Older patients with delusional disorder

[annoyedpsychiatrist]

Lately ive had quite the influx of older females (>65 years old) with delusional disorder (no other psychotic sx, pure delusions, no obvious medical etiology). These are quite hard to treat as you can imagine, due to low insight, questionable med compliance (i try to get family involved as much as possible) and poor response to antipsychotics vs other psychotic sx. Has anyone had any particular luck with a certain method or treatment? I see a large number of geriatric patients (probably over half my patient load) so ive been getting random cases like these.

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[Celexa]

What type of delusions?

I actually find somatic delusions to respond quite well to antipsychotics.

If it's paranoid delusions, particualrly if of infidelity, in a pt without a prior hx of psychotic symptoms, I've found that very often comes as part of dementia and much harder to treat. Can be challenging to sort out delusions from high anxiety/memory problems making someone look paranoid (and sometimes it's both).

 

[comp1]

What are the delusions? I haven't really conceptualized delusional disorder as something akin to schizophrenia. It's usually more like an anxiety disorder. You treat with a SSRI assuming there's no gross disorganization or hallucinations. If the delusions are about people stealing from them...you're headed towards dementia.

 

[annoyedpsychiatrist]

Paranoid delusions, not really somatic delusions. I have two very similiar cases that come to mind

Both patients 60s. One had paranoid delusions that her husband was putting speakers in her car, room, etc that would transmit a strange noise. She heard it at work, and then believed her boss was "in on it" so she quit her job (luckily theyre already wealthy anyways). No other psychotic sx. Well dressed, normal affect, highly intelligent. No memory issues, normal executive functioning. The random noise stopped a month ago (supposedly but she could be hearing it) but shes still convinced her husband installed speakers to make noises. Believed it would say stuff like "you should die" and "you wont make it" etc. With this it was delusions and AH i suppose, but very weird presentation. For a while the AH only occured in her bedroom, then her car, then stopped completely for the last month. no CAH. It was almost like a brief psychotic episode but lasted sesveral months.

Another lady in her 60s. Also very intelligent, sucessful, delusional disorder that again occured within the last year same as above. Shes paranoid people have infiltrated her savings account, and that people have hacked her phone/gps and will change her GPS while shes driving to mess with her. Other stuff too but thats the gist Has to use a uber to get to apts. Otherwise, normal memory/attention/intelligence, etc. No obvious medical causes. No possible way drugs could be an etiology. She has no AH/CAH.

Both have no prior psych hx, no obvious neuro findings, or medical causes. Normal attention/concentration/memory.

Neither have AVH (besides the first as mentioned above intermittently)/CAH.

 

[Sushirolls]

brain MRI showing anything?
EEG showing anything?
PSG check for OSA, skip HST.

MOCA? Neuropsych testing?

B vitamin labs?

Supplements?
Cannabis ... remember its a supplement not a drug! /sarcasm

Go for haldol. It works.

CAH abbreviation, what's that? command auditory hallucinations?

 

[Stagg737]

Has anyone had any particular luck with a certain method or treatment?

Neuropsych testing and appropriate imaging. What you're describing sounds like NCD-type delusions even without other confirmed problems.

No memory issues, normal executive functioning.

Otherwise, normal memory/attention/intelligence, etc. No obvious medical causes. No possible way drugs could be an etiology.

How do you know this for these patients? Patient report? Spouse report? They're at the right age where symptoms may be subtle and fairly innocuous even to a spouse who isn't highly attentive. I've had several similar consults come through where spouses didn't notice much difference but then kids would say stuff like "yea, we've noticed some little things with mom that just seem off". Highly intelligent and organized/efficient individuals can do a pretty dang good job hiding or coping with early deficits. Imo a neurocog work-up is a must for these people and can uncover surprising levels of impairment.

Also, the bold may be correct, but don't completely rule it out. I've been shocked more than once by patients I couldn't believe were using illicit substances. Never say never.

 

[Celexa]

Paranoid delusions, not really somatic delusions. I have two very similiar cases that come to mind

Both patients 60s. One had paranoid delusions that her husband was putting speakers in her car, room, etc that would transmit a strange noise. She heard it at work, and then believed her boss was "in on it" so she quit her job (luckily theyre already wealthy anyways). No other psychotic sx. Well dressed, normal affect, highly intelligent. No memory issues, normal executive functioning. The random noise stopped a month ago (supposedly but she could be hearing it) but shes still convinced her husband installed speakers to make noises. Believed it would say stuff like "you should die" and "you wont make it" etc. With this it was delusions and AH i suppose, but very weird presentation. For a while the AH only occured in her bedroom, then her car, then stopped completely for the last month. no CAH. It was almost like a brief psychotic episode but lasted sesveral months.

Another lady in her 60s. Also very intelligent, sucessful, delusional disorder that again occured within the last year same as above. Shes paranoid people have infiltrated her savings account, and that people have hacked her phone/gps and will change her GPS while shes driving to mess with her. Other stuff too but thats the gist Has to use a uber to get to apts. Otherwise, normal memory/attention/intelligence, etc. No obvious medical causes. No possible way drugs could be an etiology. She has no AH/CAH.

Both have no prior psych hx, no obvious neuro findings, or medical causes. Normal attention/concentration/memory.

Neither have AVH (besides the first as mentioned above intermittently)/CAH.

Is it at all possible the first case had real tinnitus which then intersected with some baseline paranoid traits?

I agree with other commenters that for both of these I would want to see at least basic neuro cognitive testing. It's shocking how long people can mask deficits and that second description in particular is highly suspicious for a pt experiencing cognitive problems searching for alternative explanations.

 

[TheRightMedication]

What are the delusions? I haven't really conceptualized delusional disorder as something akin to schizophrenia. It's usually more like an anxiety disorder. You treat with a SSRI assuming there's no gross disorganization or hallucinations. If the delusions are about people stealing from them...you're headed towards dementia.

I agree that anxiety is on the differential for these cases, but for the benefit of trainees who may be reading, let's be clear that a delusional disorder is in the broader category of psychosis and is treated with antipsychotics not SSRIs.

I've never seen a case of a delusional disorder with full resolution of their one well-circumscribed fixed false belief. At best there's more distance from the delusion, we go from hostility at the gentle refusal to validate the delusion to an agreement to disagree about what's real.

 

[clausewitz2]

I agree that anxiety is on the differential for these cases, but for the benefit of trainees who may be reading, let's be clear that a delusional disorder is in the broader category of psychosis and is treated with antipsychotics not SSRIs.

I've never seen a case of a delusional disorder with full resolution of their one well-circumscribed fixed false belief. At best there's more distance from the delusion, we go from hostility at the gentle refusal to validate the delusion to an agreement to disagree about what's real.

You do very rarely get a case like this that when you really dig into the phenomenology turns out to be much more like OCD and does actually resolve pretty well with SSRIs +/- ERP but that is definitely the exception.

EDIT: sometimes the differential is quite tricky:

Obsessive-compulsive disorder and delusions revisited - PubMed

The idea that these cases may represent a form of OCD has implications for management, as, if this is correct, they should be able to respond to appropriate behavioural and/or pharmacological strategies used in OCD.

pubmed.ncbi.nlm.nih.gov

 

[Celexa]

I agree that anxiety is on the differential for these cases, but for the benefit of trainees who may be reading, let's be clear that a delusional disorder is in the broader category of psychosis and is treated with antipsychotics not SSRIs.

I've never seen a case of a delusional disorder with full resolution of their one well-circumscribed fixed false belief. At best there's more distance from the delusion, we go from hostility at the gentle refusal to validate the delusion to an agreement to disagree about what's real.

Depends a little bit on what you mean by 'full resolution'. If meaning all the way to full insight that they held a delusional belief, I agree with you that is almost nonexistent. But in terms of full elimination/mitigation of the harms the delusion is causing on a day to day basis, or resolution of the perceptual disturbance (with regard to somatic delusion) I have seen patients make a remarkable recovery on antipsychotics. They're always worth trying if the patient will take them.

 

[Stagg737]

You do very rarely get a case like this that when you really dig into the phenomenology turns out to be much more like OCD and does actually resolve pretty well with SSRIs +/- ERP but that is definitely the exception.

EDIT: sometimes the differential is quite tricky:

Obsessive-compulsive disorder and delusions revisited - PubMed

The idea that these cases may represent a form of OCD has implications for management, as, if this is correct, they should be able to respond to appropriate behavioural and/or pharmacological strategies used in OCD.

pubmed.ncbi.nlm.nih.gov

Imo, a cousin to this is also PP-OCD. I saw it a couple of times in residency where a woman was admitted to the unit for "psychosis" a couple of weeks after giving birth which turned out to be PP-OCD. When the obsessive thoughts are disturbing enough to a sleep-deprived mind it can look a lot like psychosis. Plus side is that couple of nights of solid sleep and a good clinical interview can clear things up pretty easily.

 

[annoyedpsychiatrist]

i got collateral from families both times, extensively and talked to multiple family members. The second one I do partially suspect neurocognitive component in early stages (potentially some memory deficits but hard to tell) but i can barely get her to cooperate as it is due to low insight.

First one i believe had cognitive testing which was relatively normal. I did want her to see neurology but she never followed up with my request. Insight was also limited and she was someone who presented, then stopped coming, then randomly came back

Drug use i would say would be pretty low on differential unless they were masterminds at hiding it from family. Both have family that live with them which i had talked to initially and at various points.

Biggest issue really is insight which significantly limits compliance. That is really the biggest hurdle. I try to build a therapeutic alliance, but ultimately getting them to trial medications is like pulling teeth.