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

Age and sex differences in outpatient antipsychotic prescriptions for schizophrenia: a claims data study

Most studies on antipsychotic efficacy and safety, including sex differences, focus on young schizophrenia patients. However, with an aging population, the number of older schizophrenia patients is increasing. This group faces challenges due to varying treatment responses and higher risks of adverse reactions, and guidelines often lack specific recommendations due to insufficient trials. Therefore, we investigated how age and sex influence antipsychotic prescribing practices in schizophrenia using the German Pharmacoepidemiological Research Database (GePaRD). We included patients diagnosed with schizophrenia (ICD-10 code F20.X) who had been prescribed at least one antipsychotic on an outpatient basis in at least two consecutive quarters in 2020, analyzing prescription data for 49,681 patients. Key findings include a notable preference for second-generation antipsychotics (SGAs) across all age groups, especially in younger patients, possibly due to their perceived better tolerability and efficacy. Treatment intensity with SGAs (expressed as the defined daily doses of SGAs per patient in 2020) initially increased with age, peaked among 35- to 44-year-olds, and then decreased, with the lowest treatment intensity in patients aged 65 years and older. The prescription patterns of specific SGAs and first-generation antipsychotics varied across age groups, highlighting the complexity of treatment decisions in schizophrenia management. Sex differences in prescription frequency and treatment intensity were also observed. The basic recommendation of the guideline to consider sex and age when prescribing antipsychotics therefore appears to be followed. Whether this prescribing practice is really optimal for older male and female schizophrenia patients, however, still needs to be proven in clinical trials.

Antipsychotic drug treatment of schizophrenia in later life: Results from the European cross-sectional AMSP study

OBJECTIVES

To investigate the relationship between patient age and the selection and dosage of antipsychotic drugs (APDs) for treatment of schizophrenia. We describe age effects for multiple individual APDs, thus allowing comparisons between drugs.

METHODS

Prescription data of 32,062 inpatients with schizophrenia from 2000 to 2017 were obtained from the Drug Safety Program in Psychiatry (AMSP) database. APD selection and dosage were related to patient age with sex as an influencing variable. Moreover, a systematic search of current guideline recommendations on APD treatment in patients with schizophrenia aged ≥65 years was performed.

RESULTS

Eighty percentof elderly patients (≥65 years) received a second-generation APD, most commonly risperidone. The dosage of APDs increased with age until about age 40 years, then decreased slowly at first and more steeply beyond age 55 years. The influence of age as well as sex on dosage partly differed between the individual drugs. Only one of eight schizophrenia guidelines systematically addressed specific aspects of pharmacotherapy in older adults.

CONCLUSIONS

In clinical routine, age has a significant impact on selection and dosing of APDs. Information on optimising pharmacotherapy in older adults with schizophrenia from clinical trials is needed. Guidelines should be improved regarding APD therapy specifically for older adults.

Antipsychotic-induced Hyperprolactinemia in aging populations: Prevalence, implications, prevention and management

This paper reviews the prevalence, implications, prevention and management of antipsychotic-induced hyperprolactinemia in aging populations. Antipsychotics are indicated mainly for the treatment of psychotic illness but are also used in other conditions. Complications induced by antipsychotics increase with age, due to age-related changes in drug metabolism and excretion. Almost all antipsychotics lead to hyperprolactinemia by blocking dopamine D2 receptors in the anterior pituitary gland, which counteracts dopamine's inhibitory action on prolactin secretion. The main findings of this narrative review are that, though many of the known side effects of high prolactin levels lose their salience with age, the risk of exacerbating osteoporosis remains critical. Methods of preventing antipsychotic-induced hyperprolactinemia in older individuals include using antipsychotic medication (AP) as sparingly as possible and monitoring AP serum levels, regularly measuring prolactin levels, closely monitoring bone density, treating substance abuse, and teaching patients stress management techniques. When hyperprolactinemia symptoms cannot be otherwise managed, adjunctive drugs are available. Potential helpful adjuncts are: dopamine agonists, antipsychotics with partial agonist properties (e.g. aripiprazole), selective estrogen receptor modulators, and metformin. Because a gold standard for prevention/treatment has not been established, clinical decisions need to be made based on safety and individual circumstance.

The Prevalence of Negative Symptoms Across the Stages of the Psychosis Continuum

BACKGROUND

Patients in every stage of the psychosis continuum can present with negative symptoms. While no treatment is currently available to address these symptoms, a more refined characterization of their course over the lifetime could help in elaborating interventions. Previous reports have separately investigated the prevalence of negative symptoms within each stage of the psychosis continuum. Our aim in this review is to compare those prevalences across stages, thereby disclosing the course of negative symptoms.

METHODS

We searched several databases for studies reporting prevalences of negative symptoms in each one of our predetermined stages of the psychosis continuum: clinical or ultra-high risk (UHR), first-episode of psychosis (FEP), and younger and older patients who have experienced multiple episodes of psychosis (MEP). We combined results using the definitions of negative symptoms detailed in the Brief Negative Symptom Scale, a recently developed tool. For each negative symptom, we averaged and weighted by the combined sample size the prevalences of each negative symptom at each stage.

RESULTS

We selected 47 studies totaling 1872 UHR, 2947 FEP, 5039 younger MEP, and 669 older MEP patients. For each negative symptom, the prevalences showed a comparable course. Each negative symptom decreased from the UHR to FEP stages and then increased from the FEP to MEP stages.

CONCLUSIONS

Certain psychological, environmental, and treatment-related factors may influence the cumulative impact of negative symptoms, presenting the possibility for early intervention to improve the long-term course.

Predictive Factors of Treatment Resistance in First Episode of Psychosis: A Systematic Review

Background: Clinical and functional outcome improvement in psychotic disorders is a challenge for the investigators. Recent advances offered opportunities for ameliorating the course of the illness during its early stages and for identifying treatment-resistant patients. Patients who had not response to two different antipsychotics, administered at correct doses for a sufficient period, can be operationally considered treatment-resistant. Available evidence suggested that the response's trajectory to the antipsychotic treatment revealed that a small proportion of subjects are poor responders (8.2%), the majority of patients have a moderate response (76.4%), and only 15.4% can be considered rapid responders with the greatest magnitude of response. Patients with first episode of psychosis generally obtain a more favorable response profile. Nevertheless, in around 25% of these patients symptoms of psychosis persist with a worse long-term course of illness. Objectives: The aim of this review is to report current evidences on the main predictors of treatment non-response in patients at early stage of psychosis. Methods: We used a specific string that guaranteed a high sensitive search in pubmed. We included the following types of publications: randomized-controlled trials, observational studies, longitudinal studies, retrospective studies, case-control studies, open-label investigations, cohort studies, and reviews. Publications must concern predictors of treatment resistance in early psychosis. Results: Forty-seven records were included: 5 reviews, 3 meta-analyses, 22 longitudinal studies, 2 retrospective studies, 1 naturalistic study, 6 randomized controlled trials, 2 open-label studies, 2 case-control studies, 4 cohort studies, 2 retrospective studies. Several factors were identified as predictors of treatment resistance: lower premorbid functioning; lower level of education; negative symptoms from first psychotic episode; comorbid substance use; younger age at onset; lack of early response; non-adherence to treatment; and longer duration of untreated psychosis. The role of gender and marital status is still controversial. More evidences are needed about neurobiological, genetic, and neuroimaging factors. Conclusions: The identification of specific predictive factors of treatment resistance in patients with first episode of psychosis ameliorates the quality of clinical management of these patients in the critical early phase of schizophrenia.

Age Impacts Olanzapine Exposure Differently During Use of Oral Versus Long-Acting Injectable Formulations: An Observational Study Including 8,288 Patients

PURPOSE

Olanzapine is a commonly prescribed antipsychotic available as oral and long-acting injectable (LAI) formulations. Data are lacking on the use and safety of olanzapine-LAI in older patients. The aim of this study was to investigate the effect of increasing age on olanzapine exposure during oral versus LAI administration in a real-life setting.

METHODS

This observational study was based on routine therapeutic drug monitoring data collected during 2005-2017. As a measure of exposure, absolute concentrations and concentration/dose ratios of olanzapine were defined as outcome variables. Linear mixed-model analyzes were used to allow for inclusion of multiple samples per patient and adjustment for covariate effects.

RESULTS

Olanzapine concentrations and doses from 8,288 patients (21,378 measurements) were included. The number of patients on oral treatment was 7,893 (42%, 50 years or older), while 395 were using olanzapine-LAI (27%, 50 years or older). In contrast to oral use, where the dose-adjusted concentration of olanzapine increased significantly for patients 50 years or older (P < 0.001), increasing age had no effect on olanzapine concentration following LAI administration (P = 0.550). The effects of smoking habits and gender were equal in oral and olanzapine-LAI users.

CONCLUSION

While the dose-adjusted systemic exposure of olanzapine increases by age after oral administration, these novel findings from a large patient population show that systemic exposure of olanzapine-LAI is unaffected by age, probably due to the lacking influence of age-related changes in gastrointestinal absorption and/or presystemic metabolism. From a pharmacokinetic point of view, it is therefore no reason to restrict the use of olanzapine-LAI in older patients requiring long-term treatment.

[Diseases of the schizophrenia spectrum disorder in old age : Diagnostic and therapeutic challenges]

BACKGROUND

The number of people with diseases of the schizophrenia spectrum in old age will increase significantly in the coming years. In the literature the topics of schizophrenia and delusional disorders in older and old people are inadequately represented.

AIM

This article gives an overview of the most important diagnostic and differential diagnostic characteristics. Another important aspect is the pharmacological and non-pharmacological treatment options in old age.

MATERIAL AND METHODS

The S3 guidelines of the German Association for Psychiatry, Psychotherapy and Psychosomatics (DGPPN) from 2006, the guidelines of the World Federation of Societies of Biological Psychiatry (WFSBP) from 2012, 2013, 2015 and the consensus statement of the Austrian Association for Neuro-Psychopharmacology and Biological Psychiatry (ÖGPB) from 2016 formed the basic literature for this review. In addition, a targeted search in the databases PubMed, PubPsych and Cochrane Library as well as in German Journals, such as DerNervenarzt, Neuropsychiatrie, Psychiatrische Praxis and Zeitschrift für Gerontologie und Geriatrie concerning the keywords schizophrenia, delusional disorder, diagnostics, therapy and older people was carried out.

RESULTS

Besides aspects on epidemiology, clinical manifestation, diagnostics, differential diagnostics and course of the illness, pharmacological and non-pharmacological treatment options are presented.

CONCLUSION/DISCUSSION

In clinical practice a clear diagnostic assignment is often a challenge in older and very old people with psychotic symptoms, The necessary pharmacological treatment is available but is limited by tolerability, comorbidities and polypharmacy. Non-pharmacological treatment options have hardly been investigated.

Systematic Literature Review of the Methods Used to Compare Newer Second-Generation Agents for the Management of Schizophrenia: A focus on Health Technology Assessment

BACKGROUND

The challenges of comparative effectiveness to support health technology assessment (HTA) agencies are important considerations in the choices of antipsychotic medications for the treatment of schizophrenia.

OBJECTIVES

Our aim was to assess the study methods used and outcomes reported in the published literature to address the question of comparative effectiveness of newer antipsychotic agents and the adequacy and availability of evidence to support HTA agencies.

DATA SOURCE

A systematic search of the PubMed database from 1 January 2009 to 30 September 2013 was conducted to identify studies evaluating new atypical antipsychotics reporting on comparative effectiveness.

STUDY SELECTION

The systematic review comprised of studies on schizophrenia patients where at least two drugs were being compared and at least one treatment group received one of the following second-generation antipsychotics: risperidone, olanzapine, aripiprazole, paliperidone, asenapine, iloperidone, lurasidone, and quetiapine. The included studies were also required to have an efficacy, safety or economic outcome, such as Positive and Negative Syndrome Scale (PANSS) score, weight gain, resource utilization, or costs.

STUDY APPRAISAL AND SYNTHESIS METHODS

Two reviewers (BW and GK) independently applied the inclusion criteria. Disagreements between reviewers were resolved by consensus, referring to the original sources. Information on the methodology and outcomes was collected for each included study. This included study description, head-to-head drug comparison, patient population, study methodology, statistical methods, reported outcomes, study support, and journal type.

RESULTS

A total of 198 studies were identified from electronic search methods. The largest category of studies was randomized controlled trials [RCTs] (N = 73; 36.9%), which were largely directed at the regulatory endpoint. Fewer studies were undertaken for HTA-purposes cohort studies (N = 53; 26.8%), meta-analyses (N = 32; 16.2%), economic studies (N = 14; 7.1%), and cross-sectional studies (N = 13; 6.6%). Direct head-to-head comparisons preferred by HTA were dominated by the comparison involving olanzapine and risperidone, representing 149 (75.3%) and 119 (60.1%) studies, respectively. RCTs, which are the primary study type for regulatory submissions, showed a lack of bias. Studies aimed at HTA were not as well performed. Cohort studies suffered from bias in the selection of comparison groups, lack of control for confounders, and differential dropout rates. As a group, cross-sectional studies scored poorly for bias, with a primary failure to identify a representative sample. Economic studies showed highly variable bias, with bias in the representation of effectiveness data, model assumptions without validation, and lack of sensitivity analyses.

LIMITATIONS

One limitation of this systematic review is that it only included studies from 2009 to 2013, potentially excluding some earlier comparator studies, particularly those involving first-generation antipsychotics.

CONCLUSIONS

This review of comparative effectiveness studies of second-generation antipsychotic agents for schizophrenic patients revealed a wide range of study types, study methodologies, and outcomes. For traditional efficacy outcomes and select safety outcomes, there is strong evidence from many well-conducted studies; however, there are fewer studies of types preferred by HTA with limited head-to-head comparisons and a higher risk of bias in the execution of these studies.

Psychosis in Later Life: A Review and Update

Psychosis is relatively common in later life and can present in a wide variety of contexts, including early-onset and late-onset schizophrenia, delusional disorder, mood disorders, and various dementias. It can also occur as the result of numerous medical and neurological diseases and from the use of certain medications. Although identifying the cause of psychosis in older patients can be challenging, the unique clinical features associated with the different disorders can help in making the diagnosis. Accurate diagnosis of psychosis in older populations is essential, as its treatment varies depending on the context in which it appears. Despite the safety concerns regarding the use of antipsychotics in older patients, certain pharmacological treatments appear to be both efficacious and reasonably safe in treating psychosis in older populations. Additionally, although research is limited, numerous psychosocial therapies appear promising. This review summarizes the literature on the epidemiology, clinical characteristics, neuroimaging, and treatment of psychosis in later life, and serves as an update to past reviews on this topic.

Successful withdrawal from antipsychotic treatment in elderly male inpatients with schizophrenia--description of four cases and review of the literature

We describe four elderly male inpatients with chronic schizophrenia successfully withdrawn from long-lasting antipsychotic treatment. Then we review studies in which antipsychotics were discontinued in patients 65 y.o. (or at least 50 on the average) or older using PubMed (last search; August 2014). The average (±S.D.) age, duration of illness and total duration of hospitalization of the patients were 77.0±8.6 y.o., 46.0±26.9 years, and 41.0±27.3 years, respectively. Illness severity as assessed with the Clinical Global Impression (CGI)-Severity was five for three patients and six for the other. After withdrawal from antipsychotic treatment for 28.3±11.4 weeks, none showed appreciable changes in psychopathology, functioning as well as adverse effects and the resultant CGI-Improvement was four for all patients. Compared with those who needed continuous antipsychotic treatment in the same unit (n=51; mean±S.D. age: 56.0±12.1 y.o.), they were significantly older and treated with a fewer number of total psychotropics at baseline (1.50±1.00 versus 4.94±1.93 agents). A literature search failed to find any studies in which antipsychotics were discontinued exclusively in patients with schizophrenia 65 years or older and underscored a clear paucity of data on this important topic. Cessation of chronic antipsychotic treatment could be a viable option at least in some patients with geriatric schizophrenia although more systematic studies are necessary.

Geographic variation in efficacy of atypical antipsychotics for the acute treatment of schizophrenia - an individual patient data meta-analysis

Generalizability of efficacy results from medication trials across geographic regions is disputed. Geographic differences in factors such as patient characteristics, treatment practices and disease definitions might lead to differences in effect sizes across regions. This study examined geographic variation in efficacy results of schizophrenia trials with atypical antipsychotics using individual-patient data meta-analysis. Twenty-two studies including in total 5233 patients from three regions (North America, Europe, and the rest of the world) were included in the random effects meta-analysis. The effect size in North American patients was smaller in terms of mean change from baseline and in terms of responders (Hedge׳s G=0.37, 95% CI 0.28-0.46; OR 1.71, 95% CI 1.35-2.17) as compared to patients in Europe (Hedge׳s G=0.56, 95% CI 0.34-0.79; OR 2.25, 95% CI 1.62-3.12) and the rest of the world (Hedge׳s G=0.53, 95% CI 0.12-0.75; OR 2.61, 95% CI 1.66-4.17). The differences were not statistically significant. The observed differences remained when the confounding effect of unequal distribution of compounds was controlled for by analyzing separately the compounds that were studied across all three regions. Based on these results it cannot be excluded that there are differences in efficacy results of atypical antipsychotics trials across geographic regions. The observed trend towards differential efficacy across geographic regions warrants further examination of the determinants of these differences.

Late-onset schizophrenia: do recent studies support categorizing LOS as a subtype of schizophrenia?

PURPOSE OR REVIEW

To review recent literature about late-onset schizophrenia (LOS): schizophrenia with onset between ages 40 and 60 years. New findings are presented in the context of the previous literature.

RECENT FINDINGS

Newer studies continue to suggest that early-onset schizophrenia (EOS) and LOS share fundamental clinical features (i.e., positive symptoms, negative symptoms, functional deficits). One larger recent study confirmed earlier findings that LOS differs from EOS in several important ways, including predominance of women, lower severity of positive symptoms, and lower average antipsychotic dose requirement. However, this study did not find LOS patients were more likely to have the paranoid subtype or to have less severe negative symptoms compared with EOS patients. New neuroimaging and molecular studies are identifying possible differences in the underlying pathophysiology of EOS and schizophrenia developing in mid-life to late-life; however, more research is needed to confirm these findings and determine their significance. No studies evaluated treatment strategies specifically in LOS.

SUMMARY

LOS continues to be an understudied area. Recent studies add support to the idea that LOS may be a distinct subtype of schizophrenia. Studies designed to elucidate the pathophysiology of LOS in comparison with EOS and to assess treatment strategies in this population are needed.

Change in antipsychotic usage pattern and risk of relapse in older patients with schizophrenia

OBJECTIVE

The aim of this study was to explore the use of first (FGAs) and second generation antipsychotics (SGAs) in older outpatients with schizophrenia and schizoaffective disorder. Factors associated with schizophrenic relapses were also studied.

METHODS

The study sample consisting of 8792 patients aged 64 years or more was collected from Finnish nationwide registers. The register data on the use of FGAs and SGAs were followed up between 1998 and 2003. Factors associated with psychiatric hospitalization in 1999 indicating relapse were studied using logistic regression analysis.

RESULTS

The use of SGAs increased from 2.8% to 12.4%, and the use of FGAs decreased from 57.5% to 39.4%. The use of a combination of SGAs and FGAs increased from 4.0% to 8.5%. The proportion of those who did not buy any antipsychotics varied between 35.8% and 39.7%. The number of patients hospitalized on psychiatric wards within a year (1999; relapsed) was 8.8%. Factors independently associated with relapse were use of combined FGAs and SGAs [odds ratio (OR) 1.70, p = 0.001] and use of antidepressants (OR 1.27, p = 0.019). Diagnosis of cardiovascular disease was negatively associated with risk of schizophrenic relapse (OR 0.84, p = 0.040).

CONCLUSION

The use of SGAs increased while the use of FGAs decreased in older outpatients with schizophrenia. Almost 40% of the study sample did not use any antipsychotic medication. The 1-year relapse rate was 8.8%. Several factors, such as combined use of FGAs and SGAs, or antidepressants, were associated with schizophrenic relapse, whereas cardiovascular disease showed a negative association with the relapse.

Defining treatment-resistant schizophrenia and response to antipsychotics: a review and recommendation

Treatment-resistant schizophrenia (TRS) has been defined mainly by severity of (positive) symptoms and response to antipsychotics derived from a relative change in the representative scales (most frequently ≥ 20% decrease in the Positive and Negative Syndrome Scale: PANSS), but these definitions have not necessarily been consistent. Integrating past evidence and real-world practicability, we propose that TRS be defined by at least two failed adequate trials with different antipsychotics (at chlorpromazine-equivalent doses of ≥ 600mg/day for ≥ 6 consecutive weeks) that could be retrospective or preferably include prospective failure to respond to one or more antipsychotic trials. In addition, our proposed criteria require both a score of ≥ 4 on the Clinical Global Impression (CGI)-Severity and a score of ≤ 49 on the Functional Assessment for Comprehensive Treatment of Schizophrenia (FACT-Sz) or ≤ 50 on the Global Assessment of Functioning (GAF) scales to define TRS. Once TRS is established, we propose that subsequent treatment response be defined based on a CGI-Change score of ≤ 2, a ≥ 20% decrease on the total PANSS or Brief Psychiatric Rating Scale (BPRS) scores, and an increase of ≥ 20 points on the FACT-Sz or GAF. While these suggestions provide a pragmatic framework for TRS classification, they need to be tested in future trials.