Evidence-Based Reviews

Schizophrenia in older adults

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

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.

Social functioning

Improvement or deterioration in social functioning is possible as patients with schizophrenia age.¹¹ Compared with age-matched patients in the general population and those with bipolar disorder, older adults with schizophrenia need more help with activities of daily living (eg, looking after the home, using public transportation).¹¹

Clinical Point

Because coping skills may improve with age, identify and support factors that promote older adults’ psychological resilience

Cognitive impairment seems to be the most important predictor of social functioning in patients with schizophrenia at any age. Impaired social functioning also is associated with negative symptoms and movement disorders. On community integration measures (how well the person lives, participates, and socializes in his or her community), older adults with schizophrenia do roughly half as well as their age-matched peers in the general community.³ Older schizophrenia patients’ social networks seem to be smaller than those of their age-matched peers,¹ but they may experience fewer discordant interactions, such as situations with high expressed emotions. Increased psychological resilience may help older adults better adapt to changes as they age (Box).^1,12

Box

Psychological resilience may improve with age

Psychological resilience factors—such as coping skills and self-efficacy—play an important role in an individual’s ability to adapt to life stressors associated with schizophrenia and old age. One study found that a strategy of fighting back unwanted thoughts was negatively related to age, whereas acceptance and diversion were positively correlated with age, which suggests increased resilience in older adults with schizophrenia.¹² Coping skills seem to improve with aging and older patients may become more active participants in their recovery.¹ Routine clinical care of older adults with schizophrenia should focus on identifying and supporting factors that promote resilience in addition to the standard “problems-centered” approach that focuses on treating positive symptoms.

A complex assessment

Older adults with schizophrenia have an increased prevalence of:

obesity
diabetes
hyperlipidemia
coronary artery disease
myocardial infarction
limited mobility
illnesses related to smoking or substance abuse.^13,14

The severity of these conditions often is greater in older adults with schizophrenia compared with age-matched controls. Older adults with schizophrenia also have poorer access to and use of health care services and compliance with treatment regimens, and receive a lower quality of care. The incidence of physical health and neuropsychiatric problems increases with age and older adults with schizophrenia with poor functioning may be less able to recognize and report symptoms to health care providers.

Because these patients have complex health care concerns, we recommend using a checklist to help make routine visits thorough and identify and treat problems. Click here for a downloadable assessment checklist. Ideally, the initial assessment should use an interdisciplinary approach that includes the patient, family/knowledgeable informants, psychiatrist, psychiatric nurse practitioner/physician assistant, social worker, caseworker, chaplain (if appropriate), and a nurse. The initial assessment may take 2 to 3 visits to complete.

Adapting treatment

Older adults with schizophrenia can benefit from the psychopharmacologic and psychosocial interventions used for younger patients (Table 2).^15,16 However, you may need to adapt these treatments to accommodate cognitive impairment, medical comorbidities, or hearing and vision deficits. The most appropriate goal may not be recovery or rehabilitation, but making life more meaningful and satisfying for the patient and his or her family.

Pharmacotherapy. The 2009 schizophrenia Patient Outcomes Research Team (PORT) psychopharmacology treatment recommendations may be used for older adults.¹⁵ Most adverse effects of antipsychotics (except for dystonia) are more prevalent in older adults than in their younger counterparts. In general, second-generation antipsychotics (SGAs) are preferred over first-generation antipsychotics (FGAs) for treating positive symptoms in older patients because of SGAs’ lower risk of TD and EPS despite the increased risk of metabolic disorders.

Clinical Point

Second-generation antipsychotics are preferred for treating positive symptoms in older adults because SGAs have a lower risk of EPS and TD

Aripiprazole and ziprasidone are associated with significantly less risk of metabolic disorders and may be preferred in older adults who have diabetes, obesity, or hyperlipidemia. Aripiprazole has the lowest risk of QTc prolongation and may be preferred in patients who have prolonged QTc interval.¹⁵ Quetiapine and clozapine are associated with the lowest risk of EPS. Among SGAs, aripiprazole is associated with the lowest risk of prolactin elevation and sexual side effects and may be preferred in older adults who complain of sexual dysfunction or have osteoporosis.

Because rates of EPS and TDs may exceed 50% among older patients, many experts encourage clinicians to taper anti-psychotic dosages in patients with stable chronic symptoms. Tapering dosages may be critically important because EPS may affect functional performance more than positive or negative symptoms or duration of psychoses.