Diagnostic Clues in the Look for the diagnosis of atypical psychosis in the

GERI RICHARDS HALL KATHLEEN C. BUCKWALTER

/ ~ 11 too often, it is assumed that ~ elders who show signs ofcon- .g. .lkfusion are suffering from de- mentia with an organic cause, such as Alzheimer's disease, or from delu- sional depression. But such prema- ture solutions preempt the possibili- ty of a treatable, reversible disorder.

Assessing alterations in thought process in the older adult is a com- plex challenge much like unraveling a mystery. Besides looking for physi- ological explanations, the nurse can

Geri Richards flail, RN, MA, is a gerontology clinical nursing specialist at the University of Iowa Hospitals and Clinics in Iowa City. Ms. Hall is a consultant on geriatric mental health problems. Kathleen C. Buck~alter, RN, PhD, is a professor at the University of Iowa College of Nursing in Iowa City. Dr. Buckwalter is a consultant to the Abbe Center for Community Mental Health in Cedar Rapids, IA, and has developed a geropsychiatrie outreach program for the rural elderly.

search for clues throughout the pa- tient's life. I n the life-span assess- ment, the nurse interviews the client to examine his behavior patterns and perception of life events.

With Mr. Col, life-span assess- ment was successful when other means of diagnosis failed. Mr. Cof, a 72-year-old retired janitor, lived with his wife in a small midwestern indus- trial city. His family reported that he

• had been well until about 18 months before admission, when he first com- plained that a cult was after him. Ten months later, Mr. Cof had visited a psychiatrist who prescribed haloper- idol (Haldol) 3 mg/day. When the symptoms subsided, Mr. Cof stopped the medication.

As winter approached, his symp- toms recurred. The medication was restarted at 4 mg/day, without effect, then increased to 6 mg/day. This, too, was ineffective, and in late win- ter Mr. Cofwas hospitalized on a psy- chiatric unit.

His family spoke of a gradually progressive mental health distur- bance, consisting of an extensive ar- ray of delusions based on the notion that his brother-in-law had hired a re- ligious cult to persecute and murder him. The "harrassment" he suffered took the following forms: Visual halhtcinations. The cult was shining deadly ultraviolet lights into his home, and showing pictures that his wife could not see. Olfactory halhtcinations..The cult was trying to smoke him out of his home and other places using smoke bombs that produced thick, black, choking smoke. Auditory halhtcinations. Mr. Cofs deceased sister supposedly had com- posed a tape recordingofall"bad and dirty" events of his life from 19 to 72 years old. He further believed that his brother-in-law had given the tape to the cult, who played it over the radio and elsewhere to discredit him. He also heard a woman begin to sing the

202 Geriatric Nursing July/Augus-g't-1989

Past lder's history.

tape outside his window. Persecutory delusions and ideas of reference. Mr. Cof believed the cult was leaving tracks in the snow around his house after spying on him. He accused the cult of placing transmitters, microphones, and two- way mirrors in his house and of re- porting him to the FBI, who would punish him for "all sorts of things." Fearful of his impending murder, Mr. Cofdemanded that his family ac- company him to shopping malls to negotiate a payment with cult mem-

• bers to stop the harrassment. On admission, Mr. Cof wore a

clean shirt and overalls but appeared disheveled. He seemed to be sad, but was pleasani, alert, and oriented. He cooperated with all requests and smiled when answering questions.

During the admission assessment, Mr. Cof complained of episodes of shortness of breath, racing heart, al- tered sleep patterns, fatigue, and weight loss. He also worried about

memory loss; however, his mental examination was normal. When asked about current events, he be- came slightly confused. Reflexes and extremity strength were normal ex- cept for the presence of a snout reflex, in which the top lip and nose curl up when the nose is touched. This facial reflex can be an early neurological sign in dementia.

Mr. Cof complained of"rheuma- tism" in his hips, back, and knees causing discomfort and limiting function. He had a severe hearing loss only partly compensated by bi- lateral hearing aids. He denied visual problems and wore glasses only to read.

Blood pressure was 160/98; apical pulse was 68 and regular. A cardiac murmur was detected. Mr. Cofcom- plained of dull chest pain on exertion for about one year's duration. His lungs were dear.

Mr. Cofs social and psychological history were not immediately en- lightening. He and his wife of 49 years had three healthy adult chil- dren, all of whom lived nearby, were married and had families, worked full time, and visited their parents weekly:When asked if anyone in his family had a history of mental health problems, Mr. Cofsaid no.

First, the Psychiatric Diagnosis

From the assessment, it was evi- dent that Mr. Cofs problems were very complex. His complaints of memory loss, slight confusion, and the return of primitive facial reflexes suggested dementia, and this, was consistent with his CT scan, demon- strating cortical atrophy typical of dementia. However, mental status examinations and psychological test- ing did not confirm the dementia di- agnosis, but instead suggested Mr. Cofs problems were psychiatric.

Delirium also was excluded, as Mr. Col did not demonstrate any acute pathophysiological changes suffi- cient to alter brain perfusion or me- tabolism. This was validatcd by his history of a slow, insidious onset of mental status changes.

Mr. C o f s anorexia, weight loss, anxiety, and morbid ideations sug- gested a psychotic depression; how- ever, he lacked typical features of de- pression, such as loss of affect, sleep disturbances, and a sense of guilt. Moreover, he did not respond to any of the standard treatments for de-

pression. This presented further di- agnostic problems because, while his multimodal hallucinations indicated schizophrenia, this condition rarely presents itself for the first time in lat- er life.

Is It Paraphrenia?

The differential diagnosis of para- noid disorders in later life is difficult. Nevertheless, it is important to dis- tinguish among chronic schizophre- nia persisting into later life, dementia or delirium with persecutor5' delu- sions, and paraphrenia.

Some clinicians and researchers have identified a "burnout" phe- nomenon among schizophrenics in old age: The elderly patient no longer presents with typical schizophrenic symptoms but may have more affcc- rive and paranoid manifestations. Some elderly schizophrenics experi- ence continued psychotic symptoms, remaining stable but impaired, while others have only intermittent re- lapses of psychotic symptoms.

Many demented or delirious elder- ly also present with persecutory delu- sions, among the most common be- ing delusions of theft, which result in troublesome accusations of family members or other carcgivers(1).

Very little is currently known about the etiology ofparaphrenia, al- though genetic, epidemio!ogie, and developmental factors are all under investigation. It is known that pa- raphrenia is not characterized by a clouded sensorium, as is delirium, nor by progressive cognitive impair- ment, as are dementias.

"Late onset paraphrenia" differs from schizophrenia in that the his- tory is one of better functioning in adulthood with decompensation be- ginning in the late 50s or 60s(2). Pa- raphrenia is much more common in women than men.

Although the premorbid personal- ities of late-onset paraphrenics are usually healthier than those of classic schizophrenics, many paraphrenics have premorbid schizoid or eccentric personality traits with tendencies to- ward suspiciousness, oversensitivi- ty, and social isolation(3). Delusions occur in the context of a normal af- fective response and, most impor- tant, while the sensorium is clear and cognitive fimctioning good.

Between 20 and 40 percent of all late-onset paraphrenics have a signif- icant hearing impairment that may

I L

I

Gerialric Nursing July/August 19S9 203

contribute to the onset of their pa- thology(4). Hallucinations, if there are any, are consistent with a para- noid theme, and auditory hallucina- tions are the most common.

The prognosis in late-onset pa- raphrenia is quite good, with about 70 percent of these patients showing resolution or attenuation of the psy- chosis with appropriate doses of such antipsychotic medications as halo- peridol (Haldol)(5).

Based on all these diagnostic con- siderations, Mr. Cof was diagnosed to have atypical psychosis due to a dementing process.

The 'Right' Interventions Fail

The nursing diagnosis of altera- tions in thought process due to pro- gressive cognitive decline (dementia) was determined, but the consequent interventions were not successful. Mr. Cof's morbid delusions and hal- lucinations continued.

The nursing staff then introduced interventions designed to increase self-esteem in clients with psychotic depression. These, too, were unsuc- cessful: Mr. Cofstill avoided contact with others, remaining firmly con- vinced of his paranoid ideations. The nursing staff held a clinical confer- ence and decided to consult the ger- iatric nurse practitioner, who deter- mined that additional information was needed regarding Mr. Co£s val- ues, life patterns, and self-esteem, all ofwhieh pointed to a life-span assess- ment.

Life-span assessment helps to identify psychological problems in elders because it allows the nurse to gather information in a relaxed man- ner, conveying interest and concern to the client, thereby establishing a basis for trust. It also allows the client to relate present events to past expe- riences and uses reminiscence to en- hance self-esteem.

In a life-span assessment, ques- tions about childhood, school, mar- riage, jobs, and so on are modified for each situation. All of the client's an- swers are explored, giving him the maximum opportunity to provide insight and rationale for events and paths he has chosen. The interview works best if the nurse can isolate the client in a quiet, comfortable area where they will not be interrupted. If the client tends to become confused or fatigued, it is best to conduct the interview in the morning.

Clues from the Past

Mr. Cofwas born and raised on a small family farm near his present home. Shortly after birth, his mother underwent surgery for a goiter and "her nerves were never right after that." Mr. Cof was therefore raised by his eldest sister and stern father. He completed the twelfth grade, but said he could not then choose what to do after graduation. Mr. Cof's father told him, at the age of 21, that he must decide what to do with his life.

Life-Span Assessment 1. Are you a native of (town currentlyresid- ingin)?. Where were you born and raised? What did your parents do? Tell me about your family when you were growing up. 2. How far did you go in school? Why did you stop? What did you do after school? Why? Did you enjoy it? 3. How did you meet your spouse? What made him/her special? How did you de- cide to marry? Tell me about your early marriage. Was it an enjoyable time in your life? When did your children come along? How did that affect your relationship with your spouse? Your career? 4, What jobs did you hold during your ca- reer? Were they rewarding? Did they af- fect your family or social life? How did you relax? 5, When did you decide to retire? Has that been a difficult adjustment? What do you do to keep yourself busy when you are well? Does that satisfy you? Has retire- ment changed your relationships with your spouse? Family? Friends? 6. Have you had any special problems or losses throughout your life? How have you dealt with them?

Just to make a decision, Mr. Cofwent into farming, and courted and mar- ried a local woman.

He and his wife rented a farm in a nearby town. After several bad years, they were forced to leave the farm and return to Mr. Cofs home town. He wanted his father's farm, but had a disagreement with a brother and did not inherit it.

Mr. Cof then took a job digging graves and earing for gravesites. In the interview, he described this as the worst period of his life. He did not speak of interaction with his wife and children during this period, but he re- called the exact number of graves he had dug.

He blamed his brother for his un- happy situation. After several years, he found a job as a janitor at a power plant, where he worked the night shift until he retired.

Mr. Cofhad no hobbies. He didn't

enjoy reading or watching TV. Other than family visits and his weekly card games at the lodge, his only pastime was working in his yard. Mr. Cofsaid that his one regret following retire- ment was not having built a window- less structure in his back yard where he could be alone.

Mr. Cof said he saw no difficulty returning home without any plans or activities, even though he had no re- lief from the auditory, visual, and ol- factory hallucinations that had driv- en him to seek admission to the psy- chiatric unit. He said, revealingly, that he had experienced these prob- lems since age 19.

The assessment uncovered signifi- cant signposts in Mr. Cof's past that pointed to present problems. For ex- ample, a history of family mental health problems was possible, as in- dicated by his mother's "nervous dis- order." His comments and work his- tory also evidenced an inability to in- teract well with others.

The most significant factor, though, was his admission that he had experienced psychiatric symp- toms since the age of 19. This finding explained the persistent hallucina- tions and was consistent with reports in the literature of psychosis exacer- bated with hearing loss.

Based on life-span assessment data, the medical and nursing staff decided to treat Mr. Cofas if he suf- fered from chronic schizophrenia. He was placed on thioridazine (Mel- laril), a low-potency antipsychotic medication, and a new nursing care plan consistent with this etiology was started. Within one week, Mr. Col was sufficiently improved to be dis- charged to home. He no longer has hallucinations or delusions. Months after discharge, both patient and family are doing well.

References 1. Beck, C., and tteacock, P. Nursing interventi6ns

for patients with Alzheimer's disease, A'urs.Clin.A'orth Am. 23:95-124 March 1988, p. 111.

2. SmalI, G. W.,and Jarvik, L. R. Paranoid disorders in the aged. In Psychiatr.Clin.North Am., cd. by L. F. Jarvik and Q. W. Small. 5:119-129o April 1982.

3. Varner, R. V., and Gaitz, C. M. Schizophrenic and paranoid disorders in the aged. Psy- chiatr.Clin.North Am. 5:107-118, Apr. 1982.

4. Whanger, A. D. Paranoid and schizophrenic disor- ders. In Mental llealth Assessment attd Therapeut- ic Invervention with Older Adltlls. ed. by A. D. Whanger and others. Rockville, MD, Aspen Pub- lishing Co. 1984, p. 97.

5. Raskind, M. A., and others. Fluphenazine enan- thate in the outpatient treatment of late paraphre- nia. J.Am.Gcriatr.Soc. 27:459-463, Oct. 1979.

204 Geriatric Nursing July/August 1989