Psychosis and schizophrenia in later life

Psychosis means losing touch with what is real for a while. A person may see or hear things others do not, or hold strong beliefs that are not true. Most people with schizophrenia first become ill as teens or young adults. But the story does not end there. People grow old with schizophrenia, and psychosis can also start for the first time later in life.^1,3

In older adults, hallucinations and false beliefs have many possible causes. Some are treatable medical problems. Some are signs of dementia. Getting the cause right matters, because the safest medicine for one cause can be dangerous for another. This page explains the differences in plain words.

Growing older with schizophrenia

Many people reading this have lived with schizophrenia for decades. Some have done well with treatment, work, family and friends. Some have faced hard years. Aging adds new questions about health, medicines and where to live.

Physical health

People with schizophrenia live about 15 to 20 years less than the general population, on average. Most of that gap comes from physical illness, not from the mental illness directly. Heart and blood vessel disease is the leading cause.⁹

Several things add up. Type 2 diabetes is 2 to 5 times more common in people with schizophrenia. About 1 in 3 have metabolic syndrome (a group of problems such as extra belly weight, high blood pressure and high blood sugar). Smoking is common. People also get less screening and less treatment for heart and cancer risks.⁹

The good news is that this can be changed. Helpful steps include:⁹

• Regular checks of weight, blood pressure, blood sugar and cholesterol.
• Help to quit smoking.
• Vaccines and cancer screening.
• Walking or other movement that fits your body.
• One team, or teams that talk to each other, for both mind and body.

In large studies, people who stayed on long-term antipsychotic treatment did not do worse physically, and many lived longer than those who were off medicine.⁹ Clozapine and long-acting injections looked especially good in some studies, though these studies cannot prove cause.⁹ Read more in antipsychotic medicines.

Medicines in later life

Older bodies handle medicine differently. Doctors usually "start low and go slow" with antipsychotics in older adults.^2,3 Older adults are often more sensitive to antipsychotic side effects.³ Drowsiness, dizziness when standing up, and stiffness can raise the risk of falls.

Newer medicines may have less research in older people. For example, the FDA-approved label for Cobenfy (xanomeline and trospium), approved in 2024 for adults with schizophrenia, says the main trials did not include people over 65. It advises slower dose increases and a lower top dose for older adults, partly because it can make it hard to empty the bladder.¹⁰ This is as of October 2026. Ask your doctor what is known for your age.

Do not stop an antipsychotic on your own, even for a short time. One review found that a break of just 1 to 10 days roughly doubled the chance of relapse and a return to the hospital.³ If side effects bother you, talk with your doctor or pharmacist before changing anything. Our page on medicines that affect mood and memory explains how to review all your pills together.

When psychosis starts in later life

Psychosis that begins after 40 is less common than in young adults, but it is real. Experts use two groups:²

• Late-onset schizophrenia: first signs between ages 40 and 60.
• Very-late-onset schizophrenia-like psychosis: first signs after age 60.

These age lines are a guide. Experts agree they are somewhat arbitrary, but they help doctors and researchers talk about the same thing.²

What it can look like

Compared with illness that starts young, later-onset psychosis tends to have these features:^2,3

• It is more common in women.
• Suspicious beliefs are common, such as thinking neighbors are spying, stealing or plotting.
• Hallucinations may involve seeing, feeling on the skin, or smelling things, not only hearing voices.
• Disorganized speech and a flat, withdrawn manner are less common, especially after 60.
• The person is more likely to have hearing or vision loss, or to be socially isolated.

Hearing loss, poor vision and loneliness are not the whole cause. But they may make the world feel confusing and less safe, and they are worth fixing. See hearing loss and loneliness and loneliness in later life.

Outlook and treatment

Experts have found no sign that late-onset psychosis is a dementia that keeps getting worse. Memory and thinking can be a little weaker, but usually not like dementia.² The link between very-late-onset psychosis and later dementia is still unproven.³ Late-onset schizophrenia tends to have a better outlook than the early-onset type, and many people respond well to antipsychotics at low doses.³

Treatment goes beyond medicine. Support at home, help with hearing and vision, and steady contact with a clinic all matter. See therapy and recovery.

Is it schizophrenia, dementia, delirium or something else?

In an older adult, doctors rule out other causes first. Here is a simple comparison.

Delirium: an emergency to rule out

Delirium is sudden confusion with trouble focusing. A person may be drowsy and quiet, or restless and agitated. It can also bring hallucinations or false beliefs.⁴ Common triggers include infections such as a urinary tract infection or pneumonia, dehydration, pain, surgery, hospital stays and medicine side effects.⁴

Delirium is often temporary, and it usually improves when the cause is found and treated.⁴ That is why a sudden change needs a quick medical visit. Do not assume it is "just old age" or a mental illness. See hospital stays for ways to lower delirium risk.

Lewy body and Parkinson's disease

Lewy body dementia is a brain disease that often causes clear, detailed hallucinations, such as seeing people, animals or insects. These happen in up to 80% of people with it.⁵ Early hallucinations in someone who is starting to have memory or thinking trouble point toward this disease.⁵ Parkinson's disease can also cause hallucinations and false beliefs.⁷ See Lewy body dementia and Parkinson's disease dementia.

Not every hallucination needs medicine. One expert resource notes that if visual hallucinations are not upsetting to the person, a drug may not be needed. First step: look for causes such as pain, infection, constipation and medicines that can cloud thinking.⁶

Other causes to rule out

Doctors may also check for medicine side effects, alcohol or drug use, low vitamin levels, thyroid problems, stroke, seizures and severe depression with psychosis. See getting diagnosed and treatable conditions that look like dementia.

Antipsychotic warnings in dementia

Most antipsychotic medicines sold in the U.S. carry a boxed warning, the FDA's strongest kind. It says older adults with dementia-related psychosis who take antipsychotics have a higher risk of death.⁷

Here is what that means. In typical 10-week trials, about 4.5 in 100 people on the drug died, compared with about 2.6 in 100 on placebo (a pill with no medicine in it). That is roughly 1.6 to 1.7 times the risk.⁷

Some key points:

• These medicines are not approved to treat psychosis caused by dementia in general. One exception is pimavanserin, which the FDA approved only for hallucinations and delusions linked to Parkinson's disease psychosis.⁷
• In 2023, the FDA approved brexpiprazole (Rexulti) for agitation linked to Alzheimer's dementia. It keeps the same boxed warning.⁸
• Non-drug steps come first for most behavior changes in dementia. See hallucinations and delusions in dementia and medicines for agitation.

How family and caregivers can help

If you care for an older person with psychosis, these steps help:

• Do not argue about the false belief. Stay calm and kind. Acknowledge the feeling, such as fear, without agreeing or arguing about the facts. More ideas are in helping a family member with psychosis.
• Write down the timeline. Note when changes began, new medicines, falls, infections and sleep changes. Bring all medicine bottles to visits.
• Check hearing, vision and teeth. Make sure glasses and hearing aids are clean and in use.
• Keep routines and light. A steady day and good lighting reduce confusion and shadows that can be mistaken for people.
• Keep the person safe. Lock away items that could cause harm. Watch for wandering, falls and not eating or drinking.
• Look after yourself. Caregiving is hard. See caring for caregivers.

Questions people ask

For the big picture, return to the schizophrenia hub. To learn more about symptoms and causes, see signs and symptoms and causes and risk factors.

When to get help

Call the doctor the same day for sudden confusion, new hallucinations, a new fall, a fever, or refusing food or drink. Call within a few days for new suspicious beliefs, poor sleep, or a loved one who has stopped taking medicine. If you do not know where to start, see finding geriatric mental health care or our help page.

Education only. This page is general information written from the sources listed. It is not medical, legal or financial advice and does not replace a doctor, therapist or lawyer who knows your situation. How we write and check pages.