Psych · Old age psychiatry — psychosis
Late-onset psychosis
Also known as Very late-onset schizophrenia-like psychosis · VLOSLP · Late-onset schizophrenia · Late paraphrenia · Late-life psychosis · Geriatric psychosis
Exam-exhaustive fellowship reference on late-onset and very late-onset schizophrenia-like psychosis (LOS/VLOSLP) — Howard consensus age cut-offs; phenomenology including partition delusions; organic work-up and neuroimaging; differentials of dementia (including DLB), delirium, and affective psychosis; sensory impairment; antipsychotic start-low-go-slow with dementia mortality/stroke cautions; RANZCP and NICE framing. FRANZCP-primary, globally tagged.
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Target exams
Red flags
- First psychotic episode after midlife — treat as organic until work-up is complete; do not label 'late schizophrenia' on history alone
- Fluctuating attention or acute confusion — delirium pathway first, not community antipsychotic titration
- Visual hallucinations plus REM sleep behaviour, fluctuating cognition, or parkinsonism — suspect dementia with Lewy bodies; avoid typical antipsychotics
- Persecutory acting-out, weapons, fire risk, or severe self-neglect — urgent risk management and legal status review
- Suspected or confirmed dementia and antipsychotic planned — document stroke and mortality risk, target symptom, dose, and review date
- New severe rigidity, fever, autonomic instability after antipsychotic — consider NMS; stop agent and medical emergency pathway
Meet the patient
An 82-year-old widow who lives alone has called the police eleven times this month. She is certain the upstairs neighbour is pumping gas through her ceiling and touching her at night. She has not worn her hearing aid since her husband died, and the upstairs flat has been empty for a year.[9][10]
Her GP has started quietiapine 25 mg at night and asked the memory clinic to see her in eight weeks. Nobody has checked her observations, her sodium, her hearing or her brain.[3][4]
Two exam questions are live. Is this primary late-onset schizophrenia, or is something driving it? And what is the single most dangerous prescribing decision in this patient? Everything below answers both.[1][3]
References18ShowHide
- [1]Howard R, Rabins PV, Seeman MV, Jeste DV Late-onset schizophrenia and very-late-onset schizophrenia-like psychosis: an international consensus. The International Late-Onset Schizophrenia Group Am J Psychiatry, 2000.PMID 10671383
- [2]Suen YN, Wong SMY, Hui CLM, Chan SKW, et al. Late-onset psychosis and very-late-onset-schizophrenia-like-psychosis: an updated systematic review Int Rev Psychiatry, 2019.PMID 31599177
- [3]Devanand DP, Jeste DV, Stroup TS, Goldberg TE Overview of late-onset psychoses Int Psychogeriatr, 2024.PMID 36866576
- [4]Kim K, Jeon HJ, Myung W, Suh SW, et al. Clinical Approaches to Late-Onset Psychosis J Pers Med, 2022.PMID 35330384
- [5]Fischer CE, Namasivayam A, Crawford-Holland L, Hakobyan N, et al. Psychotic Disorders in the Elderly: Diagnosis, Epidemiology, and Treatment Psychiatr Clin North Am, 2022.PMID 36396273
- [6]Yang VX, Sin Fai Lam CC, Kane JPM Cognitive impairment and development of dementia in very late-onset schizophrenia-like psychosis: a systematic review Ir J Psychol Med, 2023.PMID 34187604
- [7]Kanemoto H, Satake Y, Suehiro T, Taomoto D, et al. Characteristics of very late-onset schizophrenia-like psychosis as prodromal dementia with Lewy bodies: a cross-sectional study Alzheimers Res Ther, 2022.PMID 36138485
- [8]Colijn MA, Nitta BH, Grossberg GT Psychosis in Later Life: A Review and Update Harv Rev Psychiatry, 2015.PMID 26332218
- [9]Howard R, Almeida O, Levy R Phenomenology, demography and diagnosis in late paraphrenia Psychol Med, 1994.PMID 8084935
- [10]Prager S, Jeste DV Sensory impairment in late-life schizophrenia Schizophr Bull, 1993.PMID 8303225
- [11]Scott J, Greenwald BS, Kramer E, Shuwall M Atypical (second generation) antipsychotic treatment response in very late-onset schizophrenia-like psychosis Int Psychogeriatr, 2011.PMID 21118614
- [12]Schneider LS, Dagerman KS, Insel P Risk of death with atypical antipsychotic drug treatment for dementia: meta-analysis of randomized placebo-controlled trials JAMA, 2005.PMID 16234500
- [13]Schneider LS, Dagerman K, Insel PS Efficacy and adverse effects of atypical antipsychotics for dementia: meta-analysis of randomized, placebo-controlled trials Am J Geriatr Psychiatry, 2006.PMID 16505124
- [14]Sultzer DL, Davis SM, Tariot PN, Dagerman KS, et al. Clinical symptom responses to atypical antipsychotic medications in Alzheimer's disease: phase 1 outcomes from the CATIE-AD effectiveness trial Am J Psychiatry, 2008.PMID 18519523
- [15]Jeste DV, Blazer D, Casey D, Meeks T, et al. ACNP White Paper: update on use of antipsychotic drugs in elderly persons with dementia Neuropsychopharmacology, 2008.PMID 17637610
- [16]Castle DJ, Galletly CA, Dark F, Humberstone V, et al. The 2016 Royal Australian and New Zealand College of Psychiatrists guidelines for the management of schizophrenia and related disorders Med J Aust, 2017.PMID 28918734
- [17]Kuipers E, Yesufu-Udechuku A, Taylor C, Kendall T Management of psychosis and schizophrenia in adults: summary of updated NICE guidance BMJ, 2014.PMID 24523363
- [18]Ray WA, Chung CP, Murray KT, Hall K, et al. Atypical antipsychotic drugs and the risk of sudden cardiac death N Engl J Med, 2009.PMID 19144938