Evidence-Based Reviews

Late-onset schizophrenia: Make the right diagnosis when psychosis emerges after age 60

Current Psychiatry. 2002 December;1(12):35-44

References

1. Howard R, Rabins PV, Seeman MV, et al. Consensus statement of the International Late Onset Schizophrenia Group. In: Howard R, Rabins PV, Castle DJ, (eds). Late onset schizophrenia. Petersfield, UK: Wrightson Biomedical, 1999;263-6.

2. Castle DJ, Wessely S, Van Os J, et al. Psychosis in the inner city: The Camberwell First Episode Study. Maudsley Monograph 40. Hove, UK: Psychology Press, 1998.

3. Howard R, Castle DJ, O’Brien J, et al. Permeable walls, floors, ceilings and doors: partition delusions in late paraphrenia. Int J Geriatr Psychiatry 1992;7:719-24.

4. Pearlson GD, Kreger L, Rabins PV, et al. A chart review study of late-onset and early-onset schizophrenia. Am J Psychiatry 1989;146:1568-74.

5. Castle DJ, Howard R. What do we know about the aetiology of late onset schizophrenia? Eur Psychiatry 1992;7:99-108.

6. Howard R, Graham C, Sham P, et al. A controlled family study of late-onset non-affective psychosis (late paraphrenia). Br J Psychiatry 1997;170:511-4.

7. Murray RM, O’Callaghan E, Castle DJ, et al. A neurodevelopmental approach to the classification of schizophrenia. Schizophr Bull 1992;18:319-32.

8. Prager S, Jeste DV. Sensory impairment in late life schizophrenia. Schizophr Bull 1993;19:755-71.

9. Kay DWK. The English language literature on late paraphrenia from the 1950s. In: Howard R, Rabins PV, Castle DJ (eds). Late onset schizophrenia. Petersfield, UK: Wrightson Biomedical, 1999;17-43.

10. Jeste DV, Harris MJ, Krull A, et al. Clinical and neuropsychological characteristics of patients with late-onset schizophrenia. Am J Psychiatry 1995;152:722-30.

11. Pearlson GD. Brain imaging in late onset schizophrenia. In: Howard R, Rabins PV, Castle DJ (eds). Late onset schizophrenia. Petersfield, UK: Wrightson Biomedical, 1999;191-204.

12. Castle DJ. Gender and age at onset in schizophrenia. In: Howard R, Rabins PV, Castle DJ (eds). Late onset schizophrenia. Petersfield, UK: Wrightson Biomedical, 1999;147-64.

13. Salzman C, Tune L. Neuroleptic treatment of late-life schizophrenia. Harvard Rev Psychiatry 2001;9:77-83.

14. Harris MJ, Jeste DV. Late-onset schizophrenia: an overview. Schizophr Bull 1988;14:39-55.

15. Sweet RA, Pollock BG. Neuroleptics in the elderly: guidelines for monitoring. Harvard Rev Psychiatry 1995;2:327-35.

16. Sciolla A, Jeste DV. Use of antipsychotics in the elderly. Int J Psych Clin Pract 1998;2(suppl 1):S27-S34.

17. Jeste DV, Caligiuri MP, Paulsen JS, et al. Risk of tardive dyskinesia in older patients: a prospective longitudinal study of 266 patients. Arch Gen Psychiatry 1995;52:756-65.

18. Barak Y, Wittenberg N, Naor S, et al. Clozapine in elderly psychiatric patients: tolerability, safety and efficacy. Compr Psychiatry 1999;40:320-5.

19. Madhusoodanan S, Suresh P, et al. Experience with the atypical antipsychotics—risperidone and olanzapine in the elderly. Ann Clin Psychiatry 1999;11(3):113-8.

20. Arvanitis LA, Miller BG. Multiple fixed doses of “Seroquel” (quetiapine) in patients with acute exacerbation of schizophrenia: a comparison with haloperidol and placebo. Biol Psychiatry 1997;42(4):233-46.

21. Kay DWK, Roth M. Environmental and hereditary factors in the schizophrenias of old age (‘late paraphrenia’) and their bearing on the general problem of causation in schizophrenia. J Mental Sci 1961;107:649-86.

22. Aguera-Ortiz L, Reneses-Prieto B. The place of non-biological treatments. In: Howard R, Rabins PV, Castle DJ (eds). Late onset schizophrenia. Petersfield, UK: Wrightson Biomedical, 1999;233:60.-

23. Fowler D, Garety P, Kuipers E. Cognitive behavioural therapy for psychosis: theory and practice. Chichester, UK: Wiley, 1995.

Older patients taking antipsychotics face an increased risk of extrapyramidal symptoms (EPS), especially parkinsonism and akathisia.¹⁶ Anticholinergics are poorly tolerated and may cause urinary retention, constipation, blurred vision, exacerbation of glaucoma, and delirium. Cardiovascular side effects, especially orthostatic hypotension, may lead to falls and significant injury and may exacerbate coexisting cardiovascular disease.

Neuroleptic-induced tardive dyskinesia (TD) is another potential complication. Jeste et al found the cumulative annual incidence of drug-induced TD to be five times greater among older psychotic patients than among younger ones (26% vs. 5% after 1 year).¹⁷ Duration of exposure and total cumulative amount of prescribed neuroleptics remain significant risk factors for TD in older patients.

Atypical antipsychotics, with their less-adverse side-effect profiles and lower risk of EPS (and probably TD as well) are the preferred first-line drugs for late-onset schizophrenia. These agents also have been associated with improved cognition in younger patients with schizophrenia, a potentially significant benefit in the older patient.

Table 2

ANTIPSYCHOTIC DOSAGES RECOMMENDED FOR VERY LATE-ONSET SCHIZOPHRENIA

Drugs	Initial dosages	Maintenance dosages
Olanzapine	1 to 5 mg/d	2.5 to 15 mg/d
Risperidone	0.25 to 0.5 mg/d	0.5 to 3 mg/d
Quetiapine	12.5 to 25 mg/d	75 to 150 mg/d

No well-controlled trials of clozapine in very late-onset schizophrenia have been performed. According to one literature review,¹⁸ most older psychotic patients showed moderate to marked improvement at relatively low dosages (mean dosage 134 mg/d). The reviewers concluded that clozapine was safe and well tolerated but suggested that agranulocytosis may occur at higher rates in this group than in younger patients. Clozapine’s potent anticholinergic action and its marked sedative effects limit its use in very late-onset schizophrenia to treatmentresistant patients or those with severe TD.

Data on the use of other atypical agents in very late-onset schizophrenia are limited. Risperidone has been associated with significant improvements in older patients with schizophrenia.¹⁶ Risperidone, olanzapine, and quetiapine have all been found to be safe, well-tolerated, and effective in managing late-life psychotic disorders.^16,19,20 As with neuroleptics, recommended starting and maintenance dosages of the atypicals are lower than those used in younger patients (Table 2).¹³

A “start low, go slow” approach is warranted, and dosages should be adjusted according to clinical response. Communicate with the patient’s primary care physician to learn of any potential drug-drug interactions with medications being given for comorbid illnesses.

Electroconvulsive therapy has been reported to be useful in several studies, but data on its use in very late-onset schizophrenia are limited.²¹

Psychosocial interventions. One review of the role of non-biological treatment in very late-onset schizophrenia²² stressed the need to develop trust between patient and psychiatrist, so that the patient clearly views the treatment team as allies (Table 3). To that end, look for thoughts, feelings, or situations that may have precipitated the onset of psychosis, and explore their subjective meaning with the patient. Address any clear losses that are identified, such as the recent death of a spouse or other family member.

Table 3

DOs AND DON’Ts OF MANAGING AN OLDER PATIENT WITH SCHIZOPHRENIA

Do	Don’t
Offer practical solutions to perceived difficulties (e.g., help resolve familial conflicts or housing/financial difficulties rather than get involved with delusional interpretation of events) Assess degree of loneliness by exploring the patient’s wishes/fears of social contact Assess the patient’s social needs by talking with the patient, family physician, and (if applicable) nurse Contact family members early and involve them in planning Correct visual and hearing impairments as much as possible	Make initial demands on the patient. Often the patient is hostile at first; this can undermine treatment Confront delusional system directly. Acknowledge concerns but don’t directly challenge beliefs; otherwise the patient will become unresponsive ‘Take sides’ in paranoid disputes the patient may be having with neighbors or others Apply diagnostic labels early. Build patient rapport before rendering a diagnosis Act alone. Involve primary care physician and family as appropriate

Don’t

Offer practical solutions to perceived difficulties (e.g., help resolve familial conflicts or housing/financial difficulties rather than get involved with delusional interpretation of events)
Assess degree of loneliness by exploring the patient’s wishes/fears of social contact
Assess the patient’s social needs by talking with the patient, family physician, and (if applicable) nurse
Contact family members early and involve them in planning
Correct visual and hearing impairments as much as possible

Make initial demands on the patient. Often the patient is hostile at first; this can undermine treatment
Confront delusional system directly. Acknowledge concerns but don’t directly challenge beliefs; otherwise the patient will become unresponsive
‘Take sides’ in paranoid disputes the patient may be having with neighbors or others
Apply diagnostic labels early. Build patient rapport before rendering a diagnosis
Act alone. Involve primary care physician and family as appropriate

Find out if the patient is isolated and to what degree he or she feels lonely. Encourage the patient to engage in activities that he or she once enjoyed, and subtly introduce the patient to an appropriate community support group. Suggesting participation in group leisure activities may also help. Ascertain the patient’s living arrangements and basic needs. You may need to refer the patient to a social agency for assistance with housing, finances, nutrition/diet, and transportation.

Reminiscence therapy, through which patients are encouraged to reflect on their lives, can be useful for patients with very late-onset schizophrenia. Through reflection, patients can review past successes and painful experiences and move toward ultimate resolution of conflict and current difficulties.²²