I used to be, until fairly recently, a Senior Sister for older adults with complex needs. I have seen some actions by GPs who have limited or no expertise in diagnosing and treating older people. For example, I recently answered a thread by a daughter whose mother had suddenly developed psychotic symptoms. The doctor had misdiagnosed and treated this lady, leaving her at high risk of falls, malnutrition and dehydration. I have written this for anyone who finds they need more knowledge to challenge or just talk to professionals on behalf of their relative.
Poor treatment can lead an older person to be put in a care 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 to get it removed, and all treatment from then on is with this label in mind. Antipsychotics are often prescribed, even though NICE guidelines say that this is largely unacceptable and can be dangerous to older people.
What to do when there are signs of psychosis
If your relative suddenly starts to hear voices, noises and develops delusional thinking, make sure you investigate. Ask for or look for the following things:
Check for infection
The urinary tract and chest should be checked for infection. Unbelievably, urinary tract and chest infections are the commonest causes of severe confusion in elderly people and are often missed or not checked first. A simple urine test is all that is needed to detect a urinary tract infection.
Blood test
A full scan of all blood tests which cover all major functions in their body. Commonly poor kidney function, liver function, anaemia (which is common in older adults), malnutrition and dehydration and many more things need to be checked. Many of these can lead to confusion in the elderly.
Rule out stroke
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, dementia may be prevented. A purely physical examination by the doctor is not sufficient. They should order a specialist x-ray of the brain.
Check hearing and vision
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 their peripheral vision.
Early stages of dementia
Only a psycho-geriatrician or psychologist should diagnose this. However, many times other professionals feel they have the right to throw this label around.
Grief
Recent grief can cause confusion in all of us, but for some reason, we often don’t notice it in older people because they may 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 hidden trauma
It is more common than you may care to believe that older women suffer sexual abuse. This can lead to PTSD, but the older person may not always express this the same way as in someone younger, and it can look like confusion. Elder abuse happens in families, again more often than one might think.
Medication side effects and contraindications
It is not uncommon that a doctor does not notice medication side effects or contraindications and/or that there is a build-up of toxicity from medications.
Check for infections elsewhere in the body
Infections can occur elsewhere in the body. An example is cellulitis, an infection in the skin that is very dangerous and can lead to blood poisoning. Unfortunately, the older person may try to home-treat this, not realising how dangerous this is.
Recent hospital stay
A recent hospital admission for any reason can cause confusion on returning home. Many older people have a network of people who help them in the community, but when they are admitted, this may fall apart, leaving the older person bewildered and depressed.
Depression
Older people often do not react in the classic ways to depression and may see and hear things that are not there. They may also develop delusions trying to account for this feeling. Depression is commonly misdiagnosed as an illness in older people and is the most common reason for older adults to be labelled as having dementia and/or psychosis. If a person suddenly becomes confused, it is almost certainly not dementia.
Loneliness
Loneliness is widespread in older people and can lead to hearing deceased relatives talking and to 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 may be diagnosed by a doctor who doesn’t know the 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 gets help from people from 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
For example, I have looked after several people who were in 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’s actually PTSD (post-traumatic stress disorder).
Lack of sleep
This is 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 oversedation. Also, they may wake from a dream and believe the dream is reality.
Psychiatric medications
Psychiatric meds for anxiety or depression can lead to the person becoming apparently psychotic when it is the meds themselves causing this.
Dehydration and malnutrition
Dehydration and malnutrition are widespread in older people. Both can cause severe psychotic symptoms due to the lack of essential ingredients needed for the brain. Dehydration is common because older people often do not drink enough in case of incontinence. Malnutrition can be present in an obese person as well as a thin person.
Misreading of differences 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.
Lying relatives
Sometimes, relatives wish their ‘loved one’ to enter a home, so they make things up!! I have found this happens more often than we care to believe.
Epilepsy
Epilepsy that has developed after a mini-stroke can look and sound like psychosis when people are recovering from the fit.
Lifelong psychosis
Some older adults have had psychosis all their lives, but have lived without incident or medication. The psychosis just gets 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 older person who “suddenly” develops psychotic symptoms needs a full and thorough investigation before any such diagnosis.
Medication and psychosis
If they get a diagnosis, maybe due to organic psychosis (dementia), you must be alert to the medication given to them. Doctors who don’t consider the older person’s body’s inability to process the drug may accidentally prescribe too large a dose.
There are many ways to care for a person who has psychotic symptoms and is elderly, which do not involve medication at all. Too often, antipsychotic medication is given to stop a person from making distressing sounds or behaviour, such as undressing or screaming.
Antipsychotics are normally NOT advised for the elderly as they can lead to premature death. For example, Risperidone and Haloperidol have been banned for the elderly yet are still prescribed! If there is no other recourse but meds, then the dose must be extremely low as the older person will be grossly oversedated on a dose that a younger person could tolerate. Also, it can increase the psychotic symptoms! The medication 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 are necessary to assess the drug levels in the body as in older people, they often build up and are not processed as in the young.
A Tale of Green Mice
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!
The takeaway
Always check the truth before jumping to conclusions. If she had been younger, no-one would have jumped immediately to the conclusion she was psychotic.
About the Author
Calypso is a member of the Mental Health Forum Staff Team and a former Senior Nursing Sister for elderly people with complex needs.
Useful resources
Talk About Psychosis and Dementia
Next review due: 24 June 2024