of Parkinson disease: a review. JAMA. 2014;311(16):1670–83. A recent, well-sourced review of the current state of the pharmacologic treatment of Parkinson’s Disease.

    PubMed  Google Scholar 

  74. Miyasaki JM, Shannon K, Voon V, et al. Quality standards subcommittee of the American Academy of Neurology. Practice parameter: evaluation and treatment of depression, psychosis, and dementia in Parkinson disease (an evidence-based review): report of the quality standards subcommittee of the American Academy of Neurology. Neurology. 2006;66(7):996–1002.

    CAS  PubMed  Google Scholar 

  75. Cummings J, Isaacson S, Mills R, et al. Pimavanserin for patients with Parkinson’s disease psychosis: a randomised, placebo-controlled phase 3 trial. Lancet. 2014;383(9916):533–40. Published, positive results from phase 3 RCT for a novel treatment (Pimvanaserin) for psychosis in Parkinson’s disease.

    CAS  PubMed  Google Scholar 

  76. Byers AL, Yaffe K, Covinsky KE, Friedman MB, Bruce ML. High occurrence of mood and anxiety disorders among older adults: the national comorbidity survey replication. Arch Gen Psychiatry. 2010;67(5):489.

    PubMed Central  PubMed  Google Scholar 

  77. Luppa M, Sikorski C, Luck T, et al. Age- and gender-specific prevalence of depression in latest-life—systematic review and meta-analysis. J Affect Disord. 2012;136(3):212–21. A systematic review of 24 studies regarding the prevalence of late-life depression. This systematic review showed a pooled prevalence of DSM-IV MDD of 7.2% in adults >55 years old and pooled prevalence of depressive disorders in the same age group of 17.1%.

    CAS  PubMed  Google Scholar 

  78. Kessler RC, Birnbaum H, Bromet E, Hwang I, Sampson N, Shahly V. Age differences in major depression: results from the national comorbidity survey replication (NCS-R). Psychol Med. 2010;40(2):225–37.

    CAS  PubMed Central  PubMed  Google Scholar 

  79. Steffens DC, Fisher GG, Langa KM, et al. Prevalence of depression among older Americans: the Aging Demographics and Memory Study. Int Psychogeriatr. 2009;21(5):879–88.

    PubMed Central  PubMed  Google Scholar 

  80. Brodaty H, Luscombe G, Parker G, et al. Increased rate of psychosis and psychomotor change in depression with age. Psychol Med. 1997;27(5):1205–13.

    CAS  PubMed  Google Scholar 

  81. Blazer, D., Steffens, D., & Koenig, H. Mood disorders. In The American Psychiatric Publishing textbook of geriatric psychiatry, 4th Edition. American Psychiatric Publishing, Inc. 2009.

  82. Meyers BS, Klimstra SA, Gabriele M, et al. Continuation treatment of delusional depression in older adults. Am J Geriatr Psychiatry. 2001;9(4):415–22.

    CAS  PubMed  Google Scholar 

  83. Grimby A. Bereavement among elderly people: grief reactions, post-bereavement hallucinations and quality of life. Acta Psychiatr Scand. 1993;87:72–80.

    CAS  PubMed  Google Scholar 

  84. Van der Wurff FB, Stek ML, Hoogendijk WL, et al. Electroconvulsive therapy for the depressed elderly. Cochrane Database Syst Rev. 2003;2:CD003593.

    PubMed  Google Scholar 

  85. Andreescu C, Mulsant BH, Rothschild AJ, et al. Pharmacotherapy of major depression with psychotic features: what is the evidence? Psychiatr Ann. 2006;36:31–8.

    Google Scholar 

  86. Meyers BS, Flint AJ, Rothschild AJ, et al. A double-blind randomized controlled trial of olanzapine plus sertraline vs olanzapine plus placebo for psychotic depression: the study of pharmacotherapy of psychotic depression (STOP-PD). Arch Gen Psychiatry. 2009;66:838–47.

    CAS  PubMed Central  PubMed  Google Scholar 

  87. Wilson KC, Mottram PG, Vassilas CA, et al. Psychotherapeutic treatments for older depressed people. Cochrane Database Syst Rev. 2008;1:CD004853.

    PubMed  Google Scholar 

  88. Unutzer J, Simon G, Pabiniak C, et al. The treated prevalence of bipolar disorder in a large staff-model HMO. Psychiatr Serv. 1998;49(8):1072–8.

    CAS  PubMed  Google Scholar 

  89. Hirschfeld RM, Calabrese JR, Weissman MM, et al. Screening for bipolar disorder in the community. J Clin Psychiatry. 2003;64(1):53–9.

    PubMed  Google Scholar 

  90. Kessler RC, Berglund P, Demler O, et al. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):593–602.

    PubMed  Google Scholar 

  91. Sajatovic M, Blow FC, Ignacio RV, et al. New-onset bipolar disorder in later life. Am J Geriatr Psychiatry. 2005;13(4):282–9.

    PubMed  Google Scholar 

  92. Leboyer M, Henry C, Paillere-Martinot ML, et al. Age at onset in bipolar affective disorders: a review. Bipolar Disord. 2005;7(2):111–8.

    PubMed  Google Scholar 

  93. Hamshere ML, Gordon-Smith K, Forty L, Jones L, Caesar S, Fraser C, et al. Age-at-onset in bipolar-I disorder: mixture analysis of 1369 cases identifies three distinct clinical sub-groups. J Affect Disord. 2009;116(1–2):23–9.

    PubMed  Google Scholar 

  94. Kessing LV. Diagnostic subtypes of bipolar disorder in older versus younger adults. Bipolar Disord. 2006;8(1):56–64.

    PubMed  Google Scholar 

  95. Van Gerpen MW, Johnson JE, Winstead DK. Mania in the geriatric patient population: a review of the literature. Am J Geriatr Psychiatry. 1999;7(3):188–202.

    PubMed  Google Scholar 

  96. Young RC, Schulberg HC, Gildengers AG, Sajatovic M, Mulsant BH, Gyulai L, et al. Conceptual and methodological issues in designing a randomized, controlled treatment trial for geriatric bipolar disorder: GERI-BD. Bipolar Disord. 2010;12(1):56–67.

    CAS  PubMed Central  PubMed  Google Scholar 

  97. Beyer JL, Greenberg RL, Marino P, Bruce ML, Al Jurdi RK, Sajatovic M, et al. Social support in late life mania: GERI-BD. Int J Geriatr Psychiatry. 2014. doi:10.1002/gps.4093. An analysis of the NIMH GERI-BD database (n = 100) illustrating the importance of close social interactions on limiting time to treatment during illness episodes. Non-family interactions were less important in this study.

    Google Scholar 

  98. Al Jurdi RK, Schulberg HC, Greenberg RL, Kunik ME, Gildengers A, Sajatovic M, et al. Characteristics associated with inpatient versus outpatient status in older adults with bipolar disorder. J Geriatr Psychiatry Neurol. 2012;25(1):62–8. An exploratory study of initial participants in the ongoing GERI-BD RCT study of geriatric bipolar patients. It showed an association between ethnicity (non-Hispanic Caucasian), history of treatment with a first generation antipsychotic medication, and the presence of psychotic symptoms and inpatient treatment status.

    PubMed Central  PubMed  Google Scholar 

  99. Gildengers AG, Mulsant BH, Al Jurdi RK, Beyer JL, Greenberg RL, Gyulai L, et al. The relationship of bipolar disorder lifetime duration and vascular burden to cognition in older adults. Bipolar Disord. 2010;12(8):851–8.

    PubMed Central  PubMed  Google Scholar 

  100. Safer DJ, Magno Zito J, Safer AM. Age-grouped differences in bipolar mania. Compr Psychiatry. 2012;53(8):1110–7. An age-group comparison study showing a higher prevalence of disordered thought content in older adults versus a higher rate of aggression and irritability in younger adults.

    PubMed  Google Scholar 

  101. Sajatovic M, Chen P. Geriatric Bipolar Disorder. Psychiatr Clin N Am. 2011;34(2):319–33.

    Google Scholar 

  102. Jeste DV, Lanouette NM, Vahia IV. Schizophrenia and paranoid disorders. In: Blazer DG, Steffens DC, editors. Textbook of geriatric psychiatry. 4th ed. Washington: American Psychiatric Press; 2009. p. 317–31.

    Google Scholar 

  103. Harris MJ, Jeste DV. Late-onset schizophrenia: an overview. Schizophr Bull. 1988;14:39–45.

    CAS  PubMed  Google Scholar 

  104. Keith SJ, Regier DA, Rae DS. Schizophrenic disorders. In: Robins LN, Regier DA, editors. Psychiatric disorders in America: the epidemiologic catchment area study. New York: Free Press; 1991. p. 33–52.

    Google Scholar 

  105. Copeland JRM, Davidson IA, Dewey ME, Gilmore C, Larkin BA, McWilliam C, et al. Alzheimer’s disease, other dementias, depression and pseudodementia: prevalence, incidence and three-year outcome in Liverpool. Br J Psychiatry. 1992;161:230–9.

    CAS  PubMed  Google Scholar 

  106. Kua EHA. Community study of mental disorders in elderly Singaporean Chinese using the GMS-AGECAT package. Aust NZ J Psychiatry. 1992;26:502–6.

    CAS  Google Scholar 

  107. Copeland JR, Dewey ME, Scott A, Gilmore C, Larkin BA, Cleave N, et al. Schizophrenia and delusional disorder in older age: community prevalence, incidence, comorbidity, and outcome. Schizophr Bull. 1998;24(1):153–61.

    CAS  PubMed  Google Scholar 

  108. Castle DJ, Murray RM. The epidemiology of late-onset schizophrenia. Schizophr Bull. 1993;19(4):691–700.

    CAS  PubMed  Google Scholar 

  109. Cohen CI, Vahia I, Reyes P, Diwan S, Bankole AO, Palekar N, et al. Schizophrenia in later life: clinical symptoms and well-being. Psychiatr Serv. 2008;59:232–4.

    PubMed  Google Scholar 

  110. Howard R, Rabins PV, Seeman MV, Jeste DV. Late-onset schizophrenia and very-late-onset schizophrenia-like psychosis: an international consensus. Am J Psychiatr. 2000;157(2):172–8.

    CAS  PubMed  Google Scholar 

  111. Jeste DV, Wolkowitz OM, Palmer BW. Divergent trajectories of physical, cognitive, and psychosocial aging in schizophrenia. Schizophrenia bulletin. 2011;37(3):451–455. An recent article pointing toward the aging paradox of individuals aging with schizophrenia: accelerated aging, increased medical comorbidity and mortality with stable cognitive aging, while psychosocial function, well-being, self-management, and recurrence rates tend to improves with age.

  112. Post F. Schizo-affective symptomatology in late life. Br J Psychiatry. 1971;118(545):437–45.

    CAS  PubMed  Google Scholar 

  113. Baran XY, Young RC. Bipolar and depressive types of schizoaffective disorder in old age. Am J Geriatr Psychiatry. 2006;14(4):382–3.

    PubMed  Google Scholar 

  114. Meesters PD, de Haan L, Comijs HC, Stek ML, Smeets-Janssen MMJ, Weeda MR, et al. Schizophrenia spectrum disorders in later life: prevalence and distribution of age at onset and sex in a Dutch catchment area. Am J Geriatr Psychiatry. 2012;20(1):18–28. Dutch prevalence study of late-life psychotic disorders, including delusional disorder, evidencing a 0.03% prevalence of this disorder.

    PubMed  Google Scholar 

  115. Maher B. Delusional thinking and cognitive disorders. Integr Physiol Behav Sci. 2005;40:136–46.

    PubMed  Google Scholar 

  116. Marriott R.G., Neil W., Waddingham S. Antipsychotic medication for elderly people with schizophrenia. Cochrane Database Syst Rev. 2006;25.

  117. Essali A, Ali G. Antipsychotic drug treatment for elderly people with late-onset schizophrenia. Cochrane Database Syst Rev. 2012;2:CD004162.

    PubMed  Google Scholar 

  118. Jeste DV, Barak Y, Madhusoodanan S, Grossman F, Gharabawi G. International multisite double-blind trial of the atypical antipsychotics risperidone and olanzapine in 175 elderly patients with chronic schizophrenia. Am J Geriatr Psychiatr. 2003;11(6):638–47.

    Google Scholar 

  119. Sable JA, Jeste DV. Antipsychotic treatment for late-life schizophrenia. Curr Psychiatry Rep. 2002;4:299–306.

    PubMed  Google Scholar 

  120. Huang X, Zhong Z, Zhang J. The effects of risperidone and olanzapine on the glucose metabolism and lipid metabolism in elderly patients with schizophrenia. J Clin Psychosom Dis. 2007;13(1):1–3.

    CAS  Google Scholar 

  121. Patterson TL, McKibbin C, Mausbach BT, et al. Functional adaptation skills training (FAST): a randomized trial of a psychosocial intervention for middle-aged and older patients with chronic psychotic disorders. Schizophr Res. 2006;86:291–9.

    PubMed  Google Scholar 

  122. Granholm E, McQuaid JR, McClure FS, et al. Randomized controlled trial of cognitive behavioral social skills training for older people with schizophrenia: 12-month follow-up. J Clin Psychiatry. 2007;68:730–7.

    PubMed  Google Scholar 

  123. Manepalli JN, Gebretsadik M, Hook J, Grossberg GT. Differential diagnosis of the older patient with psychotic symptoms. Prim Psychiatry. 2007;14(8):55–62.

    Google Scholar 

  124. Richards CF, Gurr DE. Psychosis. Emerg Med Clin North Am. 2000;18(2):253–62.

    CAS  PubMed  Google Scholar 

Download references

Compliance with Ethics Guidelines

Conflict of Interest

Michael M. Reinhardt has received a training grant from the Health Resources and Services Administration.

Carl I. Cohen receives funding from the Health Resources and Services Administration and the State University of New York Health Network of Excellence.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Author information

Authors and Affiliations

  1. Department of Psychiatry and Behavioral Sciences, Division of Geriatric Psychiatry, SUNY Downstate Medical Center, 450 Clarkson Ave, Box 1203, Brooklyn, NY, 11203, USA

    Michael M. Reinhardt & Carl I. Cohen

Authors
  1. Michael M. Reinhardt
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Carl I. Cohen
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Michael M. Reinhardt.

Additional information

This article is part of the Topical Collection on Geriatric Disorders

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Reinhardt, M.M., Cohen, C.I. Late-Life Psychosis: Diagnosis and Treatment. Curr Psychiatry Rep 17, 1 (2015). https://doi.org/10.1007/s11920-014-0542-0

Download citation

  • Published:

  • DOI: https://doi.org/10.1007/s11920-014-0542-0

Keywords

  • Late-life psychosis
  • Geriatric psychosis
  • Psychosis
  • Geriatric
  • Elderly
  • Dementia
  • Neurocognitive disorders
  • Schizophrenia
  • Delirium
  • Primary psychotic disorders
  • Secondary psychotic disorders
  • Psychotic disorder due to another medical condition
  • Delusional disorder
  • Schizoaffective disorder
  • Major depressive disorder
  • Bipolar disorder
  • Substance/medication-induced psychotic disorder