Asian Journal of Psychiatry 25 (2017) 74–78

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Asian Journal of Psychiatry

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Asian pearls

Clinical characteristics of patients with non-affective, non-organic, late

onset psychosis
Sureshkumar Ramasamya,* , Srikala Bharathb
a
Department of Psychiatry, PSG Institute of Medical Sciences and Research, Coimbatore, 641004, Tamilnadu, India
b
Department of Psychiatry, National Institute of Mental Health AND Neurosciences (NIMHANS), Bangalore, Karnataka, India

A R T I C L E I N F O A B S T R A C T

Article history: Objective: Schizophrenia and related psychotic disorders are predominantly studied in young population.
Received 30 July 2016 However some individuals do develop psychotic disorder for the first time during their old age. The aim of
Received in revised form 17 October 2016 this study is to look at the clinical characteristics of non-affective, non-organic, late onset psychosis.
Accepted 23 October 2016
Participants and methods: Retrospective chart review study, medical records of all patients registered
Available online xxx
between 1st of January 2006 and 31st May 2011 at geriatric clinic in NIMHANS, Bangalore was screened,
83 files with a diagnosis of late onset psychosis and meeting the study criteria were systematically
Keywords:
analyzed.
Psychosis
Schizophrenia
Results: The mean age at onset of illness was 67  10 years; 98.8% were married, females formed 67.5% of
Late onset the sample, commonest phenomenon was delusions followed by hallucinations, 80.5% of the subjects
Elderly psychosis had delusion of persecution, 38.5% had referential delusion, 51.8% had accusative and derogatory auditory
Geriatric psychosis hallucinations, negative symptoms was seen only in 2.4% of subjects, none had formal thought disorder.
3.6% had co-morbid Axis II diagnosis.
Conclusion: Despite its rarity non affective, non organic, late onset psychosis forms a distinct group with
unique manifestation. Further systematic research is needed for better understanding of this condition.
ã 2016 Elsevier B.V. All rights reserved.

1. Introduction catatonic or confused agitated symptoms, but with less affective

flattening (Harris and Jeste, 1988; Jeste et al., 1988, 1995; Mayer
Schizophrenia and related Non-Affective psychotic disorders et al., 1993; Pearlson et al., 1989; Rabins et al., 1984). Subsequently
are predominantly studied in adolescence and young adults. there are lot of studies on late onset psychosis (LOP), mostly from
However some individuals do develop psychotic disorder for the developed countries of Europe and America, but the research
first time during their old age. Community prevalence estimates findings in this area is struck with difficulties because neither ICD
for schizophrenia range from 0.1% to 0.5% (Castle and Murray, 1993; 10 nor DSM V contain separate codes of diagnosis for ‘late onset
Copeland et al., 1992, 1998; Kua, 1992). 1-year prevalence rate of schizophrenia’; different terms being used to describe a similar
schizophrenia in individuals between ages 45 and 64 is 0.6% (Keith illness occurring in old age and using different age cut-off to be
et al., 1991). For individuals over 65 years of age, incidence rate of called late onset psychosis (LOP) (Howard et al., 2000). But other
schizophrenia with first onset after 44 years is 12.6 per 100,000 limitations of existing literature in this field are some studies
population per year (Copeland et al., 1998). The Studies on late- include patients who had early onset psychosis but grown old,
onset schizophrenia began with Manfred Bleuler, Late onset including patients with affective disorder and organic psychosis.
schizophrenia constituted 15% of patient whom he examined; 4% Some of these confusions were cleared after The International Late
of the patients had an onset after 60 (Bleuler, 1943). About 50% of Onset Schizophrenia group came up in the year 2000 with
the patients with late-onset schizophrenia had symptoms that consensus on nomenclature defining Late Onset Schizophrenia and
were similar to those seen in early onset schizophrenic patients. Very Late Onset Schizophrenia like Psychosis. For developing
However he did report certain striking differences; more than 50% countries like India and China with their large population and
of patients had Paraphrenia like symptoms, depressive, anxious, increasing geriatric population, late onset psychosis is a major
concern. Socio cultural factors like globalization, migration,
breaking up of joint families, poorer healthcare facilities etc in
* Corresponding author. developing countries in Asia are certainly different to that of
E-mail addresses: [email protected], developed countries in Europe and America. There are many
[email protected] (S. Ramasamy).

http://dx.doi.org/10.1016/j.ajp.2016.10.017
1876-2018/ã 2016 Elsevier B.V. All rights reserved.
 S. Ramasamy, S. Bharath / Asian Journal of PsychiatryAJP 25 (2017) 74–78 75

factors that increase the risk of developing psychiatric disorder in is appropriate for use in assessing dementia in elderly people in
elderly like loss of close relatives, social network, previous status in India. This is a 12-item uni-dimensional scale which measures
society, sensory functions, functional ability, and health (Skoog, mobility, instrumental and personal care activities, the scale has
2008).These psycho socio cultural factors can influence the good internal consistency (Pandav et al., 2002). Each item is scored
presentation of individuals with late onset psychosis. Currently either 0 or 1, less number of 1 score, in other words lower total
there is a paucity of literature on the clinical manifestation of late scores indicates better functioning.
onset psychosis in Asia especially from India. So the aim of this 3. Neuropsychiatric Inventory (NPI) – The purpose of NPI is to
study is to study the clinical characteristics of non-affective, non- obtain information on the presence of psychopathology. The NPI
organic, late onset psychosis in an Indian set-up. was developed for application to patients with Alzheimer’s disease
and other dementias, but it may be useful in the assessment of
2. Methods behavioral changes in other conditions aswell. It assesses ten
behavioral symptoms including psychotic and affective symptoms
2.1. Study design & setting and two neurovegetative symptoms. The NPI has been proven to be
sensitive to change with treatment, it is available in many
This is a retrospective chart review study conducted at the languages, has been shown to be valid and reliable in cross-
Geriatric clinic & Services in National institute of mental health and cultural studies (Wood et al., 2000).
neuro sciences (NIMHANS) Bangalore, a tertiary care hospital in 4. Geriatric Depression Scale (GDS) – Short version – GDS short
India, which caters to individuals with psychiatric, neurology and version is a 15 item scale.The GDS was found to have a high
neurosurgery problems. Geriatric clinic is run by a multi sensitivity and specificity. The validity and reliability of the tool
disciplinary team which includes psychiatrists, neurologists, neuro have been supported through both clinical practice and research. In
psychologists and social workers. All the patients attending a validation study comparing the Long and Short Forms of the GDS
geriatric clinic are assessed using a semi structured workup for self-rating of symptoms of depression, both were successful in
proforma, thorough physical examination, Hindi Mental State differentiating depressed from non-depressed adults with a high
Examination scale (HMSE) which is an Indian adaptation of Mini correlation (Sheikh and Yesavage, 1986). Scores of 0–4 are
Mental State Examination, Geriatric Depression Scale (GDS), considered normal; 5–8 indicate mild depression; 9–11 indicate
Clinical Dementia Rating Scale (CDR), Neuro Psychiatric Inventory moderate depression; and 12– 15 indicate severe depression.
(NPI) and Everyday Abilities Scale for India (EASI). They also
undergo basic investigations like complete haemogram with 2.4. Statistical analysis
peripheral smear, random blood sugar test, liver function test,
renal function test, serum electrolytes and Computerized tomog- Descriptive statistics (frequency, ratio, mean, standard devia-
raphy of brain. Other investigations are done if necessary. tion) was used to define the socio demographics and clinical
characteristics of the patients. Chi square test and Fisher’s exact
2.2. Study participants tests were conducted for to compare the symptomatology between
different age groups. Person’s correlation test was used to analyze
We retrieved and screened medical records of all patients who the association between cognitive functions and different varia-
got registered in the geriatric clinic between 1st of January 2006 bles, with p value of <0.05 considered as significant. The data was
and 31st of May 2011. In this study we included medical records of analyzed using SPSS version 19.
patients diagnosed to have psychosis (Schizophrenia, delusional
disorder, acute psychosis, nonspecific psychotic disorder, other 3. Results
psychotic disorder) as per International classification of disease
10th version (ICD-10), who were above 50 years of age at the time Among the 83 medical records that were reviewed, the mean
of onset of psychosis and those who followed up in geriatric clinic age of the patient was 69  9 years at the time of initial
atleast for 3 months. We excluded files of patients whose diagnosis consultation, and age ranging between 51 and 91 years. The
was other than psychosis, who developed psychotic symptoms average age at the time of onset of illness was 67  10 years. The
secondary to affective disorder or substance use or organicity mean duration of illness was 2.5 years (SD  2.2 years); 55.4% of the
(epilepsy, cerebral tumors etc), dementia, whose age at onset of patients were uneducated and 54.2% belonged to low socio
psychosis was below 50 years, those who had major mental illness economic class.
in the past and medical records that lacked sufficient data. Finally
we selected 83 medical records which satisfied our inclusion and 3.1. Socio demographics and clinical characteristics
exclusion criteria, these records were analyzed.
This study was approved by NIMHANS Institute ethics The socio demographics and clinical characteristics of the
committee, written informed consent was not taken as it is a patients are depicted in (Table 1). The sample had female
retrospective chart review, and anonymity of all patients was preponderance; with number of females being almost double
maintained. that of males. Except one person all others were married, most of
them followed Hindu religion. Psychosis not otherwise specified
2.3. Materials (psychosis NOS) was the most common diagnosis in these patients,
followed by schizophrenia, delusional disorder and acute and
1. Hindi Mental Status Examination (HMSE) – Is an Indian transient psychosis. Interestingly all patients diagnosed with acute
adaptation of Mini Mental Status Examination (MMSE) that is being and transient psychosis developed illness only at 60 years. Only
used in epidemiological studies of dementia in India. It contains 23 3/83 (3.6%) patients had Axis II disorder (Anankastic personality
items which test different components of intellectual capability. disorder – 1; Anxious avoidant personality disorder – 1; and
The scale has a total score of 31, a score less than 19 is indicative of Paranoid personality disorder 1) Precipitating factor was noticed
dementia and warrants a detailed cognitive assessment (Ganguli in 12% of these patients, with some developing psychosis following
et al., 1995). a loss of family member, some following hearing or visual
2. Everyday Abilities Scale for India (EASI) –This is brief, reliable impairment etc. Positive family history was found in more than
and valid scale to assess activities of daily living, with norms, which 20% of patients, with nearly 11% of them had either a first or second