Authors: Isaac Kah Siang Ng, Joo Wei Chua, Yit Shiang Lui, Li Feng Tan, Desmond Boon Seng Teo
Categories: Problem-Solving for Acute and Critical Care [CME Article]
Source: Singapore Medical Journal
Psychosis is a clinical syndrome of altered perception of reality, characterised by one or more of the following features[1,2]:
Classically, Schneider’s first-rank symptoms,[3] which include audible hallucinations (thought echo, voices arguing or commenting), thought interference (withdrawal, insertion, broadcasting), delusions of control (made volitional acts, impulses and affect) and delusional perception, were used to describe patients with schizophrenia.
The estimated prevalence of psychosis in older adults was 5%–10% locally and internationally.[4,5,6] In a rapidly ageing population, acute care physicians need to be familiar with managing elderly patients with first-onset psychosis that may manifest in various ways, such as agitation/aggression, paranoia, food refusal or sudden inability for self-care.[7,8]
Older adults are persons aged ≥60 years, based on the United Nations definition of older persons[9] and a similar age cut-off to local studies like the WiSE study.[6] The evaluation and management of acute psychosis in older adults is different from those for young adults due to salient differences in clinical disease manifestations, underlying aetiologies and choice of treatment, influenced by factors such as disease epidemiology, age-related physiological changes and medical comorbidities. For example, primary psychotic disorders such as schizophrenia tend to occur more commonly in younger patients from late teens to early thirties, while organic psychoses feature more prominently in older adults due to higher burden of medical comorbidities that may predispose to neurological/metabolic disturbances, higher incidence of polypharmacy and use of traditional/complementary/herbal medicines. In addition, unlike younger patients with classical schizophrenia spectrum disorders who may present with florid first-rank symptoms,[3] late onset paraphrenia in older adults has a predominant delusional component without concomitant thought disorder or personality change.[10] Finally, the choice and dosing regimen of antipsychotics in older adults depends on the patients’ clinical profile and medical comorbidities, taking into consideration age-related changes in pharmacokinetics and pharmacodynamics.
The aetiologies of acute psychosis are shown in Box 1. In older adults, it is particularly important to first rule out organic causes of psychoses, as primary psychoses rarely present in this age group and elderly patients have a higher burden of medical comorbidities and polypharmacy that predispose to organic pathologies. In addition, organic psychoses may be reversible if the underlying precipitant is addressed in a timely manner. For example, in an elderly patient with altered mentation, delirium should always be considered, with underlying precipitants to be investigated. This is because atypical disease presentations are fairly common in the geriatric population due to age-related homeostatic changes, with a tendency for clinical insults to manifest first at the organ with least reserves, such as the brain which may have undergone age-related atrophy and neurodegenerative changes. As such, delirium can be the first presentation of an underlying illness such as pneumonia, and early detection of delirium with prompt treatment of the underlying precipitant can reduce the duration and severity of symptoms.[11] In addition, cerebrovascular disease and neurodegenerative disorders are common in the older population and interestingly, studies have reported the prevalence of psychoses in patients with previous stroke, Parkinson’s disease and Alzheimer’s dementia to be 5%,[12] 10%[13] and 41%,[14] respectively. Locally, older adults commonly consume traditional Chinese medicines or herbal supplements for health and wellness, and some of these products may be adulterated with exogenous steroids for their anti-inflammatory effect.[15] In such cases, it may be prudent to consider the possibility of steroid-induced psychosis, which is a rare but well-established dose-dependent adverse effect of systemic corticosteroids.[16]
In the realm of primary psychoses in elderly patients, ‘very late onset schizophrenia-like psychosis’ is used to describe elderly patients with onset of schizophrenic features.[17] Interestingly, ‘late paraphrenia’ was previously used to describe a unique entity of elder-onset psychosis that commonly occurs in females, with predominant features of paranoid delusions and hallucinations, in the absence of thought disorder, negative symptoms or personality change.[10,17] Nonetheless, it is important to recognise that the diagnosis of schizophrenia can be made only when the psychotic symptoms last for at least 6 months.
Initial evaluation for acute psychosis in older adults involves taking a comprehensive psychiatric and clinical history, with corroborative history from the next-of-kin, and performing a targeted examination based on the likely differential diagnoses. Firstly, psychiatric history-taking involves characterising the nature of psychotic symptoms, identifying associated neuropsychiatric symptoms such as mood and cognitive changes and assessing the degree of functional and psychosocial impairment. A list of salient questions in the psychiatric history-taking is detailed in Supplementary Table 1 [Appendix]. Importantly, the nature of psychotic manifestations may favour certain aetiologies — the presence of bizarre delusions and thought disorders would be suggestive of schizophrenia spectrum disorders, while the presence of pseudohallucination (voices in the head) and mood congruent symptoms are associated with affective states, such as mood disorders (depression, bipolar disorder) or endocrine conditions (thyroid dysfunction). During the psychiatric interview, a mental state examination is usually concurrently performed by observing the patient’s overall appearance (e.g. grooming, posture), behaviour (e.g. eye contact, body language), psychotic manifestations (including hallucinations, delusions and thought/speech disorders), mood/affect, cognition, insight and risk assessment (of suicide/self-harm and harm to others). Patients who are deemed to pose significant risks to themselves or others might require involuntary admission to the Institute of Mental Health under Singapore’s Mental Health (Care and Treatment) Act 2008. Secondly, corroborative history should be obtained from the patient’s next-of-kin to document the spectrum of observed psychotic behaviours, delineate the timeline of symptoms, identify possible precipitating events and determine the veracity of patient’s delusional claims. Furthermore, performing a comprehensive geriatric assessment with the patient’s caregiver provides a holistic picture of the premorbid medical history, cognition, mood, function, ambulatory status and social set-up. In the context of psychopathology, it is useful to characterise the patient’s premorbid personality and adjustment, which may influence disease pathogenesis, psychiatric insight and eventual functional outcomes.[18] Thirdly, clinical history-taking and examination should be performed to identify symptoms and signs of an underlying organic pathology.
In patients with an acute change in mentation with psychotic symptoms, the Confusion Assessment Method is a well-validated tool to screen for delirium, based on the presence of the (a) altered mentation as compared to patient’s baseline (acute onset and follows a fluctuating course); (b) inattention; and either (c) disorganised thinking or (d) altered level of consciousness.[19] Essentially, delirious patients typically demonstrate hyperactivity (e.g. agitation, aggression, restlessness) and/or hypoactivity (e.g. lethargy, drowsiness, psychomotor retardation), with features of inattention such as difficulty focusing in a conversation or distractibility, and disorganised thought process manifesting as tangential, incoherent or irrelevant speech. Besides diagnosing delirium, the underlying precipitant needs to be identified by looking for infective features and focal neurological deficits suggestive of intracranial event, checking for distended bladder or high post-void residual urine volume in acute urinary retention, performing a digital rectal examination for impacted stools and reviewing the drug chart for potential medications that may predispose to delirium (e.g. anticholinergics, opioids, sedatives).
Subsequently, to evaluate for neurological causes of psychiatric manifestations, patients should be assessed for focal neurological deficits (e.g. numbness, weakness, speech/swallowing difficulties, visual loss), cognitive impairment, executive dysfunction, pre-existing cardiovascular risk factors, and history of neurological disorders or head trauma. Red-flag features of raised intracranial pressure, such as early morning headache associated with nausea/vomiting that is worse on exertion/coughing/sneezing or lying supine, Cushing’s ‘triad’ of bradycardia, hypertension and irregular respiratory rate, papilloedema on fundoscopy and false localising cranial nerve VI palsy, should always be excluded. To assess for common metabolic/endocrine disorders, it is useful to take a dietary history, evaluate the patient’s nutritional status and screen for features of hyper/hypothyroid states, hypercortisolism, anaemia and uraemic/hepatic/hypercapnic encephalopathy.
Finally, a comprehensive review of all prescribed medications, traditional medicines and herbal supplements, and any alcohol or recreational drug use should be conducted with the patient and caregiver, and the process of drug identification and reconciliation can be facilitated by inpatient pharmacists.
In general, investigations comprise blood and urine tests, neuroimaging, electrophysiological studies and/or procedures like lumbar puncture [Supplementary Table 2, Appendix]. The type and extent of evaluation depends on the clinical suspicion, goals of care and diagnostic objectives.
Routine blood tests performed include full blood count, urea/creatinine/electrolytes, liver function tests, serum glucose, thyroid function test, vitamin B12 and folate levels. These tests are useful to easily identify reversible metabolic derangements, evaluate renal/liver function that may influence antipsychotic choice/dosing, depending on the drug pharmacokinetics, predominant site of metabolism and toxicity profile in renal/liver impairment, and potentially guide further lines of investigations. Other laboratory and urine tests may be performed depending on clinical suspicion. For example, in patients with chronic cough or insomnia/anxiety requiring frequent use of symptomatic medications or in those with known history of drug abuse/dependence, a urine drug screen for opiates, ephedrine/pseudoephedrine and benzodiazepines should be done. For patients who have consumed complementary medicine products from unlicensed providers, further testing for adulterated drug components and heavy metals may be considered.
Neuroimaging modalities such as computed tomography and magnetic resonance imaging of the brain are usually performed to rule out structural brain lesions. Interestingly, a systematic review of 16 studies by Forbes et al. in 2019 found inadequate evidence to support routine brain imaging in patients with acute psychosis in the absence of neurocognitive impairment.[20] However, the studies included in the review involve a disproportionately younger age group, possibly due to a higher prevalence of psychotic illness amongst them. Furthermore, given that many neurological conditions such as cerebrovascular events, intracerebral haemorrhage and neurodegenerative conditions become more prevalent with older age, it is prudent to have a lower threshold to performing neuroimaging in older adults when they present with first-onset psychosis. Electroencephalogram may be useful in patients with previous cerebrovascular events, structural brain pathologies or clinical concerns of ictal events, to look for epileptiform activity, in particular features of temporal lobe epilepsy, which has a known association with psychosis.[21]
Finally, lumbar puncture may be performed to assess for central nervous system infections, neuroinflammatory conditions such as autoimmune/paraneoplastic encephalitis, and neurodegenerative disorders including multiple sclerosis and Prion disease.[22] However, cerebrospinal fluid studies are not routinely recommended in proposed guidelines for the workup of psychosis,[22] likely due to the procedural risks involved. In addition, performing a lumbar puncture in an acutely psychotic and agitated patient is foreseeably difficult and will probably require the use of procedural sedation which carries additional risks.
Management principles for older adults with acute psychoses include addressing potentially reversible organic causes, attaining symptomatic control, and importantly, developing a targeted treatment and follow-up plan tailored to the patient’s clinical symptomatology, premorbid profile and overall goals of care.
Firstly, while establishing a definitive association between an organic derangement, such as a metabolic/electrolyte abnormality, and the acute psychotic event may be difficult, every effort should be made to identify and correct any potentially reversible organic precipitants as soon as possible. Secondly, for symptomatic control of psychotic symptoms, both non-pharmacological and antipsychotic medications can be trialled.
Non-pharmacological measures may include cognitive behavioural therapy (CBT) and other psychotherapies, verbal de-escalation in acute agitation, involvement of family in patient care and environmental modifications to optimise patient safety (e.g. placing patient near the nursing counter, removal of sharp/dangerous objects in the surroundings). Outside of formal CBT sessions by clinical psychologists, a simple CBT approach that frontline clinicians can adopt includes exploring the psychotic symptoms with the patients to help them gain insight and come up with coping strategies. For example, patients can be educated to recognise that ‘how they think will influence how they feel and behave’. When they hear voices about a false/delusional belief, they can find ways to come up with alternative explanations, test out the belief (reality testing) or attempt to normalise the experience. Effective methods of verbal de-escalation have been previously described, including engaging and listening attentively to the patient, responding in a manner that validates the patient’s feelings and concerns while avoiding verbal or non-verbal cues of provocation/confrontation, offering choices and setting limits.[23]
In most settings, however, pharmacological interventions in the form of antipsychotics are often required for symptomatic control. In particular, early initiation of antipsychotic treatment should be considered when the psychotic symptoms significantly impair the ability to provide necessary clinical care (e.g. vitals monitoring, performing scans/procedures) or lead to risk of self-harm or harm to others (e.g. in command hallucinations with violent content). The usual antipsychotics used in elderly patients, with their commonly prescribed doses and side effect profile, are detailed in Table 1. Antipsychotic medications can be classified into first-generation (typical) antipsychotics and second-generation (atypical) antipsychotics. There exists mechanistic differences between the two classes of medications — for instance, typical antipsychotics predominantly exert their effects through dopamine receptor antagonism, whereas atypical antipsychotics have a lower affinity for dopaminergic receptors and relatively high affinity for serotonergic receptors, with a wider range of receptor targets.[24,25] In general, prescription of oral antipsychotics to elderly patients should follow the old adage of ‘start low and go slow’, and as a rule of thumb, given at approximately half of standard adult dosing. In acutely agitated patients who refuse or are unable to tolerate oral medications, usage of intramuscular antipsychotics (e.g. haloperidol) when necessary can be considered. In the longer term, patients with medication compliance issues may benefit from a switch to long-acting depot injectable antipsychotics, but a psychiatrist referral would be warranted in such cases.
Ultimately, the treatment and follow-up plan should be tailored to the individual patient’s clinical profile, premorbid state and overall goals of care. For example, psychotherapies may be less effective in patients with comorbid personality disorders and poor clinical insight. In addition, certain antipsychotic drugs may not be suitable or require close monitoring when started in patients with particular medical comorbidities (e.g. haloperidol is contraindicated in Parkinson’s disease/Lewy body dementia, second-generation antipsychotics should be used with caution when there is prolonged QTc on electrocardiogram). Finally, goals of care should be determined by patient’s premorbid function and medical comorbidities, and there is a need to consider any previously documented advanced care planning discussions. Depending on the patient’s care needs and social set-up, appropriate siting of care needs to be arranged (such as institutionalisation in psychiatric nursing homes, engagement of home medical/nursing services).
In summary, we described a systematic approach to the older adult with acute psychosis [Figure 1]. A multidisciplinary team comprising various medical specialties, nursing staff and allied health professionals is necessary to provide the appropriate clinical care and facilitate the process of discharging and reintegration of these patients back into the community, through inpatient rehabilitation, caregiver training, behavioural management strategies, psychosocial support and community-based services. On discharge, longitudinal follow-up may be provided in an outpatient psychiatric, geriatric or general medicine clinic to monitor the disease trajectory and titrate antipsychotic medications based on the patients’ clinical response and side-effect profile.
Figure 1 Chart shows the suggested algorithm for evaluation and management of older adults with acute psychosis.
Nil.
There are no conflicts of interest.
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