1. Schizophrenia in Older Adults Zvi D. Gellis, PhDStanley G. McCracken, PhD, LCSW Director, Center for Mental Health & AgingSenior Lecturer Hartford Geriatrics Faculty ScholarThe University of Chicago State University of New York at Albany Resource Review for Teaching Resource Review for Teaching

2. 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.

3. 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.

4. 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.

5. 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 non- medical drugs; over-the-counter drugs; and herbal preparations.

6. 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.

7. 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).

8.  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

9.  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

10. Positive symptoms Decrease or remain steady Negative symptoms Increase Disorganized speechDecreases Verbal under-productivityIncreases in severity Cognitive functioning Decline: institutionalized indiv. Change assoc w/benign aging: younger, community dwelling. (Cognitive deficits associated w/social and adaptive deficits) Symptom Changes Older Adults with EOS

11. 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.

12. 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.

13. 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.

14. 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.

15.  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

16.  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

17.  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. Psychosocial Treatments