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Guest Editorial: Psychosis in the Elderly

lution of geriatric psychiatry than our current understanding of psychosis in the elderly. In the mid-1980s, Dilip Jeste and others published the earliest work that challenged our then current understanding of schizophrenia.That work established the presence of a previously ignored entity: late-onset schizophrenia. Those early studies contributed not only to our understanding of the special sensitivity of elderly patients presenting with this syndrome to treatment side effects, such as extrapyramidal symptoms, but also to the realization that early-onset and late-onset schizophrenia could be distinct clinical entities.As Dr Targum and I discuss in the first article in this issue, this subject remains a topic of debate. Regardless of the individual positions that clinicians and researchers may hold in this ongoing discussion, the debate currently on the forefront of the research agenda concerns the need to obtain scientifically valid information that will permit the appropriate characterization of the diverse conditions responsible for the onset of psychotic symptoms in elderly persons. This quest has led researchers to identify and clinically characterize specific conditions that can result in psychotic syndromes in elderly individuals. A review of the literature shows that by the late 1980s, the first articles reporting case series of psychotic patients suffering from Parkinson’s disease who responded to antipsychotic treatment had been published. By the early 1990s, these data had been confirmed by a large, double-blind, placebo-controlled study. At approximately the same time, studies demonstrating the efficacy of antipsychotic treatment in dementia were reported. In the late 1990s, clinicians and researchers agreed on operational criteria for the psychosis of Alzheimer’s disease, accepting the presence of unique characteristics in each of these groups of patients (see Table 1 in my and Dr Targum’s article in this issue). The recognition of these and other syndromes (delirium, major depression, etc) that can cause psychosis in the elderly is an acknowledgement of the complex nature of the phenomena. The assessment of the diverse biological correlates of psychosis in the elderly reported in the article by Karim and Burns in this issue not only reminds us of the diverse nature of the etiology of psychosis in the elderly but also points to the need to address different and concomitant problems that can appear simultaneously in a given individual. If the goal of a clinician is to achieve significant improvement in a given individual, the clinician should be able to address all aspects of disease that are present in the individual and result in symptoms of psychosis.To accomplish this task, the clinician should be able to acknowledge, identify, and treat all the etiologic factors being expressed as the psychotic symptoms. A closer evaluation of all aspects resulting in psychotic symptoms in a given patient goes beyond the biological correlates of the symptoms.As noted in every article in this issue, research has shown that a comprehensive assessment of a problem must include the environmental and cultural determinates involved in the onset of its symptoms. The goal of this special issue of the Journal of Geriatric Psychiatry and Neurology is to present a comprehensive yet reader-friendly review of a broad range of issues that are critical to understanding and treating psychosis in the elderly.The first article, by myself and Dr Targum, provides an overview of the classification and treatment of the most common disorders leading to psychosis in the elderly. The article emphasizes the diversity and distinct characteristics of psychosis in the most common disorders found in the elderly and sets the tone for the more detailed discussions that follow. The article by Karim and Burns takes a disorder-bydisorder approach to exploring the biological correlates of psychosis in the elderly. The article explores information on neuropathology, brain imaging, brain receptor sensitivity, and genetics to establish possible biological correlates for psychosis in this population. The authors conclude that there is ample evidence to suggest that biological substrates underlie many psychotic symptoms. What is less clear is any causal link between brain changes and the expression of symptoms. Karim and Burns also share their excitement about newly reported links between the presence of psychosis and specific genetic markers. They believe that these new findings may represent evidence of true biological determinants of psychosis. Finally, the authors also acknowledge the limitations of a purely biological scope when evaluating the etiological aspects of psychosis in the elderly. Hoeh, Gyulai,Weintraub, and Streim review the pharmacological treatment of psychosis.They describe on a disorder-by-disorder basis the limited available literature on large, multicenter, double-blind, placebo-controlled studies evaluating the pharmacological treatment of psychosis in the elderly.They also remind clinicians of the need to address the concomitant medical and possible iatrogenic components of the symptoms and the need to use nonpharmacological approaches to care. Cohen-Mansfield reviews not only the nonpharmacological aspects of patient care but also the nonbiological aspects of the etiology of psychosis in the elderly, as well Guest Editorial: Psychosis in the Elderly