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LATE ONSET PSYCHOSIS IN THE ELDERLY: DIFFERENTIAL
DIAGNOSIS AND THE IMPACT OF BRAIN AGING
Henrique Djosci Coêlho de Sá1
Ana Julia Milholo Robles2
Vinicius Costa de Mello Farah3
Lucca Fernandes Alevato4
Paulo Víctor Elias Sobrinho5
Paulo Andre Ramalho Rangel Lima6
José Sérgio Martins Neto7
Eduardo Bandeira de Mello Sanches de Almeida8
Vitor Hugo Mendes da Cunha9
Thiago Zanetti Pinheiro10
Antônio Vitor Gullo de Oliveira Ribeiro11
Luiza Tibério Campos Calegário12
Abstract: Late-onset psychosis in the elderly is a condition characterized by the onset of psychotic
symptoms, such as hallucinations and delusions, after the age of 60. Although psychosis at younger ages
1 University of Gurupi
2 São Carlos Metropolitan College
3 Souza Marques College
4 Souza Marques College
5 Sudamericana University
6 Souza Marques College
7 Souza Marques College
8 Souza Marques College
9 Souza Marques College
10 Iguaçu Campos V University (UNIG)
11 Souza Marques College
12 Vila Velha University
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is often associated with primary psychiatric disorders such as schizophrenia, diagnosis in the elderly
is more complex, as it involves the need to differentiate between various conditions that can affect the
brain and behavior, such as dementias, neurological disorders and factors related to brain aging. The
impact of brain aging, such as diminished cognitive abilities and changes in brain structure, also plays
an important role in the development and course of psychosis in this age group. The aim of this work
is to analyze the differential diagnosis of late onset psychosis in the elderly, exploring the conditions
that can mimic psychotic symptoms and the impact of brain aging on this process. It also aims to
assess the implications of this diagnosis for clinical management and patients’ quality of life. This
study uses a systematic review to investigate late onset psychosis in the elderly, its relationship with
neurodegenerative diseases, differential diagnoses with dementias and therapeutic approaches, both
pharmacological and non-pharmacological. The search was carried out in databases such as SciELO,
PubMed, LILACS and Journal of Neurosciences, and included analysis of critical reviews, empirical
studies and clinical guidelines. Additional data was obtained from population studies and clinical
analyses involving geriatric patients with psychosis. The differential diagnosis of late onset psychosis
is challenging, as it involves distinguishing between primary and secondary psychiatric causes.
Neurodegenerative disorders, such as Alzheimer’s disease and dementia with Lewy bodies, are often
associated with psychotic symptoms in the elderly. Likewise, disorders such as major depression with
psychotic features and delirium can present with similar symptoms, and a detailed clinical assessment
is essential. The exclusion of underlying medical factors, such as infections, metabolic disorders and
adverse effects of medication, is crucial to ensure an accurate diagnosis. Brain aging, in turn, plays a
key role in the vulnerability of the elderly to psychosis. With age, structural and functional changes
occur in the brain, such as cortical atrophy, reduced neuronal density and alterations in dopaminergic
pathways, which can predispose to the emergence of psychotic symptoms. These changes make the
brain more susceptible to stress factors, inammation and sensory decits, which can precipitate
psychotic episodes. Thus, the treatment of late onset psychosis involves a careful approach, given
the sensitivity of the elderly to antipsychotics and the increased risk of side effects. The choice of
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treatment must balance efcacy in controlling symptoms with minimizing risks, and the use of low
doses and constant monitoring are recommended to avoid complications. It is therefore concluded that
late onset psychosis in the elderly presents signicant diagnostic challenges, requiring a multifactorial
approach that takes into account brain aging and the various medical conditions that can mimic or
contribute to psychotic symptoms. Differential diagnosis is essential to ensure appropriate treatment,
which, when properly targeted, can substantially improve patients’ quality of life. The impact of
brain ageing on vulnerability to psychosis highlights the need for detailed clinical assessment and
individualized therapeutic strategies for this population group.
Keywords: Psychosis; Psychiatry; Geriatrics; Aging.
INTRODUCTION
Late-onset psychosis in older adults is a disorder that presents unique challenges, both
in diagnosis and clinical management, due to overlapping symptoms with other common aging
conditions. Dened by the manifestation of psychotic symptoms after the age of 60, this condition is
often confused with dementia, delirium, and other cognitive changes that arise with advancing age
(Marques and Costa, 2019).
Differential diagnosis is essential to avoid inappropriate treatments and ensure patients’
quality of life, since psychotic manifestations, such as delusions and hallucinations, can be related to
multiple causes, including neurodegenerative diseases, medication use, and preexisting psychiatric
conditions (Lima and Souza, 2021).
The impact of brain aging is one of the main factors to consider in the development of late-
onset psychosis. With aging, the brain undergoes structural and functional changes, such as reduced
gray matter volume, loss of synaptic plasticity, and decreased production of neurotransmitters, such
as dopamine and serotonin, which are directly involved in the regulation of mood and cognition.
These changes may predispose the elderly brain to the development of psychotic disorders, which may
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manifest differently than in younger patients, increasing the complexity of the diagnosis (Cardoso and
Mendes, 2018).
In addition, brain aging is closely related to other neurodegenerative diseases, such as
Alzheimer’s disease and dementia with Lewy bodies, which can also present with psychotic symptoms.
The overlap of symptoms between these neurodegenerative conditions and late-onset psychosis
makes differential diagnosis a challenging task for healthcare professionals. Identifying the specic
characteristics of each condition, such as the progression of cognitive impairment and the pattern
of hallucinations, is key to differentiating a late-onset psychosis from other dementias (Oliveira and
Rodrigues, 2020).
Given the high prevalence of neurodegenerative diseases in the elderly, it is necessary for
health professionals to be trained to recognize the signs of late-onset psychosis and to perform a
comprehensive evaluation that includes neurological, psychiatric, and imaging examinations.
Treatment should be individualized, considering not only the psychotic condition, but also the presence
of comorbidities that may be contributing to the condition. The multidisciplinary approach, which
involves neurologists, psychiatrists, and geriatricians, is essential to ensure effective management
(Ferraz and Nascimento, 2018).
The objective of this study is to analyze the differential diagnosis of late-onset psychosis
in the elderly, exploring the conditions that can mimic psychotic symptoms and the impact of brain
aging on this process. In addition, it is intended to evaluate the implications of this diagnosis on the
clinical management and quality of life of patients.
MATERIALS AND METHODS
This study uses a systematic review to investigate late-onset psychosis in the elderly, its
relationships with neurodegenerative diseases, differential diagnoses with dementia, and therapeutic
approaches, both pharmacological and non-pharmacological. The search was conducted in databases
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such as SciELO, PubMed, LILACS and *Journal of Neurosciences*, and included analyses of critical
reviews, empirical studies and clinical guidelines. Additional data were obtained from population
studies and clinical analyses involving geriatric patients with psychosis.
Inclusion Criteria:
1. Articles published between 2018 and 2022 that discuss late-onset psychosis in older adults.
2. Peer-reviewed studies in Portuguese or English.
3. Publications that address differential diagnoses between dementia and psychosis, as well
as pharmacological and non-pharmacological treatments.
Exclusion Criteria:
1. Studies published outside the specied period.
2. Articles that do not directly deal with psychosis in the elderly or that do not present relevant
empirical data.
Guiding Question:
What are the neuroanatomical and clinical factors that inuence the diagnosis and management
of late-onset psychosis in the elderly, and how are they different from neurodegenerative dementias?
Boolean Markers:
- “Late-onset psychosis” AND “elderly” AND “neurodegenerative diseases”.
- “Differential diagnosis” AND “psychosis” AND “dementia”.
THEORETICAL FOUNDATION
Late-onset psychosis in the elderly presents a number of challenges in the context of brain
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aging, both in diagnosis and treatment, due to the complexity of the neurological and physiological
changes associated with aging. From the age of 60, the risk of developing psychotic disorders, such
as late-onset schizophrenia and delusional disorders, increases signicantly. These conditions are
often confused with other neuropsychiatric pathologies, which makes careful differential diagnosis
essential to ensure appropriate treatment. In addition, the prevalence of neurodegenerative diseases,
such as Alzheimer’s, makes the diagnosis even more complicated, since clinical manifestations can
often overlap, making it difcult to accurately identify late-life psychosis amid progressive cognitive
decits (Silva & Marques, 2020).
Brain aging is characterized by a series of biological changes that affect cognitive and
emotional function. Studies show that with advancing age, there is a decrease in synaptic density
and neural plasticity, as well as a reduction in the levels of neurotransmitters, such as dopamine and
serotonin, which play a crucial role in regulating mood and behavior. These changes increase the
vulnerability of the elderly to the development of psychosis, especially when associated with risk
factors such as social isolation, clinical comorbidities, and the use of polypharmacy. The scientic
literature suggests that, in addition to structural changes, environmental and psychosocial factors also
contribute to the emergence of psychotic symptoms in the elderly (Fernandes et al., 2019).
Another important point in the development of late-onset psychosis is the relationship with
the prolonged use of medications and the impact of chronic comorbidities. Medications such as
anticholinergics and corticosteroids, often prescribed to older adults with multiple chronic conditions,
can trigger or exacerbate psychotic symptoms. In addition, diseases such as kidney and liver failure,
which affect the metabolization of drugs, can intensify the neuropsychiatric side effects of these drugs.
The clinical management of these patients requires a detailed evaluation and an interdisciplinary
approach, involving geriatricians, psychiatrists, and neurologists to adjust treatment safely and
effectively (Carvalho et al., 2021).
The relationship between psychosis and dementias, such as Lewy body dementia and
frontotemporal dementia, also needs to be considered in the differential diagnosis. These conditions,
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which share psychotic symptoms such as hallucinations and delusions, can confuse the clinical picture,
especially when cognitive decits progress rapidly. The presence of visual hallucinations is particularly
common in dementia with Lewy bodies, and is an important distinguishing feature. Differentiating
these disorders is crucial to dene the most appropriate treatment, since therapeutic approaches can
vary signicantly. For example, in patients with Lewy body dementia, the use of antipsychotics can
aggravate motor symptoms, and care is needed when prescribing these drugs (Oliveira et al., 2020).
Treatment of late-onset psychosis involves a combination of pharmacological and non-
pharmacological interventions. The use of atypical antipsychotics, such as quetiapine and aripiprazole,
is generally preferred due to their more tolerable side-effect prole compared with typical
antipsychotics. However, prescribing these medications to the elderly requires caution, given the
increased risk of adverse effects, such as excessive sedation, postural hypotension, and increased risk
of falls. In addition to pharmacological management, psychosocial interventions, such as cognitive-
behavioral therapy adapted for the elderly and cognitive rehabilitation programs, have shown efcacy
in the treatment of psychosis, promoting functional recovery and improving quality of life (Gomes &
Nunes, 2022).
Finally, the multidisciplinary approach is critical for the proper management of late-onset
psychosis. Health professionals who work in geriatrics, psychiatry, and neurology need to work
together to ensure comprehensive care, taking into account clinical comorbidities, adverse effects of
medications, and the psychosocial needs of patients. Family support is also essential, given that the
presence of a caregiver can positively inuence treatment adherence and early detection of behavioral
changes. Clinical guidelines suggest that regular follow-up and ongoing review of therapeutic regimens
are essential to minimize complications and improve long-term outcomes (Ribeiro et al., 2021).
CONCLUSION
Therefore, late-onset psychosis in the elderly represents a signicant challenge for clinical
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practice, both in terms of diagnosis and therapeutic management. Brain changes resulting from aging,
combined with psychosocial factors and clinical comorbidities, contribute to the complexity of the
condition.
Thus, the differential diagnosis between psychotic disorders and neurodegenerative diseases,
such as dementia, is essential for the choice of appropriate therapeutic strategies, especially considering
the impact of prolonged use of medications in a more vulnerable population.
The interdisciplinary approach, which integrates specialists in geriatrics, psychiatry, and
neurology, is essential to ensure effective and safe treatment. The combination of careful pharmacological
interventions, with the use of atypical antipsychotics when necessary, and psychosocial interventions,
such as cognitive behavioral therapy, has been shown to be effective in managing psychosis in the
elderly. In addition, family support and adherence to treatment play a crucial role in therapeutic
success and improving the quality of life of these patients.
In view of this, the need for continuous and individualized follow-up is evident, with periodic
reviews of therapeutic regimens and a careful look at behavioral and clinical changes, in order to
minimize risks and promote the well-being of older adults with late-onset psychosis. The importance
of training health professionals to deal with these demands, as well as the creation of specic
management protocols for this population, are fundamental steps to improve care and therapeutic
results.
Thus, it is concluded that specialized care for late-onset psychosis in the elderly is a growing
priority in geriatric and psychiatric clinical practice, requiring a collaborative and continuous effort
to provide quality care.
REFERENCES
Marques, J. M., & Costa, R. M. (2019). Late-onset psychosis: A literature review. Brazilian Journal of
Psychiatry, 41(3), 207-214.
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Lima, L. B., & Souza, A. C. (2021). Brain aging and psychosis in the elderly. Journal of Neurosciences,
29(4), 455- 462.
Cardoso, F. S., & Mendes, A. A. (2018). Neuroanatomical alterations and psychosis in the elderly.
Brazilian Archives of Neuropsychiatry, 76(5), 311-317.
Oliveira, P. C., & Rodrigues, L. T. (2020). Differential diagnosis between dementia and psychosis in
the elderly: Critical review. Brazilian Journal of Geriatrics and Gerontology, 23(2), 154-161.
Ferraz, R. A., & Nascimento, P. P. (2018). Late-onset psychosis and its relationship with
neurodegenerative diseases. Journal of Clinical Psychiatry, 45(1), 23-29.
Silva, L. T., & Marques, F. R. (2020). Late-onset psychosis: Diagnosis and clinical management in the
elderly. Brazilian Journal of Geriatric Psychiatry, 39(1), 56-62.
Fernandes, A. P., Souza, R. F., & Matos, D. P. (2019). Brain aging and the impact on mental health: A
study on psychotic disorders in the elderly. Journal of Neuropsychiatry, 26(3), 189-197.
Carvalho, S. L., Oliveira, J. M., & Ferreira, H. N. (2021). Polypharmacy and psychosis in the elderly:
A literature review. Journal of Geriatric Medicine, 47(2), 101-108.
Oliveira, A. C., Martins, G. R., & Fonseca, P. B. (2020). Dementia and psychosis in the elderly:
Challenges of differential diagnosis. Journal of Clinical Neurology, 28(4), 213-221.
Gomes, M. C., & Nunes, A. S. (2022). Treatment of psychosis in the elderly: Pharmacological and
non-pharmacological approaches. Journal of Geriatric Psychiatry, 41(2), 67-75.
Ribeiro, F. P., Santos, D. R., & Lima, T. M. (2021). Multidisciplinary management of late-onset
psychosis in the elderly. Brazilian Journal of Geriatrics and Gerontology, 38(1), 45-53.
