Schizophrenia most commonly presents early in life, but at least 20% of patients have onset after the age of 40 years. The Diagnostic and Statistical Manuel of Mental Disorders (DSM)-5 states that "late-onset cases can meet the diagnostic criteria for schizophrenia", but it is not clear whether this is the same condition as schizophrenic early-life, as well as, schizophrenia like psychosis >65 years. In the late 1990s, an international conference of experts reviewed the available evidence concluding -onset of symptoms between 40 and 60 years should be conceptualized as a subtype of schizophrenia, termed Late-onset schizophrenia (LOS). They also concluded that schizophrenia-like symptoms arising >60 years, when the risk of primary neurodegenerative dementias is greater, are more likely to have a distinct underlying (i.e., degenerative rather than neurodevelopmental) pathology. The name very-late-onset-schizophrenia-like-psychosis (VLOSLS) was recommended to describe this group (Maglione et al, 2014) LOS has a 0.1% lifetime prevalence and VLOSLS >65 years 0.3% respectively. Ms. A., a 71-year-old divorced women, was brought by her son to the hospital with change in behavior and suspiciousness. No significant past history. Mental status examination revealed no thought or affective disorders. Patient had well organized paranoid/referential/persecutory delusions, often directed toward family, also partition delusions, believing that nurses could enter the room and could observed, harmed, stolen from her, also described the experience of being sexually assaulted. Auditory, olfactory, and tactile hallucinations were present, and somatic and will passivity. Neuropsychiatric examination revealed no abnormality. Mini-mental status examination (MMSE) score was 30/30, Addenbrooke's Cognitive Examination Revised (ACE-R) was 100/100. Magnetic resonance imaging (MRI) brain showed age related cortical atrophy. A trial of dose gradually titrated up to 6 mg oral risperidone was initiated, with no response, so clozapine was added until 200mg with satisfactory response.Diagnosis of psychosis in older populations is essential, to provide accurate treatment strategies and new neuroimaging and molecular studies to possible identifying differences in the underlying biology of early, late and very late-onset schizophrenia. A multi-modal treatment involving individual care planning, judicious prescribing of antipsychotic medication, psychological support, education, and family and community resources is essential.
