Stanley G. McCracken, PhD, University of Chicago

Zvi D. Gellis, PhD, University of Pennsylvania.

Profile

• Purpose: To teach master’s-level direct practice social work students about schizophrenia in older adults.
• Audience: Masters-level social work students.
• Audience Size: Maximum 40.

Content

• Core Values
  • To recognize and treat older adults as people first.
  • To understand that older adults have goals and desires just like younger people, which may include independent living, meaningful and enjoyable activities, and mature relationships, and that they also have the capacity to learn, grow, and achieve these goals.
  • To foster and promote the understanding that older adults deserve courtesy, respect, and dignity in all interactions.
  • To provide a safe, caring environment in which to live.
  • To advocate for evidence-based interventions and services that are sensitive to diversity.
  • To attempt to change the environment to meet the resident’s needs.
  • To make every effort to support attempts to build and maintain skills and promote independence.
• Informational Competencies.At the end of this module, students will know:
  • That the prevalence of schizophrenia varies greatly according to setting.
  • That psychotic symptoms can be produced by a number of different conditions.
  • The differences between early, late, and very late onset schizophrenia.
  • That early onset schizophrenia has a number of different patterns for the course of the illness over time.
  • That antipsychotic medication is effective in treating schizophrenia, but that no one drug or category of medication has proven more effective than any other.
  • That conventional and atypical antipsychotic drugs have different profiles of side effects and risks.
  • That there is less research on non-pharmacological treatments for schizophrenia than there is for pharmacological interventions.
  • That most non-pharmacological interventions used in treatment of older adults with schizophrenia are extensions of practices used in younger individuals.
  • That cognitive behavioral therapy, social skills training, and individual placement and support all have some evidence supporting their effectiveness with older adults with schizophrenia.

Time Needed:

45-80 minutes, depending on class size and time spent on exercise.

Training Format:

Didactic lecture, exercises.

Equipment

Chalkboard, flipchart, or dry erase board with markers.
LCD projector & laptop computer.

Slides

PowerPoint slides

Literature Review

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.]

Epidemiology of Psychotic Symptoms in Older Adults

• The prevalence of psychotic disorders, specifically schizophrenia and schizophreniform disorder, is low among adults over 65. However, the prevalence of psychotic symptoms is high.

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 in the elderly are more often associated with the presence and treatment of medical conditions, dementia, and other organic changes, and mood disorders than with psychotic disorders.

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).

• When an older adult experiences psychotic symptoms, perform a differential diagnosis to identify the reason for symptoms and to rule out/identify medical and pharmacological precipitants of these symptoms.
• Determining the etiology of psychotic symptoms in elderly individuals (see decision tree below). A number of the steps involve medical determinations that must involve a physician to determine etiology of the psychotic symptoms.
• Take a thorough history to determine whether the individual has experienced psychotic or other psychiatric symptoms, has had a current or prior psychiatric diagnosis or treatment, or has a family history of psychiatric problems (e.g., psychotic or mood disorders, suicide, dementia). Take history from the individual and one other person who is quite familiar with him or her.
  • The initial purpose of assessment: determine nature of symptoms, when they started and relationship with any stressors, and the degree of impairment and distress that they are causing.
  • Gather information on use of prescribed medications, alcohol and other non-medical drugs, over-the-counter drugs, and herbal preparations.

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).

Older Adults with Early Onset Schizophrenia

• Two conflicting historical views of EOS: 1) schizophrenia has a course that is chronic and, if not deteriorating, is stable and usually nonremitting; 2) positive symptoms (such as hallucinations and delusions) “burn out” over time and are replaced by increasing negative symptoms (such as reduced affective experience and expression and reduced verbal output).
• Research has found a wide variety of outcomes among individuals with EOS:
  • A substantial proportion of individuals recover over time.

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.

• There is a wide variety of symptom patterns among individuals with EOS, much of which depends on whether the sample was from the community or institutional settings.
• Data suggest that positive symptoms either decrease or remain steady over time and that negative symptoms may increase over time.
• Symptoms of verbal disconnections (disorganized speech) decrease over time, while symptoms of verbal underproductivity (alogia) increase over time. This implies that positive symptoms do not necessarily decrease over time—individuals just may no longer talk about these symptoms.

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).

• Cognitive impairment. Some studies show abnormal cognitive decline, whereas others show rates of decline associated with normal aging. Impaired social functioning and adaptive functioning are strongly associated with cognitive impairment, weakly associated with negative symptoms, and not associated with positive symptoms.

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).

• One should expect a large cohort effects among older adults with schizophrenia. Each successive 10-year age cohort is more likely than their predecessor to have been treated with antipsychotic medication early in the course of their illness and more likely to have received atypical antipsychotic medication. The effect of this remains to be seen.

Late Onset and Very Late Onset Schizophrenia

• Research in this area is limited by the fact that, in the absence of treatment records, it is difficult to reliably determine the age of onset of symptoms of schizophrenia. Common unawareness of the illness along with memory impairments make retrospective judgments about the timing of symptom onset suspect.
• There also are a number of terminology problems when examining the literature.

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).

• Compared with EOS, later onset is characterized by:
  • Greater prevalence of visual, tactile, and olfactory hallucinations; persecutory, partition, reference, control, and grandiose ability delusions; and third-person, running commentary and accusatory or abusive auditory hallucinations.
  • Lower prevalence of formal thought disorder and affective flattening or blunting.
  • Risk factors: lower familial prevalence, female gender, cognitive impairment, and possibly sensory impairment.

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).

Treatment of Schizophrenia in Older Adults

Pharmacological Treatment

• Overall, the literature suggests the following:
  • Antipsychotic medication is effective in reducing psychotic symptoms in older adults with schizophrenia.
  • Apparently, no drug or category of drugs is any more effective than any other.
  • Adverse effects differ between the typical and atypical medications with typical medication having increased extrapyramidal symptoms (EPS), particularly tardive dyskinesia in older adults, and atypical medication having increased risk of elevated glucose and tri-glycerides; however, risk of death is not higher for users of atypical antipsychotic medications than for users of ones.
  • Doses may need to be lower among older adults, particularly among individuals with later onset of the disorder, and should be increased gradually.
  • Medication management of older adults should be individualized due to differences in how drugs are metabolized and to the potential of concurrent medical conditions to cause or exacerbate harmful effects and the potential of drug interactions with medications used to treat these concurrent conditions.

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.

Psychosocial Treatments

• Far fewer studies have examined the effectiveness of non-pharmacologic treatments of schizophrenia in older adults, compared to pharmacological treatments.
• Cognitive behavioral treatment (CBT), social skills training (SST), and a combined skills training and health management interventions:
  • are well tolerated,
  • have low dropout rates,
  • are associated with positive outcomes, such as reductions in positive symptoms and depression; improved social and community functioning, cognitive insight, and independent living skills.
• Social skills training targeting instrumental skills, such as riding public transportation, improves everyday living skills among Latino older adults.
• Individual placement and support (IPS) is effective in producing paid and volunteer work among middle-aged and older adult veterans with schizophrenia.

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.

• A review of the behavioral and cognitive behavioral literature that includes older adults with severe mental illnesses (including but not limited to schizophrenia) suggests the following principles (Liberman, 2003):
• Biological and psychological interventions should be integrated, personally relevant goals and quality of life should be seen as more important than syndromal definitions of the disorder, and multimodal treatments should be provided to attain multidimensional improvements in the individual..
• Older adults with schizophrenia can learn to control their symptoms and manage medications, and learn and generalize social and independent living skills for community adaptation.
• Environmental supports need to be “wrapped around” to ensure that the needs of older adults with schizophrenia are being met, because it is not unreasonable to expect that these persons will need to learn or relearn the full range of skills needed to live autonomously in the community.
• Older adults with treatment refractory psychotic symptoms appear to benefit from cognitive therapy.
• Social learning and token economy procedures are effective for individuals with schizophrenia regardless of age.
• Behavior therapy appears to protect against stress-related relapse when effective in promoting coping skills and may reduce the amount of medication necessary for symptom stabilization and relapse prevention.

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).]

References

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.

World Health Organization. (1992). ICD-10, Classification of mental and behavioral disorders. Geneva: Author.

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. 

Go to next page for a Literature Review associated with this section.