Symptomatic remission in a multiracial urban population of older adults with schizophrenia

Trauma and resistance to antipsychotic treatment in schizophrenia: A narrative review

This review explored whether trauma exposure is associated with poorer response to antipsychotic treatment in schizophrenia patients. A systematic search identified eight studies, of which five reported an association between trauma and non-remission of psychotic symptoms (n = 4) or treatment-resistant schizophrenia (TRS, n = 1). Although evidence supporting the link between trauma and resistance to antipsychotic treatment is scarce, trauma history should be systematically investigated in all persons with TRS, as there is a growing body of evidence showing that schizophrenia patients benefit from therapies for post-traumatic symptoms.

Ageing with schizophrenia: an update

PURPOSE OF REVIEW

The aim of this review was to summarize the recent literature on the clinical symptoms, functioning, outcomes and treatments for older adults with chronic schizophrenia.

RECENT FINDINGS

The number and proportion of older adults with schizophrenia is rapidly increasing. Schizophrenia is a heterogeneous disorder and older adults with schizophrenia display significant variability in symptom severity, quality of life and overall outcomes. Many achieve stable disease remission, some display persistent nonremission and others experience fluctuating symptoms. Depression is commonly reported, and although rates of suicide are higher when compared with age-matched peers, the excess mortality seen in this population is mainly attributed to natural causes of death. Cognitive decline and reduced illness awareness have important implications for functional status and quality of life. Antipsychotics remain essential in the treatment regimen, although elderly patients with chronic disease may be good candidates for gradual dose reduction. Interdisciplinary treatment approaches as well as nonpharmacologic psychosocial interventions play a critical adjunctive role in the treatment of older adults with schizophrenia.

SUMMARY

Research focusing on schizophrenia in late life is sparse. Too often, older patients are eliminated from research studies or averaged in with all age groups. Thus, there continues to be gaps in our understanding of modifiable predictors of remission and recovery, and the most efficacious and safest treatment approaches for this age group.

Remission amongst elderly schizophrenia patients

Remission in elderly patients has been little studied. The present analysis utilized a European database to focus on the elderly. Using five different instruments examining remission, we report that aging did not adversely affect remission in the elderly. Management of elderly schizophrenia patients should thus be targeted towards remission.

Course and predictors of symptomatic remission in late-life schizophrenia: A 5-year follow-up study in a Dutch psychiatric catchment area

BACKGROUND

The number of older schizophrenia patients is growing, the majority being treated in outpatient settings. Reported symptomatic remission rates in younger cohorts vary largely. Further insight into course trajectories and putative predictors of remission in older persons with schizophrenia is needed.

METHODS

5-year follow-up course trajectories of symptomatic remission were examined in a catchment area-based group of 77 older Dutch patients (mean age 66.0 years) with schizophrenia or schizoaffective disorder. A modified version of the 'Remission in Schizophrenia Working Group' criteria was used to determine remission status. In individuals who did not fulfil remission criteria at baseline (n = 56), predictors of conversion to remission status at 5-year follow-up were analysed using multivariable regression analyses.

RESULTS

A substantial increase in remission rate at 5-year follow-up (27.3% at baseline (T1), 49.4% at follow-up (T2)) was found. Of all participants, 23.4% was in remission at both assessments and 46.8% was in non-remission at both assessments. 26.0% of the participants converted from non-remission at T1 to remission at T2, while 3.9% fell back from remission at T1 to non-remission at T2. Two significant baseline predictors of conversion to remission at follow-up were found: lower score on the PANSS positive symptom subscale, and having a partner.

CONCLUSION

Symptomatic remission was as an attainable goal for almost half of all older patients with schizophrenia or schizoaffective disorder at 5-year follow-up. With a lower PANSS positive symptom subscale score, and having a partner emerging as the only predictors of conversion to remission, there remains a need to search for modifiable predictors.

Advances in the Conceptualization and Study of Schizophrenia in Later Life

A crisis looms as research and clinical programs have not kept pace with dramatic increases in the number of older adults with schizophrenia. This article provides an overview of the advances in the conceptualization and study of schizophrenia in later life. Theoretic and clinical models in psychiatry and gerontology are integrated. Specifically, recovery is examined in the context of aging, how clinical dimensionality affects diagnoses in older adults, how various features of schizophrenia are implicated in models of accelerated and paradoxic aging, and how outcome in later life is a more dynamic and heterogeneous than assumed previously.

Characteristics and Service Use of Older Adults with Schizoaffective Disorder Versus Older Adults with Schizophrenia and Bipolar Disorder

OBJECTIVE

The purpose of this study was to determine if schizoaffective disorder in older adults is differentiated from schizophrenia and bipolar disorder with respect to community functioning, cognitive functioning, psychiatric symptoms, and service use.

DESIGN

Secondary analysis of baseline data collected from the Helping Older People Experience Success psychosocial skills training and health management study.

SETTING

Three community mental health centers in New Hampshire and Massachusetts.

PARTICIPANTS

Adults over the age of 50 (N = 139, mean age: 59.7 years, SD: 7.4 years) with persistent functional impairment and a diagnosis of schizoaffective disorder (N = 52), schizophrenia (N = 51), or bipolar disorder (N = 36).

MEASUREMENTS

Health status (36-Item Short Form Health Survey [SF-36]), performance-based community living skills (UCSD Performance-Based Skills Assessment), neuropsychological functioning (Delis-Kaplan Executive Functioning subtests), psychiatric symptoms (Brief Psychiatric Rating Scale, Center for Epidemiologic Studies Depression Scale, Scale for the Assessment of Negative Symptoms), medical severity (Charlson comorbidity index), and acute service use.

RESULTS

Older adults with schizoaffective disorder had depressive symptoms of similar severity to bipolar disorder, and thought disorder symptoms of similar severity to schizophrenia. Schizoaffective disorder compared with schizophrenia was associated with better community functioning, but poorer subjective physical and mental health functioning as measured by the SF-36. Older adults with schizoaffective disorder had greater acute hospitalization compared with adults with schizophrenia, though their use of acute care services was comparable to individuals with bipolar disorder.

CONCLUSIONS

Findings from this study suggest that schizoaffective disorder in older adults occupies a distinct profile from either schizophrenia or bipolar disorder with respect to community functional status, symptom profile, and acute services utilization.

Symptomatic Remission Determines Functional Improvement and Quality of Life in Schizophrenia

INTRODUCTION

Schizophrenia is a chronic illness that negatively affects the quality of life and psychosocial functions. Defined criteria to assess remission in schizophrenia are considered to be useful in the long-term follow-up of patients and in discriminating diagnostic factors. This study investigated the quality of life and functionality in schizophrenia patients in symptomatic remission (R-Sch) and not in remission (Non-R-Sch).

METHODS

Sociodemographic data were collected for 40 R-Sch and 40 Non-R-Sch patients, and the following scales were administered: the Clinical Global Impression-Severity (CGI-S) Scale; Positive and Negative Syndrome Scale (PANSS), World Health Organization Quality of Life Questionnaire-Short Form, Turkish Version (WHOQOL-BREF-TR), Quality of Life Scale for Schizophrenia Patients (QLS), and Global Assessment of Functioning Scale (GAF).

RESULTS

The total and all subscale scores of PANSS and the CGI-S score were significantly lower in the R-Sch group than in the Non-R-Sch group, whereas the GAF scores and all subscales of QLS and WHOQOL-BREF-TR were significantly higher.

CONCLUSION

This study demonstrates that improvement in symptoms in schizophrenia patients improves quality and functionality in all areas of life, suggesting that an improvement in symptoms is the most important determinant of functional recovery in the treatment of schizophrenia.

New perspectives on schizophrenia in later life: implications for treatment, policy, and research

Worldwide, in the past few decades, the demographics of older people (ie, people 55 years and over) with schizophrenia have changed completely with respect to absolute numbers of people affected, the proportion of all people with the disorder, life expectancy, and residential status. The ageing schizophrenia population has created vast health-care needs and their medical comorbidity contributes to higher mortality than in the general population. Proposals to classify schizophrenia into early-onset, late-onset, and very-late-onset subtypes now should be tempered by the recognition that comorbid medical and neurological disorders can contribute to psychotic symptoms in later life. The concept of outcome has become more nuanced with an appreciation that various outcomes can occur, largely independent of each other, that need different treatment approaches. Data show that schizophrenia in later life is not a stable end-state but one of fluctuation in symptoms and level of functioning, and show that pathways to improvement and recovery exist. Several novel non-pharmacological treatment strategies have been devised that can augment the clinical options used to address the specific needs of older adults with schizophrenia.

The effects of aging on insight into illness in schizophrenia: a review

OBJECTIVES

Impaired insight into illness is a prevalent feature of schizophrenia, which negatively influences treatment adherence and clinical outcomes. Little is known about the effects of aging on insight impairment. We aimed to review the available research literature on the effects of aging on insight into illness in schizophrenia, in relation to positive, negative, and cognitive symptoms. Ultimately, we propose a trajectory of insight in schizophrenia across the lifespan.

METHOD

A systematic Medline® literature search was conducted, searching for English language studies describing the relationship of insight into illness in schizophrenia with aging.

RESULTS

We identified 62 studies. Insight impairment is associated with illness severity, premorbid intellectual function (i.e. IQ), executive function, and memory. Insight impairment improves modestly during midlife, worsening again in late life. It tends to fluctuate with each episode of psychosis, likely in relation to worsening positive symptoms that improve with antipsychotic treatment. The relationship between insight impairment and cognitive dysfunction appears to attenuate with age, while the relationship with lower premorbid intellectual function is preserved. The association between impaired insight and negative symptoms is unclear.

CONCLUSIONS

The available literature suggests that the course of insight impairment follows a U-shaped curve, where insight impairment is severe during the first episode of psychosis, modestly improves over midlife, and declines again in late life. Future studies are required to investigate the trajectory of insight into illness and its core domains across the lifespan from prodromal phase to late life.

Longitudinal study of remission among older adults with schizophrenia spectrum disorder

OBJECTIVE

Although studies have found that as many as half of older community-dwelling adults with schizophrenia were in symptomatic remission, these findings had been based on cross-sectional data. This study examines longitudinal changes in symptom remission rates and predictors of remission.

METHODS

The original sample consisted of 250 persons with schizophrenia spectrum disorders aged 55 and over living in New York City who developed the disorder before age 45. Data on 104 follow-up interviews are presented. Mean follow-up was 54 months (range: 12-116 months); mean age was 61 years, 55% were male, and 55% were white. A modified version of the Remission in Schizophrenia Working Group criteria was used for determining remission status.

RESULTS

There was a nonsignificant decline in the percentage attaining remission (49% baseline, 40% follow-up); 25% were in remission at both assessments, 35% were not in remission at either assessment, 25% went from remission to nonremission, and 16% went from nonremission to remission. Four significant baseline predictors of remission were found at follow-up: higher community integration, greater number of entitlements, fewer psychotropic medications, and lower frequency of psychiatric services. Baseline remission status predicted having more total contacts at follow-up.

CONCLUSION

Older adulthood is not necessarily a quiescent period, and there is considerable fluctuation in remission status. Two social variables-community integration and entitlements-predicted remission on follow-up, thus suggesting social interventions may be especially useful strategies for this population.

Characteristics of auditory hallucinations and associated factors in older adults with schizophrenia

OBJECTIVE

To examine the characteristics of auditory verbal hallucinations and associated factors in older adults with schizophrenia.

METHODS

One hundred ninety-eight persons aged 55 and older living in the community who had developed schizophrenia before age 45 years were assessed for the presence, topography, content, and subjective qualities of auditory hallucinations. George's social antecedent model of psychopathology was used to examine 17 predictor variables of auditory hallucinations.

RESULTS

Thirty-two percent experienced auditory verbal hallucinations. More than half heard voices daily, heard good/pleasant voices, or had command hallucinations; 25% obeyed "bad" voices, whereas 87% obeyed "good" voices. There were no significant differences in depression and social functioning between persons judging their voices to be good versus bad. In logistic regression analysis, depressive symptoms, Positive and Negative Syndrome Scale delusion score (>2), and male gender were associated with auditory verbal hallucinations.

CONCLUSION

Older adults with schizophrenia had a lower rate of auditory verbal hallucinations than had been reported previously for younger persons with schizophrenia. For most features of auditory verbal hallucinations, older adults had similar rates to younger persons. However, older adults were more apt to judge their voices as good and more likely to obey the good voices than those voices perceived as bad. From a clinical standpoint, this may be construed as a potentially useful coping strategy. However, subjective judgments about voices did not significantly affect mood or functioning, and the presence of auditory verbal hallucinations was associated with more depressive symptoms.

Prevalence of negative symptoms and associated factors in older adults with schizophrenia spectrum disorder

OBJECTIVE

To examine the prevalence of negative symptoms and associated factors in older adults with schizophrenia spectrum disorder living in the community.

METHODS

The sample consisted of a multiracial sample of 198 persons aged 55 and more with a schizophrenia spectrum disorder that developed the disorder before the age of 45; 39% and 61% lived independently and in supported community residences, respectively. George's Social Antecedent Model of Psychopathology was used to examine 16 predictor variables of negative symptoms, based on scores of 4 or more on any of the PANSS negative symptom items.

RESULTS

Forty percent of the sample met the criteria for the presence of negative symptoms, and this decreased to 19% when potential secondary symptoms were excluded. In bivariate analysis, 10 variables were found to be significantly associated with the presence of negative symptoms, but when the model was tested in logistic regression analysis, only 3 variables retained significance: greater positive symptom scores (odds ratio [OR] = 1.26), lower cognitive scores (OR = 0.96), and fewer confidantes (OR = 0.80).

CONCLUSION

Negative symptoms do not dominate the clinical picture in later life, and levels of negative symptoms appear to be no higher than in younger schizophrenia populations. The relative paucity of significant variables and their modest effect sizes suggest that treatment for negative symptoms in later life will depend largely on strategies directed specifically at the negative symptoms.

Cognitive impairment in late life schizophrenia and bipolar I disorder

OBJECTIVE

Evidence in younger populations suggests quantitative but not categorical differences in cognitive impairments between schizophrenia and bipolar disorder. It is uncertain whether a similar distinction applies to patients in later life.

METHODS

We compared the cognitive abilities of older, community-living schizophrenia patients, controlling for their state of symptomatic remission, with those of older euthymic patients with bipolar I disorder. The study included 67 patients with schizophrenia (20 in symptomatic remission, 47 not in symptomatic remission; mean age 68 years) and 74 euthymic bipolar I patients (mean age 70 years), who were compared using analysis of covariance on clinical and neuropsychological variables (e.g., attention/working memory, verbal memory, executive function and verbal fluency) and contrasted with 69 healthy controls.

RESULTS

Remitted (SR) and non-remitted (SN) schizophrenia patients and bipolar I (BP) patients were impaired relative to healthy controls, with mostly large effect sizes for verbal memory (Cohen's d: SR 1.34, SN 1.48, BP 1.09), executive function (Cohen's d: SR 0.87, SN 1.29, BP 0.71) and verbal fluency (Cohen's d: SR 1.09, SN 1.25, BP 0.88), but smaller effect sizes for the domain of attention/working memory (Cohen's d: SR 0.26, SN 0.18, BP 0.52). Differences in cognitive performance between the remitted schizophrenia patients and the bipolar I patients were not significant.

CONCLUSIONS

In both older patients with schizophrenia and with bipolar disorder, serious and pervasive cognitive deficits can be demonstrated. Trait-related cognitive deficits in schizophrenia and bipolar disorder may share major phenotypic similarity in later life.

Management of schizophrenia in late life with antipsychotic medications: a qualitative review

Although patients with schizophrenia are reported to have excess mortality compared with the general population, many affected patients will nonetheless survive and continue to have the disorder in later life. Consequently, geriatric schizophrenia will be a significant public health concern in the years to come, and evidence-based treatment of schizophrenia in older patients is becoming an urgent issue. However, there has been a paucity of comparative data to guide selection of antipsychotics for schizophrenia in late life. The primary aim of this review was to synthesize the available evidence on management of late-life schizophrenia with antipsychotic medications; a secondary aim was to evaluate treatment resistance in this population. Accordingly, PubMed and EMBASE were searched using the keywords 'antipsychotics', 'age' and 'schizophrenia' to identify psychopharmacological studies of antipsychotics in late-life schizophrenia (last search 30 April 2011). The literature search identified 23 prospective studies of use of antipsychotics for schizophrenia in older patients (generally age ≥65 years), including eight double-blind trials. The sample size was smaller than 40 patients for 52% of the studies. Two of the double-blind studies were post hoc analyses and one was a placebo-controlled trial. In the largest double-blind study, olanzapine (n = 88, median dose 10 mg/day) and risperidone (n = 87, median dose 2 mg/day) were compared in patients not resistant to these therapies, with similar effects. There have also been several open-label trials of these two agents that have shown efficacy and tolerability in non-resistant patients. Evidence on other antipsychotics has been scarce and less robust. The gold standard for treatment-resistant schizophrenia is clozapine. However, almost all of the studies of clozapine to date have effectively excluded older patients with schizophrenia. Only one small study has evaluated clozapine (n = 24, mean dose 300 mg/day) in comparison with chlorpromazine (n = 18, mean dose 600 mg/day) in a difficult-to-treat older population; the investigators reported that both treatments were similarly efficacious. Furthermore, there has been little compelling evidence in favour of or against augmentation of antipsychotics with other psychotropic medications in the older age group. Treatment of non-resistant, late-life schizophrenia with olanzapine and risperidone appears to be supported by the available evidence. However, data on geriatric patients with schizophrenia are generally scarce, particularly for treatment-resistant subpopulations, underscoring the need for more research in this important area.

The relationship between trauma and clinical outcome variables among older adults with schizophrenia spectrum disorders

OBJECTIVE

Stressful and traumatic life events have been implicated in the etiology and persistence of symptoms in schizophrenia, but little is known about their impact in later life. This article contrasts lifetime trauma among older persons with schizophrenia with their age peers in the general population, and examines whether greater trauma is associated with higher rates of nonremission of positive and negative symptoms, depression, or anxiety symptoms in the schizophrenia group.

METHODS

The schizophrenia group consisted of 198 community-dwelling persons age 55 and older who developed a schizophrenia spectrum disorder before age 45. A community comparison group (N = 113) was recruited using randomly selected block-groups. Using the Trauma and Victimization Scale, the frequency × severity of lifetime traumatic events scores were calculated. In the schizophrenia group, subjects were dichotomized into low and high trauma groups.

RESULTS

As compared to the community group, the schizophrenia group scored significantly higher on the total score and on 6 of 11 items of the Trauma and Victimization Scale. The schizophrenia group had significantly more traumatic events before age 17. In logistic regression analysis, a high level of trauma accumulated across the lifespan in the schizophrenia group was associated only with non-remission of positive symptoms; however, the persistence of positive symptoms was not associated with a traumatic event prior to age 17.

CONCLUSION

Early trauma may play some role in the development of schizophrenia, but it does not seem to have any special role in the persistence of positive symptoms in later life. Rather, accumulated stressors may be more relevant clinically. The findings suggest that it may be profitable to consider therapies that reduce the psychological impact of traumatic events.

Factors associated with good self-management in older adults with a schizophrenic disorder compared with older adults with physical illnesses

The number of older people living with a schizophrenic disorder (SD) is increasing yet little attention paid has been paid to the needs of this population relative to people with other chronic illnesses. In order to achieve optimal functioning people with a SD need to manage their illness and its impact; therefore, this study set out to determine the factors associated with self-management in this population. The illness management of people over 50 years of age and living with schizophrenia (n= 84) was compared with their peers who were diagnosed with a chronic physical illness (n= 216). Participants completed a survey that included an illness management inventory, self-rated health and sense of coherence. The results demonstrated that participants with a SD had lower illness management levels, particularly for understanding their symptoms and taking appropriate actions in relation to health care. Poor self-rated health and the presence of comorbid conditions had a pervasive negative effect on self-management factors in the SD group, whereas being married, having a greater sense of coherence and being voluntary to treatment had a positive effect. Nurses need to develop strategies to address general health and self-management in older adults living with a SD.

Recovery style predicts remission at one-year follow-up in outpatients with schizophrenia spectrum disorders

Although people with schizophrenia use various coping strategies, it is largely unknown how their coping style contributes to remission of the illness. The concept of recovery style-either by sealing over or integrating-reflects an important distinction. We wanted to examine whether recovery style predicts remission at a 1-year follow-up. We examined the recovery style, insight, therapeutic alliance, and symptoms in 103 patients with psychotic disorders. To assess the remission status, the symptoms were measured at 6 and 12 months. Logistic regression analyses were used. Results showed that scoring an extra category toward integration (six categories exist) increased the odds of remission 1.84-fold (95% confidence interval, 1.11 to 3.03). Insight and therapeutic alliance were not predictive. Although remission was also predicted by positive symptom levels at baseline, this did not influence the effect of recovery style. In conclusion, independently of symptom levels, insight, or therapeutic alliance, an integrating recovery style increases the odds of remission at a 1-year follow-up.

Symptomatic remission and associated factors in a catchment area based population of older patients with schizophrenia

BACKGROUND

Symptomatic remission and its associated factors have been evaluated in several studies of younger schizophrenic patients. Although the number of older individuals with schizophrenia is rapidly growing, evaluations of remission in elderly patients are scarce and limited to samples of convenience, questioning their generalizability to unselected patient populations.

METHODS

We assessed the rate of symptomatic remission in a cohort of older Dutch schizophrenic patients within a psychiatric catchment area. In addition, we examined the association of symptomatic remission with measures of mental health treatment, social functioning, cognition, mood, and quality of life.

RESULTS

With a rate of 29.4%, symptomatic remission in this catchment area based cohort of older schizophrenic patients (mean age 68 years) was markedly lower than the rates reported for convenience samples. Remission was more frequent in schizoaffective patients, compared to patients with schizophrenia. Remitted patients were more adherent to psychiatric services and scored higher on measures of social functioning. No association with symptomatic remission could be demonstrated for cognition, mood, and quality of life.

CONCLUSION

The modest rate of symptomatic remission in this treated sample of elderly schizophrenic patients questions the notion that old age is associated with high levels of symptomatic remission. The concurrent validity of the remission concept in elderly patients merits further investigation, given the limited number of demonstrated associations.

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.

Recovery and wellness amidst schizophrenia: definitions, evidence, and the implications for clinical practice

Emerging evidence from longitudinal studies has suggested that many with schizophrenia can meaningfully recover over time. Recovery, though, is not a uniform process but varies from person to person and can involve a range of different experiences including the attainment of psychosocial milestones, the remission of symptoms, and changes in self-experience or personal narrative. To address the issue of recovery from schizophrenia, this article reviews currently evolving definitions of recovery and possible ways to understand recovery as involving both an objective and two subjective dimensions. Emerging operational definitions are explored and then empirical research is reviewed regarding actual rates and forms of recovery. It is concluded that although many with schizophrenia experience significant challenges linked with illness over time, more people than not experience meaningful periods of relative wellness. Implications for how daily practice can reinforce and promote recovery are discussed.