schizophrenia in old age

8/14/2019 Schizophrenia in Old Age

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Schizophrenia In Old Age

Dr Ayedh Alkhadem

Al-Amal Psychiatric Hospital


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Historical Background

Little research done compared to schiz.in young

In 1693 sir isaac newton experienced an episodeat age 51

Remitted after 18 months ,sym.includedpar.del.,social withdral,reference 2 convers.

That never ocuured Emil Kraepelin described dementia praecox as

an adolescent /early adult onset

Initail studies of LOS by Bleuler


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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


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Epidemiology

Approx. 23% of schizophrenics have onset after40

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 timesmore (oestrogen-mediated dopaminergicinhibition)


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Etiology

Familial association 4 LOS similar to that ofearly-onset schizophrenia but not 4 VLO.

CT and MRI studies have found nonspecificstructural changes similar to those noted inearly-onset patients

No evidence it is neurobiologically d/f from

early


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Genetic factors Sex

Sensory deficits

Premorbid personality

Social Isolation

Demonstrable brain abnormality


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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


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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) differencesthat are independent of the illness. Not necessarilyd/f in pathophys. or etiolgy


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Differential Diagnosis

Early onset schiz.

Mood disorder

Delusional disorder Psyc. Due to gen. med. Condition

Substance induced psychosis


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Course and Prognosis

usually chronic but may be interrupted by partialremissions 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


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Treatment

better symp. improvement with antipsychotic than early-onsetillness .

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


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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 anelevated lifetime morbid risk

Back


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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.

Back


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Sensory deficits

Visual impairment is also more common inelderly paranoid pts than those with affectivedisorder

higher coincidence of visual and hearingimpairment in paranoid than affective patients.

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PremorbidPersonality

consistent presence of abnormal personalitytraits( schizoid or paranoid)

unsociability, reticence, suspiciousness, and

hostility 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 prodromalsymps.

Earlier onset are associated with more severe neg. anddisorganized symps. and greater cognitive deficits (esp.learning and abstraction)

late-onset : less severe symptoms with somewhat betterpreservation 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,dont 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 functioningoutside 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 withpsychotic symptoms at some point

Delusions in AD : nonbizarre, episodic, andpreceded 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 thesubstance and decrease when it has beendiscontinued

symptoms have been provoked and maintained

by the substance use Back

schizophrenia in old age

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