The history of research in the area of schizophrenia in the elderly is riddled with structural problems, including a lack of consensus on age cutoffs, nomenclature, and confidence by many researchers that schizophrenia could develop independently of organic disease. This essay reviews the research literature and concludes that much more needs to be done across the board because little attention is being paid to this demographic.
Schizophrenia in the Elderly: Robustness of the Research Literature
The American psychiatric community has historically ignored the presence of schizophrenia in older adults, especially the elderly, because many researchers and clinicians had attributed the etiology of the disease to organic causes such as dementia (Howard, Rabins, Seeman, & Jeste, 2000). A substantial body of European studies, however, have revealed that a small percentage of schizophrenia patients experience their first symptoms of psychosis after the age of 60 independent of organic causes. The lack of progress in this area has been attributed to the nomenclature assigned to the different schizophrenia age groups, which remains confusing, with some research groups designating first diagnoses after the age of 40 as late-onset, while others set the age boundary at 55 or 60-years of age. The naming of the disease has also been confusing, with early researchers, such as Kraepelin in 1919, calling the condition paraphrenia to distinguish it from psychosis caused by dementia.
These problems continue to the plague the research literature, which tends to make it difficult to conduct systematic literature reviews on schizophrenia in the elderly. However, a search of Medline using the string "literature review AND late-onset schizophrenia" retrieved 62 citations. This essay will examine a few recent reviews as a way to evaluate the current state of research in this area.
Reviewing the Reviews
An important milestone in late-onset schizophrenia research and care occurred after a group of researchers and clinicians met for two days in 1998 to try and provide an international consensus on the definition of late-onset schizophrenia (Howard, Rabins, Seeman, & Jeste, 2000). The International Late-Onset Schizophrenia Group agreed that schizophrenia, regardless of the age of onset, is a heterogeneous disease and is more properly referred to as 'schizophrenias' or schizophrenia spectrum disorder. They also agreed to distinguish between late-onset schizophrenia, with a cutoff of 40-years of age, with very-late-onset schizophrenia-like psychosis with a cutoff of 60-years of age.
Although the International Late-Onset Schizophrenia Group provided nomenclature help, they also agreed that research in this area is lagging due in part to past disagreements on symptomology, nomenclature, and etiology (Howard, Rabins, Seeman, & Jeste, 2000). They reviewed published studies on this topic and some epidemiological and treatment data was available to the group in 1998, but the quality and consistency of the findings were generally low. Their recommendations included future research in epidemiology, symptomology, pathophysiology, etiology, and treatment, because so little is known about this disease in aging adults.
More recently, a systematic review of late-onset schizophrenia in the elderly focused on the issue of antipsychotic medication use (Essali & Ali, 2012). Based on the title of this publication these researchers did not use the nomenclature recommended by the International Late-Onset Schizophrenia Group and instead combined the terms 'elderly' with 'late-onset' in the title. They also used a cutoff of 65-years of age. Since this review is published in the reputable Cochrane Database of Systematic Reviews it is hard not to wonder if the research community has largely ignored the recommendations of the International Late-Onset Schizophrenia Group.
Essali and Ali (2012) provided a brief review of the current state of epidemiological research in this area of medicine, but the most recent publication cited was published in 2000. Based on their review of the literature the prevalence of mental disorders among the elderly is above 12%, with schizophrenia representing 0.1% of these patients. Schizophrenia among the elderly is not very common, with just 3% of all schizophrenics experiencing their first symptoms over the age of 60.
A search for 'elderly' and 'schizophrenia' in Cochrane Reviews retrieved a number of recent systematic literature reviews addressing neuroleptic use in elderly patients suffering from schizophrenia. Based on quick scan of this search result, the main focus of ongoing research appears to be neuroleptic use and efficacy. Essali and Ali (2012) noted, however, that current recommendations for neuroleptic use in the elderly are based primarily on studies investigating the efficacy and side effects of these drugs in younger schizophrenia patients. The review by Essali and Ali (2012) represented an update on a prior review published in 2001, which found no studies meeting their selection criteria. When they repeated their systematic review 11 years later they could include only one study. Given that neuroleptics represent the pharmacologic foundation upon which any treatment strategy for schizophrenic patients, including the elderly, there is a great need for additional studies in this area, especially concerning side effects and interactions with other medications.
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