BEHAVIORAL IMPROVEMENT IN THE OLDER SCHIZOPHRENIC PATIENT: DRUG AND SOCIAL THERAPIES*

Antipsychotic drug treatment for elderly people with late-onset schizophrenia

BACKGROUND

Schizophrenia is usually considered an illness of young adulthood. However, onset after the age of 40 years is reported in 23% of patients hospitalised with schizophrenia. At least 0.1% of the world's elderly population have a diagnosis of late-onset schizophrenia which seems to differ from earlier onset schizophrenia on a variety of counts including response to antipsychotic drugs.

OBJECTIVES

To assess the effects of antipsychotic drugs for elderly people with late-onset schizophrenia.

SEARCH METHODS

We searched the Cochrane Schizophrenia Group Trials Register (January 2010) which is based on regular searches of CINAHL, EMBASE, MEDLINE and PsycINFO. We inspected references of all identified studies for further trials. We contacted relevant authors of trials for additional information.

SELECTION CRITERIA

All relevant randomised controlled trials that compared antipsychotic drugs with other treatments for elderly people (at least 80% older than 65 years) with a recent (within five years) diagnosis of schizophrenia or schizophrenia like illnesses.

DATA COLLECTION AND ANALYSIS

For the 2010 search, two new review authors (AE, AG) inspected all citations to ensure reliable selection. We assessed methodological quality of trials using the criteria recommended in the Cochrane Handbook for Systematic Reviews of Interventions. AE and AG also independently extracted data. For homogenous dichotomous data, we planned to calculate the relative risk (RR) and 95% confidence interval (CI).

MAIN RESULTS

There were no included studies in the original version of this review (2002 search). The 2010 search for the current update produced 211 references, among which we identified 88 studies. Only one study met the inclusion criteria and was of acceptable quality. This was an eight-week randomised trial of risperidone and olanzapine in 44 inpatients with late-onset schizophrenia. All participants completed the eight-week trial, indicating that both drugs were well tolerated. Unfortunately, this study provided little usable data. We excluded a total of 81 studies, 77 studies because they either studied interventions other than antipsychotic medication or because they involved elderly people with chronic - not late-onset - schizophrenia. We excluded a further four trials of antipsychotics in late-onset schizophrenia because of flawed design. Five studies are still awaiting classification, and one is on-going.

AUTHORS' CONCLUSIONS

There is no trial-based evidence upon which to base guidelines for the treatment of late-onset schizophrenia. There is a need for good quality-controlled clinical trials into the effects of antipsychotics for this group. Such trials are possible. Until they are undertaken, people with late-onset schizophrenia will be treated by doctors using clinical judgement and habit to guide prescribing.

Schizophrenia in late life

Antipsychotics, whether conventional or atypical, are the primary class of medications for the treatment of late-life psychosis. Although the efficacy of neuroleptics in controlling agitation and psychosis associated with late-life dementia has been established, evidence for their efficacy in treating core symptoms of late-life schizophrenia other than behavioral dyscontrol is just emerging. More controlled clinical trials are needed. The available data suggest that atypical neuroleptics are therapeutically efficacious, with a more favorable side-effect profile than conventional neuroleptics. This literature further suggests the importance of low therapeutic doses and careful attention to the emergence of side effects. Future studies must distinguish between patients with true schizophrenic disorder and patients with psychosis secondary to dementia, affective illness, or organic impairment. Patients must be characterized further as having EOS versus LOS because these disorders may differ in symptom profile, course, and response to treatment. There is also a need in future studies to separate out the results of treatment of patients with EOS who have been severely ill for most of their lives from those whose course has been less devastating. Within these two groups, treatment response, effective dose ranges, and sensitivity to side effects can be scrutinized more carefully.

Antipsychotic treatment for late-life schizophrenia

The clinical characteristics of schizophrenia in older persons vary to some extent, depending on whether the onset of illness was earlier or later in life. Regardless of age of onset, antipsychotic medications are the mainstay of treatment. Age-related physiologic changes make older persons more sensitive to the therapeutic and toxic effects of antipsychotics. There is a paucity of controlled studies on the efficacy of antipsychotic medications in older persons with schizophrenia. Existing data suggest that atypical antipsychotics are at least as efficacious as and better tolerated than the conventional agents. In late-life schizophrenia, important adverse effects of antipsychotics include sedating, anticholinergic and cardiovascular effects, extrapyramidal symptoms, and tardive dyskinesia. Certain atypical antipsychotics are associated with a risk of metabolic changes as well as agranulocytosis. Clinical recommendations include a thorough diagnostic evaluation followed by treatment with low doses of atypical antipsychotics. Medication alone is likely to be less effective than when it is combined with an appropriate psychosocial intervention.

Treatment of schizophrenia and delusional disorder in the elderly

With increasing longevity, greater numbers of patients with schizophrenia and delusional disorder will be surviving into advanced age. Antipsychotics form the core of the treatment for both of these psychotic disorders. Treatment of elderly patients with antipsychotics is, however, complicated by a much higher risk of adverse effects such as tardive dyskinesia. More is known about treating patients with schizophrenia than those with delusional disorder. The introduction of newer atypical antipsychotics may herald a new era in the pharmacotherapy of elderly psychotic patients. Nonetheless, judicious dosing is essential in the geriatric population. We discuss the benefits and limitations of the main forms of treatment.

Social dramatics: social skills development for the chronically mentally ill

The purpose of this study was to investigate the use of social dramatics as a clinical tool for teaching social skills to the chronically mentally ill on adult inpatient units of a state hospital. The research tested the hypothesis that patients exposed to social dramatics with videotape feedback would demonstrate greater ability to perform social skills as measured by the Nurses' Observation Scale for Inpatient Evaluation (NOSIE-30). Fifteen schizophrenic adults of both sexes meeting specific criteria were randomly assigned to experimental and control groups. Subjects were exposed over an 8-week period to randomly introduced social dramatic scenarios. The Wilcoxin test for two independent samples was used for testing differences between experimental and control groups. The research findings supported the hypothesis for one positive factor, social competence. The findings did not support any treatment effect on either social interest and personal neatness or irritability, manifest psychosis, and psychotic depression. There were no significant differences on the total score NOSIE-30. Recommendations for psychiatric nursing are made. Limitations of research methodologies and sample size were addressed.