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Onset of Schizophrenia at Age 100—or Psychosis as the Presenting Symptom of a Cognitive Disorder?

TO THE EDITOR: I read with interest the case report of a woman with onset of schizophrenia at the age of 100.¹ However, although this woman seems relatively cognitively intact, I suspect that the role of demonstrable cognitive dysfunction is underemphasized in this case, thus leading to misdiagnosis.

New-onset psychosis in elderly patients is typically thought to result from a cognitive disorder, dementia or delirium, until proven otherwise. This case approaches these diagnoses appropriately, and, in particular, suggests an early diagnosis of delirium secondary to a urinary tract infection—as reflected in a Mini-Mental State Exam (MMSE) score of 17/30. It is later suggested that this patient does not have dementia because she scored 27/30 on a repeat MMSE. Indeed, she performed well on additional psychometric measures, including the Trails B task and tests of verbal fluency. Interestingly, EEG is interpreted as normal despite documented slowing into the 3–6-Hz range.

Although an MMSE score of 27 is impressive, the MMSE does not adequately test for frontal/subcortical-based executive dysfunction. Indeed, we just presented the case of a woman in our Cognitive Disorders clinic who scored 29/30 on the MMSE but, on formal neuropsychological testing, was shown to have extensive cognitive deficits. Other patients of ours have scored normally on MMSE testing but had frank dementia on further cognitive assessment; one of these patients carried an early-onset autosomal dominant Alzheimer disease presenilin-1 mutation. Also, I am unaware of any literature supporting the conclusion that 3-Hz slowing on EEG is normal for any age. I suspect that more extensive neuropsychological testing of this patient would have demonstrated numerous deficits, cutting across multiple cognitive domains, which would support the initial premise that new psychotic symptoms in this case and in other elderly patients occur atop a substrate of demonstrable cognitive dysfunction.

If diagnostic criteria are formally applied, and one concludes that this patient has new-onset and enduring delusions occurring in a clear sensorium, most consistent with a diagnosis of schizophrenia, then I would contend that this case remains even more remarkable for its demonstration of the limitations inherent in a phenomenologically- and syndromally-based diagnostic system, rather than for its description of an atypical case of late-onset psychosis.

REFERENCES

1. Cervantes AN, Rabins PVR, Slavney PR: Onset of schizophrenia at age 100. Psychosomatics 2006; 47:356–359[Abstract/Free Full Text]

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