A Case of Very-late-onset Schizophrenia-like Psychosis.

This paper presents the case of a 67-year-old woman who visited the Psychiatry Department complaining of persecutory ideas and auditory hallucinations after a buccal cancer operation. On neuropsychological testing, she demonstrated paranoid psychosis and bizarre thoughts. Hospital admission was recommended for supportive care and treatment with antipsychotics. She was initially treated with olanzapine, but this medication had little effect and was replaced with amisulpride, which reduced the residual symptoms. The aim of this report was to discuss the diagnostic process and treatment of very late-onset schizophrenia-like psychosis.

INTRODUCTION

Although the onset of schizophrenia generally occurs in late adolescence or early adulthood, some patients become ill in middle or late adulthood. The diagnosis of very late-onset schizophrenia-like psychosis (VLOSLP), which may have validity and clinical utility, has been proposed for patients who experience the onset of symptoms after the age of 60 years.1,2) VLOSLP shows some characteristics similar to those of early-onset schizophrenia in terms of psychopathology, non-specific brain-imaging abnormalities, course of illness, and treatment response.3) The aim of this paper was to describe the diagnostic process and treatment of a case of VLOSLP.

CASE

The patient is a 67-year-old Korean woman with no previous history of psychiatric problems serious enough to require psychiatric treatment. She had been an active female shaman for more than 30 years, but this work had not affected her judgment or reality. No one in her family had received medical services from the psychiatric department, and alcohol abuse was not suspected. With the exception of behaviors manifested during the performance of exorcisms, the patient did not exhibit improper behavior or elevated mood; therefore, a mood disorder could not be diagnosed.

In October 2009, she was diagnosed with buccal cancer and underwent oral cavity excision surgery. After the operation, adjuvant radiation therapy was recommended, but she refused further treatment due to a rumor that radiation therapy causes great harm. Unfortunately, in January 2010, pain in the oral cavity was aggravated, and she became anxious about dying from cancer. At the same time, she began to hear a male voice whispering about her every movement and developed a persecutory idea that neighbors would steal her house after her death.

When she visited the Psychiatry Department in July 2010, she complained of auditory hallucinations in the form of voices about her movements. She reported that several cameras in her house watched her and that she would be killed by neighbors while she was sleeping. Based on these reports, we suggested hospitalization for close observation and correct diagnosis.

During the patient's psychiatric interview, she reported auditory hallucinations, ideas of reference, and persecutory delusions. No abnormalities emerged from a physical examination, a blood test, or electroencephalography. The brain MRI showed mildly diffuse brain atrophy (Fig. 1).

Fig. 1

Axial T2W1 image showing diffuse and mild brain atrophy.

Neuropsychological testing was difficult to complete due to the patient's inattention and evasiveness. Table 1 shows the results of the patient's neuropsychological assessment. The results of the Korean Consortium to Establish a Registry for Alzheimer's Disease assessment (CERAD-K; Table 2) did not meet criteria for cognitive impairment.

Table 1

Results of neuropsychological testing

BGT, Bender Gestalt Test; K-WAIS, Korean-Wechsler Adult Intelligence Scale; MMPI, Minnesota Multiphasic Personality Inventory; SCT, Sentence Completion Test; SCL-90-R, Symptoms checklist 90-Revised; Pa, Paranoid; per, Ideas of persecution; abx, Aberrant experiences; PSYC, Psychoticism; BIZ, Bizarre mentation; PHOB, Phobic anxiety.

Table 2

Korean Version of the Consortium to Establish a Registry for Alzheimer's Disease (CERAD-K)

In summary, we diagnosed this patient with VLOSLP on the basis of her psychotic symptoms and test results.4,5)

The patient was initially treated with 10 mg of olanzapine, which she tolerated well, and the dose was increased to 20 mg. During her admission, her perceptual disturbance was reduced. However, residual persecutory ideas remained at the time of her discharge, so we changed medication from olanzapine to amisulpride. After 3 months, we increased her amisulpride dose to 400 mg, and her residual symptoms almost disappeared.

DISCUSSION

A wide variety of general medical conditions in elderly patients can present with psychotic symptoms. Before diagnosing schizophrenia in elderly patients, it is necessary to rule out delirium, dementia, substance-related disorders, delusional disorder, and dissociative disorder.

Late-onset schizophrenia (after 45 years of age) is briefly described in the Diagnostic and Statistical Manual of Mental Disorders-fourth edition-text revision.4) Cases of late-onset schizophrenia share many similarities with those of earlier-onset schizophrenia, although a number of differences have also been observed.6,7) For example, more women than men are diagnosed with late-onset schizophrenia, and socially isolated people are more likely to be diagnosed with the disease. Furthermore, late-onset schizophrenia is more likely to involve persecutory delusions and hallucinations and less likely to involve disorganized and negative symptoms.4,8)

Because elderly patients with psychosis are more sensitive to extrapyramidal side effects, atypical antipsychotics appear to be safer than classic antipsychotics for this population. Additionally, elderly patients may be more susceptible to drug interactions and metabolic changes.9) The atypical antipsychotic amisulpride has a satisfactory safety profile for the elderly patient.2)

In conclusion, we decided to change our patient's medication from olanzapine to amisulpride because of remaining perceptual disturbances that were not eliminated during olanzapine therapy. Amisulpride proved to be effective because it reduced residual symptoms.3) Amisulpride is not only an atypical antipsychotic; it also acts as a dopamine partial agonist and D2 receptor. It is safer for elderly patients because of its low propensity for side effects.

Korea is expected to become an aged society, with a projected elderly population greater than 15%, before 2020 (OECD, 2007).10) The rapid increase in the size of the elderly Korean population in terms of both absolute numbers and relative proportions has significant consequences for the epidemiology of mental disorders, especially psychosis.11) Therefore, effective diagnosis and treatment for late-onset disorders such as VLOSLP are required.