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EV1245

New-onset psychosis in older adults: a case illustrating diagnostic complexity

NEW-ONSET PSYCHOSIS IN OLDER ADULTS: A CASE HIGHLIGHTING DIAGNOSTIC COMPLEXITY

Preserved cognition in late-onset psychosis does not exclude secondary causes; vascular and sensory contributions should continue to be actively assessed in the differential diagnosis.

The aim of this case report is to illustrate the complexity of evaluating potentially overlapping etiologies of psychosis in an older adult; late-onset psychosis requires distinguishing primary psychiatric disorders from neurodegenerative disease, mood disorders, cerebrovascular pathology, and sensory impairment. An 82-year-old woman was assessed by the psycho-oncology service for progressive auditory hallucinations over three years; indistinct voices within music gradually developed into daily third-person running commentary and dialogues between a hostile female voice and a protective male voice. Although distressing, the symptoms partially subsided in the presence of an external sound source or when the patient left home. The clinical presentation included a persecutory delusion of being watched, a somatic delusion that a device had been implanted in her body, and a previous auditory hallucination commanding her to harm herself, while cognition remained largely preserved (MoCA 26/30) and daily functioning was maintained. The assessment addressed chronology, phenomenology, safety, cognition, functioning, sensory impairment, and medical and neurological contributions; neuroimaging revealed lacunar infarcts, microangiopathic changes, and microbleeds, and hearing loss was also identified. No single finding was diagnostic; preserved cognition reduced the likelihood of major neurocognitive disorder, while vascular changes and hearing loss made secondary explanations plausible. Although complex auditory hallucinations involving third-person running commentary, persecutory beliefs, and a somatic delusion supported a primary psychotic disorder such as very late-onset schizophrenia-like psychosis (VLOSLP), onset after age 60 necessitates investigation for secondary causes. The differential diagnosis considered VLOSLP, vascular contributions, major neurocognitive disorder, and sensory deprivation hallucinosis together. The report ultimately emphasized that late-onset psychosis requires careful clinical assessment and neuroimaging, and that diagnosis should be based not on a single feature but on an integrated consideration of chronology, cognition, functioning, sensory status, and imaging findings.

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