Practical Geriatrics: Directions for Research and Policy on Schizophrenia and Older Adults: Summary of the GAP Committee Report

The committee on aging of the Group for the Advancement of Psychiatry (GAP) believes we face a crisis in mental health care for older persons. It involves older persons with serious and persistent mental illness other than dementia, who constitute approximately 2 percent of the population over age 54, or about one million persons (1,2). During the next 30 years, their number will double as postwar baby boomers reach old age (3). This generation of persons with chronic mental illness will have spent considerably less time in mental institutions than earlier generations and thus will need to negotiate health and social service systems that may be unprepared to deal with them.

Because older persons with schizophrenia constitute the majority of older persons with serious and persistent mental illness, and perhaps are most at risk with respect to clinical, social, and service needs (1,4), it is critical to focus initially on them. Furthermore, an examination of schizophrenia in later life, when it has attained its most complex and developed forms, may provide many of the keys to the disorder itself (5). This paper is a summary of a report prepared by the GAP committee on aging. The full report will be published elsewhere (6).

MEDLINE and PsychINFO literature searches revealed that only 1 percent of articles on schizophrenia have focused on aging individuals. The committee wished to provide an overview of the current state of knowledge, stimulate new research, and examine the implications for research and policy. In the report we focus primarily on the 85 percent of persons with schizophrenia who develop the disorder before age 45 and who age with it. The late-onset disorder has been well described in recent years and may represent a neurobiologically distinct disorder (7,8).

Where do we find aging persons with schizophrenia?

Although the Epidemiologic Catchment Area (ECA) study found prevalence rates of schizophrenia of only .3 percent among persons age 65 and over, the study tended to undersample in areas where persons with mental illness may be concentrated (9). However, several writers believe that prevalence rates are about 1 percent (2,5). We estimate that at least 85 percent of older people with schizophrenia live in the community; the remainder reside in nursing homes or as psychiatric inpatients.

How does schizophrenia change over the life course?

Interpretation of the literature on aging and schizophrenia requires an appreciation of a biopsychosocial life course perspective that integrates the changes that occur over a lifetime among persons with schizophrenia with the normal changes of aging in neuroendocrine systems, cognition, physical health, coping, and adaptation (3,10,11).

Psychopathology

Schizophrenia appears to be quite plastic over the life course (3,12). In general, a trend toward a reduction in positive symptoms has been noted, but unfavorable courses may also emerge (13,14,15). Investigators disagree about improvement in negative symptoms; some believe that negative symptoms dominate the picture in later life, whereas others contend that such symptoms relent (16,17,18). Negative symptoms have been found to correlate with cognitive deficits and soft neurological signs (19).

Levels of depression may be high among older persons with schizophrenia, with more than two-fifths showing signs of clinical depression (13,20). The depression has been linked to positive symptoms, poor physical health, low income, and diminished network support (20).

Men and women are equally prone to develop schizophrenia, but the onset is earlier in men. Moreover, schizophrenia in women is milder in the first decade, but symptoms increase in the second and third decades, when men's symptoms generally diminish (21). Disparities between men and women in the onset and early course have been attributed to various biological and social factors. However, the decline with age in the female advantage that is seen in the early course of illness may be secondary to the greater impact on women of loss of family and other emotional support, rather than being hormone induced (21).

Neuropsychological functioning

Older persons with schizophrenia may experience a double jeopardy: many exhibit neuropsychological deficits early in the disorder, and due to aging and other lifetime deprivations, such as limited education, unemployment, and institutionalization, their cognitive function may further decline in later life. These deficits are not as severe nor as progressive as in Alzheimer's disease (19,22,23,24,25,26,27), although they have substantial impact on community functioning (28,29)

Social functioning

Global measures of social functioning have produced inconclusive results, with some studies finding appreciable improvement over the life span and others finding marked social impairment (14,30,31,32). Nevertheless, when researchers have looked at specific components of social functioning, a trend toward improvement has been noted. For example, coping strategies seem to evolve with aging, and individuals may become more active participants in their recovery (33,34,35).

As with younger persons who have schizophrenia, the social networks of older persons with the illness tend to be smaller than those of their age peers. However, older persons may experience fewer discordant interactions, such as situations with high expressed emotions (36). Social support has been found to be the best predictor of level of functioning (37). One study found that a majority of older persons with schizophrenia were satisfied with their lives, but that their level of satisfaction was lower than that of their age peers (38). Higher subjective well-being was associated with subjective factors, such as perceived social support and self-rated health, rather than with objective factors such as physical impairment or income.

Impaired social adaptive functioning has been linked to higher levels of cognitive deficits, negative symptoms, and movement disorders (39). Increasingly, aging for persons with schizophrenia, like aging for persons in general, is no longer viewed as a decremental process but one of adaptation, compensation, and plasticity (40).

Comorbidity

The extent and consequences of medical comorbidity among older persons with schizophrenia have been generally unappreciated (41). Nearly half of comorbid medical conditions are missed (42,43). Some illnesses may be more prevalent among persons with schizophrenia, such as cardiovascular disorders—especially coronary artery disease and myocardial infarction—and diabetes (44,45,46). Nevertheless these illnesses may not be specific to people with schizophrenia but to those with chronic mental illness.

Jeste and coworkers (41) postulated that while older persons with schizophrenia did not have more physical illnesses than their age peers, their illnesses may be more severe. They concluded that persons with schizophrenia may receive less than adequate health care. Both structural barriers in the health care system and physicians' attitudes may create impediments to care. Mortality rates among persons with schizophrenia have been estimated to be two to four times the rates in the general population (41); however, it is not clear if excess mortality also occurs with advancing age (47).

The comorbidity of schizophrenia and chemical abuse among older adults has likewise received little attention. For persons with schizophrenia of all ages, the ECA study reported a lifetime prevalence of alcoholism and drug use disorders of 33 percent and 28 percent, respectively (48). Although the prevalence of chemical abuse has been found to be low—less than 3 percent—among older persons with schizophrenia (20), greater potential exists for problems with the next generation of older persons with the illness, given the dramatic increase in drug use during the past 30 years.

Treatment and rehabilitation

It remains unclear to what extent neuroleptics affect the natural history of schizophrenia (3). In several long-term studies, nearly half of the recovered patients had discontinued their medication (15). On the other hand, several extensive reviews of outcome studies have found that neuroleptics had favorable long-term effects on symptoms (49,50). However, because rates of extrapyramidal symptoms and tardive dyskinesia may exceed 50 percent among older patients, clinicians have been encouraged to taper neuroleptic dosages in older outpatients with stable chronic symptoms (51).

Tapering dosages may be of critical importance because extrapyramidal symptoms may affect functional performance to a greater extent than positive or negative symptoms or duration of psychoses (52) and tardive dyskinesia may be associated with greater cognitive impairment (53). Jeste and colleagues (54) found that about 60 percent of older persons with schizophrenia withdrawn from medication did not relapse over a mean of six months.

The utility of psychosocial approaches, especially group activities, in spurring improvement among older patients has also been recognized (12).

Cohler and Beeler (34) pointed out that in developing outcome goals, especially for older persons with schizophrenia, the most appropriate goal may not be recovery or rehabilitation per se, but making life more meaningful and satisfying to the individuals and those close to them.

Caregivers' needs

More elderly relatives are caring for middle-aged persons with chronic mental illness; a third of caregivers are over age 65, and a tenth are over age 75 (55). It appears that older caregivers are more burdened by issues of responsibility, such as who will care for the patient when they become incapacitated or die, whereas younger caregivers are more burdened by the behavioral concomitants of the illness (35). Minority caregivers may be especially concerned about issues of responsibility (35). Some writers have pointed to the satisfaction that can be derived from caregiving; over time, the aging relative may come to rely on the patient for physical and emotional support (34,35,56).

Service needs

Only a handful of studies have described services for aging chronically mentally ill persons and their impact on objective and subjective well-being (57). Meeks and Murrell (58) state that despite impoverishment and the presence of significant symptoms, older persons with chronic mental illness generally receive little support from the mental health system beyond medication. In a survey by the GAP committee on aging of 13 leaders in community psychiatry, a majority of respondents said that none of a list of ten mental-health-related services for older persons were adequate in their communities. The committee believes that it is necessary to develop age-appropriate services that include treatment alternatives to long-term hospitalization, residential models, community support programs, and psychoeducational programs.

Economic implications of serving older persons

Recent data indicate that costs for community care of persons with schizophrenia are significantly higher for those age 65 and over than for those age 30 to 64, perhaps partly due to their medical comorbidity or increased cognitive impairment (59). Thus improvements in psychopathology and social integration with age do not necessarily translate into any direct opportunity for cost saving (60).

Many factors do not bode well for aging persons with schizophrenia: the persistent underfunding of mental health programs versus those in general medicine, the continued orientation of Medicare toward inpatient rather than community care, the fragmentation and inconsistency in the level of services nationwide, the anticipated decline in Medicaid and Medicare funding for mental health, and serious concerns about the ability of managed care programs to adequately serve the most severely mentally ill among older persons (61,62,63). Moreover, current policies may inadvertently move many older persons with schizophrenia into more costly settings such as nursing homes and other restricted environments because adequate supportive services are not available in the community. Conversely, policies may not be broad enough to ensure that these individuals have access to institutional or supportive care when their illness necessitates it.

Recommendations

Because the number of older persons with schizophrenia will increase dramatically over the ensuing decades, policy makers must begin to reorder research and service priorities to anticipate this growth. Our overview of the status of older persons with schizophrenia indicates that in many instances appreciable alterations in psychopathology, neuropsychological status, social functioning, and health distinguish older persons from younger persons with the disorder. From our review, we believe that some of the most critical research areas concern the elaboration of several factors:

• Improving the levels of subjective and objective measures of mental, physical, and social well-being

• Diminishing levels of psychopathology, such as positive and negative symptoms, depression, and neuropsychological deficits

• Improving the illness-related behavior of older persons with schizophrenia and their service use

• Diminishing burden among caregivers of older persons with schizophrenia

• Enhancing services for older persons with schizophrenia and their caregivers

• Decreasing the economic costs of providing services to older persons with schizophrenia and their caregivers and determining the optimal mechanisms for funding these services

• Improving the knowledge base and service delivery of psychiatrists and primary care physicians serving this population.

Methodologically, addressing these issues poses several challenges. First, it will be necessary to develop samples that capture the range of residential, clinical, geographic, and sociodemographic diversity of the older population with schizophrenia. Second, it is essential to develop the appropriate instrumentation to operationalize variables in the issues listed above. Recent community-based and institutional studies of older persons with the illness have used an array of scales to assess psychopathology, cognition, and psychosocial functioning that can provide the basis for future work. Thus the foundation is now in place to begin to construct a knowledge base from which we can better address the needs of older persons with schizophrenia.

Acknowledgment

The authors thank Carole Lefkowitz for her assistance.

The members of the committee on aging of the Group for the Advancement of Psychiatry are Carl I. Cohen, M.D., chair, Gene D. Cohen, M.D., Karen Blank, M.D., Charles Gaitz, M.D., Ira R. Katz, M.D., Ph.D., Andrew Leuchter, M.D., Gabe Maletta, Ph.D., M.D., Barnett S. Meyers, M.D., Kenneth Sakauye, M.D., and Charles Shamoian, M.D., Ph.D. Send correspondence Dr. Cohen at the State University of New York Health Science Center at Brooklyn, Box 1203, 450 Clarkson Avenue, Brooklyn, New York 11203 (e-mail, [email protected]). Marion Z. Goldstein, M.D., is editor of this column.