Good morning again and welcome. My name is Vishal Madan. I'm the Chief of Education and Deputy Medical Director at the American Psychiatric Association. I'm delighted to see all of you join the first edition of APA's Virtual Immersive Series with the focus of providing an update on geriatric psychiatry today. When we thought of creating the virtual immersive, the idea was to design a comprehensive review on specific topics where clinicians like all of us could take a deeper dive into specific areas of psychiatry and education, immerse themselves into practical, educational, and clinical aspects and have immediate access to experts in the field without waiting for our larger meetings each year. Today's virtual immersive course has been designed with clinicians in mind, as I was mentioning, clinicians who want to gain expertise in caring for older adults with common psychiatric disorders. Throughout this course, the outstanding faculty members will be discussing epidemiology assessment and evidence-based treatment approaches for common psychiatric disorders in older adults. Next slide, please. Throughout today, you will hear from a series of speakers, as I was mentioning, who will focus on all the topics that we want to cover as clinicians in the older adult population. Here, for your reference, is a schedule of the presentations today. Following today's discussion and conversations, you'll also receive information on how to access the recordings for today. Next slide, please. I also wanted to mention that the PDF of these slides will be available in the chat tab. You can see here how to look for that at the bottom of your screen. Next slide, please. Also captioning for today's presentations is available. To enable the captions, click show captions at the bottom of the screen. Click the arrow as shown in this picture and select full transcript to open the captions in a side window. Next slide, please. Please feel free to submit your questions throughout the presentations by typing them in the question area, which is found in the attendee control panel, again, at the bottom. We will reserve about 10 minutes at the end of each presentation for questions and answers. Next slide, please. Without any further delay, I would like to introduce my colleague and chair for this review course, Dr. Rajesh Thampy. Dr. Thampy is the professor and chair and the inaugural Padia Family Endowed Chair for the Department of Psychiatry at Creighton University School of Medicine and Catholic Health Initiatives in Omaha. Prior to his current role, Dr. Thampy was chair with the Department of Psychiatry at Cleveland Clinic Akron General Hospital in Akron, Ohio. He also serves as a professor of psychiatry in an adjunct role at the Yale School of Medicine in Connecticut. Dr. Thampy is the past president of the American Association of Geriatric Psychiatry and also their inaugural historian. So if you have any questions about AAGP, he's our go-to man all the time. He also serves as the program chair or served as program chair for the 2017 AAGP annual meeting back in Dallas, Texas. Also the past president of the APA's IMG or National Medical Graduate Caucus. He serves as a distinguished fellow of both the APA and the AAGP. Dr. Thampy has received multiple, multiple outstanding faculty, outstanding teacher awards and outstanding research awards. You know, to name a few, he's received the geriatric academic career award from the Department of Health and Human Services. In addition, he's been a recipient of the 2021 Jack Weinberg award for geriatric psychiatry given by the APA, as well as the George Tarjan award for international medical graduates also given by the APA. He has over 200 publications on a variety of topics in geriatric psychiatry. He also serves as the editor in chief of the World General Psychiatry. Till yesterday, he was the editor of 10 books. He just mentioned to me that the 11th book is ready to go. And I'm truly excited to see all the work he mentions about using algorithms in specific aspects and clinical aspects of geriatric psychiatry. Without any further delay, I'll hand it over to Dr. Thampy. He will be presenting on psychotic disorders. Thank you. Thank you. Thank you, Dr. Madan, for the invitation to do this course and for the kind and personal introduction. It's greatly appreciated. And I wanted to welcome everyone, you know, on this Wednesday morning for the presentation. You know, we have started with psychotic disorders in older adults, and that's only just because, you know, no one else was willing to present the first thing in the morning. So, I decided that I'm just going to do this to start with. I have no personal conflicts of interest to disclose for this presentation. And I also wanted to thank my colleagues, Dr. Ilse Wieckers and Susan Lehman. They have presented this particular topic with me on multiple previous APA annual meetings. So, I have updated the slides for this presentation. I thank them for their efforts in providing some of that information. Next slide, please. Next slide, please. So, the objectives for this particular presentation are very straightforward. I'm going to talk a little bit about the prevalence of psychotic disorders among older adults. I'll talk about evidence-based workup for psychotic disorders in older adults, especially the new onset of psychosis, and then talk more about how do you distinguish between the various etiologies for psychotic disorders among older adults, and then go through the evidence-based treatment for these disorders. Next slide, please. So, the available evidence indicates that psychotic disorders are not uncommon in older adults. The Epidemiological Catchment Area Survey, which is the ECA survey, showed that between 16 and 23 percent of older adults had some sort of psychotic symptoms. What we also know is that between 11 and 13 percent of older adults who have decreased visual equity present with vivid visual hallucinations. What we also know is 50 percent of individuals with dementia experience psychotic symptoms, and late-onset psychosis accounts for about 10 percent of psychiatric admissions in the elderly. One thing I wanted to differentiate is having a disorder versus those symptoms causing impairments are two separate things. As I go through these slides, you will realize that some of these symptoms or disorders, although the patients present with those, if there is no significant impairment in functioning or subjective or objective distress from family members, we usually don't prescribe anything. So, I just want to make that separation. Next slide, please. So, what are the risk factors for the development of psychosis in late life? We know that comorbid psychiatric illnesses, especially neurocognitive disorders, including dementia and delirium, are one of the most common risk factors for the development of new-onset psychosis in older adults. There is a genetic predisposition, although less common than in the younger adult population, and you'll see that in the subsequent slides. It is more common in women than in men, and again, in the subsequent slides, you will see that as the person gets older, there is greater representation of females in the development of new-onset psychosis. Social isolation is a very common risk factor for the development of psychosis in late life. Sensitive deficits, which probably also is associated with social isolation, including visual and hearing impairments, are a big risk factor for the development of psychosis in later life. Cognitive changes, that is the onset of cognitive problems, may herald new-onset psychosis, and when we look at the differentiation between different psychotic illnesses, that's one of the first questions we ask, is there an onset of cognitive decline? Polypharmacy, we are talking about both prescribed medications and drugs of abuse that combined together can actually worsen cognition, can cause new-onset psychosis. Certain pre-morbid personality traits, especially those individuals with cluster A personality traits, especially paranoid personality disorders, are very high risk for developing psychotic disorders in late life. Poor take a relationship, where there is a conflict between the individual with psychiatric illness and the caretaker, is a big risk for development of psychosis in late life. As I stated earlier, substances of abuse, when you add them on to the prescribed medications that older adults are receiving, that also increases the risk of developing psychosis in late life. We'll discuss each of these when we talk about the particular disorders. Next slide, please. One thing all of you should know is that secondary psychosis, that is psychosis due to medical conditions, due to prescribed medications, due to drugs of abuse, is much more common than in primary psychosis. 60% of all psychotic disorders in late life can be attributed to secondary causes. These include, like I said before, medications, drugs of abuse, medical illnesses that, you know, urinary tract infection, pneumonia, brain lesions, or cerebrovascular disease, and of course, then the development because of the progressive cognitive decline or dementia. We also know that secondary psychosis, especially those associated with general medical conditions, have really poor prognosis, including death. Next slide, please. So here is a classification. This is not the DSM-5 or the DSM-5-TR classification. This is an etiologic classification. So psychotic disorders can be classified into primary psychotic disorders, where the thought disorder is the main problem, followed by secondary psychotic disorders. Among the primary psychotic disorders, schizophrenia spectrum disorders are most common. The second most common type of primary psychotic disorder is affective psychosis. These are individuals who have either bipolar disorder or major depressive disorder, and they develop psychotic symptoms because of the severity of either of these two illnesses. So bipolar I disorder, manic episode, severe with psychotic symptoms, or major depressive disorder, severe with psychotic symptoms. And among the schizophrenia-related disorders, then you have schizophrenia, schizoaffective disorder, schizophrenia-formed disorder, delusional disorder, and brief psychotic disorder. Next slide, please. So among the psychotic symptoms, among the secondary psychotic disorders, psychotic symptoms associated with dementia are the most common. So if there are folks among this group who are going to be taking their boards, that is one of the questions that people ask, which is the most common etiology for the development of psychosis in late life? It is Alzheimer's disease and Alzheimer's dementia. If it's a single etiology, if they ask about what is the single most combined etiologies, then it is secondary psychotic disorders, which encompasses all these different disorders, including psychotic symptoms due to neurocognitive disorder, especially dementia, psychotic symptoms associated with delirium, with Parkinson's disease, paranoid personality disorders, which are not uncommon in late life, psychotic symptoms due to other medical and surgical disorders like hyperthyroidism, brain tumors, medication or substance-induced psychotic symptoms, and then Charles Bonnet syndrome. And we'll talk about each of these in the subsequent slides. Next slide, please. So if you're seeing a patient with psychotic symptoms in late life, how should you proceed? First and foremost, a good history is very, very important in differentiating the various etiologies for psychosis in late life. What you need to ask first is, is there associated cognitive change or cognitive decline in this individual? If the answer is yes, then what you need to know is that this is probably because of dementia with psychosis. If the patient does not have cognitive issues, but has a previous history of psychotic symptoms, then it is most probably a primary psychotic disorder, which includes both affective psychosis or schizophrenia spectrum disorders. If the patient has had no previous psychotic symptoms, then you need to think more about could this be secondary psychotic disorder that includes because of delirium. If you rule out the etiologies for delirium, then you need to know whether it's chemically induced. That means either because of prescribed medications or drugs of abuse. You need to look whether there are underlying medical conditions, like if the patient has hyperthyroidism, the patient has a brain tumor, if the patient has had a stroke, any of these you have to rule out. And if not, then it is probably a primary psychotic disorder, which can definitely occur in late life. Next slide, please. For primary psychotic disorders, the question that you have to ask is, does affective symptoms predominate? That means you are trying to rule out between schizophrenia spectrum disorders and bipolar disorder with psychosis or major depression with psychosis. If the patient has affective symptoms as their predominant symptom, and then the psychotic symptoms develop, then you need to ask, is this a mania with psychosis or is this depression with psychosis? If the affective symptoms are not predominating, then you need to ask, okay, does the patient have both delusions and hallucinations or the patient has delusions only? If the patient has delusions only, then it is probably a delusional disorder, which is not uncommon in late life. And if the patient has delusions and hallucinations, then you need to look at three specific disorders. Brief psychotic disorder, that means symptoms are more than 24 hours, but less than one month. Symptoms are between one and six months, which is schizophrenia form disorder, and symptoms are more than six months, that is schizophrenia and schizophrenia. Next slide, please. So once you get a good history, you're looking at, okay, is there some, are there any specific symptoms that we can find that we can have any, we can look at the etiology for these psychotic symptoms? There are certain differential risk factors and typical signs and symptoms, and I'll go through those with each of these disorders. What we need to know, as I had said earlier, women predominate the psychotic disorder spectrum in late life. Three fourths of the cases are women, usually in their 70s. Like I said earlier also, Alzheimer's disease and Alzheimer's dementia are the most common reasons for psychosis in late life. It's a number one, if it is single etiology. What we also know is that if the patient has mania and psychosis in late life, that means the patient has higher propensity to have medical and neurological disorders and greater risk for mortality. In majority of these individuals, there is an identifiable structural brain abnormality, either in terms of a decline in atrophy or cerebrovascular disease. So those are common themes that you would see with these individuals. So, you know, whether to get an MRI or not, you have to make a clinical decision, and we'll talk about the decision tree in the next few slides. Next slide, please. So there are three sort of schizophrenia spectrum disorders that I wanted to talk about. Early onset or typical onset schizophrenia. These are individuals who develop psychotic symptoms earlier in life, late teens, early 20s. Then there is the late onset psychosis, which happens in middle age, that is after the age of 40. Then there is a very late onset schizophrenia like psychosis, or what used to be called as paraphernalia. These are individuals who develop first onset of psychotic symptoms after the age of 60. What we know is that 40% of older adults with schizophrenia may develop a clinically significant depression. And the presence of depressive symptoms in these individuals is a bad prognostic outcome. Next slide, please. So what are the factors associated with late onset schizophrenia? So we have talked a little bit about in the previous slide, family history of schizophrenia. So these individuals may have family history of schizophrenia, but not as much as typical onset schizophrenia. So it's less, but it still can be present. Again, females predominate the psychotic spectrum disorders. Sensory deficits, both primary auditory and visual deficits. So these are your individuals who are living by themselves, who have sensitive deficits, who are not really taking care of themselves. So social isolation is an issue. Abnormal pre-morbid personality. These are individuals who have, you know, schizoid or schizotypal or paranoid personality disorders, and they isolate themselves because they don't trust anyone. They may also have sensory and visual deficits, which all add up to worsening psychosis. I've had patients who have been brought in by adult protective services. They were living in squalor, not taking care of themselves. And because of the stench of dead cats in the house, one of the patients had to be brought into the hospital. She had no relatives. She had no contact with any friends. And she had rotting food in the refrigerator, and we had to place her at a skilled nursing facility. And this is a classic case of late-onset schizophrenia. Majority of these individuals are never married and don't have any children or family members. Probably because of worsening psychosis, they isolate themselves and don't trust anybody. And they're more common in lower social classes. Next slide, please. Very late-onset schizophrenia, like psychosis, or used to be called as paraphernalia in the past. 25% of these individuals have onset of these symptoms in later life. Seven is to one is the female to male ratio, so highly predominant in women. This is a board question that has been asked in the past when I was taking the boards. They have extensive persecutory delusions. So positive symptoms predominate the clinical picture rather than negative symptoms. They have more sensory deficits. They have more premorbid personality deficits. And they also need lesser doses of antipsychotic medication, so a quarter to half the adult dose. Another important point to remember is these individuals do present with more cognitive deficits than either late-onset schizophrenia or typical onset or early-onset schizophrenia. Next slide, please. So here is a table from one of my articles in Psychiatric Times on differentiating various different types of schizophrenia. So late-onset schizophrenia, very late-onset schizophrenia like psychosis, and early-onset schizophrenia. As you can see, there is an age difference. So late-onset is 40 to 60. Very late-onset is greater than 60. Early-onset or typical-onset is less than 40. Female preponderance. So as you age, more women are present in the schizophrenia spectrum disorders. Less family history as you age. So typical-onset schizophrenia has more family history, followed by late-onset. Less in very late-onset schizophrenia like psychosis. Early childhood maladjustments, more typical in typical-onset or early-onset schizophrenia, less so in the other two. Brain structural abnormalities, significantly more in very late-onset schizophrenia like psychosis, usually atrophy and cerebrovascular disease. Negative symptoms are significantly more in early-onset or typical-onset schizophrenia than the late-onset or very late-onset psychosis. Progressive cognitive deterioration, as can be expected with the aging population, significantly more in very late-onset schizophrenia like psychosis. Antipsychotic dosing is half to a quarter of the dose in older adults. About half in late-onset schizophrenia like psychosis, and about a quarter in very late-onset schizophrenia like psychosis. Risk of tardive dyskinesia is highest in very late-onset schizophrenia like psychosis, probably because of the cerebrovascular disease and cerebral atrophy, and also more women. If you remember, tardive dyskinesia is significantly more in women, especially who are aging. Next slide, please. A little bit about the other primary psychotic disorders. Brief psychotic disorders, as you know, last between 24 hours and one month. They can occur with or without stress. Individuals who develop it with stress have a better prognosis, and they eventually return back to full functioning. Uninformed disorder, symptoms are between one month and six months. The good prognostic features are the sudden onset of symptoms, that is, within four weeks of any event. Confusion or perplexity at the height of psychotic symptoms is a good prognostic indicator. Positive symptoms are good prognostic indicators. Negative symptoms and cognitive symptoms are bad prognostic indicators. Good premorbid social and occupational functioning, that is, that means these are individuals who are well-adjusted. They tend to have better prognosis than people who are maladjusted. Absence of blunt or a flat affect, again, associated with negative symptoms is a bad prognostic indicator. Schizoaffective disorder, I point this out to my residents all the time. The depressive type of schizoaffective disorder predominates in late life. They usually present with what appears to be a major depressive episode. I have a patient like that now. Unless you take a good history, you're not going to be able to differentiate between major depressive disorder, recurrent psychosis, versus schizoaffective disorder with depressive type, because if you have to ask whether the patient has underlying psychotic symptoms in the absence of any particular mood disorder, more common in women than in men. It also tends to occur later in women than men. I have one patient who has a classic picture of schizoaffective disorder, depressive type. She was diagnosed with major depressive disorder recurrent, but the psychotic symptoms remained even after the depressive symptoms abated. Next slide, please. Now, bipolar disorder. I will be doing a talk later on about bipolar disorder in late life, and we'll talk more in detail about this. If the individual has psychotic symptoms because of a bipolar affective disorder, it can be either due to a manic episode or a depressive episode in the bipolar spectrum. They have lower rates of familial illness than in typical onset bipolar disorder. They have more medical and neurological comorbidities. This is one thing if you take from this lecture series, is that medical problems predominate in older adults, and these medical problems can cause all kinds of psychotic disorders, so you don't have to rule these out first before you embark upon treatment of any of the psychotic disorders that we are going to talk about today. They usually have longer duration of illness. They usually have more depressive episodes than manic episodes. If the patient has a manic episode, it usually has mixed features. That means they have dysphoric features rather than pure euphoric mania. They have greater mortality rates because of comorbid medical and cerebrovascular disease, and they have higher rates of suicide than age-controlled populations without bipolar disorder, whereas suicide rates are lower than typical onset bipolar disorder, but suicides are more than general population when you compare these individuals. Next slide, please. Major depressive disorder. As you all know, major depression is very common in older adults, and they account for about 25 to 50% of inpatient geriatric admissions. What we know is that psychotic symptoms occur in about 7% of younger adults with major depressive disorder, but 25% of major depressive episodes in late life can have psychotic symptoms, so 3.5 times more common in older adults. Patients may present with different kinds of delusions, nihilistic delusions, somatic delusions, poverty-based delusions. They have no money. People have stolen from them. Everything is doom and gloom. These individuals have greater rates of insomnia. They have much more somatic symptoms, so they have a lot of physical complaints. They have diurnal variation of mood, and they have very poor insight into the illness, so if you have to treat them, you may need to have involuntary treatments, including involuntary ECT treatments. Delusions are less common in these individuals, so it is usually delusions predominating the picture. These individuals also are usually single, widowed, or living alone, so more socially isolated individuals develop these symptoms. Poor prognostic indicators are frequent recurrences, so these individuals have multiple hospitalizations back-to-back because the symptoms are not being treated adequately. They get hospitalized repeatedly. They have cognitive deterioration, and major depression, more severe episodes, are an independent risk factor for the development of cognitive decline and dementia, and you have to treat it actively. Suicidality is very high in these individuals, so you have to make sure that you have a good aftercare treatment plan when you discharge these patients from the hospital because they may have frequent episodes, they may have recurrent ED visits, and they may have significant suicidal ideation, so an illness to be very careful about when you're treating. Next slide, please. A little bit about Alzheimer's disease and development of psychotic symptoms. What we know is that 30 to 50 percent of individuals with Alzheimer's disease do develop psychotic symptoms. I'll do a longer talk in the end on behavioral disturbance and dementia, and then we'll go over these symptoms. Hallucinations are present in 20 to 30 percent, so unlike schizophrenia, these individuals present with more visual hallucinations, and I will also highlight in my last talk that the psychosis seen in late life and psychosis seen in dementia are phenomenologically. That means they look similar in picture to psychosis in early life, but the etiologies and the neurobiology may be different, so in dementia with psychosis, antidepressants like citalopram and sertraline have been beneficial in treating these symptoms, so although phenomenologically similar, etiologically and neurobiologically they're different. They're more common in women. That is a common theme through this particular presentation that psychotic symptoms in late life women predominate the clinical picture. They are considered a distinct phenotype because they're associated with more severe cognitive decline. They're also associated with more rapid progression of the cognitive decline. There are two main subtypes. The first one is where individuals have misidentification and hallucinations. These are the Capgras and Fergulis delusions of misidentification and individuals presenting with more visual hallucinations, and there is a second subtype, which is individuals who are present with persecutory or paranoid delusions. Next slide, please. This is a table which differentiates between psychosis of dementia and psychosis of schizophrenia. This is from one of my articles, so if you look at the prevalence, the psychotic symptoms are highly prevalent in individuals with dementia. Schizophrenia, as you all know, the prevalence of schizophrenia in general population is about 1%. Bizarre and complex delusions are very rare in individuals with dementia. They usually have persecutory or paranoid delusions, whereas bizarre delusions are much more common in individuals with schizophrenia. Misidentification are much more common in psychosis of dementia, rare in schizophrenia, although it can occur. Hallucinations, visual in dementia, auditory in schizophrenia. Schneiderian first-rank symptoms, which includes auditory hallucinations, thought broadcasting, control of thought, that includes delusions of control, delusions of perception, are all more common in individuals with schizophrenia, where much more rare in individuals with dementia. Past history of psychosis, rare in individuals with dementia, more common in individuals with schizophrenia. Eventual remission of symptoms are more common in individuals with dementia, less common in individuals with schizophrenia, although now we know that schizophrenia spectrum disorders are 1,000 different disorders which are lumped together again because of the phenotype, so prognosis may be different for each of these disorders. Maintenance antipsychotic therapy should not be done in individuals with dementia because the antipsychotic medications, as you all know, have the black box warning for cerebrovascular adverse events and death. In schizophrenia, you have to maintain these individuals on antipsychotic medications for a much longer period of time to maintain remission. Next slide, please. So dementia with Lewy bodies. As you know, dementia with Lewy bodies is thought to be the second most type of dementia in Europe. In the United States, we consider vascular dementia as the second most common type of dementia after Alzheimer's disease. These individuals with dementia with Lewy bodies have extensive Lewy bodies, which are intracytoplasmic inclusions of dead cells. They are made of alpha-synuclein, so they are usually seen subcortically in individuals with Parkinson's disease, but cortically and subcortically in individuals with dementia with Lewy bodies. So Lewy body dementia is not the same as dementia with Lewy bodies. Lewy body dementia includes dementia with Lewy bodies plus Parkinson's disease dementia. These individuals have the central feature, that means they have a dementic illness, so they have progressive cognitive deterioration, including problems with attention and executive functioning. The core features include fluctuating cognition, recurrent complex visual hallucinations, which are usually quite well-formed and detailed, and spontaneous features of Parkinsonism. Suggestive features include REM behavior disorder, where individuals are active during REM sleep. Usually in REM sleep, your body is atonic, so cannot respond, but in these individuals, the patients can move their bodies during the REM sleep, and these can appear actually years before the onset of dementia and Parkinsonism. They have severe sensitivity to neuroleptic medications. About 50% of these individuals have neuroleptic sensitivity. The uptake of dopamine, low dopamine transport of reuptake is seen either on SPECT or PET scans. Supportive features include repeated falls in syncope, transient unexplained loss of consciousness, autonomic dysfunction, hallucinations, and other modalities, which show spatial abnormalities or other psychiatric disturbances. If you want to diagnose dementia with Lewy bodies, you have a probable diagnosis if the individual has dementia, which is the central feature, plus two or more of the core features, that is fluctuating cognition, recurrent hallucinations, or spontaneous Parkinsonism. You can have a probable diagnosis if you have dementia plus core feature, plus one or more of the suggestive features. If you have a possible dementia DLB diagnosis, then you need dementia plus one core feature, or dementia plus one or more suggestive features. You can actually make a diagnosis based on that. These individuals may be misidentified as individuals presenting with delirium because of the fluctuating cognition, profound inattention, and also the presence of visual hallucinations. The problem is when you treat these individuals for behavioral disturbances with antipsychotic medications, they become Parkinsonian very quickly because of the neuroleptic sensitivity. That may be a differentiating feature. Another important differentiation is Parkinson's disease dementia. Individuals with Parkinson's disease dementia usually have Parkinson's disease for a long time, at least 10 to 15 years before they develop cognitive decline, whereas individuals with dementia with Lewy bodies present with simultaneous cognitive decline and Parkinsonian features, or the development of Parkinsonian features within a year of cognitive decline. That is how you differentiate between dementia with Lewy bodies versus Parkinson's disease dementia. Next slide, please. As you know, psychotic symptoms are very common in individuals with delirium. Older adults are prone to developing delirium in later life. Dr. Kirsten Wilkins is actually going to do a talk today on delirium in late life. She's going to talk about etiology assessment and management. What we know is that medication-induced delirium or iatrogenic delirium is very, very common because people give medications which can precipitate delirium in older adults and thereby development of psychosis. We can differentiate delirium versus schizophrenia or mania by the kinds of symptoms the patient presents with. Usually, patients have an acute onset of symptoms within hours to days of the inciting problem. Patients have fluctuating course. They're good during the daytime, but get much more disturbed during the nighttime, also called sundowning. Patients usually have fragmented and unsystematized delusions, whereas in schizophrenia and mania, they may be systematized and more organized delusions. Visual hallucinations predominate the picture in delirium, whereas in schizophrenia and mania, they're usually auditory hallucinations. These individuals have significant cognitive decline, especially impaired attention. Usually, patients with schizophrenia or mania, unless they're so ill that they cannot function, usually their attention and concentration and orientation are fairly good. By these symptoms, you can actually differentiate delirium from schizophrenia or mania. Next slide, please. This is a table from one of my articles on psychosis in late life, and I've differentiated the different types of illnesses and how you can differentiate these symptoms. You can please read it at your own time because it's a complex site and there's a lot of information, but everything that I said. A simple way to understand is delirium is just acute onset, more visual hallucinations. Alzheimer's disease is subacute or chronic, and they have progressive cognitive decline. Cognition changes, function changes, behaviors emerge, along with that psychosis occurs. Dementia with Lewy bodies can be misunderstood as delirium, but these individuals have significant neuroleptic sensitivity. It is also an insidious course in dementia with Lewy bodies. Depression, subacute, usually acute or subacute, worsening depressive symptoms, emergence of psychotic symptoms when the depression gets worse, and these individuals usually have delusions and not hallucinations. These are the basic features that can help you differentiate between these four common disorders among older individuals. Next slide, please. Psychosis and Parkinson's disease. Like I said, psychotic symptoms are not uncommon in individuals with Parkinson's disease. About 10 to 40% of these individuals present with psychotic symptoms. Risk factors for the development of psychosis and Parkinson's disease are higher dose of dopaminergic drugs, especially levodopa. Many of you may have had patients who start to have visual hallucinations when the neurologist is titrating up on the levodopa. Greater disease severity is associated with the development of psychotic symptoms in Parkinson's disease patients. These individuals usually also have more cognitive decline, so that is why they have the onset of psychotic symptoms. They usually tend to have greater depression than individuals who don't have these symptoms. They also have greater visual acuity, which may lead to the development of psychotic symptoms, especially visual hallucinations. These psychotic symptoms are associated with worse prognosis than what you would see with decline in motor functioning. They cause considerable caregiver distress because these individuals become extremely paranoid and agitated and can be aggressive. They are a serious threat to the patient's ability to maintain independence because they are not able to function well by themselves because they are usually more cognitively impaired or have more depressive symptoms and they start to get more agitated when these psychotic symptoms emerge. Next slide, please. Paranoid personality disorder, not uncommon in older adult population, often seen in clinical situations in the outpatient clinic or inpatient hospitals. They are more common in men than in women. This is the only time where, you know, psychotic symptoms or psychotic disorders are more common in men than in women. Paranoia tends to increase with age during the course of medical illnesses. So these individuals often come to the hospital and they are being treated by their doctors and they do not trust the medical professionals because of their personality disorder and that can lead to a lot of difficult situations. Other features are extreme distrust or suspicion of others. They think that they know more than the physicians who are taking care of them. They avoid close relationships and if they have a close relation with somebody, they distrust that person also. They're always looking for a hidden meeting and they're reading hostile intentions into the actions of others. They're quick to challenge loyalties of loved ones and often appear cold and distant to their loved ones. They usually shift blame and tend to carry grudges. I had one patient in the clinic like this and he was very, very difficult. We just saw him for just evaluating his symptoms and he was refusing to take any psychotropic medications, but just to keep a watch and making sure that the psychosis does not get worse and there is no agitation or aggression towards family. We just saw him regularly every month in the clinic and he would challenge us every time. All we did was just talk to him, discuss any issues that he's having and never forced prescriptions of medications into him. We were very clear on our intention why we were seeing this individual. Again, it was an older man. He was married, but he was distrustful of his wife from the very beginning. The distress had gotten worse, but not to the point where he was harming himself or herself. That's why we didn't do any active interventions. This usually appears in childhood and adolescence and then it starts to become problematic when they need more medical care as they age. They're also more common in individuals who have family members with delusional disorders. As you know, psychotic symptoms can occur due to various neurological, medical, infectious, metabolic, or endocrine abnormalities. Here is a list of all the different medical disorders that can present with psychotic symptoms. They often present with hallucinations first, especially visual hallucinations, followed by delusions. Whereas in individuals with major depression, they usually present with more persecutory delusions and less visual hallucinations. Charles Bonnet syndrome. This may be a question that may be asked on the board exam. It is not uncommon. As of right now, I have seen a total of three patients with Charles Bonnet syndrome. This condition was first described by Charles Bonnet and his uncle, who was having significant visual hallucinations in the absence of any other psychopathology other than cognitive decline. So they don't have any symptoms of schizophrenia, major depression, bipolar disorder. They may have cognitive decline. So there may be cerebrovascular or structural changes within the brain. Charles Bonnet himself developed these visual hallucinations when he was aging. The kinds of hallucinations are really well formed. They may have what is called Lilliputian hallucinations where people see little people. They have complex images, colors, and patterns. They may see animals, plants, or trees, and inanimate objects. I had a patient when I was working full-time at Yale who had this complex visual hallucinations of the Scandinavian family, you know, who were living, you know, in her attic. And she said she could see them. They were a whole family. They were, she could hear them talk, smile, do different things, but they were not responding back to her. and she did not find these complex hallucinations to be distressing. The daughter brought her for an assessment. She was in her mid-90s. There was some cognitive decline, and after discussing with the daughter, because these symptoms did not appear to be distressing, we did not give any psychotropic medications because the risk versus benefit indicated that the risk of treating with, you know, antipsychotic medications was significantly more than not treating those symptoms. So I just followed her in the outpatient clinic. So the evidence also suggests that antipsychotic medications are not always beneficial in these individuals, and you have to do a risk-benefit analysis. Many of these individuals have changes in visual functioning. They have macular degeneration, so correction of the visual deficits may actually be all you need to know, rather than, you know, prescribing antipsychotic medications. There is also a musical form of Charles Bonnet syndrome. I have had one patient with that. This is a lady with significant sensorineural hearing deficit, and when we improved her, you know, her hearing by providing with hearing aids, the hallucinations got better, not completely gone because it was difficult to treat that severity of deafness. So Charles Bonnet syndrome is not uncommon. Treatment is mainly treatment on the underlying ocular or auditory pathology, and antipsychotic medications may produce symptomatic benefit, but you have to do a risk-benefit analysis before treating these individuals. Next slide, please. Medications induce psychotic symptoms. Any medication can cause psychotic symptoms in older adults. Antiparkinsonian drugs, anticholinergics, or antihistaminics are the usual culprits in most cases. Tricyclic antidepressants and stimulants and sedative hypnotics may also cause a problem, but are less likely, so it's usually antiparkinsonian and anticholinergic drugs that cause the problems. Greater the load of these medications, that means if you have injudicious polypharmacy, these older individuals can develop psychotic symptoms, usually presenting individual hallucinations and may then have delusions. Next slide, please. Substance-induced psychotic symptoms, both over-the-counter medications and substances abuse can cause psychotic symptoms. Like I said before, antihistaminics and anticholinergics are very, very common. Cold medications, cough suppressants, sleep aids, allergy medications, all can precipitate psychotic symptoms in older adults, usually in individuals who are prone to developing their symptoms, especially individuals who have higher risk of developing dementia or delirium. These are people who are more likely to develop these symptoms. They're also more likely to develop these symptoms if they have underlying other medical problems like Parkinson's disease, pneumonia, urinary tract infection. Substances of abuse, both intoxication and withdrawal, can cause psychotic symptoms, so always rule out secondary psychosis, and among the secondary psychosis rule-outs is medications or drugs of abuse that can cause psychotic symptoms. Next slide, please. Diagnostic evaluation. History is the most important first step. A thorough history, which will help you differentiate between primary psychosis and secondary psychosis. You should rule out substance of abuse because older adults do tend to use substances exactly how they used it when they were younger, but the problem is now their body is not able to tolerate these substances as they were when they were younger. You have to rule out other psychiatric disorders, major depression, bipolar disorder, schizophrenia spectrum disorders. Substances of abuse, like I said, you have to rule them out. You also have to rule out prescribed medications that may actually be causing problems like the antiparkinsonian medication, tricyclic antidepressants, antihistamines, or anticholinergics. These individuals may have a family history. If you remember what I said before, as you age, the family history becomes less prominent, but some of these individuals may have. You have to do a good physical examination because you may rule out secondary causes of psychosis like Parkinson's disease. I had a patient who was admitted to the inpatient unit and the outpatient provider felt that the patient was internally preoccupied. That means had severe delusions and hallucinations and was so immobile because of these psychotic symptoms, but when I saw the patient, I thought that the patient had Parkinson's disease, so we call neurology to come back and they assessed the patient. They agreed that this is probably Parkinson's disease. They treated with Sinemet and the patient was discharged in three to four days. We didn't try any psychotropic, any other psychotropic medications. It was just the Parkinsonian medications that tried, so you have to do a good physical exam to rule out other medical conditions that can cause a psychosis. Psychosocial assessment is important because many of these individuals may not be able to function well and may need high levels of care. You should do lab work to rule out secondary causes for psychosis, including drug screens to rule out drugs of abuse. Neuroimaging, especially if you're suspecting a neurocognitive disorder or if you're suspecting any kind of cerebrovascular disease, then neuropsychological testing, neuroimaging is very important. Neuropsychological testing is important in situations where you are not able to identify the etiology for why this patient is having psychosis, so you want to rule out normal aging versus a progressive neurocognitive disorder versus depression versus personality disorder. I have found neuropsychological testing to be very effective in identifying the etiology, so you can actually identify and then develop a treatment plan based on these findings. Next slide, please. Scales for assessing psychotic symptoms. Here are some of the scales that are available, usually not used in clinical practice because, as you can clearly see, they take time. A clinical global impression of change is a scale that is fairly short, but it doesn't tell you about psychotic symptoms. It gives you the global functioning, and we do tend to use that from time to time in the clinical setting. The BPRS, I think, in my opinion, is the best scale to assess psychotic symptoms in late life, but it takes a long time, so not routinely used in clinical practice, but I used it in that one patient that I had, you know, late-onset, very late-onset schizophrenia-like psychosis to rate the severity of the symptoms. Next slide, please. This is a workup for psychotic symptoms in late life. It is exactly what I have talked about before, good history, including collateral information, good cognitive assessment to rule out neurocognitive decline, good physical examination to rule out secondary causes of psychosis, laboratory examination, including MRI scans to rule out underlying medical disorders or neurovascular disorders, neuropsychological testing when you're not very sure of what the etiology for the patient's psychosis is. Next slide, please. Choice of medications is based on the etiology of psychosis in late life. For primary psychotic disorders, antipsychotics, typical antipsychotics are preferred because they have a better tolerability profile than typical antipsychotics. Typical antipsychotics are effective, but they have significant extrapermental symptoms and risk of tardive dyskinesia, so they have fallen out of favor because of the adverse effect profile. In individuals with affective psychosis, if it's major depression, you co-treat with an antidepressant plus an antipsychotic or use ECT. If it's a patient with bipolar disorder, manic episode, then a mood stabilizer with an antipsychotic, or if you're using an antipsychotic as a mood stabilizer, monotherapy may be beneficial. If the patient has psychotic symptoms due to delirium, remember treatment of delirium, Dr. Kirsten Wilkins will point it out, is the treatment of the underlying causes. You can treat the associated symptoms or behavioral symptoms with antipsychotic medications, including haloperidol. You know, you are going to use these medications for a very short period of time and then discontinue them. So, the efficacy of haloperidol and tolerability is as good as atypical antipsychotic medications. For psychotic symptoms due to Parkinson's disease, you taper off and discontinue medications that can worsen the symptoms, including dopaminergic drugs, and then you use, you know, pimivansirin or quetiapine or clozapine as needed. For Charles Bonnet syndrome, you correct visual pathology and use antipsychotics if needed. For substance-induced psychosis, you discontinue these medications. Next slide, please. General rules of prescribing psychotropic medications. Try the medications which have the most amount of evidence in treating these symptoms. So, atypical antipsychotics is what we use for primary psychotic disorders. Antidepressants, especially the SSRIs, plus atypical antipsychotics or ECT for, you know, major depression psychosis. For bipolar disorder psychosis, you use mood stabilizers with antipsychotic medications. Start low, go slow, don't keep on going. You have to carefully assess for efficacy versus adverse effect profile. If the patients are stable on these medications for four to six months, you try to taper off the medications and see how patients do. So, don't continue these medications for years on end because people will have more problems later on with these medications, even after the symptoms have subsided. Sometimes, you may need to use multiple different medications before you find the right medication or medication combinations. Next slide, please. Rarely, medication trials fail. If the trial is failing, do not panic. Do not do injudicious polypharmacy. Reformulate and see if your primary diagnosis is correct. In this case, if you are in doubt, ask a colleague to, you know, evaluate the patient and see if they can find what the etiology is. And if you are going on a second trial or third trial, use judicious doses of medications and don't combine multiple different classes of medications. Always look for underlying secondary causes for psychosis in late life because 60% of psychotic disorders have an underlying medical etiology. Next slide, please. As you know, FDA approved indications for psychosis in late life are schizophrenia, bipolar disorder, major depression, psychosis associated with Parkinson's disease, and agitation in AD dementia. As you know that we have a new medication that is approved. Breck proprosol is approved. It is only approved for agitation associated with AD dementia, not for psychosis in dementia. It is not FDA approved for anxiety or insomnia. Next slide, please. Risks of antipsychotic medications. These are all of that you can see, including sedation, anticholinergic symptoms. That means urinary retention, blurred vision, orthostatic hypotension. Extrapyramidal symptoms are very common in old age. If you use typical antipsychotic medications, QTC prolongation, metabolic side effects, including weight gain, hyperlipidemia, hyperglycemia, acute kidney injury, cerebrovascular events, death, and cognitive decline. The last three, you have to be very careful when you're using the medications in individuals with dementia. Next slide, please. So here is a chart with all the different antipsychotic medications compared in older adults. As you know, the typical antipsychotic medications more extrapyramidal symptoms, more orthostasis, whereas the atypicals, mainly metabolic side effects, are more predominating. EPS, more common in older adults, especially with the use of typical antipsychotics. Next slide, please. So when you use antipsychotic medications, you know, the evidence suggests that both typical and atypical side effects are more common in older adults. The evidence suggests that both typical and atypicals are effective, but typical antipsychotics have greater adverse effect profile, especially extrapyramidal symptoms. When you look at atypical antipsychotics, olanzapine and respiradone have been found to be effective and are equal tolerability. There is no specific randomized control trial of the newer agents, including paliperidone. There is a mixed-age study of paliperidone, which shows that it was effective. But as you will see in the consensus guidelines, we use respiradone and olanzapine as our first and second-line drugs. Next slide, please. So this is the expert consensus survey, which showed that the first line is respiradone, followed by quetiapine, olanzapine, and erpropyzol. As you see, for primary psychotic disorder, schizophrenia, usually these are at almost a similar doses as you would do in younger adults. What we also know is that once the patient's symptoms of psychosis gets better, you can taper off these medications without significant return in psychotic symptoms. And it can be done by up to 40 percent of the baseline doses of medications. And what it does, it decreases the risk of adverse effects in these individuals once they are stable. Next slide, please. This is a meta-analysis looking at antipsychotic medications for schizophrenia, indicating that there were 18 randomness control trials. There were about 1,225 individuals. The mean age was between 57 and 73 years. Paliperidone, this is the mixed-age study, showed that it was as good as placebo only, and it was also well-tolerated. So again, not great data for paliperidone. Whereas if you look at olanzapine, it was found to be more superior to haloperidol, better for negative symptoms, and fewer dropout rates than respiradol. In this particular meta-analysis, olanzapine was better than haloperidol, as was expected, whereas respiradone and haloperidol, more prolactin increase than olanzapine. So this is what the meta-analysis of older adults with schizophrenia showed, but this is not what you would use for dementia with psychosis, and we will discuss that in the last presentation of today. Next slide, please. Psychosocial treatments are very beneficial in older adults with spectrum disorders. These include what are available even for the general population, including the ACT treatment, supportive employment, cognitive behavior therapy, family-based services, token economy, skills training, psychosocial intervention for substance use, and weight management. These are also effective for older adults with schizophrenia spectrum disorders. There are specific treatments for older adults with schizophrenia, psychosocial treatments. These include functional adaptation skills training, cognitive behavior, social skills training, help older people experience success program, and supportive employment. So these are all effective. So if you have the ability to refer patients for these programs, please do, because they have been shown to be highly effective. ECT, very effective in treatment of psychosis in late life, both for primary psychotic disorders and in refractory symptoms of psychosis and dementia. They are very effective, and they are very well tolerated. There is no evidence to suggest that ECT increases the risk of dementia. Two large meta-analyses have shown that data. Unilateral first, and if the patient does not respond to unilateral, you do bilateral ECT. So please keep this in the back of your mind if the patient is not responding to psychotropic medications. Next slide, please. So in summary, psychotic disorders are not uncommon. Etiologies are varied, but secondary psychosis predominates. 60% of the cases are due to secondary psychosis. Medications and psychosocial interventions are very effective. Doses of medications need to be adjusted based on the age and the comorbidities of the individual. As you know, antipsychotics should not be used consistently in individuals with dementia. Brexproposol is approved for the treatment of agitation and Alzheimer's disease, not for psychosis and Alzheimer's disease, and a thoughtful approach by identifying the etiologies but ruling out secondary psychosis and using judicious medication or medication combinations is the way to go. I think that is the last slide. Next slide, please. Here are the references. Now I'm going to answer the questions. We have about eight questions in the chat, and I'll try to answer all of them. So Violet, can you just let everybody know how they can download the slides? And some people are saying that the audio quality is poor. We apologize for that. So the third question is, is it common to see paranoia as well in dementia with Lewy bodies or visual hallucinations are the primary psychotic symptoms? Thank you for asking that question. Yes, visual hallucinations are more common, but paranoid thoughts and paranoid delusions can occur in these individuals. And the treatment would be, like I said before, you can use, you know, you can use either pimivanserin, you can use clozapine, you can use quetiapine, or you can also add a cholinesterase inhibitor that may slow down the progression of the cognitive decline. So the next is, could you email the PDF of slides for the presentation? So Violet, could that be possible? Yes, we'll put it in the chat in a couple minutes. Yeah. So the next question is, how do you treat sundowning without antipsychotics when behavioral and environmental interventions have maxed out? So yes, I will answer this question here and also in the last presentation. So if the behavioral interventions have been maxed out, melatonin has been shown to be beneficial for training sundowning in individuals with either dementia or Parkinson's disease or other conditions. You can also use low-dose antipsychotic medications in individuals who have refractive symptoms. You can also treat, if the patient has Alzheimer's disease dementia, you can also treat with cholinesterase inhibitors. So those are the three lines of treatment. Melatonin in general, people with Alzheimer's disease dementia, you can use cholinesterase inhibitors, and you can use antipsychotic medications at low dose for a short period of time in individuals with, you know, these symptoms in dementing illnesses. And so one of the questions is, what do you classify Charles Bonnet syndrome under DSM-5 for insurance purposes? I would classify psychotic disorders due to underlying medical condition or unspecified psychosis or psychotic disorder unspecified. So those are the two classifications that I've used. I usually put it under, you know, due to a general medical condition, but if they come back and say that's not acceptable, then I would use psychotic disorder unspecified. Another question is, have you seen agitation or worsening of visual hallucinations with agents like memantine? Thank you for asking that question. So we wrote a review paper on memantine. We did not find in any of the randomized control trials that worsening of visual hallucinations was seen or agitation was worse in these individuals. My request is if you see patients like that, you have to rule out underlying medical conditions that may be causing the worsening of psychosis or visual hallucinations. But if you have ruled all that out, and the patient is doing worse, then of course the best bet is to discontinue the medication and see how the patient does. So thank you, Ebony, for putting the, you know, the link for the downloading the slides. So thank you everyone for patiently waiting. I apologize that we've gone a little bit over time. But, you know, Dr. Treveson will be our next presenter talking about, you know, substance use disorders in late life. Thank you very much.

geriatric psychiatry

psychotic disorders

older adults

American Psychiatric Association

Virtual Immersive Series

Dr. Vishal Madan

Dr. Rajesh Thampy

atypical antipsychotics

late-life psychosis

individualized care