Anne Hassett

A descriptive study of first presentation psychosis in old age

Objective: This report describes the characteristics of a sample of elderly subjects presenting with their first episode of psychosis in old age. Method: Forty-six (38 females and eight males) patients were assessed on a variety of cognitive, psychopathological and personality measures. Results: Female preponderance, social isolation and early cognitive deficits were findings of this study which have been replicated by other studies of late-onset psychosis. In contrast, hearing loss was not overly represented in this sample. Personality style differed significantly from accepted norms of adult personality traits, with lower scores for dimensional ratings of neuroticism, extraversion and openness to change. Conclusions: The descriptive findings in this study suggest that psychosocial factors require further investigation in patients presenting with late-onset psychosis. Comparison with younger first-onset psychotic subjects will be the subject of a later report.

Admissions of elderly patients from English-speaking and non-English-speaking backgrounds to an inpatient psychogeriatric unit

Objective: The aim of this study was to compare differences between elderly patients from non-English-speaking backgrounds (NESB) and English-speaking backgrounds (ESB) admitted to an acute psychogeriatric unit. Method: Sociodemographic and clinical variables were collated from inpatient files for a 12-month period and analysed according to NESB and ESB status. The 1996 Australian Census data were used for comparison of catchment area representation of different ethnic groups. Results: With a few exceptions, admission rates for elderly patients from NESB reflected the representation of that ethnic group in the catchment area population figures. No significant differences were found between the two groups for mean age, length of stay and previous admissions to the unit. Patients from NESB were less likely to be admitted voluntarily and less likely to be diagnosed with affective disorder. These differences were more marked for males, who were more likely to be diagnosed with dementia. Conclusions: These findings suggest that further investigation is required into the accessibility of psychiatric hospitalisation for elderly patients from NESB. Under recognition of disorders such as depression and reluctance to accept necessary inpatient management are two possible factors that should concern mental health service providers for the ethnic elderly. A subsequent analysis will examine if differences also exist between elderly patients from NESB and ESB who receive community-based psychiatric treatment. Implications for mental health service provision for the elderly from NESB are discussed.

Schizophrenia and delusional disorders with onset in later life

Transtornos mentais do espectro da esquizofrenia sao comumente associados a inicio na primeira fase da vida adulta. Quando sintomas psicoticos nao-afetivos emergem pela primeira vez em fases tardias da vida, a apresentacao clinica tem semelhancas e diferencas em relacao as sindromes de inicio precoce. Essa situacao resultou em debate continuo sobre o status nosologico da psicose de inicio tardio e sobre se ha fatores de risco associados a esse pico de incidencia na terceira idade. Embora deficits cognitivos precoces sejam frequentemente identificados entre esses pacientes, ainda nao foi possivel estabelecer se problemas cognitivos estao associados a um quadro demencial dos idosos. Comprometimento sensorial, isolamento social e historia familiar de esquizofrenia tem sido associados a psicose de inicio tardio, mas esses fatores de risco parecem exercer um papel nao-especifico sobre a vulnerabilidade. Ainda que as questoes sobre o diagnostico mais adequado para esses quadros clinicos permanecam nao resolvidas, os psiquiatras precisam formular estrategias de tratamento que levem em consideracao a complexa constelacao de sintomas da apresentacao clinica de pacientes idosos psicoticos.

The Case for a Psychological Perspective on Late-Onset Psychosis

Objective:A conceptual framework is proposed for studying late-onset psychotic disorders. This incorporates developmental and psychological perspectives to complement the biological focus of most recent studies in this area. Method:Studies of late-onset psychosis that focus on the specificity of neuroimaging abnormalities, family history and sensory deficits were reviewed. Aspects of the developmental and personality literature were then examined with the goal of ascertaining their relevance for the emergence of psychosis in late life. Possible future directions incorporating biological and psychological approaches are proposed. Results:The biological abnormalities identified in studies of late-onset psychosis lack the specificity to stand alone as aetiological factors. Neuroimaging changes and sensory impairment are commonly found in study subjects; however, they also occur in elderly persons without psychiatric illness as well as in those with other late-onset psychiatric disorders. Perhaps it is more appropriate to regard these changes as conferring a vulnerability to psychosis in old age, but symptoms do not develop unless other risk factors, either longstanding or ageing-related, are also present. Developmental studies of late life that have used Eriksons concept of a final lifestage crisis of achieving ‘ego-integrity’, suggest that personality style may be influential in determining the negotiation of this last maturational task. Failure to do so results in ‘despair’, fragmentation of self-image and paranoid fears. To date, there has been little investigation of the relevance of these developmental and personality factors for the emergence of psychosis in old age. Conclusions:If we are to advance our understanding of late-onset psychotic disorders, research in this area needs to move beyond the elusive search for specific biological markers. A model of causation that integrates the longitudinal perspective of lifestage tasks with personality and biological vulnerability factors provides a broad framework which protects against premature foreclosure on aetiological determinants.

Mental health care for our ageing Australian population

Objective: In the context of the National Strategy for an Ageing Australia, the aim of this paper was to highlight some of the challenges for aged mental health services as our population ages. Conclusions: The demand for greater consumer participation in treatment planning and provision, and the increasing complexity of managing medical and psychiatric comorbidity in our ‘old-old’ population will be major drivers for improving our models of clinical practice and forging stronger partnerships between the public and private sectors.

A profile of inpatient admissions to an aged psychiatry service in Victoria

Objective: The study aimed to characterize the demographics, diagnostic makeup and aspects of patient management for the inpatient population of a large aged psychiatry service. Method: Sociodemographic and clinical variables were retrospectively collated from inpatient files and discharge summaries over a 3-year period. Age, gender, country of birth, diagnostic group, length of stay, involuntary care status and number of admissions were described and analysed. A total of 604 patients were included in the study, with complete data available for 516. Results: Approximately half of the patients were aged 65–75 years and 59.3% were female. More than half had been born outside of Australia. The primary diagnosis was an affective disorder in 39.0% of admissions, dementia in 27.5% and psychotic illnesses in 25.8%. The median length of stay was 28 days; 60.8% had a period of involuntary care and 79.8% had only one admission. Conclusion: In the near future, aged psychiatry services will face increased numbers of patients and rising expectations. To best respond to these challenges, we need to have an understanding of current patient and service profiles. The findings of this study illustrate a range of patient, diagnostic and management variables in aged psychiatry practice. This information can be used for comparison with other services and in planning for future development of services.

A patient who changed my practice: The lady with a plumher in her roof

The psychotic elderly patient described in this paper resisted treatment because her delusional beliefs gave her life some purpose and meaning. This case illustrates that clinicians need to be mindful that psychotic symptoms can serve an adaptive function for patients, and their removal may leave them with a void in their lives that they find difficult to tolerate.