
- Vol 38, Issue 12
Improving Outcomes in Late-Life Schizophrenia
What treatment strategies are available to improve the quality of life for older adults who are aging with schizophrenia?
Older adults with schizophrenia include individuals with both early- and late-onset illness. A distinction based on age is not a separate diagnosis in the ICD or the DSM-5; however, the International Late-Onset Schizophrenia Group has proposed subdividing the diagnosis of schizophrenia into distinct age groups.1 A listing of the 3 distinct age groups is found in
We focus here on treatment strategies to improve the
Early-Onset Schizophrenia
Although patients diagnosed with
In our clinical experience, adults with EOS will often develop adverse effects in association with medications that are no longer effective as they age. Staying receptive to changes in the needs of the older patient, as well as to the challenges presented for the family and caregivers, helps ensure the formulation of a treatment plan that is manageable and sustainable in the community.
Case Study 1
“Ms Kahn” is an African American woman, aged 63 years, who was diagnosed with schizophrenia during her adolescence. Her disease course is notable for prominent positive symptoms despite treatment with clozapine for more than 10 years. Her medical course is notable for chronic constipation complicated by paralytic ileus, severe
Ms Kahn recently experienced an episode of paralytic ileus, which required a medical admission, followed by a psychiatric admission for a review of her medication regimen and a gastrointestinal consultation. An attempt was made to maintain Ms Kahn on clozapine because of her favorable response as compared with other atypical antipsychotics. Clozapine could be successfully maintained, however, only with a complex bowel regimen including osmotic diuretics, stool softeners, laxatives, gastric transit accelerators, and enemas. Subsequently, Ms Kahn’s sister reported the difficulty of maintaining this complex regimen, and family meetings were arranged with the patient and her multidisciplinary medical team that included her gastrointestinal specialist. Ultimately,
This case illustrates the challenges of treating aging adults diagnosed with EOS. The importance of collaborative care among the treatment teams, the patient, their family, and caregivers cannot be overemphasized. The case also illustrates the need for regular interdisciplinary communication when working with older adults who are diagnosed with multiple medical comorbidities. Finally, it underscores the importance of parsimony in medication regimen for older patients, especially those with schizophrenia.1
New-Onset After Age 40 Years
Delusions and hallucinations in patients 40 years or older are usually associated with co-occurring medical illness, cognitive impairment, inappropriate medications, and sensory deficits.3,4 When such illnesses are not contributing to the origin of new-onset psychosis, a diagnosis of late-onset schizophrenia (LOS) or very late-onset schizophrenia (VLOS) should be considered. A summary of key risk factors for developing LOS and VLOS is found in
Epidemiology
Epidemiology data for psychosis diagnosed after age 40 years are sparse, although some estimates state that 20% to 25% of patients with
Case Study 2
“Ms Garcia,” a Hispanic woman aged 65 years, presented to the emergency department (ED) for sudden onset of strange thoughts and behaviors, accompanied by her husband. She had no personal or family history of psychiatric disorders, and was retired and the mother of 1 adult son. At home, she had been wandering aimlessly without eating or drinking for several days. Despite evidence to the contrary, Ms Garcia feared her son had been abducted.
In the ED, she was suspicious, irritable, and disheveled. Ms Garcia was admitted to the medical unit where an exhaustive workup, including blood tests, heavy metals panel, lumbar puncture, and brain imaging, did not suggest a contributing etiology. She was transferred to psychiatric care, where she was diagnosed with VLOS. Her symptoms responded well to a gradual titration of olanzapine 10 mg at bedtime. During her hospitalization, she responded favorably to group interventions focused on recreational activities, peer supports, social skills training, and cognitive-enhancing interventions.
Engagement with Ms Garcia’s family began in the ED and continued throughout her admission. Early contacts obtained collateral history and information on the patient’s level of daily functioning. As her admission progressed, family meetings provided psychoeducation about her diagnosis and treatment planning to encourage the engagement of her family as collaborators in her care. Particular attention was given to the family’s language preferences, cultural values, and spiritual beliefs, and how these might influence their understanding of her diagnosis and treatment plan. Ms Garcia was referred to a community adult recreational center where she enjoys participating with peers and staff in social activities and treatment groups. Working with the family and case manager, her treatment team continues to monitor her symptoms, providing regular cognitive and functional assessments of other possible etiologies for her psychosis, such as
This case illustrates the importance of a comprehensive history and medical workup for older adults to rule out secondary causes of psychosis prior to a diagnosis of VLOS.4 Determining the correct diagnosis is imperative to facilitate early intervention and treatment. This case also illustrates good clinical practice of obtaining collateral information while engaging with the patient and the family in a manner that is
Clinical Evaluation
Privacy and communication are essential for a thorough clinical evaluation. Privacy is important because adults are concerned about discussing personal matters in the presence of their adult children and nonfamilial caregivers. Language barriers are bridged with translation services.
Adults with Disabilities
For older adults with disabilities, mobile apps are useful.5 Properly fitted eyeglasses and hearing aids in good working condition are essential. Patients who are deaf or hearing impaired necessitate specialized interpreter services.6
Clinical Presentation
There are significant differences in the clinical presentations of EOS when compared with LOS and VLOS, which have fewer negative symptoms. Patients diagnosed with LOS and VLOS tend to have a more successful history of employment and of intimate relations when compared with those with EOS.
Hallucinations and Delusions
The persecutory delusions of LOS are notable for accusatory voices and persecutory third-person commentaries. These symptoms are unlike the partition delusions and persecutory beliefs common in VLOS.
Cognitive Features
Teasing out the cognitive symptoms associated with LOS and VLOS that are superimposed on an aging brain can be difficult. Older adults with schizophrenia have twice the likelihood of developing dementia when compared with healthy peers.7 For clinical presentations that are complex, a comprehensive neuropsychological battery of testing with brain imaging can be helpful to clarify the diagnosis.
Pharmacology Treatment
Initial interventions with older patients should begin with a review of all medications, including prescribed treatments, herbal remedies, and over-the-counter supplements. This review is important to identify possible drug-to-drug interactions and medications that are on the Beers Criteria for Potentially Inappropriate Use in Older Adults.8 Care should be taken to avoid the risks and hazards of polypharmacy.
Antipsychotics have long been established as the
Early extrapyramidal symptoms (EPS) and advancing age are known risk factors for tardive dyskinesia (TD), a condition associated with higher mortality in psychiatric patients.10 Monitoring for EPS and TD is imperative. The Abnormal Involuntary Movement Scale should be used to monitor symptoms and to rate their severity.
Once EPS is diagnosed, a reasonable first step is to lower the antipsychotic dosage while considering a switch to an antipsychotic with less risk of EPS. Caution should be used with the addition of agents that may increase anticholinergic load.
Once TD is diagnosed, continued treatment with antipsychotics should be reviewed, including whether to discontinue treatment, decrease the dosage, or switch to an antipsychotic with less dopamine blockade. FDA-approved medications for the treatment of TD, such as the selective vesicular monoamine transporter 2 inhibitors valbenazine and deutetrabenazine, should be considered, especially for patients for whom continued use of antipsychotics is indicated. Given that the cumulative duration of antipsychotic treatment increases the risk of TD, antipsychotic dosage adjustments should be routinely considered in the older adult.
Psychosocial Interventions
In the older adult, the treatment plan should reflect an array of supports, ideally in an integrated care setting. Integrative care models have been shown to be effective for community-dwelling adults with severe mental illness, and efforts are being made to disseminate this collaborative approach on a global scale.11
Examples of other effective psychosocial interventions include family therapy, peer support, occupational therapy, cognitive behavioral therapy, cognitive remediation, and social skills training. Community resources, social programs, and support for caregivers are also known to promote and sustain recovery and to minimize the loneliness,
Concluding Thoughts
Improving outcomes in late-life schizophrenia begins with a thorough medical evaluation to rule out secondary sources of psychosis. Ideally, treatment is patient-centered, culturally sensitive, and includes the judicious use of antipsychotics and psychosocial interventions.
More research is needed to understand the development of schizophrenia in late life. Initiatives to minimize the disease burden and improve the quality of life for older adults with schizophrenia and their families /caregivers are important. These interventions benefit society as a whole and should be a legislative priority.
Dr Diaz is an assistant clinical professor of psychiatry at Columbia University Irving Medical Center. Dr Clarke is an assistant clinical professor of psychiatry at Columbia University Irving Medical Center. Dr Holderness is an associate clinical professor of psychiatry at Columbia University Irving Medical Center. Drs Diaz, Clarke, and Holderness do not have any financial conflicts of interest to disclose.
References
1. Howard R, Rabins PV, Seeman MV, Jeste DV.
2. World Health Organization. Global Health Risks: Mortality and Burden of Disease Attributable to Selected Major Risks. World Health Organization; 2009.
3. Tampi RR, Young J, Hoq R, et al.
4. Cohen CI, Meesters PD, Zhao J.
5. Accessibility apps. iAccessibility.com. Accessed September 28, 2021.
6. Barnett S, McKee M, Smith SR, Pearson TA.
7. Cai L, Huang J.
8. 2019 American Geriatrics Society Beers Criteria® Update Expert Panel.
9. Alexopoulos GS, Streim J, Carpenter D, Docherty JP; Expert Consensus Panel for Using Antipsychotic Drugs in Older Patients.
10. Woerner MG, Alvir JM, Saltz BL, et al.
11. Bartels SJ, DiMilia PR, Fortuna KL, Naslund JA.
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