Untreated OSA and Worsening Psychotic Symptoms in a Geriatric Patient with Schizophrenia: A Case Study

Abstract

<h3>Introduction</h3> In addition to being a debilitating mental disorder, schizophrenia comes with a host of medical comorbidities, that can shorten the lifespan of those living with this illness by 10-25 years. Among these comorbidities is obstructive sleep apnea (OSA), which studies have shown to be more prevalent among patients with schizophrenia, even when controlling for gender, age, other comorbidities, and duration of antipsychotic use. The treatment of schizophrenia and its comorbidities in advanced age is an important consideration in geriatric psychiatry, as the number of patients living with schizophrenia over the age of 60 has been estimated to reach 10 million worldwide by 2050. However, there is limited research on the clinical management of OSA as a complication in geriatric patients with schizophrenia. Here we present the case of a patient with longstanding schizophrenia complicated by obstructive sleep apnea. <h3>Methods</h3> Patient was assessed and followed in a Veterans Hospital-associated long-term care facility by a geriatric psychiatry consultation-liaison service with the assistance of a multidisciplinary team. Here, we present the case and offer a review of the current literature surrounding schizophrenia and obstructive sleep apnea in the geriatric population. <h3>Results</h3> This is a case report of Mr. G, a 78-year-old man with a psychiatric history of schizophrenia and medical comorbidities of lymphedema, morbid obesity, and obstructive sleep apnea. Mr. G was diagnosed with schizophrenia in his early 20s during military service and was maintained on psychotropics for many years with a high degree of functioning, including being able to hold several "odd jobs" and live relatively independently. Throughout his life, Mr. G described baseline auditory hallucinations that were often a nuisance but disappeared when talking to others. As Mr. G got older, he sustained several injuries that made it more difficult for him to live independently, and he was moved into an ALF. Here, his course has been complicated by chronic obstructive sleep apnea likely precipitated by morbid obesity. The case is further complicated by the fact that Mr. G has an intense aversion to wearing masks and has failed multiple trials of CPAP mask. In this context, he has described a worsening of the auditory hallucinations in frequency and intensity, and also in his own affective response to the hallucinations- namely, he is more distressed by them now than he was as a young man. Furthermore, this change has not been responsive to titration in antipsychotics or psychotropic augmentation. <h3>Conclusions</h3> This case demonstrates the need for further research into the relationship between obstructive sleep apnea and schizophrenia, particularly in alternative clinical options. Multiple epidemiological studies have found that OSA is highly prevalent in patients with schizophrenia, and a recent pilot study found that treatment with CPAP improved cognition in patients with schizophrenia. Of particular interest, a recent retrospective case-control study showed similar adherence to CPAP between patients with schizophrenia and control groups. However, it must be noted that although adherence to CPAP was not markedly different from control groups, it was still only approximately 36% after the one-year mark, indicating the need for further development into treatment modalities and adherence measures for those living with schizophrenia, particularly in the geriatric population. <h3>This research was funded by</h3> No Funding Sources to Report