Psychosis and the Elderly Person — (Mental Health Forum)

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Mental Health Forum

November 25, 2013

I used to be, until fairly recently, a Senior Sister for elderly people with complex needs. I have seen some terrible actions by GPs who have limited or no expertise with diagnosing and treating the elderly person. I recently answered a thread by a daughter whose mother had suddenly developed psychotic symptoms, and the doctor had badly misdiagnosed and treated this lady, leaving her at high risk of falls, malnutrition and dehydration. I have written this for anyone who finds they are in need of more knowledge in order to challenge or just talk to professionals on behalf of their relative.

Poor treatment can lead an elderly person to be put in a Home because of the label dementia being put on them, when this is not the case. Once that label is there, it is very hard for it to be removed, and all treatment from then on is with this label in mind. Anti psychotics are often prescribed, even though NICE guidelines say that this is largely unacceptable and can be dangerous to the elderly.

So if your relative suddenly starts to hear voices, noises and develop delusional thinking, investigations need to be made before any psychiatric label is given. So you will need to ask for, or look for:

• A urine test or chest to be checked, both for infection. Unbelievably these are the commonest causes of severe confusion in elderly people and are often missed or not checked first.
• A full scan of all blood works, by tests which cover all major functions in their body. Commonly poor kidney function, liver function, anaemia (which is common in elderly people), malnutrition and dehydration and many more things need to be checked. Many of these can lead to confusion in the elderly.
• Ask if the person can have a full assessment for a stroke. Many strokes in the elderly do not cause physical disability, but can cause temporary or permanent behaviour changes. Many little strokes can start a chain reaction leading to dementia. If checked early, then this may be prevented. A purely physical examination by the doctor is not sufficient. There should be a specialist x-ray done of the brain.
• Hearing and vision need to be thoroughly checked. I have known people labelled psychotic, when all that was wrong was they misheard or misinterpreted things in peripheral vision.
• Early stages of dementia need to be checked. Only a psycho-geriatrician or psychologist should diagnose this. However, many times other professionals feel they have the right to throw this label around.
• Recent grief can cause confusion in all of us, but for some reason, it is often not noted in the elderly because they often react differently from younger people.
• Hidden alcohol abuse. This is far more common than many relatives care to believe. This especially true in women.
• Recent severe trauma that is being hidden. It is more common than you may well care to believe that women who are elderly suffer sexual abuse. This can lead to PTSD but in the elderly, this is not expressed the same way as someone younger, and can look like confusion.
• Medication contra-indications not noticed by a doctor (common) and a build up of toxicity from medications.
• Infections elsewhere in the body. Cellulitis, which is an infection in the skin is very dangerous and can lead to blood poisoning. The elderly are apt to home treat this not realising how dangerous this is.
• Recent hospital admission for any reason can cause confusion on returning home. Many elderly people have a network of people who help them in the community, but when they are admitted, this may fall apart leaving the elderly person bewildered and depressed.
• Depression. Elderly people often do not react in the classic ways to depression and may see and hear things that are not there as a result. They may also develop delusions trying to account for this feeling. Depression is the single most misdiagnosed illness in the elderly and the commonest reason for the elderly to be labelled as having dementia and/or psychosis. If a person suddenly becomes confused, it is almost certainly not dementia.
• Loneliness. A very common condition in the elderly and can lead to hearing deceased relatives talking, believing false beliefs. I have seen many elderly people admitted with “dementia” which magically disappears once they are in the company of others!!
• Taken to live in a new part of the country. Relatives, often well meaning, take their relative to live near them so they can help them. Confusion is very common with this, and is diagnosed by a doctor who does not know this person as dementia and or psychosis.
• English as a second language. More and more people are coming from other countries to live here in their old age. Culture shock, isolation because of language problems, and loss of close friends and relatives can lead to severe loneliness and depression. Psychotic symptoms are common as a result, but these are temporary if the person is helped by their own culture.
• Different cultural norms of behaviour. I have nursed people who come from cultures where hearing voices is a shamanic event. In Western medicine, this is diagnosed as madness.
• A history of severe abuse from decades ago. I have looked after several people who were in the Concentration Camps in the second world war. As they become older, they remember these events more and more clearly. This can often lead to great fear and anxiety and ‘seeing’ the events as though real. Again this is sometimes diagnosed as psychosis when it is actually PTSD.
• Loss of sleep. Very, very common and can lead directly to apparent psychosis, which again magically disappears with sleep. However, sleeping pills are not always a good answer, as the person can get up in the night due to continence problems and fall because of over sedation. Also waking from a dream and believing the dream is reality.
• Psychiatric meds for anxiety or depression. These too can lead to the person becoming apparently psychotic, when it is the meds themselves causing this.
• Dehydration and malnutrition. Very, very common in the elderly. Both can cause severe psychotic symptoms due to lack of essential ingredients needed for the brain. Dehydration is common because elderly people do not drink enough in case of incontinence. Malnutrition can be present in an obese person as well as a thin person.
• Misreading of a lifetime difference in lifestyle. I have cared for men who were cross dressers who were labelled psychotic because they dressed as women, and had done so all their life.
• Relatives who wish their ‘loved one’ to enter a Home and make things up!! I have found this happen more often than we care to believe.
• Epilepsy which has developed after a mini stroke, which can look and sound like psychosis when they are recovering from the fit.
• Hidden psychosis they have had all their lives, but lived with without incident or medication which has just been noticed because they are old!!

These are the reasons that come to mind after 37 years of nursing. I may have missed some reasons which others can add to the list. As you can see, an elderly person who “suddenly” develops psychotic symptoms, needs a full and thorough investigation before any such diagnosis is given.

If the diagnosis is given, maybe due to organic psychosis (dementia), then you must be on alert to the medication given to them. Overdosing is very common by doctors who do not take into account the elderly person’s body inability to process the drug.

There are a lot of ways to care for a person who has psychotic symptoms and is elderly, which do not involve medication at all. Too often anti psychotic medication is given to stop a person making distressing sounds or behaviour, such as undressing, or screaming. Anti psychotics are NOT advised for the elderly as they can lead to premature death (eg Risperidone and Haloperidol has been banned for the elderly, yet is still prescribed!). If there is no other recourse but meds, then the dose must be extremely low as the elderly person will be grossly over sedated on a dose that a younger person could tolerate. Also it can increase the psychotic symptoms! It should also be reviewed monthly for its effects, something very few doctors are willing to do. As a relative, you must insist that this is done, no matter how annoyed the doc is with you. Regular blood tests need to be done to assess the drug levels in the body as in the elderly, they often build up and are not processed as in the young.

As a last mention, I would like to tell you a story of a lady who was brought to an assessment unit with “clear” psychosis. This lady had lived alone for years in her flat. One day she rang up the landlord to complain about the green mice which were running around. She wanted him to send a vermin controller around to get rid of them. He rang her relatives who came round to see her. She told them all about the green mice and was very angry when they told her this was in her mind as it was not possible. They said they were going to send a doctor to see her. She threw them out in anger.

The doctor came round but she refused him entry as he said he wanted to talk about her false belief in the green mice. Becoming more and more upset at the way she was being treated, she barricaded the door in fear they would take her away. The doctor called the police, who called a psychiatrist. He dutifully arrived and tried to talk to her that she needed this belief in green mice to be investigated and she needed help.

After a lot of shouting from her and ever more patronising comments from the psychiatrist, the police broke in and took her away to the unit to be assessed for psychosis. A week later her relatives went into her apartment to collect some clothes for her. As they were packing up some clothes, the niece suddenly screamed and her husband came to her side. She pointed to the floor, and there was a green mouse! They investigated closer and realised that the edges of the room had mould growing on it, and the mice had brushed up against it and caught the mould onto their fur and sure enough, they were green!!!

Always check the truth before jumping to conclusions. If she had been younger, no-one would have jumped immediately to the conclusion she was mad.