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Clinical and cognitive diversity of psychotic states arising in late life (late paraphrenia)

Published online by Cambridge University Press:  09 July 2009

O. P. Almeida ,
R. J. Howard ,
R. Levy ,
A. S. David ,
R. G. Morris  and
B. J. Sahakian
O. P. Almeida*
Affiliation:
Section of Old Age Psychiatry, Institute of Psychiatry, London
R. J. Howard
Affiliation:
Section of Old Age Psychiatry, Institute of Psychiatry, London
R. Levy
Affiliation:
Section of Old Age Psychiatry, Institute of Psychiatry, London
A. S. David
Affiliation:
Section of Old Age Psychiatry, Institute of Psychiatry, London
R. G. Morris
Affiliation:
Section of Old Age Psychiatry, Institute of Psychiatry, London
B. J. Sahakian
Affiliation:
Section of Old Age Psychiatry, Institute of Psychiatry, London
*
1Address for correspondence: Professor Osvaldo P. Almeida, Departamento de Psiquiatria da FMUSP, Rua Dr Ovidio Pires de Campos S/N, São Paulo – SP, CEP: 05403–010, Caixa Postal 8091, Brazil.
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Synopsis

This study aimed to explore the heterogeneity of paranoid psychosis with onset in late life by using cognitive factors in a centroid method of cluster analysis. Forty-seven subjects were allocated to two different clusters, the first with 24 (51·1 %) and the second with 23 (48·9 %) patients. Their cognitive attainment was evaluated against the performance of 33 elderly controls, all groups being matched for age, sex, and the numbers of years of education. Patients in cluster 2 showed a pattern of widespread cognitive impairment, which involved general measures of cognitive performance (MMSE, CAMCOG, WAIS-R verbal and performance scores), memory (digit and spatial span, delayed matching-to-sample, recognition memory for words and faces), and executive functions (verbal fluency, extra and intra-dimensional shift ability, spatial working memory, and planning). In contrast, patients in cluster 1 were only impaired on their extra-dimensional set shift and planning abilities, suggesting a more specific and restricted executive functioning deficit. We also analysed the impact that the use of antipsychotic medication could have had on patients' cognitive performance, which was shown to be negligible. In addition, there was no difference between the clusters with regard to the number of patients using neuroleptics, suggesting that the medication was unlikely to have introduced a performance bias in the two patient clusters. The validity of the subdivision of these patients into two separate groups was further supported by other clinical findings. Patients in cluster 1 exhibited more severe psychotic symptoms, as measured by the SAPS, than their counterparts in cluster 2, and were also more likely to display first-rank symptoms of Schneider. Conversely, cluster 2 membership was strongly associated with the presence of neurological signs and negative symptoms. We suggest that psychotic states arising in late life are a heterogeneous condition that may be best divided in two: ‘type A’, including patients with a wide range of psychotic symptoms, mild increase in the frequency of neurological signs, and cognitive deficits restricted to executive functions, and ‘type B’, which includes patients with less complex psychotic symptoms associated with a marked increase in the frequency of neurological signs and generalized cognitive impairment. The basis for this subdivision and the prospect for future studies are discussed.

Type
Original Articles
Information
Psychological Medicine , Volume 25 , Issue 4 , July 1995 , pp. 699 - 714
Copyright
Copyright © Cambridge University Press 1995

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References

Almeida, O. P. (1994). The paranoid states of late life. In Psychiatry for the Elderly (ed. Pitt, B.). Gaskell: London.Google Scholar
Almeida, O. P., Howard, R., Levy, R. & David, A. S. (1995). Psychotic states arising in late life (late paraphrenia)-1. Psychopathology and nosology – The role of risk factors. British Journal of Psychiatry 166, 205–214.CrossRefGoogle Scholar
Andreasen, N. C. (1984). The Scale for the Assessment of Positive Symptoms (SAPS). University of lowa: lowa City.Google Scholar
Bilder, R. M., Turkel, E., Lipschutz-Broch, L. & Lieberman, J. A. (1992). Antipsychotic medication effects on neuropsychological functions. Psychopharmacology Bulletin 28, 353–366.Google ScholarPubMed
Blessed, G., Blacki, S. E., Butler, T. & Kay, D. W. K. (1991). The diagnosis of dementia in the elderly: a comparison of CAMCOG (the cognitive section of the CAMDEX), the AGECAT program, DSM-III, the Mini-Mental State Examination and some short rating scales. British Journal of Psychiatry 159, 193–198.CrossRefGoogle ScholarPubMed
Bornstein, R. A., Nasrallah, H. A., Olson, S. C., Coffman, J. A., Torello, M. & Schwarzkopf, S. B. (1990). Neuropsychological deficit in schizophrenic subtypes: paranoid, nonparanoid, and schizoaffective subgroups. Psychiatric Research 31, 15–24.CrossRefGoogle ScholarPubMed
Burns, A. & Levy, R. (1992). Clinical Diversity in Late Onset Alzheimer's Disease. Oxford University Press: Oxford.Google Scholar
Burns, A., Jacoby, R. & Levy, R. (1990). Psychiatric phenomena in Alzheimer's disease. British Journal of Psychiatry 157, 72–94.CrossRefGoogle ScholarPubMed
Cassens, G., Inglis, A. K., Appelbaum, P. S. & Gutheil, T. G. (1990). Neuroleptics: effects on neuropsychological function in chronic schizophrenic patients. Schizophrenia Bulletin 16, 477–499.CrossRefGoogle ScholarPubMed
Cummings, J. L. (1985). Organic delusions; phenomenology, anatomical correlations, and review. British Journal of Psychiatry 146, 184–197.CrossRefGoogle ScholarPubMed
Cummings, J. L. (1992). Psychosis in neurologic disease: neurobiology and pathogenesis. Neuropsychiatry, Neuropsychology and Behavioral Neurology 5, 144–150.Google Scholar
Cutting, J. (1987). The phenomenology of acute organic psychosis: comparison with acute schizophrenia. British Journal of Psychiatry 151, 324–332.CrossRefGoogle ScholarPubMed
David, A. S. (1990). Insight and psychosis. British Journal of Psychiatry 156, 798–808.CrossRefGoogle ScholarPubMed
Davison, K. (1983). Schizophrenia-like psychoses associated with organic cerebral disorders: a review. Psychiatric Developments 1, 1–34.Google ScholarPubMed
Esiri, M. (1991). Neuropathology. In Psychiatry in the Elderly (ed. Jacoby, R. and Oppenheimer, C.), pp. 113–147. Oxford University Press: Oxford.Google Scholar
Flint, A. J., Rifat, S. L. & Eastwood, M. R. (1991). Late-onset paranoia: distinct from paraphrenia? International Journal of Geriatric Psychiatry 6, 103–109.CrossRefGoogle Scholar
Förstl, H., Burns, A., Luthert, P., Cairns, N. & Levy, R. (1993). The Lewy-body variant of Alzheimer's disease: clinical and pathological findings. British Journal of Psychiatry 162, 385–392.CrossRefGoogle ScholarPubMed
Förstl, H., Burns, A., Ley, R. & Cairns, N. (1994). Neuropathological correlates of psychotic phenomena (hallucinations, delusions and delusional misidentification) in confirmed Alzheimer's disease. British Journal of Psychiatry 165, 53–59.CrossRefGoogle ScholarPubMed
Holden, N. L. (1987). Late paraphrenia or the paraphrenias? A descriptive study with a 10-year follow-up. British Journal of Psychiatry 150, 635–639.CrossRefGoogle ScholarPubMed
Howard, R., Förstl, H., Almeida, O., Burns, A. & Levy, R. (1992 a). Computer-assisted CT measurements in late paraphrenia with and without Schneiderian first rank symptoms: a preliminary report. International Journal of Geriatric Psychiatry 7, 35–38.CrossRefGoogle Scholar
Howard, R., Förstl, H., Naguib, M., Burns, A. & Levy, R. (1992 b). First-rank symptoms of Schneider in late paraphrenia: cortical structural correlates. British Journal of Psychiatry 160, 108–109.CrossRefGoogle ScholarPubMed
Howard, R., Almeida, O. P. & Levy, R. (1994). Phenomenology, demography and diagnosis in late paraphrenia. Psychological Medicine 24, 397–410.CrossRefGoogle ScholarPubMed
Hymas, N., Naguib, M. & Levy, R. (1989). Late paraphrenia: a follow-up study. International Journal of Geriatric Psychiatry 4, 23–29.CrossRefGoogle Scholar
Isaacs, B. & Kennie, A. T. (1973). The Set Test as an aid to the detection of dementia in old people. British Journal of Psychiatry 123, 467–470.CrossRefGoogle Scholar
Jacoby, R. & Levy, R. (1980). Computed tomography in the elderly –2. Senile dementia: diagnosis and functional impairment. British Journal of Psychiatry 136, 256–269.CrossRefGoogle ScholarPubMed
Jorgensen, P. & Munk-Jørgensen, P. (1985). Paranoid psychosis in the elderly. Acta Psychiatrica Scandinavica 72, 358–363.CrossRefGoogle ScholarPubMed
Kay, D. W. K. & Roth, M. (1961). Environmental and hereditary factors in the schizophrenias of old age (‘late paraphrenia’) and their bearing on the general problem of causation in schizophrenia. Journal of Mental Science 107, 649–686.CrossRefGoogle ScholarPubMed
Liddle, P. F. & Morris, D. L. (1991). schizophrenic syndromes and frontal lobe performance. British Journal of Psychiatry 158, 340–345.CrossRefGoogle ScholarPubMed
McKeith, I. G., Perry, R. H., Fairbairn, A. F., Jabeen, S. & Perry, E. K. (1992). Operational criteria for senile dementia of Lewy body type (SDLT). Psychological Medicine 22, 911–922.CrossRefGoogle ScholarPubMed
Miller, B. L., Lesser, I. M., Boone, K. B., Hill, E., Mehringer, C. M. & Wong, K. (1991). Brain lesions and cognitive function in late-life psychosis. British Journal of Psychiatry 158, 76–82.CrossRefGoogle ScholarPubMed
Miller, B. L., Lesser, I. M., Mena, I., Villanueva-Meyer, J., Hill-Gutierrez, E., Boone, K. & Mehringer, M. (1992). Regional cerebral blood flow in late-life-onset psychosis. Neuropsychiatry, Neuropsychology and Behavioral Neurology 5, 132–137.Google Scholar
Milner, B. (1963). Effects of different brain lesions on card-sorting. Archives of Neurology 9, 90–100.CrossRefGoogle Scholar
Milner, B. (1964). Some effects of frontal lobectomy in man. In The Frontal Granular Cortex and Behaviour (ed. Warren, J. M. and Akert, K.), pp. 313–331. McGraw-Hill: New York.Google Scholar
Milner, B. (1971). Interhemispheric differences in the localization of psychological processes in man. British Medical Bulletin 27, 272–277.CrossRefGoogle ScholarPubMed
Morice, R. (1990). Cognitive inflexibility and pre-frontal dysfunction in schizophrenia and mania. British Journal of Psychiatry 157, 50–54.CrossRefGoogle ScholarPubMed
Mortimer, A. M., McKenna, P. J., Lund, C. E. & Manuzza, S. (1989). Rating of negative symptoms using the High Royds Evaluation of Negativity (HEN) Scale. British Journal of Psychiatry 155 (suppl. 7), 89–91.CrossRefGoogle Scholar
Naguib, M. (1993). Late Paraphrenia: Phenomenology, Classification and Risk Factors Implicated in its Causation. Ph.D. thesis, University of London.Google Scholar
Naguib, M. & Levy, R. (1987). Late paraphrenia: neuropsychological impairment and structural brain abnormalities on computed tomography. International Journal of Geriatric Psychiatry 2, 83–90.CrossRefGoogle Scholar
Norušis, M. J. (1992). SPSS/PC + 5.0 Statistical Data Analysis for Windows. SPSS Inc.: Illinois.Google Scholar
Olson, S. C., Nasrallah, H. A., Coffman, J. A. & Schwarzkopf, S. B. (1991). CT and MRI abnormalities in schizophrenia: relationship with negative symptoms. In Negative Schizophrenic Symptoms: Pathophysiology and Clinical Implications (ed. Greden, J. F. and Tandon, R.), pp. 146–160. American Psychiatric Press: Washington, DC.Google Scholar
Owen, A. M. (1992). Fronto-striatal Mechanisms in Planning and Attention. Ph.D. thesis, University of London.Google Scholar
Owen, A. M., Downes, J. D., Sahakian, B. J., Polkey, C. E. & Robbins, T. W. (1990). Planning and spatial working memory following frontal lobe lesions in man. Neuropsychologica 28, 1021–1034.CrossRefGoogle ScholarPubMed
Owen, A. M., Roberts, A. C., Polkey, C. E., Sahakian, B. J. & Robbins, T. W. (1991). Extra-dimensional versus intra-dimensional set shifting performance following frontal lobe excisions, temporal lobe excisions or amygdalo-hippocampectomy in man. Neuropsychologia 29, 993–1006.CrossRefGoogle ScholarPubMed
Post, F. (1966). Persistent Persecutor States of the Elderly. Pergamon Press: Oxford.Google Scholar
Post, F. (1980). Paranoid, schizophrenia-like and schizophrenic states in the aged. In Handbook of Mental Health and Aging (ed. Birren, J. E. and Sloane, R. B.), pp. 59–615. Prentice Hall: Englewood Cliffs.Google Scholar
Psychopharmacology Research Branch, NIMH (1976). Abnormal Involuntary Movement Scale (AIMS). In Assessment Manual for Psychopharmacology, Revised (ed. Guy, W.), pp. 534–537. National Institute of Mental Health: Rockville, MD.Google Scholar
Quintal, M., Day-Cody, D. & Levy, R. (1991). Late paraphrenia and ICD-10. International Journal of Geriatric Psychiatry 6, 111–116.CrossRefGoogle Scholar
Robinson, A. L., Heaton, R. K., Lehman, R. A. & Stilson, D. W. (1980). The utility of the Wisconsin Card Sorting test in detecting and localizing frontal lobe lesions. Journal of Consulting and Clinical Psychology 48, 605–614.CrossRefGoogle ScholarPubMed
Sahakian, B. J., Morris, R. G., Evenden, J. L., Heald, A., Levy, R., Philpot, M. & Robbins, T. W. (1988). A comparative study of visuo-spatial learning and memory in Alzheimer-type dementia and Parkinson's disease. Brain 111, 695–718.CrossRefGoogle Scholar
Sahakian, B. J., Downes, J. J., Eagger, S., Evenden, J. L., Levy, R., Philpo, M. P., Roberts, A. C. & Robbins, T. W. (1990). Sparing of attentional relative to mnemonic function in a subgroup of patients with dementia of the Alzheimer type. Neuropsychologia 28, 1197–1213.CrossRefGoogle Scholar
Sahgal, A., Lloyd, S., Wray, C. J., Galloway, P. H., Robbins, T. W., Sahakian, B. J., McKeith, I. G., Cook, J. H., Disley, J. C. A. & Edwardson, J. A. (1992). Does visuospatial memory in senile dementia of the Alzheimer type depend on the severity of the disorder? International Journal of Geriatric Psychiatry 7, 427–436.CrossRefGoogle Scholar
Shallice, T. (1982). Specific impairments of planning. Philosophical Transactions of the Royal Society of London B 298, 199–209.Google ScholarPubMed
Simpson, G. M., Lee, J. H., Zoubok, B. & Gardos, G. (1979). A rating scale for tardive dyskinesia. Psychopharmacology (Berlin) 64, 171–179.CrossRefGoogle ScholarPubMed
Tombaugh, T. N. & McIntyre, N. J. (1992). The Mini-Mental State Examination: a comprehensive review. Journal of the American Geriatric Society 40, 922–935.CrossRefGoogle ScholarPubMed
Warrington, E. K. (1984). Recognition Memory Test Manual. NFER-NELSON: Windsor.Google Scholar
Weinberger, D. R. (1988). Schizophrenia and the frontal lobe. Trends in Neuroscience 11, 367–370.CrossRefGoogle ScholarPubMed
Weinberger, D. R., Berman, K. F. & Zec, R. F. (1986). Physiologic dysfunction of dorsolateral prefrontal cortex in schizophrenia. I. Regional cerebral blood flow evidence. Archives of General Psychiatry 43, 114–124.CrossRefGoogle ScholarPubMed
World Health Organization (1992). The ICD-10 Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines. World Health Organization: Geneva.Google Scholar
Zubenko, G. S., Moossy, J., Martinez, J., Rao, G., Claassen, D. & Kopp, U. (1991). Neuropathologic and neurochemical correlates of psychosis in primary dementia. Archives of Neurology 48, 619–624.CrossRefGoogle ScholarPubMed