Schizophrenia and Anxiety in Late Age

Kim S. Griswold

CLINICAL PEARLS

Older individuals with mental health problems receive most of their health care in primary care settings.
Women in late age are more likely than men to present with anxiety disorders or late-onset schizophrenia.
Phobias may become more pronounced with aging, and can represent generalized anxiety or posttraumatic stress disorder.
The fragility of the autonomic nervous system in late age may enhance the anxiety response.
A late-onset delusional disorder unrelated to dementia may be a variant of schizophrenia.
Benzodiazepines have been overused in this population, and are often the cause of falls and confusion in the elderly.
Benzodiazepines with shorter half-lives are safer in older persons because they do not produce active metabolites, and are inactivated by direct conjugation in the liver.
Buspirone is well tolerated in the elderly.
Anxiety comorbidity in schizophrenia is often underdiagnosed.
Before prescribing and during the course of use with atypical antipsychotics, monitor for weight gain, and abnormal lipid and glucose levels.
In the management of anxiety and psychotic disorders, patient and family support and education are crucial.

A consensus statement has declared a national crisis in geriatric mental health care, because the current health care system appears inadequate to meet the demands of the expected increase in numbers of elderly individuals with mental health problems.¹ In the Surgeon General’s Report, disorders that will cause major disability for individuals over age 65 include dementia, depression, and schizophrenia.² Older persons with mental health disorders are more likely to have unmet needs and suffer from an “expertise gap” in care, meaning failure to incorporate research findings into practice.³

Mental health problems (excluding dementia) occur in approximately 13% of individuals over age 65, and the effects of aging on mental health may represent changes
in behavior as a consequence of organic disease, acute or chronic illness, medications, or alterations in the socioenvironmental milieu.⁴,⁵ Most older individuals with a psychiatric disorder present initially to their primary care physician rather than to a mental health professional.⁶,⁷ Primary care clinicians who are informed about the presentation and treatment of the more common mental health problems in this age-group will be better able to provide both the mental health and medical care so often needed. This chapter will discuss the primary care presentation and management of schizophrenia and anxiety disorder in the geriatric population. The goals are to provide an understanding of and an evidence-based approach to the presentation, recognition, and management of anxiety and schizophrenia in later life, and the effects of these conditions on health, behavior, and functional status.

EPIDEMIOLOGY AND SIGNIFICANCE TO AGING

The prevalence of psychiatric disorder among individuals over age 65 is approximately 12.3% to 16%, with a higher prevalence rate among women (13.6% for women, versus 10.5% among men).¹,⁸ Due to increased life span and better treatment of psychiatric illnesses, it is predicted that over the next three decades the number of elderly with mental illness will more than double, reaching 15 million in 2030.

Table 21.1 presents the current community prevalence rates for older versus younger persons per the Epidemiological Catchment Area study.¹ As shown in the table, the 1-year prevalence rate in groups over age 65 is approximately 2.2% for generalized anxiety disorder (GAD) and 0.3% for schizophrenia. However, one study suggests that for patients over age 60, the annual incidence of schizophrenia-like psychoses increases by 11% with each 5-year age increase.⁹ Specific figures for older persons indicate a prevalence rate of 4.8% for phobias (agoraphobia, social, and simple phobia), 0.1% for panic disorder, and 4.6% for GAD; although these rates should be viewed with caution because of the lack of dedicated research focusing on anxiety disorders in late age.¹⁰ Anxiety may present as a comorbid condition with a physical illness or other psychiatric disorders; the prevalence of GAD in elderly persons may demonstrate a temporal increase.¹¹

Several sources indicate that among individuals over age 65, the prevalence rate for anxiety disorders in urban and rural primary care practices range from 6% to 10%; and approximately 30% of older patients may present with anxiety symptoms.¹² Even these numbers may be an underrepresentation. For example, one study found low rates of psychiatric diagnosis and treatment in an older population even when an appropriate screening tool was used.¹³

SCHIZOPHRENIA

Description

Schizophrenia is a disturbance of thought and behavior, and probably represents a variety of disorders with heterogeneous causes and variable expressions.¹⁴ An early classification of “dementia precox” proposed by Emil Kraeplin described a deteriorating course marked by delusions and hallucinations, although cognitive abilities were less affected—making the term dementia somewhat misleading in this historical context. Eugen Bleuler was the first to use the word “schizophrenia,” and he also categorized symptoms into the “4 A’s” of looseness of associations, affective symptoms, autism, and ambivalence. Kurt Schneider proposed diagnostic signs and symptoms that are the basis of the Diagnostic and Statistical Manual criteria.

Pathophysiology in Late-age Schizophrenia

Etiology is seldom known. In later ages, symptom occurrence may be associated with sensory impairments and social isolation, although not with progressive dementia.¹⁵ In several studies, when compared to patients with an earlier age onset, patients with late-age schizophrenic-like symptoms were more likely to be women, had higher functioning in areas of learning and abstraction, and required lower doses of neuroleptic medications.¹⁶

Magnetic resonance imaging (MRI) examination of patients with late-age onsets of schizophrenia demonstrate either no increase in structural abnormalities, or larger thalami.¹⁶ Paraphrenia is a term that has been used to describe an apparent form of schizophrenia with initial presentation in late life marked by hallucinations and delusions, but with less significant affective disturbance.¹⁴ Due to ambiguity about the presentation and epidemiology of this later onset schizophrenia-like syndrome, an international group formed to review the literature agreed that diagnoses of late-onset (after age 40) and very-late-onset (after age 60) schizophrenia-like psychoses have “face validity and clinical utility.”¹⁵ Like its earlier age counterpart, the very late age presentation of schizophrenia-like symptoms is presumed to represent a group of heterogeneous disorders, characterized by delusional thinking, hallucinations, variable degrees of social-environmental dysfunction, and some cognitive impairment; in contrast to early-age onset schizophrenia, late-age symptoms include a higher prevalence of visual hallucinations, and a lower rate of affective flattening and formal thought disorder.¹⁵

Schizophrenia may be the most expensive psychiatric disorder.¹⁷ In one community-based study, the health-related quality of life was worse in middle-aged and older persons with schizophrenia than it was for patients with acquired immunodeficiency syndrome.¹⁷,¹⁸

TABLE 21.1 PREVALENCE OF PSYCHIATRIC DISORDERS AMONG YOUNGER VERSUS OLDER ADULTS

		Younger Adults (Aged 30-44 y), ECA		Older Adults (Aged ≥65 y), ECA		Older Adults
DSM-III Diagnostic Category		1-y Prevalence	Lifetime Prevalence	1-y Prevalence	Lifetime Prevalence	Prevalence of Clinically Significant Symptoms
Affective disorders
	Any	2.7 (Men)	6.6 (Men)	0.6 (Men)	1.6 (Men)	15-25^7,8
		7.9 (Women)	15.3 (Women)	1.5 (Women)	3.3 (Women)
	Major depression	3.9	7.5	0.9	1.4
	Dysthymia	—	3.8	—	1.7
	Bipolar I	1.2	1.4	0.1	0.1
	Bipolar II	0.3	0.6	0.1	0.1
Anxiety disorders						17-21⁹
	Panic disorder	0.7 (Men)	1.8 (Men)	0.04 (Men)	0.1 (Men)
		1.9 (Women)	3.1 (Women)	0.4 (Women)	0.7 (Women)
	Phobic disorder	6.1 (Men)	10.5 (Men)	4.9 (Men)	7.8 (Men)
		16.1 (Women)	22.6 (Women)	8.8 (Women)	13.7 (Women)
	Generalized anxiety disorder	3.6	4.9-6.8	2.2	2.6-4.3
	Obsessive-compulsive disorder	2.1	3.3	0.9	1.2
Alcohol abuse/dependence		14.1 (Men)	27.9 (Men)	3.1 (Men)	13.5 (Men)	7-8 community-dwelling elderly persons who consume 12-21 drinks per wk¹⁰
		2.1 (Women)	5.5 (Women)	0.5 (Women)	1.5 (Women)	10-15 older primary care patients may have alcohol-related problems^11,12
Other drug abuse/dependence		—	6.7	—	0.1	—
Schizophrenia		1.5	2.3	0.2	0.3	—
Antisocial personality disorder		1.5	3.7	0.0	0.3	—
Cognitive impairment
	Severe^a	0.3 (Aged 35-54 y)	—	1.0 (Aged 55-74 y)	—	—
				5.0 (Aged ≥75 y)	—	—
		3.1 (Aged 35-54 y)		7.5 (Aged 55-74 y)	—	—
	Mild	—	—	19.1 (Aged ≥75 y)	—	—
Any psychiatric disorder (excluding cognitive impairment)		23	39	13	21	—
^aAlthough not a psychiatric disorder per se, suicide is generally secondary to a major mental illness such as depression or schizophrenia. Suicide rates increase with advancing age (especially in white men) and seem to be increasing among more recent cohorts of older persons. Among older patients in primary care, the prevalence of suicidal ideation is 0.7% to 1.2%. Data are presented as percentages.
ECA, Epidemiologic Catchment Area study (which used DSM-III criteria).
Reprinted from Jeste DV, et al. Consensus statement on the upcoming crisis in geriatric mental health: Research agenda for the next two decades. Arch Gen Psychiatry. 1999;56(9):848-853.

Genetics

There is no concrete evidence of familial aggregation in the later-age onset of schizophrenia, although some evidence exists that families of these patients may have a greater prevalence of affective disorders.¹⁵ The later onset schizophrenia-like disorder more commonly occurs in women, raising the possibility of an estrogenic protective effect in some women prior to menopause.¹⁶

Differential Diagnosis

In Table 21.2, the differential diagnosis for schizophrenia-like illness is presented. Kaplan and Sadock have proposed guidelines for diagnosis that include careful investigation for identifiable organic disease, a reevaluation at each episode of symptoms for possible organic etiology, and a complete family history. One example of an organic cause is epitomized by the now defunct term general paralysis of
the insane, which referred to schizophrenia-like symptoms and was due to tertiary syphilis.¹⁹

TABLE 21.2 DIFFERENTIAL DIAGNOSIS OF SCHIZOPHRENIA-LIKE SYMPTOMS AND ICD CODES

Medical	Neurologic	Psychiatric
Drug-induced (amphetamine, hallucinogens, belladonna, alkaloids, alcohol hallucinosis, barbiturate withdrawal, cocaine, PCP)	Epilepsy (345.90) (particularly temporal lobe epilepsy)	Atypical psychosis (298.9) Brief reactive psychosis (298.8)
	Neoplasm (191.9)	Malingering (V65.2)
Delirium (780.09)	CVA (434.91)	Mood disorder (296.90)
AIDS (042)	Cerebral lipoidosis (330.1)	Paranoid disorder (297.9)
Acute intermittent porphyria (277.1)	Head trauma (959.01)	Personality disorder (301.9)
	Creutzfeldt-Jakob disease (046.1)	Schizoaffective disorder (295.70)
B₁₂ deficiency (266.2)		Schizophreniform disorder (295.4)
Fabry disease (272.7)	Fahr-Volhard disease (403.00)
CO poisoning (986)	Hallervorden-Spatz disease (333.0)
Heavy metal poisoning (984.9)
Homocystinuria (270.4)	Herpes encephalitis (054.3)
Pellagra (265.2)	Huntington chorea (333.4)
Systemic lupus (710.0)	Metachromatic leukodystrophy (330.0)
	Neurosyphillis (094.9)
	Normal pressure hydrocephalus (331.4)
	Wernicke-Korsakoff syndrome (291.1) (alcoholic) (294.0) (nonalcoholic)
	Wilson disease (275.1)
AIDS, acquired immunodeficiency syndrome; CVA, cerebrovascular accident; CO, carbon monoxide; PCP, Phencyclidine.
Reprinted from Kaplan HI and Sadock BJ: Synopsis of psychiatry, 7th ed, with permission.

CASE ONE

Ms. F. is 65 years old and was diagnosed with paranoid schizophrenia as a young woman. When you first started caring for her 5 years ago, she would not let you examine her and exhibited paranoid delusional thinking. Three years ago, she allowed you to begin physical exams, and began to follow through with her mammograms and other preventive care visits. She was stable on her psychiatric medications, until she was moved from one assisted living home to another. At that time, she began to lose weight and became more withdrawn—with an increase in the negative symptoms of schizophrenia. Her family noted that she seemed depressed. Medical workup was benign, except for ill-fitting dentures, causing pain when she ate. She was able to discuss some of her feelings of sadness with you. With an adjustment of her medication, family support, and new dentures, Ms. F. was able to integrate into her new home and her symptoms stabilized. At her last visit with you, she showed you pictures of her niece and nephew with real satisfaction.

Workup

Older patients who have been treated for chronic schizophrenia over the course of years may exhibit signs of tardive dyskinesia or other extrapyramidal symptoms. If an older patient begins to display unusual symptoms indicative of psychosis or other behavioral disturbance, a complete history and physical examination might include a laboratory evaluation of endocrine function, including thyroid testing, metabolic abnormalities, dietary deficiencies, infection such as tertiary syphilis, and trauma.²⁰ Patients should be queried about medication compliance, usual prescription, and over-the-counter (OTC) medications, homeopathic preparations, and use of alcohol and recreational drugs. Sensitive inquiries should be made about the patient’s living situation, and the possibility of elder abuse or domestic violence.

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