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Clinical Case Discussion: The Elderly Patient with Psychosis

Objective: To present a clinical case of an elderly person with psychosis and to discuss associated diagnostic and treatment issues. Methods: A case from 1 of the authors' clinical practices was presented in English and French to several groups of Canadian psychiatrists attending a teaching day on psychosis. Three geriatric psychiatrists acted as facilitators, soliciting the clinical experiences of the participants in the discussion. The authors integrated clinical content from these sessions with results of a Medline search on psychosis in elderly persons. Results: The assessment of elderly patients with psychosis is more often than in younger patients by overlying organicity, including delirium due to illness or medication use, dementia, or sensory deficits. Treatment might further worsen cognitive, affective, and functional impairment through adverse effects such as extrapyramidal symptoms (leading to decreased mobility and general functioning), anticholinergic effects (predisposing to delirium), and hypotension (predisposing to falls). Newer antipsychotics with less hazardous side effect profiles have an increasing role, but they must be coupled with psychosocial support to maximize the patient's independent functioning and quality of life after discharge. Conclusions: Assessment and treatment of the elderly person with psychosis must consider a wide variety of biopsychosocial variables, seeking to minimize further treatment-related deterioration. Controlled studies of antipsychotics in elderly people must be conducted in a variety of diagnostic situations that reflect their actual use in the community, and information must be propagated effectively among general psychiatrists, family physicians, and geriatric psychiatrists. The role of nonpharmacologic interventions in elderly persons with psychosis is even less well understood and deserves further study.