Schizophrenia In Old Age

Dr Ayedh Alkhadem

Al-Amal Psychiatric Hospital

 Historical Background


Little research done compared to schiz.in young

In 1693 sir isaac newton experienced an episode
at age 51

Remitted after 18 months ,sym.included
par.del.,social withdral,reference 2 convers.
That never ocuured

Emil Kraepelin described dementia praecox as
an adolescent /early adult onset
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Initail studies of LOS by Bleuler

Martin Roth1952 applied the term Late Paraphrenia for pts.
After age 60\

DSM-I , DSM-II didnt specify age of onset criteria for schiz

DSM-II used the term involutional paraphrenia

DSM-III restricted Dx of schiz.for those b4 age 45

DSM-III-R included a late onset category for pts. 45Yrold or
later.

ICD-10, DSM-IV, and DSM-IV-TR dont include diagnoses for
late onset schiz,

DSM-IV-TR mention differences b/w Late and early onset
schiz.

international late-onset schizophrenia group Reach consensus

 Epidemiology

Approx. 23% of schizophrenics have onset after
40

About 13% in 5th decade,7% in 6th,3% later

the 1-year prevalence rate of schiz. between
ages 45 and 64 is 0.6% ,0.1-0.5%above 65

Late onset schiz. Affects women 2 to 10 times
more (oestrogen-mediated dopaminergic
inhibition)
 Etiology

Familial association 4 LOS similar to that of
early-onset schizophrenia but not 4 VLO.

CT and MRI studies have found nonspecific
structural changes similar to those noted in
early-onset patients

No evidence it is neurobiologically d/f from
early

Genetic factors

Sex

Sensory deficits

Premorbid personality

Social Isolation

Demonstrable brain abnormality
 ClinicalFeatures

More similar than d/f w/ earlyonset schiz.

The most common features of LOS are per del., that
may be bizarre and aud hall.

Partition delusions

less severe negative symptoms

lower daily doses of antipsychotics

less frequent loose associations and inapp. Affect

mostly paranoid or undiff subtype

low prevalence of thought disorder(abt 5% of pts )
and affective blunting

Schneiderian first-rank syms are less prevalent

(eg,Thought insertion, block, and withdrawal
uncommon)

higher prevalence of visual hallucinations

Sym. differences could be related to cohort
differences or age-associated (CNS) differences
that are independent of the illness. Not necessarily
d/f in pathophys. or etiolgy
 Differential Diagnosis

Early onset schiz.

Mood disorder

Delusional disorder

Psyc. Due to gen. med. Condition

Substance induced psychosis
 Course and Prognosis

usually chronic but may be interrupted by partial
remissions and exacerbations

prognosis : better than that in early-onset

quite responsive to antipsychotics used in lower doses

mortality (esp from suicide) probably comparable to
that in early-onset

factors assoc.with positive outcome : female gender,
later onset, paranoid subtype, less severe negative
symptoms, and better premorbid functioning
 Treatment

better symp. improvement with antipsychotic than early-onset
illness .

substantially reduced doses of antipsychotics are necessary

Maintenance therapy is frequently required

Elderly pts are more susceptible to antipsychotic side effects

Atypical antipsy. have become the agents of choice

Lack of data for clozapine prevents its use in old pts.

augmentation of antipsychotic therapy :antidepressants

Psychosocial treatment :CBT, social skills training
 Genetic

Life time risk for schiz. In FDR is 10% ,holds
true for age onset upto 50 yrs.

FDR of pts with very-late-onset (> 59 years)
schizophrenia-like psychoses do not have an
elevated lifetime morbid risk

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Back
 Sex

Females are at much higher risk in the late-life
population

female-to-male ratios 2:1 to 10:1

Estrogens could have protective actions.

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 Sensory deficits

Visual impairment is also more common in
elderly paranoid pts than those with affective
disorder

higher coincidence of visual and hearing
impairment in paranoid than affective patients.

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 PremorbidPersonality

consistent presence of abnormal personality
traits( schizoid or paranoid)

unsociability, reticence, suspiciousness, and
hostility
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Low marriage rate,less children if marreid

educational and occupational adjustment
generally good

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
Determining the onset

insidious onset of symptoms

premorbid traits difficult to diff. from prodromal
symps.

Earlier onset are associated with more severe neg. and
disorganized symps. and greater cognitive deficits (esp.
learning and abstraction)

late-onset : less severe symptoms with somewhat better
preservation of affect and social functioning.

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
mood disturbances common during the prodromal, active,
and residual phases

mood-congruent or mood-incongruent psychotic
features :H/O mood sym.

Mood symps. in schiz. have a brief duration, in prodormal
& residual,don’t meet criteria.

MD cPF:Affective sym. Precede psych.

Shizoaffective: major episode in active phase,psych.
Present 4 2wks without prominent mood sym.

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
lack of prominent aud or visual hall.

absence of deterioration in areas of functioning
outside the delusional scope

necessarily nonbizarre and involve situations
that may occur in real life

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
thorough evaluation for underlying medical
disorders

1/3 of pts with a diagnosis of AD may present with
psychotic symptoms at some point

Delusions in AD : nonbizarre, episodic, and
preceded by cognitive decline

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
amphetamines, cocaine, and phencyclidine, can
produce symps.

Diff. from schizophrenia after a period of
abstinence

symptoms appear to be exacerbated by the
substance and decrease when it has been
discontinued

symptoms have been provoked and maintained
by the substance use
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