Stanley G. McCracken, PhD, University of Chicago
Zvi D. Gellis, PhD, University of Pennsylvania.
45-80 minutes, depending on class size and time spent on exercise.
Didactic lecture, exercises.
Chalkboard, flipchart, or dry erase board with markers.
LCD projector & laptop computer.
Review of the literature
[Note about language: In this module we will use the language recommended by the International Late-Onset Schizophrenia Group (Howard, Rabins, Seeman, Jeste, & the International Late Onset Schizophrenia Group, 2000) in referring to the age of onset of symptoms of schizophrenia: Earlier Onset Schizophrenia (EOS), prior to age 40; Late Onset Schizophrenia (LOS), onset from 40 to 60; Very Late Onset Schizophrenia (or Schizophrenia-like Psychosis, VLOS), onset after age 60.]
The prevalence of psychotic disorders among the elderly ranges from 0.2% to 4.75% in community samples, to 8% to 10% in geropsychiatry units and nursing homes (Zayas & Grossberg, 1998). The epidemiologic catchment area (ECA) study data showed a 0.2% point prevalence and 0.3% lifetime prevalence among adults over 65 (Keith, Regier, & Rae, 1991). Note that the ECA study did not include individuals with onset of symptoms after 45. More recent estimates place the true prevalence of schizophrenia at about 1% among older adults; stated another way, apparently 13.6% of people with schizophrenia are 65 or older (Cohen, 2003). However, the prevalence of psychotic symptoms varies among different populations and settings. Ostling and Skoog (2002) found that 10.1% of their sample of community-dwelling non-demented adults over 85 experienced psychotic symptoms, most of which were associated with depression, disability in daily life, and visual deficits. Psychotic symptoms among individuals with dementias can be over 60% (Zayas & Grossberg, 1998).
Psychotic symptoms also can be produced by a number of different medical conditions and their treatment: e.g., delirium; sensory impairments; drugs and medications; medical and surgical procedures; and neurological, infectious, metabolic, and endocrine disorders (Desai & Grossberg, 2003). Even in a specialty geropsychiatry clinic, the majority of older adults presenting with psychotic symptoms are diagnosed with dementia, major depression, delirium, and organic psychoses related to medical conditions and treatment (Holroyd & Laurie, 1999).
Cognitive impairment is associated with schizophrenia; however, the progression of cognitive decline in an aging individual with schizophrenia parallels the decline seen in normal aging. Significant cognitive decline should raise the index of suspicion about the presence of dementia, which may be comorbid with another psychiatric disorder. Recent changes in orientation, awareness of the environment, or ability to attend indicates the possibility of delirium (Desai & Grossberg, 2003).
Harding (2003) reviewed 10 long-term (>20 years) longitudinal studies looking at recovery from schizophrenia over time. From the methods reported in these studies, it appears likely that the majority of the subjects in the studies would meet DSM-IV criteria for schizophrenia. The rate of recovery or significantly improvement ranged from 46 to 84% for clinical recovery and 21 to 77% for social recovery; thus, there is considerable variability in the rate of recovery, particularly for social/functional recovery. Findings from these 10 long-term follow-up studies challenge the notion that schizophrenia has a chronic, deteriorating course with little hope of recovery.
Studies of individuals with chronic symptoms or who require hospitalization due to exacerbation of symptoms have shown that positive symptoms of schizophrenia continue throughout life (Davidson et al., 1995; Harvey et al., 1998). Davidson and colleagues (1995) found a linear decrease in severity of positive symptoms from ages 25 to 95, but individuals over 65 years old continued to experience significant psychotic symptoms. The researchers also found an age-related increase in severity of negative symptoms and cognitive impairment, and a positive correlation between negative symptoms and cognitive impairment. Harvey et al. (1998) found that cognitive impairment was a stronger predictor of adaptive functioning than either positive or negative symptoms across individuals from nursing homes, long-term hospital settings, and the community; and this was true across all levels of severity of the illness. Data from community-dwelling older adults with schizophrenia suggest that there are a number of individuals who have significant levels of positive symptoms that are stable over time (Harvey, 2005).
Studies showing cognitive decline have mostly been conducted in individuals over 65 with a chronic course of institutionalization and living in hospitals or nursing homes at the time of the investigations. Data indicating less evidence of cognitive decline (i.e., no more than would be associated with benign aging) have typically included younger, community-dwelling individuals with no evidence of chronic institutional stays and a better lifetime course of the illness (Harvey, 2005; Kurtz, 2005). Deficits in social and adaptive functioning are most strongly associated with cognitive deficits, only weakly associated with negative symptoms, and not associated with positive symptoms; furthermore, functional deficits tend to be preceded by deficits in cognition (Friedman et al., 2002; Harvey, 2005).
The DSM-III prohibited a diagnosis of schizophrenia if the onset of symptoms was after age 45, and DSM-III-R provided a specifier to be used for onset after 44 (American Psychiatric Association [APA], 1980, 1987). Estimates are that 15-20% of individuals with schizophrenia have onset after age 44 (Folsom et al., 2006). Thus, the vast majority of older adult clients with schizophrenia will be among those with EOS. The term paraphrenia (experiencing hallucinations and delusions in the absence of functional deterioration or disturbance of affective response, and showing abnormal pre-morbid personality and social functioning; predominantly found in women) was included in the ninth edition of the International Classification of Diseases (ICD-9, 1980) (Howard et al., 2000). Neither the current edition of the ICD (ICD-10) nor that of the DSM (DSM-IV-TR) provides a separate code for late onset schizophrenia (World Health Organization [WHO], 1992; APA, 2000).
Later onset is characterized by greater prevalence of visual, tactile, and olfactory hallucinations; persecutory, partition (belief that people, animals, materials or radiation can pass through a structure that would normally constitute a barrier), reference, control, and grandiose ability delusions; and third-person, running commentary and accusatory or abusive auditory hallucinations. There also is a lower prevalence of formal thought disorder and affective flattening or blunting. Both formal thought disorder and negative symptoms are very rare in onset after 60 (Almeida, Howard, Levy, & David, 1995; Howard, 2001; Howard, et al., 2000; Palmer, McClure, & Jeste, 2001). Individuals with LOS and particularly VLOS appear to have a reduced prevalence of schizophrenia among family members, compared with individuals with EOS (Howard, 2001). Other risk factors for later onset schizophrenia include female gender, cognitive impairment, and possibly sensory impairment (Wynn Owen, & Castle, 1999).
A review of 14 studies suggests that both typical and atypical antipsychotic drugs are effective in relieving symptoms of schizophrenia in older adults. Some studies found that atypical antipsychotic drugs were slightly more effective than typical drugs at reducing positive, negative, and affective symptoms, and that they had reduced parkinsonism, EPS, and other side. Other studies did not find differences between atypical and typical antipsychotic drugs; and Van Citters and colleagues noted methodological limitations in the studies that did find a difference between atypical and typical antipsychotic drugs (Van Citters, Pratt, Bartels, & Jeste, 2005).
Gareri and colleagues (2006) examined adverse effects of nine atypical antipsychotic medications (including a number that are not available in the U.S.) in older adults with dementia or psychotic disorders. Although they noted a reduction in EPS, compared with typical antipsychotic medications, they also noted increased plasma glucose levels in individuals with or without a history of diabetes, elevated triglycerides, and increased risk of death with some of the atypical antipsychotic drugs. Jeste and associates (2005) also reviewed the literature on use of atypical antipsychotic drugs in older adults with dementia or schizophrenia. They reported that while trials involving older adults with schizophrenia have found that atypical antipsychotics are associated with improvements in psychopathology, it is not clear whether differences in efficacy exit among the different medications (Jeste, Dolder, Nayak, & Salzman, 2005). The Agency for Healthcare Research and Quality (AHRQ) released a report looking at the comparative safety of typical and atypical antipsychotic medications based on data gathered in British Columbia (Schneeweis, Setoguchi, Brookhart, Dormuth, & Wang, 2007). Among a mixed group of older adults (including individuals with dementia, mood disorders, psychotic disorders, and comorbid medical conditions), use of atypical antipsychotic medications was not associated with a higher a mortality rate compared with use of typical or conventional antipsychotic medications.
Van Citters and colleagues (2005) reviewed five studies that investigated three manualized, psychosocial interventions developed for older adults with psychotic symptoms and disorders. These included a combined skills training and cognitive behavioral intervention (Cognitive Behavioral Social Skills Training, CBSST), a social skills training program (Functional Adaptation Skills Training, FAST), and a combined skills training and health management intervention for community-dwelling older adults with serious mental illnesses (ST+HM). These interventions were well tolerated by the participants, had low dropout rates, and were associated with positive outcomes such as reductions in positive symptoms and depression; and improvements in social and community functioning, cognitive insight (insight about delusional beliefs), and independent living skills (Van Citters et al., 2005). CBSST and FAST are listed in SAMHSA’s National Registry of Evidence-based Programs and Practices (NREPP, http://www.nrepp.samhsa.gov/).
The FAST program was used as the basis for a group intervention targeting areas, such as public transportation, that had been identified as being problematic for middle-aged and older Latinos (Programa de Entrenamiento para Desarrollo de Aptitudes para Latinos, PEDAL). Individuals treated with PEDAL performed better on measures of everyday living skills at post-treatment and at 6- and 12-month follow-up sessions, but there was no change in their psychopathology (Patterson et al., 2005).
To evaluate the success of providing work for persons with schizophrenia, Twamley and colleagues (2005) compared data from three groups of middle-aged and older veterans with schizophrenia: participants in a VA Wellness and Vocational Enrichment Clinic (WAVE), participants in Department of Rehabilitation/Education Services (DOR), and participants in Individual Placement and Support (IPS). The researchers found the following rates of paid or volunteer work among the groups: IPS, 81%; WAVE, 44%; and DOR, 29%. IPS clearly performed significantly better than WAVE and DOR, but the difference between the latter two approaches was not significant.
Notably, with the exceptions listed above, little research has been undertaken on schizophrenia in minority older adults—this includes research on either the experience or the treatment of schizophrenia.
[Final note. Although there do not appear to be any studies evaluating the effectiveness of family approaches with older adults with schizophrenia, such as those developed by Carol Anderson, Ian Faloon, or William McFarlane, social workers should consider whether these models might be appropriate for older adult clients with schizophrenia and other severe mental illnesses (SMIs) who are living with family members. These family approaches were primarily designed for parents and siblings of individuals with schizophrenia (and other SMIs). Family caretakers of older adults with an SMI include very old parents (primarily mothers), siblings, and sometimes spouses or children (Lefley, 2003).]
Almeida, O. P., Howard, R. J., Levy, R., & David, A. S. (1995). Psychotic states arising in late life (late paraphrenia): Psychopathology and nosology. The British Journal of Psychiatry, 166(2), 205-214.
American Psychiatric Association. (1980). Diagnostic and statistical manual of mental disorders (3rd ed.). Washington, DC: Author.
American Psychiatric Association. (1987). Diagnostic and statistical manual of mental disorders (3rd ed., revised). Washington, DC: Author.
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text revision). Washington, DC: Author.
Cohen, C. I. (Ed.). (2003). Schizophrenia into later life: Treatment, research, and policy. Washington, DC: American Psychiatric Publishing, Inc.
Davidson, M., Harvey, P. D., Powchik, P., Parrella, M., White, L., Knobler, H. Y., et al. (1995). Severity of symptoms in chronically institutionalized geriatric schizophrenic patients. American Journal of Psychiatry, 152, 197-207.
Desai, A. K., & Grossberg, G. T. (2003). Differential diagnosis of psychotic disorders in the elderly. In Cohen, C. I. (Ed.), Schizophrenia into later life: Treatment, research, and policy (pp. 19-41). Washington, DC: American Psychiatric Publishing, Inc.
Folsom, D. P., Lebowitz, B. D., Lindamer, L. A., Palmer, B. W., Patterson, T. L., & Jeste, D. V. (2006). Schizophrenia in late life: Emerging issues. Dialogues in Clinical Neuroscience, 8, 45-52.
Friedman, J. I., Harvey, P. D., McGurk, S. R., White, L., Parrella, M., Raykov T., et al. (2002). Correlates of change in functional status of institutionalized geriatric schizophrenic patients: Focus on medical co-morbidity. American Journal of Psychiatry, 159, 1388-1394.
Gareri, P., De Fazio, P., De Fazio, S., Marigliano, N., Ibbadu, G. F., & De Sarro, G. (2006). Adverse effects of atypical antipsychotics in the elderly: A Review. Drugs & Aging, 23, 937-956.
Harding, C. M. (2003). Changes in schizophrenia across time: Paradoxes, patterns, and predictors. In C. I. Cohen (Ed.), Schizophrenia into later life: Treatment, research, and policy (pp. 19-41). Washington, DC: American Psychiatric Publishing.
Harvey, P. D. (2005). Schizophrenia in late life: Aging effects on symptoms and course of illness. Washington, DC: American Psychological Association.
Harvey, P. D., Howanitz, E., Parrella, M., White, L., Davidson, M., Mohs, R. C., et al. (1998). Symptoms, cognitive functioning, and adaptive skills in geriatric patients with lifelong schizophrenia: A comparison across treatment sites. American Journal of Psychiatry, 155, 1080-1086.
Holroyd, S., & Laurie, S. (1999). Correlates of psychotic symptoms among elderly outpatients. International Journal of Geriatric Psychiatry, 14, 379-384.
Howard, R. (2001). Late-onset schizophrenia and very late-onset schizophrenia. Reviews in Clinical Gerontology, 11, 337-352.
Howard, R., Rabins, P. V., Seeman, M. V., Jeste, D. V., & the International Late Onset Schizophrenia Group. (2000). Late-onset schizophrenia and very-late-onset schizophrenia-like psychosis: An international consensus. American Journal of Psychiatry, 157, 172-178.
Jeste, D. V., Blazer, D. G., & First, M. (2005). Aging-related diagnostic variations: Need for diagnostic criteria appropriate for elderly psychiatric patients. Journal of Biological Psychiatry, 58, 265-271.
Jeste, D. V., Dolder, C. R., Nayak, G. V., & Salzman, C. (2005). Atypical antipsychotics in elderly patients with dementia or schizophrenia: Review of recent literature. Harvard Review of Psychiatry, 13, 340-351.
Keith, S. J., Regier, D. A., & Rae, D. S. (1991). Schizophrenic disorders. In: L. N. Robins & D. A. Regier (Eds.), Psychiatric disorders in America: The epidemiologic catchment area study (pp. 33-52). New York: Free Press.
Kurtz, M. M. (2005). Neurocognitive impairment across the lifespan in schizophrenia: An update, Schizophrenia Research, 74(1), 15-26.
Lefley, H. P. (2003). Changing caregiver needs as persons with schizophrenia grow older. In C. I. Cohen (Ed.), Schizophrenia into later life: Treatment, research, and policy (pp. 251-268). Washington, DC: American Psychiatric Publishing.
Liberman, R. P. (2003). Biobehavioral treatment and rehabilitation for older adults with schizophrenia. In Cohen, C. I. (Ed.), Schizophrenia into later life: Treatment, research, and policy (pp. 223-250). Washington, DC: American Psychiatric Publishing.
Ostling, S., & Skoog, I. (2002). Psychotic symptoms and paranoid ideation in a nondemented population-based sample of the very old. Archives of General Psychiatry, 59, 53-59.
Palmer, B. W., McClure, F. S., & Jeste, D. V. (2001). Schizophrenia in late life: Findings challenge traditional concepts. Harvard Review of Psychiatry, 9, 51-58.
Patterson, T. L., Bucardo, J., McKibbin, C. L., Mausbach, B. T., Moore, D., Barrio, C., et al. (2005). Development and pilot testing of a new psychosocial intervention for older Latinos with chronic psychosis. Schizophrenia Bulletin, 31, 922-930.
Twamley, E., Padin, D. S., Bayne, K. S., Narvaez, J. M., Williams, R. E., & Jeste, D. V. (2005). Work Rehabilitation for middle-aged and older people with schizophrenia: A comparison of three approaches. Journal of Nervous and Mental Disease, 193(9), 596-601.
Van Citters, A. D., Pratt, S. I., Bartels, S. J., & Jeste, D. V. (2005). Evidence-based review of pharmacologic and nonpharmacologic treatments for older adults with schizophrenia. Psychiatric Clinics of North America, 28(4), 913-939.
White, L., Friedman, J. I., Bowie, C. R., Evers, M., Harvey, P. D., Parrella, M., et al. (2006). Long-term outcomes in chronically hospitalized geriatric patients with schizophrenia: Retrospective comparison of first generation and second generation antipsychotics. Schizophrenia Research, 88(1-3), 127-134.
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Wynn Owen, P. A., & Castle, D. J. (1999). Late-onset schizophrenia: Epidemiology, diagnosis, management and outcomes. Drugs & Aging, 15, 81-89.
Zayas, E. M., & Grossberg, G. T. (1998). The treatment of psychosis in late life. Journal of Clinical Psychiatry, 59(suppl 1), 5-10.
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