Older people with schizophrenia: a community study in a rural catchment area

Cognitive impairment and development of dementia in very late-onset schizophrenia-like psychosis: a systematic review

OBJECTIVES

This study aimed to review the evidence base regarding cognitive impairment and the development of dementia in patients with very late-onset schizophrenia-like psychosis (VLOSLP).

METHODS

We conducted a systematic literature search of PubMed, PsycINFO and Web of Science according to Preferred Reporting Items for Systematic Reviews (PRISMA) guidelines. Two reviewers independently screened records first by title and abstract and then by full text, resolving differences after each stage. Selected studies were assessed for quality using the GRADE system, and data on study design, participants, cognitive ability and rates of developing dementia were extracted and synthesised.

RESULTS

Seventeen publications were identified for review. They were generally poor in quality and heterogenous in design. VLOSLP patients were found to have impaired global cognition compared to non-psychotic controls, but no difference was found between VLOSLP patients and aged early-onset schizophrenia (EOS) patients. No single cognitive domain was consistently affected. Patients with VLOSLP demonstrated significantly higher rates of dementia diagnosis (ranging from 4.4% over 3 years to 44.4% over 15 years) than controls, but no difference was found between VLOSLP patients and aged EOS patients.

CONCLUSIONS

VLOSLP may not necessarily predict cognitive decline, but few studies have adequately investigated cohorts on a longitudinal basis. Heterogeneity between and within cohorts and varying selection criteria compromise the clinical generalisability of studies investigating the association between VLOSLP and neurodegenerative disease. Further studies on the clinical presentation, cognitive profile and neuropathology of VLOSLP with comparison to EOS/late-onset schizophrenia (LOS) and neurodegenerative disease are needed to better inform the diagnosis and management of VLOSLP.

Quality of life and its predictors in first-episode schizophrenia and individuals at clinical high-risk for psychosis

BACKGROUND

This is a cross-sectional study comparing the degree of subjective quality of life (QOL) impairment and its predictive factors in first-episode schizophrenia (FES) and individuals at clinical high-risk (CHR) for psychosis.

METHODS

Seventy-seven FES, 59 CHR, and 64 healthy controls (HC) were included. The QOL of all participants was assessed using the World Health Organization Quality of Life (WHOQOL)-Brief Form (BREF). Psychiatric symptoms of individuals with FES were assessed with the Positive and Negative Syndrome Scale (PANSS), five factors were further identified through factor analysis; for individuals with CHR and HC, the Scale of Prodromal Symptoms (SOPS) was used.

RESULTS

The total and four sub-domain scores of the WHOQOL-BREF in the FES and CHR groups were lower than those of the HC group. The overall and psychological health scores in the CHR group were lowest. In the FES group, after applying Bonferroni's correction, there is a negative correlation between the total QOL scores and anxiety/depressive symptom scores (r = -0.34, P = 0.003). The stepwise multiple regression analysis showed that the QOL of both FES and CHR group were negatively affected by anxiety/depressive symptoms and unemployment (P < 0.05).

CONCLUSIONS

Compared with FES, CHR individuals are more dissatisfied with their QOL. Although diagnostic assessment of FES and CHR relies heavily on positive symptoms, the QOL is more affected by anxiety/depressive symptoms and social functioning.

Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the management of schizophrenia and related disorders

OBJECTIVES

This guideline provides recommendations for the clinical management of schizophrenia and related disorders for health professionals working in Australia and New Zealand. It aims to encourage all clinicians to adopt best practice principles. The recommendations represent the consensus of a group of Australian and New Zealand experts in the management of schizophrenia and related disorders. This guideline includes the management of ultra-high risk syndromes, first-episode psychoses and prolonged psychoses, including psychoses associated with substance use. It takes a holistic approach, addressing all aspects of the care of people with schizophrenia and related disorders, not only correct diagnosis and symptom relief but also optimal recovery of social function.

METHODS

The writing group planned the scope and individual members drafted sections according to their area of interest and expertise, with reference to existing systematic reviews and informal literature reviews undertaken for this guideline. In addition, experts in specific areas contributed to the relevant sections. All members of the writing group reviewed the entire document. The writing group also considered relevant international clinical practice guidelines. Evidence-based recommendations were formulated when the writing group judged that there was sufficient evidence on a topic. Where evidence was weak or lacking, consensus-based recommendations were formulated. Consensus-based recommendations are based on the consensus of a group of experts in the field and are informed by their agreement as a group, according to their collective clinical and research knowledge and experience. Key considerations were selected and reviewed by the writing group. To encourage wide community participation, the Royal Australian and New Zealand College of Psychiatrists invited review by its committees and members, an expert advisory committee and key stakeholders including professional bodies and special interest groups.

RESULTS

The clinical practice guideline for the management of schizophrenia and related disorders reflects an increasing emphasis on early intervention, physical health, psychosocial treatments, cultural considerations and improving vocational outcomes. The guideline uses a clinical staging model as a framework for recommendations regarding assessment, treatment and ongoing care. This guideline also refers its readers to selected published guidelines or statements directly relevant to Australian and New Zealand practice.

CONCLUSIONS

This clinical practice guideline for the management of schizophrenia and related disorders aims to improve care for people with these disorders living in Australia and New Zealand. It advocates a respectful, collaborative approach; optimal evidence-based treatment; and consideration of the specific needs of those in adverse circumstances or facing additional challenges.

Psychiatric hospital admission and long-term care in patients with very-late-onset schizophrenia-like psychosis

OBJECTIVE

In this register-based study the rates and durations of psychiatric hospitalizations were compared between patients with very-late-onset schizophrenia-like psychosis (VLOSLP, n = 918) and elderly patients with illness onset before 60 years (n = 6142). The proportion of patients ending up in long-term care (LTC) or long-lasting psychiatric hospital care (LLP) was also studied.

METHODS

A sample of patients with schizophrenia aged 65 or over was collected from the Finnish Hospital Discharge Register. Psychiatric hospitalizations were calculated per year, and logistic regression was used to compare onset groups and factors associated with ending up in LTC/LLP.

RESULTS

Between 1999 and 2003, 27% of patients with VLOSLP and 23% of patients with earlier onset had at least one psychiatric hospitalization (p = 0.020). When the rates of patients' stays in psychiatric hospital per year were compared, the only difference was that in the first year 14% (141/918) and 11% (679/6142) had at least one day in psychiatric hospital (p < 0.001) respectively. In logistic regression onset group of schizophrenia was not associated with LTC/LLP, except weakly the VLOSLP group in women (p = 0.042, OR 1.23). Patients having any cardiovascular disease (p < 0.001, OR 0.63) or a respiratory disease (p = 0.008, OR 0.73) were less likely to end up in LTC/LLP.

CONCLUSION

The patients with VLOSLP needed more psychiatric hospital care than those with earlier illness onset. Ending up in LTC/LLP was equally common in both onset groups, but some physical diseases, such as cardiovascular and respiratory, diminished the likelihood of this.

Patients with very-late-onset schizoprhenia-like psychosis have higher mortality rates than elderly patients with earlier onset schizophrenia

OBJECTIVE

In this register-based study of schizophrenia patients aged 65 years or above, mortality and causes of death diagnosed at age of 60+ (very-late-onset schizophrenia-like psychosis, VLOSLP) were studied in comparison with sex- and age-matched general Finnish population. Standardized Mortality Ratios (SMRs) of VLOSLP patients were also compared with those of earlier onset (below 60 years) schizophrenia patients, and hazard of death was calculated between these patient groups.

METHODS

The data was obtained from Finnish nationwide registers and consisted of 918 VLOSLP patients and 6142 earlier onset patients who were at least 65 years on 1 January 1999. The register-based follow-up for mortality covered 10 years between 1999 and 2008.

RESULTS

Overall SMR was 5.02 (4.61-5.46) in the group of VLOSLP patients and 2.93 (2.83-3.03) in the group of earlier onset patients. In men, SMRs were 8.31 (7.14-9.62; n = 179) and 2.91 (2.75-3.07, n = 1316) and in women 4.21 (3.78-4.66; n = 364) and 2.94 (2.82-3.07, n = 2055). In the VLOSLP group, SMRs were higher in most causes-of-death categories such as accidents, respiratory diseases, dementias, neoplasms and circulatory diseases. However, in direct comparison adjusted for several variables, the difference between these groups was minimal (Hazard Ratio, HR, 1.16 95%CI 1.05-1.27, p = 0.003).

CONCLUSION

Patients with VLOSLP, especially men, are at even higher risk of death than schizophrenia patients with earlier onset. Physical comorbidities and accidents in the VLOSLP group mostly explained this result. Targeted clinical interventions with effective collaboration between psychiatry and primary and specialist-level somatic care are crucial to reduce their excess mortality

Theory of Mind differences in older patients with early-onset and late-onset paranoid schizophrenia

OBJECTIVE

Theory of Mind (ToM) is considered an essential element of social cognition. In younger schizophrenia patients, ToM impairments have extensively been demonstrated. It is not clear whether similar impairments can be found in older schizophrenia patients and if these impairments differ between older patients with early-onset and late-onset schizophrenia.

METHODS

Theory of Mind abilities were assessed using the Hinting Task in 15 older patients (age 60 years and older) with early-onset paranoid schizophrenia, 15 older patients with late-onset paranoid schizophrenia and 30 healthy controls. ANCOVA was performed to test differences between groups. Analyses were adjusted for level of education. Effect sizes, partial eta squared (ε(2) ), were computed as an indication of the clinical relevance of the findings.

RESULTS

Patients with early-onset schizophrenia scored significantly lower on the Hinting Task (mean 16.1; SD 4.3) compared with patients with late-onset schizophrenia (mean 18.6; SD 1.5) and with healthy controls (mean 19.0; SD 1.4). The effect size of this difference was large (ε(2)  = 0.2).

CONCLUSIONS

These results suggest that ToM functioning may be a protective factor modulating the age at onset of psychosis. Further studies into the relationship between social cognition and onset age of psychosis are warranted.

Schizophrenia spectrum disorders in later life: prevalence and distribution of age at onset and sex in a dutch catchment area

OBJECTIVES

The prevalence of schizophrenia in later life is affected by both outflow of early onset patients, due to recovery and excess mortality, and inflow of patients with a later age at onset, making it likely that characteristics of older patients differ markedly from younger patients. We assessed the prevalence of schizophrenia and spectrum disorders and their distribution according to age at onset and sex in an elderly population.

DESIGN

Case register study.

SETTING AND PARTICIPANTS

All patients age 60 years and older, in contact with the Mental Health Organization in a psychiatric catchment area in Amsterdam (the Netherlands), diagnosed with schizophrenia, schizoaffective disorder, or delusional disorder.

MEASUREMENTS

One-year prevalence estimates, including rates according to age group, age at onset, and sex. In addition, we determined the effect of using different criteria for age at onset.

RESULTS

The one-year prevalence of all disorders was 0.71%, subdivided in 0.55% for schizophrenia, 0.14% for schizoaffective disorder, and 0.03% for delusional disorder. The one-year prevalence of early-onset schizophrenia was 0.35%, of late-onset schizophrenia 0.14%, and of very-late-onset schizophrenia-like psychosis 0.05%. Variation of onset criterion affected the proportion of early-onset versus late-onset schizophrenia patients stronger in women than in men. Women outnumbered men markedly in the prevalence estimates for most diagnostic subgroups, including early-onset schizophrenia.

CONCLUSIONS

We found the prevalence of schizophrenia among older persons to be well within the range reported for younger populations. The considerable proportion with a later age at onset and the strong female preponderance are distinguishing characteristics of older patients with clinical implications.

An initial study of modifiable and non-modifiable factors for late-life psychosis

OBJECTIVE

To determine rates of psychotic symptoms and associated modifiable and non-modifiable factors among elderly long term nursing home residents without prior history of psychiatric illness.

METHOD

A cross-sectional design using the Scale for the Assessment of Positive Symptoms (SAPS) to measure psychotic symptoms, the Folstein's Mini-Mental State Exam (MMSE), and Mattis Dementia Rating Scale (DRS) to evaluate cognitive impairment. Frequency and rates of global psychotic symptoms and hallucinations, delusions, formal thought disorder, and bizarre behavior were calculated. Logistic regression was used to examine modifiable (e.g., medication use) and non-modifiable clinical characteristics (e.g., older age) associated with late-life psychosis.

RESULTS

There were 15.9% of subjects reporting delusions and 7.3% reporting hallucinations. History of stroke, poorer cognition, and receiving multiple medications showed significant association with late-life psychosis. Only stroke (OR = 9.12; 95% CI: 1.58-52.74) and receiving different classes of medications (benzodiazepines, neuroleptics, and antidepressants) (OR = 13.17; 95% CI: 2.10-85.82) remained significantly associated with psychosis after adjusting for Mattis DRS total score. Further analyses excluding subjects with MMSE scores of 24 or lower (n = 24) showed essentially the same results but subjects with better cognitive function suffered a less severe form of psychosis, essentially constituted by one symptom type (i.e., visual hallucinations).

CONCLUSIONS

Rates of late-life psychosis in this sample of nursing home residents without previous psychiatric history were high. Simultaneous use of medications including antidepressants, sedatives, and stimulants may be a clinically relevant modifiable factor to be targeted in prevention studies. Severity and type of psychosis is dependent on the severity of cognitive impairment.

Social functioning among older community-dwelling patients with schizophrenia: a review

Social dysfunction is a hallmark of schizophrenia and a major constituent of its burden of disease. There is a need for more data on social functioning of older schizophrenic patients, because their numbers are rapidly growing and most are residing within the community. This article reviews existing evidence on social functioning in community-dwelling schizophrenic patients older than 55 years, focusing on social roles, social support, and social skills. Thirty-six publications proved fit for inclusion in the review. Studies from outside the United States were underrepresented. The available data suggest that the majority of older schizophrenic patients are well behind their healthy age-peers with respect to various aspects of social functioning. At the same time, a considerable heterogeneity among patients can be found. Cognitive abilities feature as a factor of major impact on social functioning, outweighing clinical symptoms. When evaluating social functioning both objective and subjective appraisals should be taken into account, because they may highlight different aspects of social functioning. Social support, impact of gender, and specific characteristics of older-old patients figure among areas that should be given priority in future research of social functioning in late life schizophrenia.

Neurocognitive, clinical and functional correlates of subjective quality of life in Asian outpatients with schizophrenia

Quality of life (QOL) impairment is evident in patients with schizophrenia and is increasingly recognised as an important evaluation criterion of treatment outcome. Hence, this study aimed to identify the neurocognitive, clinical and functional parameters associated with subjective QOL in patients with schizophrenia within an Asian context, and specifically in an outpatient setting. This study was conducted on 83 outpatients with DSM-IV diagnosis of schizophrenia, and 47 age- and gender-matched healthy controls. All participants were administered with the World Health Organisation Quality of Life Assessment-Brief Form (WHOQOL-BREF) and Brief Assessment of Cognition in Schizophrenia (BACS), to measure quality of life and cognitive function respectively. Patients were also assessed for severity of psychopathology, as well as level of psychosocial functioning, using the Positive and Negative Syndrome Scale (PANSS) and Global Assessment of Functioning (GAF) rating scales respectively. Specific psychopathology (greater severity of PANSS negative symptoms, general psychopathology subscale scores), cognitive deficits (working and verbal memories), and lower GAF scores were correlated with poorer QOL in patients. Multivariate analyses revealed that younger age, being single and lower level of psychosocial functioning were associated with poorer QOL but level of psychosocial functioning did not appear to mediate the effects of symptoms and neurocognitive deficits on QOL. Overall, this study highlighted the need for clinicians to pay more attention to these clinical, neurocognitive and functional parameters and their integrative relationships with QOL in order to optimise the treatment outcomes of patients with schizophrenia.

Clinical characterization of late- and very late-onset first psychotic episode in psychiatric inpatients

OBJECTIVES

The goals of this study were to investigate the prevalence and initial symptoms of the late-onset schizophrenia (LOS: >40 years) and very-late-onset schizophrenia-like psychosis (VLOSLP: >60 years) nosological groups proposed by the International Late-Onset Schizophrenia Group.

DESIGN

This was a retrospective, cross-sectional, chart review study.

SETTING

The study was conducted at Centre Hospitalier Robert-Giffard (CHRG), Quebec City, Canada.

PATIENTS

The medical records of inpatients from the CHRG who presented with psychotic symptoms were analyzed.

MEASUREMENTS

Positive and negative symptoms were scored using the SAPS and SANS. Groups' symptoms were compared using chi(2), Fisher's exact tests, t tests, and exact Mann-Whitney tests. An exact conditional logistic regression analysis was performed to determine which clinical characteristics were the most predictive of the groups' classification.

RESULTS

Among the 1,767 unique, first-admission medical records reviewed, 23 (1.3%) inpatients developed their first psychotic symptoms at the age of 40-59 years old (LOS), and 13 (0.7%) at the age of 60 years and above (VLOSLP). LOS patients were more apathetic and presented more abnormal psychomotor activity than the VLOSLP. Persecutory delusions, auditory hallucinations, inappropriate social behavior, formal thought disorders and anhedonia were frequent in the two groups. A logistic regression model including psychomotor abnormalities was statistically relevant to predict the belonging to LOS group.

CONCLUSION

LOS and VLOSLP are rare. Abnormal psychomotor activity can properly differentiate VLOSLP and LOS. The nosological model proposed by the International Late-Onset Schizophrenia Group is at least partially supported by the present data.

Self-stigma, self-esteem and age in persons with schizophrenia

BACKGROUND

The relationship between self-stigma and self-esteem in patients with schizophrenia is receiving increased attention. However, studies to date have been limited to samples of persons under the age of 65.

AIM

To examine the relationship between self-stigma and self-esteem in people with schizophrenia in both younger and older age groups.

METHODS

Face-to-face interviews were completed with 86 inpatients with schizophrenia in a psychiatric hospital (mean age = 54, 55% female). Self-esteem was assessed using Rosenberg's Self Esteem Scale. Self-stigma was assessed using an adapted version of the Internalized Stigma of Mental Health (ISMI) scale. Information regarding socio-demographic characteristics and psychiatric history and symptomatology was collected.

RESULTS

Self-stigma was moderate with only 20-33% of the participants reporting high levels of stigmatization. Older participants reported lower levels of self-stigma than younger participants. A relatively strong association between self-stigma and self-esteem was found.

CONCLUSIONS

The findings point to the complexity of the association between self-stigma, self-esteem and age in people with schizophrenia. This study stresses the importance of clinicians taking the issue of self-stigma into consideration when treating young and old patients with schizophrenia.

Mild hearing impairment and psychotic experiences in a normal aging population

BACKGROUND

Hearing impairment (HI) in the elderly may be a risk factor for psychosis, but associations between HI and psychotic disorder or psychotic experiences have been reported more consistently in younger than in older populations. The aims of this study were to replicate the positive association between hearing impairment and psychotic experiences and to clarify any differences between groups of young and old individuals in a non-clinical, normal aging general population sample.

METHODS

HI, assessed at baseline and at 3-year follow-up, and psychotic experiences, assessed at 3-year follow-up, were analysed in a group of 848 individuals aged 33 to 89 years between 1999 and 2004. HI was determined on the basis of both self-report and audiometric examination. The "psychoticism" and "paranoid ideation" subscales from the SCL-90-R were used to assess level of psychotic experiences.

RESULTS

Self-reported hearing problems expressed as conversational HI (beta=0.080, 95% CI: 0.23, 7.90, p=0.038) and subjective HI (beta=0.087, 95%CI: 0.70, 10.30, p=0.025), but not audiometric objective HI, were associated with psychotic experiences. In those with hearing aids, associations with psychotic experiences were only present if accompanied by self-reported hearing problems that persisted in spite of the hearing aid. In addition, HI increased the risk for psychotic experiences specifically in younger rather than older individuals.

CONCLUSIONS

Self-reported hearing problems rather than audiometric or remediated hearing loss may contribute to the development of psychotic experiences in younger rather than in older individuals.

Social predictors of out-patient mental health contact in schizophrenia patients

INTRODUCTION

Since community-based health care was introduced, the use of mental health services by patients with serious mental disorders has been an issue of much interest. However, our knowledge of intervening factors is both scarce and partial.

OBJECTIVE

To study socio-demographic variables which may predict time-lapse (in days) between each out-patient contact among a cohort of schizophrenia patients.

METHOD

Data comes from the South Granada Schizophrenia Case Register. We used Cox's regression analysis to study the influence of the socio-demographic variables in the time lapsed between out-patient contacts.

RESULTS

After adjusting for all other socio-demographic variables included, we found that to live in a rural area and being younger independently predicted a longer time-lapse between out-patient contacts while being retired predicted a shorter interval between such contacts. Other variables such as sex, educational level and marital status did not determine such length between out-patients contacts.

CONCLUSION

Socio-demographic variables, and not only psychopathological ones, determine mental health out-patient service use.

Psychosis risk as a function of age at onset: a comparison between early- and late-onset psychosis in a general population sample

BACKGROUND

Little is known about late-onset psychosis (onset after the age 45 years) and how it relates to early-onset psychosis (before age 45 years). The aims of this study were to calculate the incidence of non-affective, non-organic psychotic symptoms across the life span and to explore the contribution of different sets of risk factors in relation to age at onset.

METHODS

Data were obtained from the three measurements of the Netherlands Mental Health Survey and Incidence Study. Symptoms of psychosis were assessed in individuals aged 18-64 years using the Composite International Diagnostic Interview. All individuals reporting first-onset of psychotic symptoms within a three-year interval were included. The degree to which sets of risk factors affected the psychosis outcome similarly across age groups was assessed.

RESULTS

The number of subjects displaying incident psychotic symptoms was similar across age groups. Cumulative incidence rates ranged from 0.3% to 0.4%. Age differences were found for life-time depressive symptoms (risk difference = 5%, 95% CI = 1%, 9%) and baseline neuroticism (risk difference = 3%, 95% CI = 0%, 6%), indicating that late-onset psychosis was less often preceded by these. In contrast, no effect modification by age was observed for female sex, hearing impairment, being single, or life-time cannabis use.

CONCLUSIONS

Onset of psychotic symptoms in late life is no rare event. Compared to early onset psychosis, the late-onset counterpart less often arises in a context of emotional dysfunction and negative affectivity, suggesting qualitative differences in aetiology and more effective premorbid coping styles.