Psychiatry Research EG

Worldwide, the number of persons aged 65 years or older has increased from 17 million in 1900 to 342 million in 1992 and is expected to increase to 2.5 billion (comprising 20% of the total population) by 2050 [1]. In other words, the proportion of elderly people in this population will increase by 65%. In the next 30 years, life expectancy will increase markedly in western countries, and it is expected to increase further [2]. In Egypt, there is a marked increase in the proportion of elderly people in the population; according to ‘The Statistical Year Book 2009,’ [3] people above 60 years of age constitute 6% of the Egyptian population and this proportion is expected to reach 11.5% by the year 2025 with the mean life expectancy around 70.1 years [4]. Cases of late-life psychoses are increasing markedly as the population of the world ages, and this will create a tremendous economic burden on the society because of the increasing rates of disability and institutionalization [5]. It is worth mentioning that Khouzam et al. [6] reported that up to 23% of the elderly population will experience psychotic symptoms that may increase the suffering of patients, family, and caregivers [5]. There is a growing awareness that late-onset psychoses constitute a heterogenous group of serious disorders of a complex nature, which present in different forms with different etiologies [7,8]. These conditions include delusional disorders, induced psychotic disorders, lateonset schizophrenia, psychosis associated with dementia, mood disorders with prevailing psychotic symptoms, and others [9,10]; clinicians must remember the nonspecific nature of psychotic symptoms to avoid errors in diagnosis [11]. Controversy still surrounds the differential diagnosis of psychoses that begin late in life [12,13]. The nosology, classification, and biological basis of psychoses in the elderly have been much debated; primary and secondary psychotic disorders of late life and their etiology are commonly considered from the view point of risk factors such as genetic predisposition triggering life events and organic cerebral dysfunction [11]. In a recent study by Woolley et al. [13], a total of 28.2% of patients with a neurodegenerative disease received a prior psychiatric diagnosis of a psychotic nature, as neurodegenerative diseases are often misdiagnosed as psychiatric disorders. Late-onset schizophrenia refers to schizophrenia or a related disorder (schizoaffective, schizophreniform, or delusional disorder) with onset of prodromal symptoms after the age of 50 years [8]. According to Diagnostic and Statistical Manual of Mental Disorders (DSM)-III-R, the onset of symptoms, including prodromal symptoms, must be after the age of 45 years. DSM-IV, however, does not specify the term ‘late onset,’ nor does it set an upper age limit for the diagnosis of schizophrenia [9]. Although DSM-IV and DSM-IV-TR criteria do not include codeable diagnoses for late-onset schizophrenia, DSM-IV and DSM-IV-TR mention differences between cases of schizophrenia with onset after 50 years compared with those with earlier onset. Moreover, DSM-III-R included a late-onset category for patients with initial presentation at the age of 50 years or later [10]. Different studies suggest that there are specific risk factors for late-onset schizophrenia that could be identified; these include female sex, visual, auditory sensory impairments, and premorbid schizoid personality [7]. In Egypt, with the increased longevity of life and the change in family system toward a nuclear one, together with the increased medical, psychiatric, and behavioral problems in the aged population, there is a great necessity to have carefully designed plans for mental health promotion of the elderly [14]. There is clearly an enormous need to clarify the clinical characteristics and range of dysfunction in cases of late-onset psychoses to streamline treatment recommendation for the already complex and vulnerable elderly population, aiming to minimize the cost of these devastating disorders through early recognition and fast intervention.