Mohammed T. Abou-Saleh

498 PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRY178 Alzheimer patients revealed persecutory ideation (20%),delusions (16%) and hallucinations (17%) to be common. Fiftyper cent of patients with multi-infarct dementia may havedelusions at some time 18 and the clinical course of diffuse Lewybody disease is particularly characterized by paranoid ideationand hallucinations 19 .The manifestations of progressive, global, cognitive impairmentwill usually be present, although dementia may present withparanoid symptoms that can be indistinguishable from functionillness 20 . Paranoid ideas are frequently related to cognitive deficits,especially memory, leading to accusations of theft 17 or problemsarising from perceptual difficulties and misidentification 8 . Likedelirium, these fluctuate and may be ferociously denied, orforgotten, at interview, although the theme and content remainfairly consistent.DepressionIf depression is of delusional proportions, biological andcharacteristic depressive symptoms are usually marked. Delusionsand hallucinations, occurring in all sensory modalities, arenormally mood-congruent but incongruent symptoms occur andmay be difficult to distinguish from those of primary paranoiddisorders.Kay et al. 21 suggested six historical variables that help distinguishaffective and paranoid psychoses: life events and family history ofaffective illness favoured an affective diagnosis, while low socialclass, few surviving children and social deafness favouredparanoid disorder. Premorbid personality proved the bestdiscriminator, with paranoid patients being solitary, shy, touchy,suspicious and emotionally aloof, and patients with affectivedisorders reporting subjective ratings of high premorbid anxiety.ManiaTraditional teaching suggested that mania in old age was bothrare and atypical in presentation. Broadhead and Jacoby’s 22prospective study found that young and older-onset patientswere clinically very similar. The onset of mania in old age is morecommon than once thought 23 and the majority of patients willhave a history of affective disorder, some 50% having had three ormore depressive episodes, with a latency of 15–17 years from firstdepression to mania 22–25 .Organic Delusional/Hallucinatory DisorderParanoid hallucinatory disorders have been associated with avariety of organic conditions 8,11,26–29 and pharmacologicalagents 5,8,11,30 . The symptoms may be typical of functional disorders26,31 and the diagnosis depends on establishing a clearaetiological link and temporal relationships between a physicaldisorder or drug and mental disturbance. As Kay 32 put it, ‘‘Had theorganic diagnosis not been reached independently of the psychiatricsymptomatology, most of the cases would have been regarded as,indubitably, schizophrenic’’.The more common causes encountered in clinical practiceinclude hypothyroidism, intra- and extracerebral tumours,epilepsy and cerebrovascular disease, and pharmacological agentssuch as psychostimulants, anti-parkinsonian and dopaminergicdrugs and steroids. Alcohol intoxication and withdrawal fromalcohol, benzodiazepines and barbiturates may all cause paranoidstates, and withdrawal syndromes should be particularlyconsidered when psychosis develops shortly after a hospitaladmission.Paranoid Personality DisorderThis is necessarily a life-long problem which must be demonstrablefrom early adulthood. It is characterized by a sensitive anddefensive attitude that causes people to feel they are victims of lifeand interpret events in a self-referential way 14 . The effects ofageing and the vicissitudes of later life may accentuate these traitsand, if dementia or functional illness supervene, will colour thesymptomatology.Late-onset SchizophreniaKay and Roth’s 2 description of the characteristic features of thiscondition has never been surpassed. Schizoid and paranoidpremorbid personality, reduced likelihood of marriage andfertility, living alone with few surviving relatives, and deafnesscontributing to social isolation, and a limited but significanthereditary predisposition for schizophrenia with female preponderance,all characterize this disorder. The whole range ofpsychopathology typical of schizophrenia may be evident,although personality is more often preserved and negative featuresless prevalent 2,3,20,33,34 . Roth and Kay 35 provide a thoughtfuldiscussion of the apparent similarities and differences of theassociated features of late- and early-onset schizophrenia.Delusional DisordersThese are conditions characterized by a persistent, circumscribeddelusional theme and if hallucinations occur they are notprominent. They are defined by their delusional content, whichmay be erotic, jealous, hypochondriacal, persecutory or grandiose.These conditions have not been the subject of systematicstudy in old age, when they are thought to be relatively rare 8 .Onset is usually in middle age but as patients normally functionwell outside their particular delusion and symptoms frequentlypersist they may present in old age. Unlike late-onset schizophrenia,delusional disorder seems not to be associated withpremorbid paranoid personality or deafness 36 , although querulentparanoia has been related to deviant personality structure 65 .Familially they appear unrelated to affective or schizophrenicillnesses 37,38 . Howard et al. 39 found dilatation of lateral and thirdventricle volumes by magnetic resonance imaging (MRI) to bemore a feature of delusional disorder than schizophrenia in oldage, as defined by ICD-10 criteria.A small retrospective study comparing paraphrenia (schizophreniaof late onset) with paranoia (delusional disorder of lateonset) found cerebral infarction on CT brain scan to be a featureof paranoia rather than paraphrenia. Furthermore, social isolationand being unmarried was not a feature of paranoiacs, withcerebral infarction suggesting separate groups defined by organicor social associations. Response to antipsychotic drugs was worsefor paranoia 40 .ASSESSMENTInterviewInterviewing paranoid elderly people may be complicated bydeafness, speech problems or visual handicap, so time andpatience are essential. An informant history is mandatory andoften several sources may be required.It is crucial to establish the interview situation, explain itspurpose, allay anxieties and put patients at their ease. The patientsshould decide whether they prefer to be seen in private or with a