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Late-Onset Psychosis — MRCPsych Paper B MCQ

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ModerateSchizophrenia & PsychosisLate-Onset PsychosisMRCPsych Paper B

A 62-year-old man develops persecutory delusions and third-person auditory hallucinations for the first time. Comprehensive assessment has found no delirium, cognitive decline, substance- or medication-induced cause, mood disorder or neurological disorder. When initiating oral antipsychotic treatment for this very-late-onset schizophrenia-like psychosis, which prescribing approach is most appropriate?

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Correct answer: D — Start at the lower end of the licensed dose range and titrate slowly

Explanation lettering: E = shown as A · A = shown as B · B = shown as D · D = shown as E

B is correct. NICE recommends initiating an antipsychotic at the lower end of its licensed dose range and titrating slowly. This is particularly important in later life because altered pharmacokinetics and greater sensitivity to adverse effects can make standard adult dosing poorly tolerated. Evidence from the UK ATLAS trial also shows that low-dose antipsychotic treatment can be effective in very-late-onset schizophrenia-like psychosis. A standard-dose initiation risks avoidable adverse effects. No antipsychotic class is routinely preferred solely because psychosis began late, so C is incorrect; selection should reflect the individual adverse-effect profile and comorbidity. Clozapine is not first-line and is generally reserved for treatment-resistant schizophrenia. Age over 60 is not itself a reason to withhold antipsychotics, although biological and psychosocial treatments should form an integrated care plan.

Reference: National Institute for Health and Care Excellence. Psychosis and schizophrenia in adults: prevention and management (CG178), section 1.3.6, How to use antipsychotic medication. 2014, amended 2021. https://www.nice.org.uk/guidance/cg178/chapter/recommendations