Social disabilities

Elderly patients with schizophrenia in long-term institutional care are known to suffer from a number of social disabilities. Reference Wing and FurlongWing & Furlong (1986) identified five factors that contributed to these disabilities:

1. • risk of harm to self and others

2. • unpredictability of behaviour and liability to relapse

3. • poor motivation and reduced capacity for self-management or performance of social roles

4. • lack of insight

5. • low public acceptability.

Different studies have shown social functioning in schizophrenia to both improve and deteriorate over time (Reference CiompiCiompi, 1980; Reference Huber, Gross and SchutlerHuber et al, 1980; Reference Harding, Brooks and AshikagaHarding et al, 1987). Some aspects of daily living such as coping skills and socialisation with family members tend to improve with age (Reference CohenCohen, 1993; Reference Cook, Lefley and PickettCook et al, 1994), but most elderly patients with schizophrenia continue to have disabilities in the higher domains of functioning such as finance, transportation, shopping and grooming (Klaplow et al, 1997). These all make community rehabilitation a challenge.

Cognitive impairment

Cognitive deficits are well known to be associated with schizophrenia (Reference Cassens, Inglis and AppelbaumCassens et al, 1990; Reference Goldberg, Hyde and KleinmanGoldberg et al, 1993). Specific deficits in the areas of executive function (Reference Shallice, Burgess and FrithShallice et al, 1991), use of language (Reference Faber, Abrams and TaylorFaber et al, 1983), memory function (Reference Saykin, Shtasel and GurSaykin et al, 1994) and visuospatial tasks (Reference Gabrovska-Johnson, Scott and JeffriesGabrovska-Johnson et al, 2003) have been reported. Cognitive deficits, more than positive symptoms, have been shown to affect the adaptive abilities required for community living (Reference GreenGreen, 1996; Reference Harvey, Silverman and MohsHarvey et al, 1999) and to be responsible for the failure of rehabilitation even in times of remission of illness (Reference Goldberg, Hyde and KleinmanGoldberg et al, 1993).

Several histological studies have reported a lack of Alzheimer-type pathological changes in schizophrenia (Reference Pantelis, Barnes and NelsonPantelis et al, 1992; Reference Casanova, Carosella and GoldCasanova et al, 1993), whereas others have shown a higher prevalence than in the general population (Reference SoustecSoustec, 1989; Reference Prohovnik, Dwork and KaufmanProhovnik et al, 1993). These findings suggest that currently available anti-dementia drugs might be of value in older people with schizophrenia.

Physical illness

Some physical illnesses have higher rates in people with schizophrenia than in the ‘normal’ population (for example, cardiovascular disorders, including coronary artery disease, and diabetes mellitus) (Reference BaldwinBaldwin, 1979; Reference Tsuang, Perkins and SimpsonTsuang et al, 1983; Reference HarrisHarris, 1988). A number of other physical disorders such as peptic ulcers, epilepsy, asthma and cancer have also been associated with schizophrenia, but the consequences of these conditions remain generally unappreciated (Reference Jeste, Gladsjo and LindamerJeste et al, 1996). Recognition of concomitant physical illness in elderly patients with schizophrenia is particularly important, as there is an increased risk of deterioration owing to lack of insight and the chances of non-compliance with treatment are high (Reference Cohen, Cohen and BlankCohen et al, 2000).

Outcome

Reference KraepelinKraepelin (1913) gave a bleak prognosis for schizophrenia, but a more heterogeneous outcome has since been described (Reference BleulerBleuler, 1974; Reference Carpenter and KirkpatrickCarpenter & Kirkpatrick, 1989). Reference Abrahamson, Swatton and WillsAbrahamson et al(1989) found that 25% of patients improved and 10% deteriorated. Reference Cutting, Kerr and SnaithCutting (1986) reviewed ten outcome studies and concluded that many patients with chronic schizophrenia continued to have a bad outcome. The five most powerful predictors of poor outcome were:

1. • social isolation

2. • having episodes of long duration

3. • a past history of psychiatric treatment

4. • being unmarried

5. • a history of behavioural disturbance in childhood.

Management

There are few studies on the use of neuroleptics in elderly patients with schizophrenia, but older people are known to be at greater risk of developing extrapyramidal symptoms and tardive dyskinesia (Reference Jeste, Gilbert and McAdamsJeste et al, 1995). Extrapyramidal symptoms can cause functional disabilities greater than those caused by the disease itself (Reference Jeste, Lohr and EasthamJeste et al, 1998), and this usually results in the use of smaller doses of antipsychotics for older patients (Reference Jeste, Gilbert and McAdamsJeste et al, 1995). It also highlights the importance of combining pharmacological treatments with psychosocial approaches such as group activities (Reference Harding, Zubin and StraussHarding et al, 1992). The newer atypical antipsychotics seem to have a reduced tendency to cause extrapyramidal side-effects and to have better effects on negative symptoms (Reference KumarKumar, 1997).

Conclusions

The literature on older people with schizophrenia is sparse and much remains to be studied. Areas for future research highlighted byReference Cohen, Cohen and BlankCohen et al(2000) include the following:

1. 1 identification of the factors that determine the subjective and objective mental, physical and social well-being of older people who have schizophrenia, with the aim of enabling their optimal functioning in the community;

2. 2 clarification of the factors that predict their levels of positive and negative symptoms, depression and neuropsychological deficits, so that the most effective long-term treatment of these symptoms can be established;

3. 3 identification of the factors that contribute to the burden on the carers of this population and, through comparison with the burden on carers of people with other disorders, the development of models to enhance support systems for older people with schizophrenia;

4. 4 determination of the optimal service mix for older people with comorbid physical and chronic mental illness and development of models of funding their care.