Summary
Late-onset psychoses can be controversial because the illness may have been ignored at an earlier age. The accompanying illnesses can include schizophrenia, mood disorders with psychotic features, delusional disorders, and neurodegenerative disorders manifested by various psychotic symptoms. Late-onset psychosis has higher morbidity and mortality rates than early psychosis. The definition of psychosis includes the presence of delusions and hallucinations. The definition of late-onset psychosis is intended to help carefully individualize the management of elderly patients because of the high risks of side effects due to related disorders.
Case Presentation
A 60-year-old female patient was admitted to the hospital by ambulance due to frostbite on her hands, which appeared to be dark spots. The patient exhibited megalomania and claimed to be a very wealthy bestselling author. The patient had previously been diagnosed with depression and anxiety, but she stopped taking her medication due to unrecognized effectiveness. Moreover, the patient had previously been diagnosed with an alcohol use disorder, but she has been sober for 1.5 years, using marijuana instead. Diagnostics revealed the presence of cannabinoids in her blood. According to the family history, her mother was diagnosed with an alcohol-related psychiatric disorder, presumably psychosis. The patient’s father was not sure that she had a mental disorder but thought that the elements of psychosis were a manifestation of ambitions.
Mental status examination includes mood changes, hyperverbalism, disorganization, megalomania, and paranoia, possibly indicative of a diagnosis of a current manic episode with psychotic features. The differential diagnosis includes schizoaffective disorder, bipolar type – current manic episode; bipolar I disorder, current manic episode with psychotic features. Diagnosis of the patient as having a late-onset psychosis is very likely because it includes all relevant symptoms and can be made based on the patient’s age.
Treatment
The patient responded very well to olanzapine 20 mg three times a day. Olanzapine is effective in schizophrenia, bipolar I disorder, depressive episodes associated with bipolar I disorder, and depression in adult patients. The patient independently asked to be discharged 2 weeks after admission. The patient and her father also made an appointment with a family therapist who is seeing their sister. The family plans to use a home health service that makes frequent visits to the nearest shelter for follow-up appointments.
Discussion
The diagnosis and treatment of patients diagnosed with late-onset psychosis is complicated by several factors. First of all, it is necessary to take into account the elderly age of patients since late-onset psychosis is predominantly diagnosed after 50 years. Late-onset psychosis is difficult to diagnose because it can have similar symptoms to schizophrenia or Alzheimer’s disease. It can also be challenging to choose a treatment since the patient is likely to have comorbidities, and different medications may conflict. Finally, late-onset psychosis may be previously unnoticed because of another illness with similar symptoms.
This case is important for clinical practice because it allows to consider the characteristic symptoms of late-onset psychosis and to track the effectiveness of olanzapine. The mechanism of action of olanzapine is not fully understood, but its effectiveness in schizophrenia may be mediated by the blockade of dopamine and 5-HT2 receptors. Caution should be exercised when dosing in the elderly, especially in the presence of other additional factors that may affect metabolism and pharmacodynamic response, as elderly patients show better absorption. Since the patient was previously diagnosed with anxiety and depression, the complex effect of olanzapine allows to remove most of the unpleasant symptoms.
A serious difficulty is diagnosing patients with a significant number of concomitant diseases of various symptoms. Since the patient had previously been diagnosed with an alcohol use disorder, additional testing was required. The analysis revealed the presence of cannabinoids in the blood, which are designed to reduce anxiety. It is unlikely that the current condition of the patient is caused by the use of psychoactive substances. Family history demonstrates the heredity of mental problems in the patient’s family. However, the patient had previously been prone to dreaming away from the real world, according to her father. It is possible that psychotic behavior may have been present long before admission to the hospital, but this has not been given sufficient attention. Finally, the patient is already diagnosed with anxiety and depression, which should also be taken into account when making a diagnosis.
Given the patient’s family history, symptoms, behavior, and age, a diagnosis of late-onset psychosis seems appropriate. Symptoms include delirium, depression, anxiety, and loss of contact with family members, which the patient demonstrates. Probably, a sharp deterioration in the condition and the manifestation of symptoms of psychosis was provoked by the refusal of medications that the patient took to treat anxiety and depression. This case helps broaden the diagnostic categories for late-onset psychosis. It becomes obvious that antipsychotics based on the blockade of dopamine receptors are an effective way to relieve an acute condition. Careful medical assistance is needed to help older patients diagnosed with late-onset psychosis. A family therapist and the use of a support service is an appropriate choice for further treatment. Thus, the diagnosis of late-onset psychosis must consider age, clinical manifestations, patient behavior, and family history. Treatment should be comprehensive and take into account possible concomitant diseases.
References
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