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Resource Review for Teaching
Schizophrenia
in Older Adults
Zvi D. Gellis, PhD
Director, Center for Mental Health & Aging
Hartford Geriatrics Faculty Scholar
State University of New York at Albany
Stanley G. McCracken, PhD, LCSW
Senior Lecturer
The University of Chicago
Epidemiology
 Prevalence of psychotic disorders is low among
individuals >65.
ECA: 0.2% point prevalence, 0.3% lifetime
prevalence in community sample, 8-10% in
geropsychiatry units.
 ECA did not count onset > 45 y.o. Estimated that
true prevalence is closer to 1%.
 In 2000, 13.6% of individuals with schizophrenia
were >65.
 The prevalence of psychotic symptoms is higher:
around 10% in a community sample >85 y.o., >60%
among adults with dementia.
Epidemiology
 Psychotic symptoms are more often associated with
medical conditions, medical and surgical procedures,
drugs and medications, dementia, delirium, or mood
disorders than with psychotic disorders.
Differential Diagnosis
of Psychotic Symptoms
 Identify/rule out medical precipitants of symptoms.
 Take thorough history.
 Involve physician.
 Gather information from older adult and someone else
who knows him/her well.
Differential Diagnosis
 History: Psychotic or other psychiatric symptoms?
Current or prior psychiatric diagnosis or treatment?
Family history of psychiatric problems (e.g., psychotic
or mood disorders, suicide, dementia)?
 Initial purpose of assessment: determine nature of
symptoms, when they started and relationship with
stressors, the degree of impairment and distress that
they are causing.
 Use of prescribed medications; alcohol and other nonmedical drugs; over-the-counter drugs; and herbal
preparations.
Age at Onset of Schizophrenia
 Early Onset Schizophrenia (EOS): before 40 y.o.
 Late Onset Schizophrenia (LOS): from 40 to 60 y.o.
 Very Late Onset Schizophrenia (VLOS): after 60 y.o.
Older Adults with EOS
 Historical views of EOS:
 Schizophrenia has a course that is chronic and, if
not deteriorating, is stable and usually nonremitting.
 Positive symptoms (e.g., hallucinations and
delusions) “burn out” over time and are replaced by
increasing negative symptoms (e.g., reduced
affective experience and expression and reduced
verbal output).
Older Adults with EOS
 Variety of outcomes over time.
 Long-term (20 years) longitudinal studies show a
high percentage recover.
 Recovered or significantly improved: 46-84% for
clinical recovery; 21-77% for social recovery.
 Most studies conducted among individuals who
became ill prior to the 1950s (and use of
antipsychotic medication).
Older Adults with EOS
 Short-term follow up and cross-sectional studies show
that a number of older adults continue to experience
significant symptoms.
 The specific pattern of symptom changes and severity
depends on whether the sample of older adults are
community-dwelling or hospitalized/in nursing homes
Older Adults with EOS
Symptom Changes
Positive symptoms
Decrease or remain steady
Negative symptoms
Increase
Disorganized speech
Decreases
Verbal under-productivity
Increases in severity
Cognitive functioning
Decline: institutionalized indiv.
Change assoc w/benign aging:
younger, community dwelling.
(Cognitive deficits associated
w/social and adaptive deficits)
Older Adults w/LOS & VLOS
 Difficult to reliably determine the age of onset of
symptoms of Schizophrenia.
 Few studies of epidemiology of LOS and VLOS.
Estimate that 15-20% have onset of schizophrenia
>44 y.o.
 Pattern of symptoms and risk factors differ between
individuals with EOS and those with later onset.
Pharmacological Treatment
 Antipsychotic drugs are effective in treating psychotic
symptoms in older adults.
 Little evidence of differences in effectiveness among
drugs and classes.
 Conventional drugs have increased EPS.
 Atypical drugs have increased risk of elevated glucose
and tri-glycerides.
 Risk of death is not higher among atypical drugs.
Pharmacological Treatment
 Doses may need to be lower in older adults
(particularly those with later onset) and raised slowly.
 Need to individualize medication management of older
adults:
 due to differences in how drugs are metabolized
 potential for concurrent medical conditions and
medication use to increase risk of harmful effects.
Psychosocial Treatments
 CBT, SST, combined skills training & health management:
 Well tolerated.
 Low drop out rates.
 Reduce positive symptoms and depression.
 Improve social and community functioning, cognitive
insight, and independent living skills.
 SST improves living skills among Latino older adults
with Schizophrenia.
 IPS improves rate of paid and volunteer work among
middle-aged and older veterans with Schizophrenia.
Psychosocial Treatments
 Principles of Behavioral and CBT among older
adults w/SMI.
 Biological and psychological interventions
should be integrated.
 Interventions should be outcome-specific.
 Personally relevant goals and quality of life are
more important that syndromal definitions of
the disorder.
 Multimodal treatments should be provided to
attain multidimensional improvements in the
individual.
Psychosocial Treatments
 Principles of Behavioral and CBT.
 Older adults with schizophrenia can learn to control
their symptoms and manage medications.
 They can 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
Psychosocial Treatments
 Principles of Behavioral and CBT.
 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
of all age groups.
 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.