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

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).

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)

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).

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.

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).

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.

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.