Psychosis in the Elderly

Abstract

Ms. A, an 85-year-old Caucasian woman, was hospitalized for increased paranoia, visual hallucinations, and agitation. According to her son, Ms. A had had "strange thoughts" for as long as he could remember. For example, for a time, Ms. A would eat only foods that were white. Still, in her adult life, she had actively participated in developing and running a successful family business with her husband and had raised two sons. When her husband died 5 years ago, Ms. A developed a major depressive disorder, single episode, severe with psychotic features. She moved to an assisted living facility and did well there until she was hospitalized 2 years ago with agitation. At that time, she was diagnosed with late-onset Alzheimer's type dementia with delusions, depressed mood, and behavioral disturbance. She returned to the assisted living facility and was stable until a few months before her current hospitalization, which was precipitated by gradually worsening paranoid delusions, visual hallucinations, severe restlessness, and difficulty in being redirected. At admission, Ms. A's responses to questions were largely irrational or irrelevant to the topic at hand. In a more lucid moment, Ms. A conveyed that she had pain, gesturing to her stomach. Her vital signs were stable; she was afebrile and normotensive. Initial mental status examination revealed Ms. A to be an unkempt, distraught, elderly woman with poor eye contact and poor attention span. She was restless and would intermittently grasp imaginary objects in the air, uttering brief phrases or nonspecific sounds in response to questions. Her thought processes were disorganized as she conveyed vague thoughts with themes of fears of dying and of being harmed. She was irritable and had a labile affect and clouded sensorium that fluctuated between periods of lucidity and of obtundation. Her insight and judgment were severely impaired. Ms. A's psychotropic medications at the time of admission included 400 mg of quetiapine daily in divided doses for delusions, hallucinations, and agitation; 500 mg of divalproex daily for mood instability and agitation; 100 mg of sertraline daily for depression and agitation; and 4-6 mg of lorazepam daily in divided doses for anxiety and agitation. Her medical history was significant for hypothyroidism, coronary artery disease, atrial fibrillation, hypertension, hypercholesterolemia, and gastroesophageal reflux disease. For these conditions, she was taking 25 μg of levothyroxine daily, 0.125 mg of digoxin daily, 40 mg of enoxaparin daily, 325 mg of aspirin daily, 50 mg of metoprolol twice daily, 40 mg of simvastatin daily, and 40 mg of pantoprazole daily. Ms. A also had a history of recurrent urinary tract infections, chronic constipation, frequent falls, and osteoporosis. She had no known drug allergies.