Late-onset psychosis — structured clinical viva

Opening move

State you will structure: risk and capacity → definitions → formulation → differentials → work-up → treatment (non-drug then drug) → dementia caution → follow-up. Do not launch into a drug name before safety and organic exclusion.[1][3]

Expected discussion points

1. Nosology

• LOS onset after 40; VLOSLP after 60 (Howard 2000).
• Not separate DSM codes; map to spectrum/medical categories.[1]

2. Phenomenology and formulation

• Partition delusions, persecutory content, relatively preserved affect historically in late paraphrenia teaching.
• Hearing loss and isolation as maintainers; collateral essential.[2]

3. Differentials

• Delirium, Alzheimer/vascular psychosis, DLB (fluctuation, visual hallucinations, RBD, parkinsonism, neuroleptic sensitivity), affective psychosis, substances, Charles Bonnet.[3][5]
• Do not diagnose irreversible dementia from one distressed cognitive screen.

4. Work-up

• Labs, ECG, sensory tests, neuroimaging for first late-onset psychosis; extended tests for red flags.[3][7]

5. Management

• Non-drug first always documented.
• Example: risperidone 0.25–0.5 mg PO with slow titration; monitor EPS, metabolic, falls, QTc.
• Response often at low–moderate atypical doses in VLOSLP series.[6]
• If dementia pathway: Schneider mortality signal; time-limited targeted use.[4]

6. Risk, legal, follow-up

• Neighbour harm, self-neglect, fire; least-restrictive legal framework (jurisdiction-specific).
• Cognitive surveillance given elevated later dementia risk in VLOSLP cohorts; watch for emerging DLB features.[5]

Examiner traps

Treating as uncomplicated young-adult FEP without imaging plan; high-dose or typical antipsychotic in possible DLB; calling it "just Alzheimer's" without formulation; ignoring hearing aids and isolation; no review date or risk–benefit documentation when dementia possible.[3][4][5]

Model synthesis (30–40 seconds)

"This is a first psychotic presentation after 60 consistent with VLOSLP construct after organic exclusion — partition delusions, sensory impairment, and social isolation feature. I will manage risk, complete labs/ECG/imaging, correct hearing and supports, start a low-dose atypical with monitoring, explicitly reconsider dementia/DLB over time, and avoid long-term high-dose antipsychotics without benefit."[1][4][6]