PSYCHOTIC DISORDERS IN ELDERLY PERSONS Carl I. Cohen, M.D., SUNY Distinguished Service Professor, Professor & Director, Division of Geriatric Psychiatry,

PSYCHOTIC DISORDERS IN ELDERLY PERSONS

Carl I. Cohen, M.D., SUNY Distinguished Service Professor, Professor & Director, Division of Geriatric Psychiatry,SUNY Downstate Medical Center Brooklyn, NY

email: [email protected]

In older adults, for all conditions: think “Comorbidity”

Any new psychiatric conditions or change in symptoms:

Must assume physical cause until proven otherwise

Two Preliminary Points

Presence of “hallucinations and/or delusions”

Key Points:  

1.Can be primary (due to psychiatric disorder) or secondary (due to medical/neurological disorder)

Definition of Psychoses:

Key Points (continued)

2.There is no reliable pathognomonic signs to distinguish primary or secondary psychosis (need to rule out secondary causes)

A) Primary psychotic disorders: Schizophrenia and related disorders

SchizophreniaSchizoaffective disorderSchizophreniform disorderDelusional disorderBrief psychotic disorder

Affective psychosesBipolar disorder with psychotic featuresUnipolar depression with psychotic

features

B)    Secondary psychotic disorders:Psychotic symptoms associated with dementia

Alzheimer’s Disease with psychosesVascular dementia with psychosesLewy Body Disease with psychosesOther dementing disorders with psychoses

Psychotic symptoms during deliriumPsychotic symptoms associated with medications and substance abusePsychotic symptoms due to medical and surgical disorders

Lifetime Risk

(1 in 4 lifetime risk)

Up to 23% of the older adult population will experience psychotic symptoms at some time, with dementia being the main contributing cause (Khouzam & Emes, 2007).

Prevalence of Psychosis in Elderly Persons • Community: 0.2% to 4.7%;

In NYC study (Cohen et al, 2004): 3% psychosis (7% Blacks vs 2% Whites), but if include paranoid ideation: 14 % of sample.

• Age 85+ (without dementia): 7.1% to 13.7%. May be prodromal for dementia Age 95+(without dementia): 7.4%

• Nursing Homes: 10% to 62%

• Geriatric Psychiatry In-Patient Units: 10% late onset psychosis--¾ are women, 40% due to AD or VaD

Etiologies of Psychoses in Older Adults

(order of frequency)1. Alzheimer’s disease and other dementias (40%)2. Depressive disorder (33%)3. Medical/toxic causes including substances (11%)4. Delirium (7%)5. Bipolar Affective Disorder (5%)6. Delusional disorder (2%)7. Schizophrenia spectrum disorders (1%)

Manepalli et al, 2007 and Webster et al, 1998

Risk Factors for Psychoses in Older Adults1. Sensory deficits2. Social isolation3. Cognitive decline4. Medical comorbities5. Polypharmacy6. Age related changes in pharmacokinetics and pharmacodynamics7. Comorbid psychiatric illnesses such as dementia and delirium8. Age-related changes in cerebral structures such as frontotemporal

cortices9. Neurochemical changes associated with agingPsychoses may be multifactorial and occurs in the context of fraility, limited reserve capacity, increased

vulnerability to stressors.

Delirium

1. Perceptual disturbances are common; however, hallucinations also are frequent:

• Hallucinations: 40% to 67%• Delusions: 25% to 50%2. Psychotic symptoms are more commonly seen with

hyperactive rather than hypoactive delirium

3.Visual > > auditory> other hallucinations4.Paranoid delusions are the most common delusions5. Clinical evaluation should help identify; dementia and

delirium are often related

Dementia

Alzheimer’s Disease 1. Prevalence of psychotic symptoms: 16% to 70%; Median: 37% for

delusions; 4% to 76% (Median 23%) for hallucinations 2. Rates of psychoses: about 20% in early stages to 50% by third or

fourth years of illness (Overall: 30% to 50%).3. Most common in middle stages.4. Hallucinations: visual> auditory> other. 5. Hallucinations most commonly people from past, e.g., deceased

relatives, intruders, animals, objects.6. Delusions: most common are false beliefs of theft, infidelity of one’s

spouse, abandonment, house not one’s home, and persecution. Decreases in later stages.

6. Different from misidentification syndromes which may be more cognitively- related: Capgras Syndrome (imposters), Phantom Boarder Syndrome(guest in house); Mirror Sign (mistakes self in mirror for someone else, TV or Magazine Sign (believes people on TV or in magazine are real).

7. Some evidence that psychotic symptoms are associated with a more rapid decline.

8. Need to rule out underlying medical problems and visual difficulties

9. Jeste & Finkel(2000) proposed classification of “Psychoses in AD” as presence of hallucinations and/or delusions of at least one month duration, even if intermittent, serious enough to disrupt life of patient or others, and patient meets criteria for AD, not explainable by delirium, drug effects, schizophrenia or other psychiatric disorders.

Vascular Dementia

Cache County study found prevalence of hallucinations similar between AD and VaD, but delusions were higher in AD (23% vs 8%).

Lewy Body Dementia

1.About half have visual hallucinations (up to 80% in some studies), and it’s an early sign in 43%.

2.Auditory hallucinations (20%) and paranoid delusions(65%) are also common

3.Some texts say psychotic symptoms are more common than in AD.

Parkinson’s disease

1. Overall rates: 20 to 60% --- about ¼ have hallucinations in PD, but ¾ have hallucinations with Parkinson’s Disease with Dementia (PDD). Thus, psychosis is more common in later stages of PD.

2. Hallucinations much more common than delusions. 3. Extrinsic causes > Intrinsic causes, i.e.,

hallucinations in PD most commonly secondary to dopaminergic agents(extrinsic). Need to assess onset of symptoms. Medications produce vivid visual hallucinations.

Affective Psychoses

Unipolar Depression1. Psychotic depression occurs in 20% to 45% of hospitalized

elderly depressed patients; 15-25% of community depressed persons.

2. Delusions are more commonly mood-congruent, including delusions of guilt, delusions of deserved punishment for moral or personal inadequacies, delusions of nihilism, somatic delusions, delusions of poverty.

3. Auditory hallucinations are less common and not easily described, such as vague derogatory voices.

4. Catatonia in severe depressive episodes

Bipolar Illness

1. Psychotic symptoms occur in context of manic or depressive episodes.

2. Bipolar depression is similar to unipolar depression with respect to predominantly mood-congruent delusions.

3. Bipolar mania also presents with predominantly mood-congruent delusions such as grandiosity, erotomania, delusions about possessing special powers.

Are Schizophrenia, Schizoaffective Disorder (SAD), and Psychotic Mood Disorder Really

One Disorder (or on a Continuum) Versus

Separate Disorders ?

Mood Disorder

Bipolar –very psychotic (formerly Schizophrenia)

Bipolar—moderate psychotic (formerly SAD)

Classic Bipolar (non-psychotic)

Lake, Psychiatric Annals, Feb, 2010

Psychotic Severity of Sx Mood

Substance Induced Psychosis 1. Prevalence of substance use disorders in elderly persons: 2%-3% in

women and 10% in men.2. Psychotic symptoms may occur during alcohol (e.g., DTs), sedative, or

barbiturate withdrawal, whereas stimulants (amphetamines, cocaine, OTC weight –reducing drugs) can cause symptoms with intoxication.

3. Opiates such as narcotic analgesics, heroin, codeine, and methadone may induce delirium, and consequently, psychoses

4. Prescribed medications that are most common causes of psychosis are antiparkinsonian drugs, anticholinergic drugs, antiarrhythmic agents, corticosteroids.

5. If tactile hallucinations occur, consider drug withdrawal states, toxic, or metabolic disturbances.

Medical Illness1. Medical illnesses can cause psychosis with and without delirium.2. DSM criteria require prominent hallucinations or delusions,

with evidence from the history, physical examination, or laboratory findings that the disturbance is physiological consequence of the general medical condition. It should not be better accounted for by another mental disorder and does not occur exclusively during the course of a delirium.

3. Typical medical causes of psychosis are neurological, infectious, metabolic, and endocrine.

4. Elderly persons are more at-risk because of high rates of physical illness, polypharmacy, and susceptibility to disruption of brain function.

Table 1. Common Medical Causes of Psychosis in Older Persons

Metabolic Vitamin B12 or folate

deficiency, electrolyte abnormalities

Infections Meningitis, encephalitis(e.g., herpes), syphilis, HIV/AIDS

Neurological Parkinson’s disease, epilepsy, subdural hematoma, stroke, Huntington’s disease (rare), tumor(rare)

Endocrine Thyroid disease, adrenal disease, hyper- or hypoglycemia

Adapted from Desai and Grossberg, 2003

Sorting Out Medical Causes of Psychoses from Non-Medical Causes• Often characterized by paranoid

delusions, persecutory thoughts, and ideas of reference

• May resemble paranoid schizophrenia but delusions are usually more concrete, non-bizarre, and changeable

• Paranoid schizophrenia is usually more abstract, bizarre, and unchanging

Pies, 2008

Schizophrenia

Early-Onset Schizophrenia Schizophrenia typically develops in the second or third decade of

life, but greater numbers of schizophrenia patients are surviving into old age.

1.Between 80-85% of persons aged 55 and over developed schizophrenia before age 45. Prevalence estimates for schizophrenia in adults aged between 45 and 60 are approximately 0.6% to 1%.

2. Over the next two decades there will be a doubling of the number of persons aged 55 and over with schizophrenia, from about 550,000 in 2005 to 1.1 million in 2025. By that time, about one-fourth of persons with schizophrenia will be in this older age bracket.

There is heterogeneity in outcome in schizophrenia into later life.

Long-term studies observing the symptoms and functioning in early-onset schizophrenia suggest that the course of schizophrenia may not be as pessimistic as previously thought, and such findings challenge the notion implied in the term dementia praecox.

Based on long-term studies carried out in Europe ranging from 22 to 37 years, Ciompi found: *20 to 27% of patients attained complete

symptomatic remission, *22 to 33% attained mild end states, *24% to 29% attained intermediate end-states, *14 to 18% attained severe end-states.

Thus, roughly half of persons exhibited recovery or mild end-states, and half showed moderate or severe end states.

1. Outcome from earlier life (depends on definitions): About half improve in psychopathology, one-third remain unchanged, and about 15% get worse. Textbook: (Jeste et al APPI Textbook of Geriatric Psychiatry,2004): 20% remission in positive and negative symptoms; 60% largely unchanged; 20% worsening of symptoms.

2. “Social recovery” was observed in about half of subjects.

3. Looking at a more comprehensive definition of recovery, Auslander and Jeste found only 8% of older outpatients attained “sustained remission,” based on symptom remission, social functioning, and medication dosage.

4. Better prognosis: female, later development of illness, better premorbid functioning, married, acute-remitting course.

Community-dwelling persons with schizophrenia—who represent about 85% of the older population—have been generally found to have a non-progressive course. The non-progressive course has led some investigators to conceptualize schizophrenia as a static encephalopathy rather than a dementing disorder.

Although approximately half of persons in the various symptom and social outcome categories achieve favorable outcomes, the correlations among outcome categories are modest (median value of .21 or about 4% shared variance). Because each of the outcome categories has been found to be associated with a variety of clinical and social variables, it is likely that effective treatments will require biological and psychosocial methods.

Table2: Symptom and Social Outcome in Schizophrenia

Outcome Categories Trend with Age Comments

Positive symptoms Improvement About half with mild or no symptoms

Negative symptoms Possible improvement About half with mild or no symptoms

Depressive symptoms Same or slightly worse About one-third no depression; one-third syndromal depression; one-third subsyndromal depression

Cognitive symptoms Slight worsening About half show only minimal or no cognitive impairment on standard tests

Adaptive Functioning Improvement About half with mild or no disability

Quality of life Possible improvement Most in “moderate” range, and higher than persons with chronic pain.

Global outcome Slight improvement, but not appreciable

About one-tenth in full recovery

Note: there is a subgroup of “poor outcome” persons (about 15 to 20%) who show marked impairment in all these categories.

Hallucinations in Older Adults with Early –

Onset Schizophrenia • 36% (71/198) of NYC sample age 55+ had

hallucinations (44/198 had 1 type; 19/198 had 2 types; 8/198 had 3+ types; 64/198 of sample had auditory hallucinations)

• Form: Clear:

• Frequency:

• Type: Evaluation:34%; mundane:34%; information 32%

• Evaluative:

87%

61% daily; 24% weekly

Good : 44%; Bad 34% bad; Mixed 10%; not sure: 12%

Late-Onset Schizophrenia

A review of studies of late-onset schizophrenia found that approximately 23% of patients with schizophrenia were reported to have experienced the onset of the disorder after age 40, with 13% in the fifth decade of life, 7% in the sixth decade, and 3% in later decades. Roughly 15% onset over age 44, but a study in the UK found 29% with onset after age 44.

“Late paraphrenia” used by Martin Roth in 1950s(UK) to describe persons with no family history who developed a schizophrenia like illness (hallucinations and delusions) after age 65. Term has been used in various ways. In ICD 9 it referred to delusional disorder in later life; similar to DSM II. Not in DSM-IV-TR or ICD10.

Demarcation

The International Late-Onset Schizophrenia Group has proposed that schizophrenia with an onset between age 40 and 60 be termed “Late-Onset Schizophrenia” and be considered a subtype of schizophrenia.

The authors believe that schizophrenia with onset in middle age is a neurodevelopmental disorder, and that differences with early-onset schizophrenia are more of degree than of kind.

No differences between early and late onset groups in: positive symptoms, family history, brain abnormalities, memory retention, or minor physical abnormalities.

The late-onset group is more likely to:1. Be female versus no gender differences in early-onset,

2. Have the paranoid subtype of schizophrenia, 3. Have lower levels of negative symptoms,4. Have less impairment in learning, abstraction, and flexibility, 5. Better premorbid functioning with respect to work and marriage.

The International Late-Onset Group also proposed the term, “Very Late Onset Schizophrenia-Like Psychosis” for disorders that begins after age 60. This disorder has features that suggest a neurodegenerative component including more brain abnormalities and neuropsychological deficits.

This disorder is also distinguished from the other two types by:

1. many more females; 2. greater prevalence of persecutory and partition delusions; 3. higher rates of visual, tactile and olfactory hallucinations; 4. lower genetic load; 5. more sensory abnormalities;6. absence of negative symptoms or formal thought disorder.

Table3. Comparison of early-onset schizophrenia , late-onset schizophrenia , and very late onset schizophrenia

  Early-Onset Late-Onset Very Late Onset

Age of onset <40 40 to 60 >60

Female preponderance - 

+ ++

Negative symptoms ++ + -

Visual, tactile and olfactory hallucinations

+ + ++

Persecutory/Partition delusions

+ ++ +++

Minor physical abnormalities

+ + -

Neuropsych deficitsLearning Retention

   ++ -

   + -

  ++(?) ++(?)

Progressive cognitive deterioration

  -

  -

 ++

Brain structure abnormalities(e.g. tumors, infarcts)

- - ++

Family history of schizophrenia

+ + -

Early childhood maladjustment

+ + -

Daily antipsychotic dose

Higher Lower Lower

Risk of TD + + ++

-=absent, + =mildly present, ++ =strongly present, +++ = very strongly present

Adapted from Jeste et al, 2004

Schizoaffective Disorder• Must have uninterrupted period of illness in

which symptoms meet Criterion A for schizophrenia and a major depressive episode, a manic episode, or mixed episode. During this episode there must have been delusions or hallucinations for at least 2 weeks in the absence of prominent mood symptoms.

• A shifting (unstable) and irrational diagnosis:

a. Differs between episodes;

b. How can having both depression and schizophrenia turn into a 3rd disorder?

Schizoaffective Disorder (cont.)

• Research suggests that schizoaffective disorder may be subcategory of schizophrenia or psychotic depression because they share epidemiology, clinical, and neuropsychological features.

• High prevalence of depressive symptoms in schizophrenia--11% to 75% depending on the level of severity-- make diagnosis more problematic.

Delusional Disorder1.Delusional disorder is differentiated from schizophrenia by a lack

of prominent auditory or visual hallucinations (and if present, related to delusional theme), and an absence of deterioration in areas of functioning outside the delusional scope.

-Distinguished from dementia by absence of cognitive impairment.

-Distinguished from mood disorder by delusions preceding any mood disturbances.

2.The delusions are non-bizarre and involve situations that may occur in real life, such as theft, suffering from a disease, spousal infidelity, or being followed.

3.  Delusional disorder difficult to differentiate from the paranoid schizophrenia, but the latter has more bizarre delusions and auditory hallucinations. Poor psychosocial functioning in delusional disorder is directly related to the delusional beliefs. 4.  Prevalence:0.03%5.  Risk factors: Persons with schizotypal or paranoid personality disorders; mixed findings regarding association with hearing loss.6.  MRI findings had no significant differences from normals. 7. The course of delusional disorder may vary but tends to be chronic, especially in those with the persecutory type of delusional disorder.

Treatment

Early-Onset Schizophreniaa. Lack of control studies, e.g., CATIE trial from ages 18 to 65.b. Recent federal warnings about increased mortality risk in elderly dementia

patients adds to the concern regarding use of antipsychotic medications.c. An expert review panel recommended risperidone (1.25–3.5

mg/day) as the first line of treatment. Quetiapine (100–300 mg/day), olanzapine (7.5–15 mg/day), and aripiprazole (15–30 mg/day) were viewed as good second-line treatments. Recommended starting dosages for late-onset persons at 25% of the recommended adult dose and maintenance doses at 25-50% of the adult dose. Often, effective doses for early-onset can be 50-75% of younger patients.

There has been only two large-scale randomized, double-blind controlled trial comparing atypical antipsychotics—risperidone(1mg to 3mg/day, median dose 2mg/day) and olanzapine(5mg to 20mg/day, median dose 10mg/day)-- in adults older than 60. Positive symptoms, negative symptoms, disorganized thoughts, and symptoms of anxiety/depression improved significantly from baseline in both groups. There were no significant differences in side effects except for more clinically significant weight gain in the olanzapine group.

Table 4. Studies supporting use of specific atypical antipsychotics in older persons with schizophrenia

  Total, n Design

Clozapine    

Chengappa et al. 1995[70] 12 Retrospective Chart Review

Factor and Brown, 1992[36]   Open Label

Risperidone    

Jeste et al. 1999[71] 53 Open Label

Madhusoodanan et al. 1999[72] 100 Open Label

Feldman et al. 2003[73] 39 Double Blinded Randomised

Jeste et al. 2004[74] 175 Double Blinded Randomised

Olanzapine    

Madhusoodanan et al 2000[75] 10 Open Label

Sajatovic et al. 1998[76] 27 Open Label

Feldman et al. 2003[73] 39 Double Blinded Randomised

Jeste et al. 2004[74] 175 Double Blinded Randomised

Quetiapine    

Arvantis and Rak, 1997 152 Open Label

Madhusoodanan et al. 2000[77] 7 Open Label

Ziprasidone    

Barak et al. 2006[78] 21 Open Label

Aripiprazole    

Madhusoodanan et al. 2004[79] 10 Retrospective Chart Review

Adapted from Vahia et al, 2007.

Risk of developing tardive dyskinesia with conventional antipsychotic medications: 29% (after 1year –nearly 6x that of younger persons), 50% (2 years), 63% (3 years). Rates substantially lower with atypical antipsychotic medications (5% after one year).

Other side effects: EPS and anticholinergic effects are higher in elderly persons.

Cognitive-behavioral social skills training (CBSST) has been found to improve coping skills, social

functioning and facilitate a more objective understanding of

subjective psychotic phenomena.

  Late-Onset Schizophrenia

a. Based on limited data, late-onset schizophrenia patients appear to have good symptomatic improvement with antipsychotic treatment compared to early-onset illness individuals.

b. Substantially reduced doses of antipsychotics are necessary in

late-onset schizophrenia patients. Maintenance therapy is frequently required, because many of these patients relapse if they discontinue the medication.

c. A lack of published data specifically examining the use of atypical antipsychotics in patients with late-onset schizophrenia, and existing investigations have frequently involved mixed samples of early- and late-onset patients.

d. Cognitive behavioral therapy and social skills training also have shown promise.

Delusional Disorders

a. Commonly, persons deny their illness. Consequently, non-adherence to antipsychotics is a common problem in the treatment

b. Antipsychotic agents often are effective, especially in agitated delusional patients. of patients with delusional disorder.

c. For refractory cases, modified electro-convulsive therapy has been reported as successful.

d. Cognitive-behavior therapy has been demonstrated as an effective treatment approach.

Parkinson’s Disease

a.Critical to adjust anti-parkinsonian medication

b.Quetiapine 12.5mg to 150mg has been effective for psychotic symptoms

c. Clozapine; 6.25mg to 50mg has been effective.

Alzheimer’s Disease

CATIE study, in which time to discontinuation did not differentiate antipsychotic medications from placebo, and black box warnings regarding higher mortality rates, suggests that medications must be used judiciously. In CATIE study, the median time to the discontinuation of treatment due to a lack of efficacy favored olanzapine and risperidone, but the time to the discontinuation of treatment due to adverse events or intolerability favored placebo. Mean doses used in CATIE trial: risperidone(1mg), olanzepine (5.5mg) , and quetiapine (56.5mg).

Recommended doses:

Risperidone:0.75mg to 1.5mg

Olanzepine: 2.5mg to 7.5mg

Quetiapine : 25mg to 200mg

Psychosocial modalities:

Sensory enhancement, structured activities, social contact, behavior therapy.

Cytochrome P450 Enzymes Cytochrome P450 Enzyme Subtype

Inhibitors Inducers

CYP1A2:clozapine

olanzapine

Fluvoxamine; grapefruit juice

Cigarette smoking

CYP2D6:clozapine

risperidone

aripriprazole

SSRIs(esp fluoxetine, paxoxetine)

CYP3A4:clozapine

quetiapine

ziprasidone aripriprazole

Ethromycin and other macrolide antibiotics, ketocanozole & other antifungal agents, protease inhibitors

Barbituates, Carbamazepine, Phenytoin, Rifampin, Glucocorticoids

Table 5. Comparison of Symptoms and Treatment of Psychosis in Alzheimer’s Disease, Older Adults with Schizophrenia, and in Parkinson’s Disease

  Psychosis of AD Schizophrenia Psychosis of PD

Prevalence of psychosis 35% to 50% About 40- 50% in non-acute states; 100% in acute states

20% to 60%

Basis for psychosis Non-cognitive manifestation of underlying pathology

Generally considered primary abnormality

Usually antiparkinsonian drugs, but not always especially late stages

Bizarre or complex delusions Rare Frequent Rare

Misidentification of caregivers Frequent Rare Rare

Common form of hallucinations

Visual Auditory Visual

Schneiderian first rank symptoms

Rare Frequent Rare

Active suicidal ideation Rare Frequent Rare

Past history of psychosis Rare Very Common (especially early-onset)

Rare

Eventual remission of psychosis

Frequent About half Often after adjustment of antiparkinsonian medication

Need for years of maintenance antipsychotics Uncommon Very common Uncommon

Meds: Risperidone Olanzapine Quetiapine

 0.75mg to 1.5mg 2.5mg to 7.5mg25mg to 200mg

1.5mg to 2.5mg7.5mg to 12.5mg 50 mg to 300mg

 Not recommendedNot recommended12.5 mg to 150mg (also Clozapine)

Adjunctive treatment Sensory enhancement, structured activities, social contact, behavior therapy

CBT, social skills training Supportive therapy

Test Yourself

Symptoms of secondary psychoses accompany which

disorder:

1. Delusional disorder

2. Schizophrenia

3. Depression

4. Alzheimer’s disease

The most frequent cause of psychosis in older persons is:

1. Schizophrenia

2. Alzheimer’s disease

3. Delusional disorder

4. Depressive disorder

In delirium, what is the most common form of hallucinations in

older persons?

1. Auditory

2. Tactile

3. Visual

4. Olfactory

In Alzheimer’s disease which of the following is true :

1. Auditory hallucinations are the most common type of hallucination

2. Psychoses are most common in the early stages of the disorder

3. Delusions concerning theft are common

4. Misidentification syndromes are a type of delusion

In Parkinson’s disease which of the following is true:

1. Extrinsic causes of hallucinations are greater than intrinsic causes

2. Rates of hallucinations are about 10%

3. The preferred treatment for hallucinations is risperidone

4. Rates of hallucinations are similar among those persons with and without dementia

In depression, which of the following is true:

1. Auditory hallucinations are common

2. Permeable wall delusion often occurs

3. Delusions are mood-congruent

4. Psychosis occurs in about 10% of hospitalized cases

In Schizophrenia, which item is true :

1. Approximately a quarter of early onset cases show recovery or mild end states

2. Men develop the disorder more commonly after age 45

3. Persecutory delusions are more common in late onset disorders

4. Prevalence of auditory hallucinations is similar to delusional disorder

Congratulations

You are now an expert in Psychoses in Older Adults