In the most recently revised edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR; American Psychiatric Association, 2022), psychosis is indicated as a cluster of “psychotic features” which generally include a loss of touch with reality, delusions, hallucinations, disorganized thoughts, specific behaviors, and negative symptoms such as blunted affect, alogia, and avolition (American Psychiatric Association, 2022; World Health Organization, 1992). Late-onset psychosis, defined by the onset of a psychotic episode after the age of 40 (Howard et al., 2000), is more prevalent than many would guess and causes significant distress to those afflicted and their caregivers.
Current estimates suggest that older adults have a 23% risk of developing psychotic symptoms in their lifetime (Reinhardt & Cohen, 2015). This does not typically include mild cases of psychosis that are easily missed or patients in nursing homes and hospitals, because these individuals are not usually included in population surveys. Individuals who develop psychosis in late life outnumber those who had longstanding, early-onset psychotic disorders and aged into late adulthood (Tampi et al., 2021). Psychosis in late life is also associated with elevated morbidity and mortality (Talaslahti et al., 2015).
Given that several etiologies can underlie the development of psychosis, it can be difficult to diagnose and effectively treat the condition accurately. A primary distinction to be made is whether the symptoms are a result of a primary psychotic disorder or a secondary psychotic disorder. In primary psychotic disorders, the symptoms of psychosis are part of the core symptoms of the disorder; these include schizophrenia, schizoaffective disorder, schizophreniform disorder, brief psychotic disorder, delusional disorder, and primary psychiatric disorders including affective disorders and some personality disorders (American Psychiatric Association, 2022). In secondary psychotic disorders, psychosis is a symptom derived from another condition, including neurocognitive disorders, delirium, medications, substance use, and other medical and neurological disorders (e.g., Parkinson’s disease; Holroyd & Laurie, 1999). Secondary psychosis comprises about 60% of cases in late life, with dementia identified as the source for most late-onset psychosis cases (Holroyd & Laurie, 1999). It is important for clinicians to obtain a thorough history, including collateral information and a medical, neurological, and neuropsychological assessment to rule out potential disorders or medication- and substance use-related causes.
One study examined the impact of military status on older patients who had developed schizophrenia earlier in life (Thorp et al., 2012). The military veterans, compared to nonveterans, were older, had a higher likelihood of being married, reported less substance use, had a lower likelihood of living in a board-and-care facility, and had a later age of onset of schizophrenia compared with nonveterans. They also had better daily functioning and better performance on some cognitive tasks than nonveterans, though they reported worse physical health. The authors suggested these relative benefits of military service may be due to military screening and/or the routine, camaraderie, and physical fitness that are inherent in military life.
To support these individuals, effective psychosocial interventions should be considered. This could involve providing individuals and their caregivers with psychoeducation, providing Cognitive Behavioral Therapy (CBT) for psychosis (CBTp), training families on how to resolve conflicts in caregiving, teaching assertive communication skills within a community, fostering social skills, and promoting a supportive environment to enhance treatment adherence. CBT has been shown to be effective in improving positive and negative psychotic symptoms (Morrison & Barrtt, 2010), though empirical evidence is still lacking for the treatment of older adults (Van Citters et al., 2005). Several programs (e.g., HOPES, FAST, CBSST) focusing on cognitive- behavioral interventions, skills training, activities of daily living skills, preventative health care, and vocational counseling have been conducted in middle-aged and older adults effectively, ameliorating symptoms of psychosis and improving social functioning and independent living skills (Granholm et al. 2020).
Electroconvulsive therapy (ECT) has also been found to be effective, particularly for psychosis cases related to major depressive and bipolar disorders (Meyer et al., 2020). Pharmacological interventions are considered a second line of treatment for psychosis in older adults due to the increased sensitivity older adults have to the adverse effects of medications (Colijn et al., 2015). However, the imminent management of symptoms with pharmacological treatment becomes crucial when the presenting symptoms are harmful to the individual or others.
In summary, though psychotic symptoms are not uncommon among older adults, there are established psychosocial and medical interventions that can provide relief for the person with psychosis as well as their families.
Authors: Samantha Carotenuto/Steven R. Thorp, Ph.D. ABPP
Samantha Carotenuto, MS., APCC, graduated with her BS in psychology with premedical concentration from Arizona State University and went on to complete her masters-level training at Grand Canyon University. She is currently an associate licensed psychotherapist, with experience working in inpatient and outpatient settings, and she is a current clinical psychology doctoral student at the California School of Professional Psychology in San Diego. She has a strong interest in the assessment and treatment of trauma related disorders and serious mental illness.
Steven R. Thorp, Ph.D., ABPP, completed his doctoral training at the University of Nevada, Reno, and worked as the Program Director for San Diego VA PTSD Clinic and as a tenure-track professor at UCSD. He has strong interests in assessment and treatment of PTSD, older adults and military populations, traditional and third-wave CBTs, stigma about mental health, and the use of technology to enhance mental health services. He is a Distinguished Professor at the California School of Professional Psychology (CSPP) at Alliant International University in San Diego.
References
American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787
Brendel, R. W., & Stern, T. A. (2005). Psychotic symptoms in the elderly. The Primary Care Companion for CNS Disorders, 7(5). https://doi.org/10.4088/pcc.v07n0506
Colijn, M. A., Nitta, B. H., & Grossberg, G. T. (2015). Psychosis in later life. Harvard Review of Psychiatry, 23(5), 354–367. https://doi.org/10.1097/hrp.0000000000000068
Granholm, E., Holden, J. L., Dwyer, K., & Link, P. (2020). Mobile-assisted cognitive-behavioral social skills training in older adults with schizophrenia. Journal of Behavioral and Cognitive Therapy, 30(1), 13–21. https://doi.org/10.1016/j.jbct.2020.03.006
Holroyd, S., & Laurie, S. (1999). Correlates of psychotic symptoms among elderly outpatients. International Journal of Geriatric Psychiatry, 14(5), 379–384. https://doi.org/10.1002/(sici)1099-1166(199905)14:5<379::aid-gps924>3.3.co;2-z
Howard, R., Rabins, P. V., Seeman, M. V., & Jeste, D. V. (2000). Late-onset schizophrenia and very-late-onset schizophrenia-like psychosis: An international consensus. The International Late-Onset Schizophrenia Group. The American Journal of Psychiatry, 157(2), 172–178. https://doi.org/10.1176/appi.ajp.157.2.172
Meyer, J. P., Swetter, S. K., & Kellner, C. H. (2020). Electroconvulsive therapy in geriatric psychiatry. Clinics in Geriatric Medicine, 36(2), 265–279. https://doi.org/10.1016/j.cger.2019.11.007
Morrison, A. P., & Barratt, S. (2010). What are the components of CBT for psychosis? A Delphi study. Schizophrenia Bulletin, 36(1), 136–142. https://doi.org/10.1093/schbul/sbp118
Rajesh R., & Tampi, M. (2021, September 13). Exploring possible etiologies for psychotic disorders in late life. Psychiatric Times. https://www.psychiatrictimes.com/view/etiologies- psychotic-disorder
Reinhardt, M. M., & Cohen, C. I. (2015). Late-life psychosis: diagnosis and treatment. Current Psychiatry Reports, 17(2), 1. https://doi.org/10.1007/s11920-014-0542-0
Talaslahti, T., Alanen, H., Hakko, H., Isohanni, M., Häkkinen, U., & Leinonen, E. (2014). Patients with very‐late‐onset schizophrenia‐like psychosis have higher mortality rates than elderly patients with earlier onset schizophrenia. International Journal of Geriatric Psychiatry, 30(5), 453–459. https://doi.org/10.1002/gps.4159
Tampi, R. R., Young, J., Hoq, R., Resnick, K., & Tampi, D. J. (2019). Psychotic disorders in late life: A narrative review. Therapeutic Advances in Psychopharmacology, 9, 2045125319882798. https://doi.org/10.1177/2045125319882798
Thorp, S. R., Sones, H. M., Glorioso, D., Thompson, W., Light, G. A., Golshan, S., & Jeste, D. V. (2012). Older patients with schizophrenia: Does military veteran status matter? American Journal of Geriatric Psychiatry, 20, 248-256. doi:10.1097/JGP.0b013e3182096ae5.
Van Citters, A. D., Pratt, S. I., Bartels, S. J., & Jeste, D. V. (2005). Evidence-based review of pharmacologic and nonpharmacologic treatments for older adults with schizophrenia.
Psychiatric Clinics of North America, 28(4), 913–939. https://doi.org/10.1016/j.psc.2005.08.001
World Health Organization. (1992). The ICD-10 classification of mental and behavioural disorders: Clinical descriptions and diagnostic guidelines. World Health Organization. https://www.who.int/publications-detail-redirect/9241544228