Academic journal article Indian Journal of Psychiatry

Clinical Practice Guideline for Management of Psychoses in Elderly

Academic journal article Indian Journal of Psychiatry

Clinical Practice Guideline for Management of Psychoses in Elderly

Article excerpt

Byline: Shiv. Gautam, Akhilesh. Jain, Manaswi. Gautam, Anita. Gautam



According to Statistics of India in April 2016 population of people above the age of 60 years has increased to 8.6 % of 121 Crores.

Age related changes in the Central Nervous System commonly seen in the process of ageing include, Gross brain atrophy, Ventricular enlargement, Selective regional neuronal loss, Remodeling of dendrite, axons and synapses, Appearance of intraneuronal lipofuscin, Selective regional decrease in neurotransmitter and neuropeptides, Selective modification of neurotransmitter metabolism, Possible dysregulation of gaseous neurotransmitter metabolism, Glucocorticoid neurotoxicity, Changes in receptors, Changes in neurotrophins, Changes in signal transduction, Impairment of calcium homeostasis, Possible changes in cell cycle regulations (eg, cyclins), Possible changes in extra cellular matrix proteins (eg. Laminin, proteoglycans), Possible regional decline in cerebral blood flow, Possible regional decline in metabolic rate and Appearance of senile plaque & neurofibrillary tangles.

Pharmacokinetic Changes With Aging

When we look at pharmacodynamics with aging changes are seen in Neurotransmitter Pharmacodynamics, Dopaminergic system, Dopamine D[sub]2 receptor in the striatum, Cholinergic system, Choline acetyl transferase, Cholinergic cell numbers and in Adrenargic system changes are seen in cAMP production in response to beta-agonists, Beta - adrenoceptor number, Beta - receptor affinity and Alpha 2 - adrenoceptor responsiveness.

Changes in Gabaminergic system show effect on Psychomotor performance in response to benzodiazepines due to Post - synaptic receptor response to GABA.

Psychosis is characterised by loss of contact with reality. DSM -5 defines it by presence of delusions, hallucinations, disorganized thinking (speech), grossly disorganized or abnormal motor behavior including catatonia or negative symptoms. In older populations its etiology, manifestations and treatment deserved special consideration. Psychosis in elderly includes schizophrenia, delusional disorders, psychotic depression, schizo affective disorders, psychotic behavior associated with dementia including Alzheimer disease, parkinsons disease, lewy body and vascular dementias.

Commonest among psychoses is schizophrenia which occurs in early age (late second and early third decade of life). In contrast to early onset schizophrenia its presentation after the age of 40 is called late onset schizophrenia and that after the age of 60 is known as very late onset schizophrenia.

Characteristic Features of Very- Late Onset Schizophrenia

Females show significantly higher number than males. Compared with early- or late-onset schizophrenia, very-late-onset schizophrenia is characterized by associated sensory impairment, Social isolation, greater likelihood of visual hallucinations, lesser likelihood of formal thought disorder and affective blunting, lesser likelihood of family history of schizophrenia, greater risk of developing tardive dyskinesia.

Drug-Induced Psychosis

Due to process of ageing Elderly patients are suffering from other physical illnesses and often receive multiple medications. Drugs that can produce psychotic symptoms in elderly patients and drug interactions and dosage must be considered when evaluating drugs as causative agents of psychotic symptoms.{Table 1}{Table 2}{Table 3}{Table 4}{Table 5}{Table 6}

Factors Contributing to Increased Risk of Psychosis in Elderly

Factors which contribute to increased risk of developing psychotic symptoms in old age include age-related deterioration of frontal and temporal cortices, pharmacokinetic and pharmacodynamic changes, Neurochemical changes, Social isolation, Sensory deficits, Cognitive decline and Polypharmacy.

Assessment and Evaluation

Systematic observation of the patient with concentration on the following areas:

*Assess symptoms to identify the problem. …

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