Evidence-Based Reviews

Schizophrenia in older adults

Current Psychiatry. 2010 September;9(9):23-A

How to adjust treatment to address aging patients’ changing symptoms, comorbidities

References

1. Cohen CI, Cohen GD, Blank K, et al. Schizophrenia and older adults. An overview: directions for research and policy. Am J Geriatr Psychiatry. 2000;8:19-28.

2. Vahia I, Bankole AO, Diwan S, et al. Schizophrenia in late life. Aging Health. 2007;3:393-396.

3. Cohen CI, Pathak R, Ramirez PM, et al. Outcome among community dwelling older adults with schizophrenia: results using five conceptual models. Community Ment Health J. 2009;45:151-156.

4. Ausland LA, Jeste DV. Sustained remission of schizophrenia among community-dwelling older outpatients. Am J Psychiatry. 2004;161:1490-1493.

5. Bankole A, Cohen CI, Vahia I, et al. Symptomatic remission in a multiracial urban population of older adults with schizophrenia. Am J Geriatr Psychiatry. 2008;16(12):966-973.

6. Harding CM. Changes in schizophrenia across time. In: Cohen CI, ed. Schizophrenia into later life: treatment, research, and policy. Arlington, VA: American Psychiatric Publishing, Inc.; 2003: 19–41.

7. Harvey PD, Howanitz E, Parrella M, et al. Symptoms, cognitive functioning, and adaptive skills in geriatric patients with lifelong schizophrenia: a comparison across treatment sites. Am J Psychiatry. 1998;155:1080-1086.

8. Morrison G, O’Carroll,, McCreadie R. Long-term course of cognitive impairment in schizophrenia. Br J Psychiatry. 2006;189:556-557.

9. Bowie CR, Tsapelas I, Friedman J, et al. The longitudinal course of thought disorder in geriatric patients with chronic schizophrenia. Am J Psychiatry. 2005;162(4):793-795.

10. Diwan S, Cohen CI, Bankole AO, et al. Depression in older adults with schizophrenia spectrum disorders: prevalence and associated factors. Am J Geriatr Psychiatry. 2007;15:991-998.

11. Berry K, Barrowclough C. The needs of older adults with schizophrenia. Implications for psychological interventions. Clin Psych Review. 2009;29:68-76.

12. Cohen CI. Age-related correlations in patient symptom management strategies in schizophrenia: an exploratory study. Int J Geriatr Psychiatry. 1993;8:211-213.

13. Leucht S, Burkard T, Henderson J, et al. Physical illness and schizophrenia: a review of the literature. Acta Psychiatr Scand. 2007;116(5):317-333.

14. Cohen CI, Vahia I, Reyes P, et al. Schizophrenia in later life: clinical symptoms and social well-being. Psychiatr Serv. 2008;59:232-234.

15. Buchanan RW, Kreyenbuhl J, Kelly DL, et al. The 2009 Schizophrenia PORT psychopharmacological treatment recommendations and summary statements. Schizophr Bull. 2010;36:71-93.

16. Dixon LB, Dickerson F, Bellack AS, et al. The 2009 Schizophrenia PORT psychosocial treatment recommendations and summary statements. Schizophr Bull. 2010;36:48-70.

17. McQuaid JR, Granholm E, McClure FS, et al. Development of an integrated cognitive-behavioral and social skills training intervention for older patients with schizophrenia. J Psychother Pract Res. 2000;9:149-156.

18. Granholm E, McQuaid JR, McClure FS, et al. A randomized controlled pilot study of cognitive behavioral social skills training for older patients with schizophrenia. Schizophr Res. 2002;53:167-169.

19. Patterson TL, McKibbin C, Taylor M, et al. Functional adaptation skills training (FAST): a pilot psychosocial intervention study in middle-aged and older patients with chronic psychiatric disorders. Am J Geriatr Psychiatry. 2003;11:17-23.

20. Patterson TL, Goldman S, McKibbin CL, et al. UCSD performance-based skills assessment: development of a new measure of everyday functioning for severely mentally ill adults. Schizophr Bull. 2001;27:235-245.

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Ms. M, age 68, seeks treatment for stress and anxiety after her sister has a stroke. Ms. M has chronic paranoid schizophrenia, and her sister has been Ms. M’s primary support since the onset of illness in her late 20s. Ms. M lives in a supported housing community. Her last psychiatric hospitalization was 16 years ago; for the past 15 years she has been stable on haloperidol, 20 mg/d. Ms. M also takes diphenhydramine, 50 mg at bedtime, to help her sleep.

Ms. M is hypertensive but does not have diabetes, obesity, or metabolic syndrome. She has mild executive dysfunction and mild extrapyramidal symptoms (EPS) but no tardive dyskinesia (TD). There is no evidence of delusions or hallucinations, although Ms. M is mildly paranoid about her neighbors. In the last year, she has been experiencing tremors and has fallen twice.

The number of older adults (age ≥65) who developed schizophrenia before age 45 is expected to double in the next 2 decades; the 1-year prevalence of schizophrenia among older adults is approximately 0.6%.^1,2 This article reviews how positive, negative, and cognitive symptoms and social functioning change over decades and discusses strategies for reducing the impact of long-term antipsychotic use on neurologic and physical health. Although some patients experience schizophrenia onset later in life, in this article we focus on older adults who developed the illness before age 45.

Symptoms change with age

Positive symptoms of schizophrenia—hallucinations, delusions, and disorganized or catatonic behavior—do not “burn out” in most older adults.³ The severity of “day-to-day” psychotic symptoms appears reduced in patients with schizophrenia who have not had recent severe psychotic episodes. Aging-associated decrease in dopaminergic and other monoaminergic activities may explain this.

Clinical Point

Positive symptoms of schizophrenia do not ‘burn out’ in most older adults

Some older adults experience sustained remission of positive symptoms and may no longer need antipsychotics.⁴ Factors that contribute to a better prognosis include:

female sex
developing the illness later in life (eg, fourth decade instead of second or third decade)
being married
obtaining appropriate treatment early in the illness.²

With treatment, positive symptoms can remit in 40% to 50% of older adults, especially those who have greater social support and fewer lifetime traumatic events.^3,5

Negative symptoms—flat affect, social withdrawal, and decreased motivation—may become worse in older adults with a history of poor functioning (especially institutionalized patients) as they age.^2,6 Changes in negative symptoms are more closely correlated with symptom chronicity, functional and cognitive impairment, soft neurologic signs such as impaired fine motor coordination, and institutionalization than with the patient’s age.⁷

Generalized cognitive deficits are ubiquitous in patients with schizophrenia and substantially impact community functioning.^1,8 Cognitive function may worsen in older schizophrenia patients with a history of poor functioning—especially institutionalized patients—as they age.⁹ Most older adults with schizophrenia who reside in the community have persistent, but generally not progressive, cognitive deficits. Low education levels, poor premorbid function, and more severe positive symptoms at baseline are associated with worse cognitive functioning at all ages.² Older adults with schizophrenia and TD have greater global cognitive deficits and greater deficits in learning than age-, education-, and subtype-matched schizophrenia patients without TD.¹

Differences and similarities in cognitive impairment in older adults with schizophrenia compared with those who have Alzheimer’s disease (AD) are listed in Table 1. The course of cognitive deficits appears to be the most sensitive measure for determining whether a patient with long-standing schizophrenia has developed concomitant AD. Individuals with AD experience a more precipitous and progressive decline in cognitive function compared with patients with schizophrenia. Neuropsychological testing is recommended to accurately diagnose AD in older schizophrenia patients as early as possible.

Table 1

Cognitive impairment: Schizophrenia vs Alzheimer’s disease

Older patients with schizophrenia	Patients with AD
No decline or mild decline over decades Impairment in visuospatial tasks Perform worse on naming and praxis skills Histopathologically different from AD	Progressive decline over months or years More global deterioration Perform worse on delayed recall Senile plaques or neurofibrillary tangles
Common to both
Degree of impairment is equal as reflected in MMSE scores Impaired recognition memory Risk factors for cognitive decline include low educational level and advanced age
AD: Alzheimer’s disease; MMSE: Mini-Mental State Examination

Depressive symptoms

More than two-fifths of older adults with schizophrenia show signs of clinical depression.¹⁰ Depression in this population is linked to positive symptoms, poor physical health, low income, and diminished network support. Routinely screen for depressive symptoms in older schizophrenia patients and institute prompt treatment as required. Assess these patients for suicide. Although suicide rates in schizophrenia patients decrease with age, they remain considerably higher than those of age-matched persons without schizophrenia.¹¹