A global health crisis is emerging because of the changing demographics and care of older adults with schizophrenia. Individuals aged 55 years and older will soon account for 25% or more of the total population of patients with schizophrenia worldwide.1 Among persons aged 60 years and older with mental and substance-use disorders, schizophrenia ranks third in causes of disability-adjusted life-years.2 Older adults with schizophrenia also have a substantial impact on health care costs, with an estimated greater expenditure per person compared with most other medical and psychiatric disorders.
Research on older patients with schizophrenia has been neglected; roughly 1% of the schizophrenia literature focuses on this population.2 With the prevalence of schizophrenia in older adults set to double and reach 1.1 million people in the US by 2025 and 10 million worldwide by 2050, greater attention to research and policy regarding this population is needed.
Morbidity and mortality
Older patients with schizophrenia include individuals with an early-onset that persists into later life and those with a late onset of this condition. There are currently two generations of older adults with schizophrenia: the “old-old” (those 75 years and older) and “young-old” (aged 55 to 74 years).2 Although more adults with schizophrenia are living longer, their life expectancy is still shorter than that of unaffected individuals. The risk of mortality is two to three times greater in patients with schizophrenia than in the general population, and this gap has been increasing over the past decades.2 In older adults with schizophrenia, the mortality rate and deaths caused by suicide and accidents are higher than in healthy peers.
Older persons with schizophrenia also have higher rates of congestive heart failure, chronic obstructive pulmonary disease, and hypothyroidism than unaffected peers. This is partially due to lifestyle factors such as poor diet, smoking, and physical inactivity as well as antipsychotic drug effects. Given the limited knowledge of the mechanisms underlying the increased morbidity and mortality in elderly patients with schizophrenia, further research is needed to identify modifiable clinical and social risk factors.
Positive and negative symptoms
It has been commonly understood that positive symptoms of schizophrenia decline in later life, while negative symptoms dominate the presentation in older age. However, findings from several studies have invalidated this notion. The International Study of Schizophrenia (ISoS) assessed 18 global cohorts over 15- and 25-year periods and found 77% of patients had no evidence of significant negative symptoms over the course of their illness.3 Similarly, a longitudinal study of institutionalized geriatric patients with schizophrenia showed no significant changes in negative symptoms over time.4 From a clinical perspective, negative symptoms do not dominate in older adults with schizophrenia and are often expressed in a similar magnitude seen in younger patients.
Cognitive deficits are a fundamental feature of schizophrenia; they are observed across the life span of affected individuals and are among the strongest predictors of functional disability. Functional disability accounts for roughly half of schizophrenia treatment costs, which increase substantially later in life. Older adults with schizophrenia have significant cognitive deficits in executive functioning, speed of processing, attention/vigilance, working memory, verbal learning, visual learning, reasoning, and problem-solving.
Research has shown a heterogeneity in the trajectory of cognitive function in older patients with schizophrenia based on residential status.5,6 Cognitive decline in community-dwelling patients with schizophrenia is similar to that in unaffected individuals until the age of 65 to 70 years. After 70 years of age, an accelerated cognitive decline in older adults with schizophrenia cannot be ruled out. Cognitive decline is also greater in older adults with schizophrenia who had long periods of institutionalization, especially those over 65 years of age.5
Dr Khan is Research Fellow, Centre for Addiction and Mental Health (CAMH), and Campbell Family Research Institute, and Department of Psychiatry, University of Toronto, Ontario, Canada; Dr Rajji is Deputy Physician-in-Chief, Clinical Research, and Chief, Adult Neurodevelopment and Geriatric Psychiatry, CAMH, and Campbell Family Research Institute. He is also Canada Research Chair, Neurostimulation for Cognitive Disorders, and Associate Professor of Psychiatry, University of Toronto. The authors report no conflicts of interest concerning the subject matter of this article.
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