Elderly Schizophrenic Patients Research Articles

QUETIAPINE FOR THE TREATMENT OF DRUG-INDUCED PSYCHOSIS IN PARKINSON's DISEASE

Objective: The authors report our complete experience with quetiapine for the treatment of drug-induced psychosis (DIP) in Parkinson's disease (PD). Background: Quetiapine is an atypical antipsychotic with clozapine-like pharmacology but without associated agranulocytosis. Psychosis occurs in 5–8% of PD patients. Design/Methods: 35 PD patients with DIP with a mean age of 75 years and a PD duration of 8.4 years on an average of 427 mg of levodopa per day received a mean dose of 40.6 mg/day of quetiapine. Twenty-four were neuroleptic-naive patients while 11 were psychiatrically stable patients on clozapine (8) or olanzapine (3) who were empirically switched over to quetiapine. Results: 20 of 24 neuroleptic-naive patients reported marked improvement to complete amelioration of psychosis. Ten patients had a mean pretreatment MMSE score of 22.5 and Brief Psychiatric Rating Scale (BPRS) score of 32.6. The mean post-treatment BPRS score of 22.8 was clinically and statistically significant, P=0.024 but the MMSE was not. 3 of 24 were unable to tolerate quetiapine due to orthostatic hypotension, headache, nausea, and persistence of hallucinations. One patient died of an unrelated cause. Of the 20 patients who remained on quetiapine, motor function remained stable, with pretreatment United Parkinson's Disease Rating Scale (UPDRS-motor) score of 45.9 and post-treatment score of 48.8, P=0.314. Five of eleven patients on clozapine or olanzapine made the crossover to quetipaine without a loss of effect or increased parkinsonism as measured on BPRS, MMSE and UPDRS. Six did not because of confusion, erratic behavior, and increased hallucinations. No crossover failure had worsened PD except for increased tremor in one. Conclusion: Quetiapine is useful and well-tolerated as a first drug to treat DIP in PD, but must be used cautiously to replace other atypical antipsychotic drugs. The quetiapine dose required is less than that for elderly schizophrenic patients.

Tardive dyskinesia in a chronically institutionalized population of elderly schizophrenic patients: prevalence and association with cognitive impairment.

Chronically hospitalized geriatric inpatients with schizophrenia are at particular risk for both tardive dyskinesia (TD) and cognitive impairment but have been insufficiently studied in this regard. Similarly, the relationship between TD and cognitive impairment has not be adequately addressed in this population. (1) To determine the prevalence of TD in a cohort of chronically institutionalized schizophrenic geriatric inpatients. (2) To examine the relationship between the manifestations of TD in various body regions and several potentially related variables including current pharmacological regimen, age, age at first hospitalization and cognitive status. TD was assessed by the Modified Simpson Dyskinesia Scale and cognitive status by the Mini-Mental State Examination (MMSE). The relationship between manifestations of TD and other variables was examined by t-tests, ANOVA, MANOVA and correlational analysis. The prevalence of TD was 60%. Prevalence increased with age but was not related to current antipsychotic or anticholinergic regimen. Mean MMSE score did not differ between groups of patients with and without TD as defined by the criteria of Schooler and Kane (1982); however, the mean MMSE score was significantly (p < 0.0004) lower in subjects with orofacial TD as defined by Waddington and Youssef (1996), and the difference was not entirely accounted for by the older age of the latter group. TD and cognitive impairment both increase with age. However, TD alone does not account for the severity of cognitive impairment in this population. The present study provides further support for the hypothesis that the correlation between TD and cognitive impairment holds primarily for the orofacial manifestations of TD.

Tardive dyskinesia in a chronically institutionalized population of elderly schizophrenic patients: prevalence and association with cognitive impairment

Background. Chronically hospitalized geriatric inpatients with schizophrenia are at particular risk for both tardive dyskinesia (TD) and cognitive impairment but have been insufficiently studied in this regard. Similarly, the relationship between TD and cognitive impairment has not been adequately addressed in this population. Objectives. (1) To determine the prevalence of TD in a cohort of chronically institutionalized schizophrenic geriatric inpatients. (2) To examine the relationship between the manifestations of TD in various body regions and several potentially related variables including current pharmacological regimen, age, age at first hospitalization and cognitive status. Method. TD was assessed by the Modified Simpson Dyskinesia Scale and cognitive status by the Mini-Mental State Examination (MMSE). The relationship between manifestations of TD and other variables was examined by t-tests, ANOVA, MANOVA and correlational analysis. Results. The prevalence of TD was 60%. Prevalence increased with age but was not related to current antipsychotic or anticholinergic regimen. Mean MMSE score did not differ between groups of patients with and without TD as defined by the criteria of Schooler and Kane (1982); however, the mean MMSE score was significantly (p<0·004) lower in subjects with orofacial TD as defined by Waddington and Youssef (1996), and the difference was not entirely accounted for by the older age of the latter group. Conclusions. TD and cognitive impairment both increase with age. However, TD alone does not account for the severity of cognitive impairment in this population. The present study provides further support for the hypothesis that the correlation between TD and cognitive impairment holds primarily for the orofacial manifestations of TD. © 1998 John Wiley & Sons, Ltd.

Human olfactory mucosa in schizophrenia.

Recent evidence indicates that developmental anomalies may underlie some symptoms of schizophrenia, while psychophysical studies have demonstrated olfactory deficits in this disease. The postmortem olfactory mucosa of elderly schizophrenic patients was examined to characterize the molecular phenotype of this tissue. The distribution of developmentally regulated cytoskeletal proteins, a synaptic vesicle protein, a neural marker protein, a receptor for trophic molecules, axonal guidance and cell migration proteins, and neuronal and glial cytoskeletal proteins of various degrees of phosphorylation was examined by immunohistochemistry. Both schizophrenic and control subjects exhibited dystrophic neurites that were immunoreactive for synaptophysin, microtubule-associated proteins (MAP1B), and neurofilament proteins. No major histochemical or morphologic differences in either the expression or distribution of these proteins were observed in the olfactory epithelium of schizophrenic compared to control subjects. These studies indicated that dystrophic neurites frequently occurred in the olfactory mucosa of both schizophrenics and neurologically normal adults. The absence of major immunocytochemical abnormalities suggested that olfactory deficits in schizophrenia may be due to more subtle cellular or molecular differences or to abnormalities in olfactory regions of the central nervous system rather than in the olfactory epithelium.

No neuropathologic evidence for an increased frequency of Alzheimer's disease among elderly schizophrenics

There is currently controversy as to the frequency of Alzheimer's disease (AD) in elderly persons with schizophrenia. Several studies have reported an increased frequency of AD in elderly schizophrenics, whereas others have found no increase. This issue is important because it has been hypothesized that medications used to treat schizophrenia may exacerbate AD histopathology. We examined autopsy cases from a state psychiatric hospital and a Veterans Affairs medical center. Charts were reviewed on 166 subjects to determine if the history warranted a DSM-IV diagnosis of schizophrenia. All subjects had complete gross and microscopic neuropathologic evaluations, which were reviewed for evidence of Alzheimer's disease. Retrospective chart review identified 51 subjects over the age of 55 who met DSM-IV criteria for schizophrenia (mean age = 71.7 years, SD = 8.6, range 56-95 years). Of these 51, only I met neuropathologic criteria for AD, a frequency of 2%. The frequency of subjects meeting neuropathologic criteria for Alzheimer's disease in our sample of schizophrenics was equal to or less than that found in the general population. Because institutionalized populations may contain an excess of elderly schizophrenic patients with severe behavioral pathologies, which may in turn reflect the presence of neurodegenerative processes such as Alzheimer's disease, our results may actually overestimate the frequency of Alzheimer's in the entire schizophrenic population. The frequency of Alzheimer's disease in the elderly with schizophrenia may be less than that in the general population.

Differential Effect of Haloperidol and Clozapine on Plasma Homovanillic Acid in Elderly Schizophrenic Patients with or without Tardive Dyskinesia

Background: Plasma homovanillic acid (HVA) changes in response to a challenge of several days with haloperidol have been found to be predictive of the therapeutic response to haloperidol over a longer period of treatment. Methods: Twenty-six elderly women who gave informed consent were divided into two groups, with or without tardive dyskinesia, and subjected to an 80-day washout, after which both the dyskinetic and nondyskinetic group was divided, and half of each group given haloperidol or clozapine. Conclusions: The nondyskinetic group had a brief rise in plasma HVA, then a decline. The dyskinetic group had no change in plasma HVA. Neither group challenged with clozapine had any change in plasma HVA.

A comparative study of elderly patients with schizophrenia and bipolar disorder in nursing homes and the community

This study compared the functioning of 188 elderly schizophrenic and bipolar disorder patients living in nursing homes and the community. Residential status and diagnostic groups were compared on measures of symptomatology, cognitive impairment, functional impairment, and behavior problems. In general, the diagnostic groups differed in symptoms, while most differences in living setting were related to cognition, functioning, and behavior. Nursing home status was significantly associated with more severe overall symptom ratings, worse cognitive impairment, greater functional impairment, more aggressive behaviors, and marital status of having never married. Self-care skills, community living skills, and marital status were most uniquely predictive of nursing home residence. However, cognitive deficits were strongly predictive of both self-care and community living skills, explaining approximately half of the variance in these variables. The implications of these findings for the treatment of elderly patients with schizophrenia and other severe mental illness are discussed.

Poor memory, negative symptoms and abnormal movements in never-treated Indian patients with schizophrenia.

Cognitive impairment, frequently found in patients with schizophrenia, may be associated with negative symptoms and dyskinesia. However, antipsychotic medication may be a confounding variable. These putative associations may be clarified by examining never-treated patients. Never-treated elderly schizophrenic patients (n = 19) living in south-east India were compared with treated patients (n = 25) and normal subjects (n = 55). Memory was assessed by the Wechsler Memory Scale, negative symptoms by the Positive and Negative Syndrome Scale, and dyskinesia by the Abnormal Involuntary Movements Scale. Normal subjects had a higher mean memory quotient than patients. There were no significant differences between never-treated and treated patients. Negative symptoms were associated with a poorer memory in the never-treated group. There was no association between memory and dyskinesia. There is an association in never-treated patients between a poorer memory and negative symptoms, but not between a poorer memory and dyskinesia.

Olfactory identification deficits in schizophrenia: correlation with duration of illness.

The authors examined the relationship between deficits in olfactory identification and duration of illness in young and elderly patients with schizophrenia. Olfactory identification performance of 38 patients with schizophrenia and 40 normal subjects was compared by using the University of Pennsylvania Smell Identification Test. The schizophrenic patients demonstrated olfactory deficits relative to the comparison group, and the elderly schizophrenic patients displayed a greater magnitude of olfactory deficit than the younger patients. Independent of normal aging effects and cognitive deficit, patients with schizophrenia showed a strong relationship between olfactory identification scores and duration of illness, which suggests that olfactory abilities decline progressively over the course of the disorder. In contrast to other neuropsychological measures that have been reported to be stable over the course of illness, olfactory identification abilities deteriorate steadily in patients with schizophrenia, even for those with relatively recent onset.

Dementia in elderly schizophrenic patients: reviewing the reviews

Summary Cognitive deficits are common in schizophrenic patients and in geriatric schizophrenic patients more than half meet the criteria for dementia. The 'dementia' observed in elderly schizophrenic patients could be an outcome variable, but may be the result of institutionalization or accumulating drug treatment. In the last decade, more than 400 studies focused on the issue of dementia in elderly schizophrenics. Evidence from emerging data underlines the presence of severe cognitive impairments and its functional consequences. It may be tentatively concluded that deficits in vigilance and secondary verbal memory hinder instrumental role functioning in a manner similar to that encountered in demented subjects. However, pathological and biochemical markers of dementia are not conclusively demonstrated in elderly schizophrenics. The role of neuroleptics in the formation of neurofibrillary pathology and the effects of cognition enhancing drugs in schizophrenia need to be elicited in the coming years.

The brain hallucinates and gets caught in the web

In the past year, we had a remarkable glimpse of brain activity during hallucination in a patient with schizophrenia (Silbersweig; figure). In his typical hallucination, a patient saw moving, coloured scenes with rolling, disembodied heads, which were giving him instructions. 150 positron emission tomography and an image-analysis protocol, designed to image transient subjective experiences, illustrated which areas had increased regional cerebral blood flow during the hallucinations. Increased brain activity was noted in visual and auditory-associated cortices, as well as paralimbic and subcortical areas. Such studies provide clues to the pathophysiology of schizophrenia and to the neural substrate of conscious perceptual experience. Fascinating new clues to schizophrenia also emerged on the genetics/epidemiology front. Gorwood and colleagues tested the hypothesis that the age of onset of schizophrenia decreases in successive generations. This inheritance pattern, anticipation, results from unstable trinucleotide repeat DNA sequences at the disease locus. The study took place on an island in the Indian Ocean and was based on 97 patients with schizophrenia belonging to 24 families with at least two generations of patients. In the younger generation, the age of onset was significantly less than the expected age of onset based on the data from the older generation. This evidence could accelerate the search for pathological genetic processes implicated in schizophrenia. Psychiatrists are concerned about the potential iatrogenic effects of typical antipsychotics, which are linked to tardive dyskinesia. These effects may be relieved by the findings of McCreadie and colleagues. Dyskinesia was assessed in four groups of elderly individuals including normal people, relatives of schizophrenics, nevermedicated patients with schizophrenia, and medicated patients. The prevalence of dyskinesia was similar in never-medicated and medicated patients (about 40%), and was significantly higher than that in first-degree relatives and normal controls (15%). McCreadie reported that never-medicated patients had classic tardive dysthinesia, including chewing movements, tongue protrusion, lip smacking, and writhing. The researchers conclude that it is the illness per se that is associated with dyskinesias in elderly schizophrenic patients. However, psychiatrists may be chagrined by the work of Mojtabai and Nicholson. These researchers evaluated the inter-rater reliability of ratings of delusions and bizarre hallucinations among 50 psychiatrists selected randomly from the American Psychiatry Association Membership Directory. The inter-rater reliability estimates were quite low (K about 0-40), and call into question the adequacy of psychiatric training.

Cognitive functioning in late-life schizophrenia: a comparison of elderly schizophrenic patients and patients with Alzheimer's disease

Previous studies have suggested that geriatric inpatients with chronic schizophrenia manifest profound cognitive impairments. This study investigated how these cognitive impairments resemble those seen in degenerative dementing conditions. The neuropsychological battery of the Consortium to Establish a Registry for Alzheimer's Disease (CERAD), widely used to characterize the cognitive deficits of patients with Alzheimer's disease, was used to compare patterns of cognitive impairment in 66 triads of subjects consisting of one elderly patient with Alzheimer's disease, one elderly, institutionalized patient with chronic schizophrenia, and one elderly, cognitively normal comparison subject who were matched on age, gender, and education. For some analyses, the two groups of patients were divided into subgroups according to the degree of their cognitive impairment (mild, moderate, or severe) as determined by their scores on the Mini-Mental State examination. Relative to the comparison subjects, both groups of patients showed cognitive deficits on each of the neuropsychological measures. The schizophrenic patients performed worse than the patients with Alzheimer's disease on tests of naming and constructional praxis but were less impaired on the test of delayed word recall. These differences were consistent across all levels of severity of globally measured cognitive impairment. Consistent with earlier findings from postmortem studies, these findings suggest that major differences exist in the neurobiologic mechanisms responsible for cognitive impairment in schizophrenia and Alzheimer's disease. Effects directly attributable to social and environmental differences between these two groups of patients may also play a role.

Abnormal Movements in Never-Medicated Indian Patients with Schizophrenia

Historical records suggest dyskinesia was observed in severely ill institutionalised patients with schizophrenia in the pre-neuroleptic era. More recent work has not found dyskinesia in never-medicated younger and middle aged patients. The present study complements this recent work and avoids the confounders of severity of illness and institutionalism by examining elderly patients in a wide variety of community settings. Movement disorders were examined in 308 elderly individuals in Madras, India, using the Abnormal Involuntary Movements Scale, the Simpson and Angus Parkinsonism Scale and the Barnes Akathisia Scale. Patients' mental state was assessed by the Positive and Negative Syndrome Scale. Dyskinesia was found in 15% of normal subjects (n = 101, mean age 63 years), 15% of first degree blood relatives of younger schizophrenic patients (n = 103, mean age 63 years), 38% of never medicated patients (n = 21, mean age 65 years) and 41% of medicated patients (n = 83, mean age 57 years). The respective prevalences for Parkinsonism were 6%, 11%, 24% and 36%; and for akathisia 9%, 5%, 21% and 23%. Dyskinesia was associated with negative schizophrenic symptoms. Dyskinesia in elderly schizophrenic patients is an integral part of the illness and not associated with antipsychotic medication.

Hospitalization and medication usage in elderly schizophrenic and bipolar patients over a ten year period

Hospitalization and medication usage in elderly schizophrenic and bipolar patients over a ten year period

Memory functions in geriatric chronic schizophrenic patients: a neuropsychological study.

This study characterized memory functions in geriatric schizophrenic inpatients with a battery of memory tests sensitive to neuropsychological impairments in either temporal or frontal brain regions. In patients clinically rated as cognitively impaired (n = 24), nearly all of these measures showed deficits relative to less impaired patients (n = 25). Factor analysis found consistent correlations between the tests and their putative cortical localization. Discriminant analysis suggested the pattern of impairments was not consistent with a generalized deficit. These results introduce the possibility, to be directly tested with neuropathological study, that the severe cognitive deficits in elderly schizophrenic patients are due to dysfunctions in either the temporal or frontal regions of the cerebral cortex, with the specific type of dysfunction varying across cases.

Risks of Withdrawing Antipsychotic Medications

IN AN excellent metaanalysis of 66 studies involving more than 4000 patients, Gilbert and colleagues¹found a cumulative relapse rate of 51.5% in Patients who had stopped taking antipsychotic medications. Of Patients who were maintained on antipsychotic medications, however, only 16.2% relapsed. The study by Gilbert et al raises important and provocative questions. For instance, what are the arguments for and against maintenance medication in schizophrenic patients? What clinical circumstances warrant stopping medications? Might the relapse rate of patients off antipsychotic medications be even higher than Gilbert et al suggest in their review? <h3>UNDER WHAT CIRCUMSTANCES SHOULD ANTIPSYCHOTIC MEDICATIONS BE WITHDRAWN? Reasons to Take Patients off Medications</h3> The risk of tardive dyskinesia is one of the reasons to minimize a Patient's time receiving antipsychotic medications. As noted by Gilbert et al, recent studies have found 1-year incidence rates of tardive dyskinesia in elderly schizophrenic patients to be greater

Hyper- and hyponatremia among geropsychiatric inpatients.

We report our experience treating 14 elderly psychiatric patients with altered sodium states. Hypernatremia occurs more commonly among elderly psychiatric patients than among their younger counterparts, and elderly hypernatremic psychiatric patients suffer most commonly from dementia. Dilutional hyponatremia is less common and less severe among elderly schizophrenic patients compared with younger patients with schizophrenia. Central nervous system changes induced by altered sodium states among elderly psychiatric patients are sufficiently similar whether hyper- or hyponatremia is present; therefore, the clinician must not wait for specific features to develop, but must quickly measure serum sodium concentration in elderly psychiatric patients with altered mental states. Treatment of hypernatremia involves rehydration with normal saline or hypotonic solutions, and treatment of dilutional hyponatremia largely involves fluid restriction.

The elderly chronic schizophrenic inpatient: A study of psychiatric morbidity in ‘elderly graduates’

AbstractThis study surveyed all chronic schizophrenic patients from 11 long‐stay wards of a mental hospital. Patients were assessed on a variety of rating scales to assess clinical psychopathology and behaviour. Patients above the age of 65 years were studied in detail and also compared with those under that age living on the same wards. It was found that all the elderly schizophrenic patients in the sample had severe deficits in the form of residual negative symptoms and thought disorder. They had significantly fewer positive but more negative symptoms as compared to a younger sample on the same wards; there was no differences between the groups for affective symptoms or thought disorder. Although there were more males in the sample, no difference was found on any of the parameters between the two sexes. It was concluded that there are significant clinical differences in the ‘elderly graduates’ as compared to younger patients living in an identical environment; such findings could assist managers and administrators in the development of plans for other patients in this age group who are likely to be relocated from psychiatric hospitals in the near future or are already living in the community.

Symptom severity and cognitive impairment in elderly schizophrenic patients

Symptom severity and cognitive impairment in elderly schizophrenic patients

Profiles of cognitive impairment in elderly schizophrenic and probable alzheimer's disease patients

Profiles of cognitive impairment in elderly schizophrenic and probable alzheimer's disease patients