The severity of TD in older adults with schizophrenia may be masked because many patients receive high doses of FGAs. When a patient’s FGA dosage is reduced to manage EPS, subclinical TD may manifest for the first time, and existing TD may become noticeably worse. Consider clozapine for long-term management of older adults who have TD; however, burdens of its use—such as weekly blood draws and anticholinergic adverse effects—may limit its use in older adults.
Lowering the anticholinergic load by reducing the dosage of drugs with anti-cholinergic activity or discontinuing anti-cholinergic medications when possible is a key component of treating older adults with schizophrenia. Doing so may improve not only patients’ cognitive function but also their quality of life by reducing other anticholinergic adverse effects, such as constipation, blurred vision, and urinary retention.
Psychosocial interventions. The 2009 schizophrenia PORT psychosocial treatment recommendations and summary statements may be followed for older adults. Recommended interventions include:
- assertive community treatment
- supported employment
- cognitive-behavioral therapy (CBT)
- family-based services
- token economy
- skills training.16
Social skills training with or without CBT can be successfully adapted for older adults. Such interventions can improve social functioning and everyday living skills. Environmental modifications—such as removing decorative mirrors from the home of a delusional patient who believes people are living in the walls—may alleviate distress.
In addition, social contact and structured activities such as group exercises may benefit older patients. Educate care-givers about ways they can work with older adults, such as distracting them or not directly challenging false beliefs. Comprehensive psychosocial interventions also can improve health care management skills.
Preliminary data indicate that CBT and skills training with role-plays, structured feedback, and homework assignments can improve quality of life of older adults with schizophrenia.17,18 Functional Adaptation Skills Training focuses on medication management, social skills, communication skills, organization, planning, and financial management.19 Those who received this training showed improvement in their functional skills that persisted for at least 3 months after treatment ended.20
Poor adherence to medication is common in older schizophrenia patients and has devastating consequences. Adherence problems are complex and often have multiple causes, which requires customized interventions that target specific causes. Patients who receive a combination of psychosocial treatment and antipsychotics are more likely to be compliant with their medication and less likely to relapse or be hospitalized.16
Addressing the social stigma associated with schizophrenia may help reduce the social isolation and loneliness that many older adults experience. Psychiatrists can help fight stigma by participating in community educational programs and encouraging patients’ families to become involved in support and advocacy organizations.
Table 2
Interventions for older adults with schizophrenia
| Symptom/problem | Intervention(s) |
|---|---|
| Positive symptoms | Second-generation antipsychotics, CBT, caregiver education |
| Negative symptoms | Second-generation antipsychotics, caregiver education, token economy |
| Cognitive symptoms | Reducing anticholinergic load, cognitive remediation |
| Social deficits | Social skills training, FAST |
| Depression | Antidepressants, CBT |
| Mobility limitations | Gait and balance strengthening exercises, physical therapy |
| Vascular risk factors | Second-generation antipsychotic with lowest risk of weight gain and hyperlipidemia, such as aripiprazole or ziprasidone |
| Cigarette smoking | Smoking cessation program |
| Severe tardive dyskinesia | Consider clozapine |
| Extrapyramidal symptoms | Second-generation antipsychotics with lowest risk of extrapyramidal symptoms, such as quetiapine or clozapine |
| Homelessness | Supported housing |
| Progressive cognitive decline | Dementia workup |
| Treatment nonadherence | Caregiver education, FAST, ACT |
| Caregiver stress | Caregiver education, support groups, psychotherapy |
| ACT: assertive community treatment; CBT: cognitive-behavioral therapy; FAST: functional adaptation skills training | |
| Source: References 15,16 | |
CASE CONTINUED: Medication changes
Ms. M’s psychiatrist tells her that her problems with tremors and falls are most likely caused by haloperidol and recommends a slow dosage reduction and discontinuing diphenhydramine. Haloperidol is decreased to 10 mg/d for 1 month and then to 5 mg/d. Diphenhydramine is decreased to 25 mg at bedtime for 7 days and then stopped.
Ms. M declines physical therapy but agrees to participate in strength and balance training offered at the supported housing community 3 times a week for 4 weeks. Tremors resolve over the next month and Ms. M has not fallen since.
Ms. M complains of insomnia and is reluctant to further decrease haloperidol unless she is prescribed a different antipsychotic and given something to help her sleep. Ms. M is started on quetiapine, 25 mg/d at bedtime. Over 3 weeks, the dosage is increased to 100 mg/d. Ms. M tolerates quetiapine well and her sleep improves. Haloperidol is then decreased to 2.5 mg/d for 1 month and then discontinued. Ms. M also is offered supportive psychotherapy every 2 weeks to address her paranoia and stress. She continues to do well on quetiapine and supportive psychotherapy.
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