Onset of schizophrenia at 100 years of age.

Although generally regarded as a disease of young adults, schizophrenia does occur in older ages. Doubts have been raised about the validity of diagnosing schizophrenia in very old age. We have described herein a rare and unique case of a woman who had onset of "schizophrenia" as per ICD-10 and DSM-IV-TR criteria at the age of 100 years. We have discussed about the validity of diagnosing schizophrenia in older age.

INTRODUCTION

Relatively very little research has been conducted regarding onset and course of schizophrenia in older adults.[1] There is a tendency among most schizophrenia researchers to ascribe late-onset psychosis to organic factors reflected in International Late Onset Schizophrenia Group advocacy to diagnose “very late onset schizophrenia-like psychosis” rather than “very late-onset schizophrenia” in those above 60 years of age.[2] As per ICD-10 and DSM-IV-TR criteria, there is no consideration for age in establishing the diagnosis.[34] We have presented herein a rare case with onset at the age of 100 years (first time in India) to support that schizophrenia can be diagnosed at an extremely old age.

CASE REPORT

Family members of Mrs. D, a 100-year-old illiterate widow, complained that for the last 9 months she remained fearful and said that someone wanted to kill her and harm her family members. She held that belief firmly, which according to everyone in the family was baseless. She would appear to be muttering abusive words and gesticulating to herself and, on being questioned by family members, she would say that she was reacting to voices of some unknown persons who were discussing about her and were planning to kill her. Her sleep also remained disturbed. There had been no complaint of forgetfulness. She had no significant medical, surgical, or psychiatric illness in the past or any significant family history. She had never used any substance. According to her family, she was an independent, intelligent, and cooperative person.

Evaluation as in-patient

On physical examination, Mrs. D had persistently raised (borderline high) blood pressure (had never been checked earlier). She had kyphosis of spine and walked with the help of a walking stick. Her neuromuscular examination including examination for hearing and vision was within normal limits. On Mini-Mental State Examination (MMSE), she scored 25/27, with points lost for not answering for year and date. Also, reading, writing, and copying the interlocking pentagons could not be done (she had never used a pen). On mental status examination, she was alert and cooperative. She had unshakable belief that there was someone who was after her to kill her. She acknowledged hearing the voices of unknown males for the past few months who discussed among themselves the plan to kill her. She heard those voices through her ears in clear consciousness. She had good immediate, recent, and remote memory and had a good fund of general information and could correctly perform simple verbal calculations. Abstraction and test judgment ability was intact and she had no insight into her psychiatric illness.

Management and course

She was prescribed tablet olanzapine 5 mg at bedtime and slept well in the ward. Her hemogram, renal, hepatic and thyroid function tests, lipid profile, serum electrolytes, and routine urinary examination were within normal range. Her chest roentgenogram and electrocardiogram were normal, echocardiography revealed type I diastolic dysfunction that was age related as per the cardiologist's opinion; magnetic resonance imaging (MRI) of brain revealed generalized age-related cerebral atrophy and electroencephalogram (EEG) was a normal awake record. She was prescribed hydrochlorthiazide 12.5 mg at bedtime by the cardiologist, and her subsequent blood pressure recordings were within normal limits. The dose of olanzapine was increased to 7.5 mg at bedtime on the seventh day. Her suspiciousness, fearfulness, and auditory hallucinations started decreasing in the second week of admission, and she was discharged on the tenth day. She achieved full remission in 3 weeks and is on regular follow-up now. She is maintaining well thereafter until date (more than 10 months).

DISCUSSION

In this patient, there was no evidence of cognitive deterioration and she was alert and oriented to time, place, and person, which excludes the possibility of dementia and delirium. Although she was unable to answer for date and year on MMSE, it is worth mentioning that she was able to score better than her son and daughter-in-law and that she was illiterate. Possibility of psychotic disorder due to a general medical condition can be ruled out as there was no evidence of medical conditions known to cause psychiatric illness from history, physical examination, and laboratory results. The MRI findings were consistent with patient's age. Also, there is no history of any substance intake, which rules out possibility of substance-induced psychotic disorder. As there were no predominant affective symptoms at any point of time, diagnosis of mood disorder with psychotic features can also be ruled out. Hence, we were left with diagnosis of schizophrenia as the patient had third person discussing type auditory hallucinations along with delusion of persecution. Good response to antipsychotic treatment without any cognitive enhancer also indicates the presence of primary psychotic illness without coexisting cognitive disorder.

Onset of schizophrenia at an age of 100 years has been reported earlier by Cervantes et al.[5] However, doubts were raised by Harrington about the presence of cognitive disorder in that case and termed schizophrenia as a misdiagnosis.[6] As that case had many medical complications that left scope for doubting the diagnosis, our case has presentation that leaves little doubt regarding the diagnosis of “schizophrenia.” It needs to be reiterated that schizophrenia is a syndrome defined by characteristic symptoms rather than aetiology. Cognitive deficits have been demonstrated in schizophrenia at all ages and schizophrenia can be diagnosed with them in the absence of “dementia” or alternative diagnosis. Absence of dementia has been confirmed on following up the cases, which indicates that the diagnosis of schizophrenia is stable even at late ages.[7] A study found that a number of patients diagnosed as schizophrenia after 50 years of age were diagnosed as demented after 5 years of follow-up; however, that study had very high attrition rate and the control group had better baseline cognitive function, raising doubts about the interpretation of results.[8] Ten-month follow-up in our patient revealed no cognitive decline. Recent research suggests that particular genotypes may cause schizophrenia to manifest at later than usual age.[910] All these factors points toward existence of schizophrenia among extremely old people.