Psychotic symptoms are either delusions or hallucinations. Delusions are unfounded ideas that can be related to suspicions or paranoid thoughts, self importance, illness, self-blame, or hopelessness. Hallucinations are abnormal perceptions in one or more of the five senses (ie, hearing, vision, feel, smell, and taste). For example, people may hear or see things that aren’t really there.

Most psychoses in older adults are related to other disorders, especially dementia, delirium, and mood disorders (see Delirium, Dementia, and Anxiety). This chapter focuses on several conditions in which psychoses are the primary symptoms.

• Schizophrenia and Delusional Disorders
• Symptoms
• Treatment and management
• Other Causes of Hallucinations in Older Adults

Schizophrenia is a chronic psychiatric disorder characterized by delusions, hallucinations, disorganized thinking patterns, difficulty in social situations, and lack of interest. Schizophrenia is not a split or multiple personality, as is often shown in movies and on television. Before schizophrenia can be diagnosed, other more common causes for psychoses need to be excluded. These include neurologic diseases (eg, stroke and Parkinson’s disease), mood disorders (eg, clinical depression and manic-depressive illness), and other emotional or mental disorders (eg, dementia and delirium). For example, a sudden change in consciousness or lack of ability to pay attention suggests delirium (see also Delirium and Dementia).

The initial onset of schizophrenia is very rare in older men, because men who develop it tend to do so in their teens or twenties. Women get schizophrenia at a somewhat older age, with about 25% of cases beginning after age 45, and 10-15% after age 59.

Schizophrenia that begins in later life is less likely to show up with the scattered thoughts and jumbled or illogical speech seen in younger people with this disease. Delirium and dementia are more likely causes for these signs in older adults.

One of the most common symptoms of schizophrenia in older adults is paranoid delusions. For example, people commonly report that their belongings are being stolen or that they are being persecuted unjustly. This is different than the suspiciousness or cynical outlook that may develop with age. Normal suspiciousness usually has a rational basis (eg, worry about safety) and no other psychotic symptoms (eg, hallucinations). Of course, normal suspiciousness can also become a problem if it leads to extreme anxiety or social isolation.

Because paranoid delusions and suspiciousness are common in schizophrenia, developing a trusting relationship is important. Confronting someone with the extreme unlikelihood or impossibility of his or her ideas is rarely effective. A better approach is to be honest and understanding and to acknowledge the distress caused by the hallucinations or delusions. Statements such as "I can see how upset you are by all of this" and "I don’t hear anything like that, but I appreciate the fact that you do" work much better than "Now you know that’s not possible." It is also important to remember that some suspicions are reasonable and should be investigated (eg, a claim that a relative is taking advantage of the older person’s finances).

Hallucinations can be caused by conditions other than schizophrenia, delirium, and dementia. One common cause is severe visual loss. About 10% of people with significant vision loss (ie, worse than 20/60 in both eyes) have visual hallucinations. (See also Vision Loss.) These hallucinations occasionally take the form of shapes, such as diamonds or rectangles. More commonly, the hallucinations are complex, with people seeing things such as children, animals, or a vivid scene as seen in a movie.

Complex hallucinations among people with vision loss is called Charles Bonnet syndrome. People with this syndrome do not have evidence of brain disease or other psychiatric illness. They are usually aware that what they are seeing cannot be real, even though it seems absolutely real and vivid. The best treatment of Charles Bonnet syndrome is information and support, including reassurance that the hallucinations are a sign of eye disease and not mental illness. Such support can also decrease the distress that can be associated with this condition, especially if the person begins to have trouble telling these visions apart from reality. Antipsychotic medications may be needed if distress is significant or leads to dangerous behavior.

Older adults with Parkinson’s disease, stroke, and other brain disorders occasionally have delusions or hallucinations, even though they may not have a mental disorder or psychiatric problems. As with Charles Bonnet syndrome, the best treatment is education, support, and the occasional, cautious use of antipsychotic drugs.

Psychoses are also sometimes caused by drugs used to treat mental or neurologic conditions (eg, some drugs used in Parkinson’s disease). Usually, a change in medication solves the problem.