The Mirror Sign: A Reflection of Cognitive Decline?

Abstract

Psychotic symptoms are common in older patients, with estimates of the prevalence of psychosis ranging from 4% to 10% in those over the age of 65 years. Often, the psychosis observed in this population is recent in onset. For example, in a retrospective study of patients over age 65 years admitted to a geriatric psychiatry inpatient service, late-life onset psychosis was observed in approximately 10% of 1730 patients. Of these, 64% suffered from delusions, most commonly of the persecution/paranoia and self-reference subtype, 29% reported hallucinations, most commonly visual, and the remaining 7% had mixed delusions and hallucinations. The psychotic symptoms were most commonly seen in the context of dementia (40%), while other common causes were major depression (33%), medical conditions (7%), and delirium (7%). Psychiatrists are often called upon to evaluate symptoms of psychosis in this population. Unfortunately the treatment of psychosis in the elderly can be difficult. It is widely acknowledged that the use of antipsychotic medication in patients with Alzheimer’s and other dementias is associated with many serious adverse effects, including sedation, delirium, falls, and even death. In a study of patients with Alzheimer’s disease (AD) who were being treated with atypical antipsychotics for symptoms of psychosis, aggression, or agitation, Schneider et al. concluded that adverse effects outweigh benefits. Due to these concerns, it is important to uncover causes of hallucinations and paranoia that may respond to behavioral interventions rather than antipsychotic medication.