This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
Studying late-onset schizophrenia and non schizophrenia
psychosis in elderly Egyptian patientsHanan Husseina, Ahmed El Shafeia, Marwa Abd El Meguidb, Marwa El Missiryb
and Mahmoud Tamarac
Departments of aNeuropsychiatry,bNeuropsychychiatry and cGeriatric, Faculty ofMedicine, Ain Shams University, Cairo, Egypt
Correspondence to Marwa Abd El Meguid, MD,Department of Psychiatry, Institute of Psychiatry, 65 ElNozha Street, Heliopolis, Cairo, EgyptTel: + 002 0105752536; fax: + 202 22678032;e-mail: [email protected]
Received 19 May 2011Accepted 12 August 2011
Middle East Current Psychiatry
2012, 19:12–22
Background
In Egypt, the proportion of elderly people in the population is increasing markedly;
cases of late-life psychoses are increasing at a rapid pace as the population of the
world ages, and this will create a tremendous economic burden on the society
because of the increasing rates of disability.
Aim
The aim of this work was to compare the sociodemographic and clinical
characteristics, daily living functioning, and cognitive impairment between late-onset
schizophrenia and other late-onset psychotic disorders.
Patients and methods
A cross-sectional comparative study was conducted on 100 patients: 50 patients with
schizophrenia with onset after the age of 50 years (group A) and 50 patients with
nonschizophrenia late-onset psychoses (group B). All patients were interviewed using The
Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders
Axis-I diagnosis were assessed using the Positive and Negative Syndrome Scale, the
Functional Assessment of Activity of Daily Living scale, section B of the Cambridge Mental
Disorders of the Elderly Examination, and the Wechsler Adult Intelligence Scale.
Results
Patients in group A were significantly younger – they were mainly women (72%), the
majority were never married (54%), and 62% were living alone – compared with group
B, who were mainly married (46%) and lived more often with their families. Among
patients with late onset schizophrenia spectrum, 70% had paranoid subtype, 12% had
delusional disorder and the rest had either undifferentiated or schizoaffective subtype.
On the other hand, 70% of group B patients had psychotic symptoms due to dementia,
20% had mood disorder with psychotic symptoms; and the rest 10% had psychosis
secondary to medical illnesses. (Group B) patients had significantly lower scores on
items assessing positive symptoms and higher scores on general psychopathology
than did (Group A) patients, the scores on negative symptoms, and also the total
PANSS scores were almost similar in both groups and did not show any significant
differences. Group A patients scored significantly better in daily living functioning,
whereas a significant number of patients of group B needed partial and complete
support. Cognitive assessment revealed that group A patients scored almost within
norms, except for memory, apraxia, abstract, and perception items, compared with
group B patients who scored significantly lower in all cognitive items.
Conclusion
Patients with late-onset schizophrenia compared with patients with other late-onset
psychoses differ in a number of psychosocial and clinical variables, daily functioning,
and cognitive abilities. The results of this study contribute to the development of a
better understanding of the elderly patient population with different types of late-onset
psychoses, which have been largely ignored in research.
Keywords:
activities of daily living, cognitive functions, late-onset psychoses, late-onset
schizophrenia
Middle East Curr Psychiatry 19:12–22& 2012 Okasha Institute of Psychiatry, Ain Shams University2090-5408
Introduction
Worldwide, the number of persons aged 65 years or older
has increased from 17 million in 1900 to 342 million in
1992 and is expected to increase to 2.5 billion (compris-
ing 20% of the total population) by 2050 [1]. In other
words, the proportion of elderly people in this population
will increase by 65%. In the next 30 years, life expectancy
12 Original article
2090-5408 & 2012 Okasha Institute of Psychiatry, Ain Shams University DOI: 10.1097/01.XME.0000407866.00571.95
Mood dis. With psychotic featuresPsychosis due to dementiaOthers
(a) Diagnostic categories: late-onset schizophrenia. (b) Diagnosticcategories: late-onset other psychoses.
Figure 2
35.621.5
58.1
115.2 114.6
29.621.9
63.1
0
20
40
60
80
100
120
140
Positivesymptoms
Negativesymptoms
Generalpsychopathology
Total PANSS
Group (A) Group (B)
P=0.001 P=0.634Insig.
p=0.01Sig.Sig.
p=0.06Sig.
Assessment of psychotic symptoms by PANSS: a comparison betweenpatients with late-onset schizophrenia (group A) and nonschizophrenialate-onset psychoses (group B). PANSS, Positive and NegativeSyndrome Scale.
Late-onset schizophrenia and nonschizophrenia psychosis Hussein et al. 17
and neurobiological differences between dementia patients
with and without psychosis. Stern et al. [50] observed that,
among dementia patients, psychosis was associated with a
greater prevalence of rapid cognitive decline. Moreover, in a
study by Jeste and Finkels [37], it was noted that those
with psychosis had greater impairment on putative
neuropsychological tests of frontal lobe function compared
with dementia patients without psychosis.
The association between cognitive functions in dementia
cases with or without psychosis should be clarified in
future studies. There was much debate on this topic;
Linda et al. [51] reported that behavioral symptoms and
cognitive functions are independent dimensions, whereas
Hopkins and Libon [52] suggested a strong relationship
between severity of psychosis and poor performance on
some cognitive functions.
From the current research, the obtained results are
important in demonstrating that the cognitive deficits
associated with late-onset schizophrenia are different
from the cognitive declines associated with dementia.
The rate of decline observed among the dementia groups
in the present sample appears to be consistent with that
reported in the literature [53,54]. Thus, the onset of
schizophrenia late in life does not appear to be a mere by-
product of a dementia disorder. The same conclusion is
consistent with the findings from studies by the Mount
Sinai research group, which examined chronically insti-
tutionalized elderly schizophrenia patients. These in-
vestigators found that the pattern of cognitive deficits of
such patients was distinct from that associated with
dementia; moreover, their postmortem neuropathological
studies indicated that the prevalence of amyloid plaques
and neurofibrillary tangles was not different from that of
age-matched healthy control individuals [55]. Unfortu-
nately, in this study, we did not compare group A patients
with healthy controls; thus, we could not comment on
cognitive decline in the late-onset schizophrenia group in
comparison with the healthy elderly population.
ConclusionPatients with late-onset schizophrenia compared with
patients with other late-onset psychoses differ in a
number of psychosocial and clinical variables, daily
functioning, and cognitive abilities. The results of this
study contribute to the development of a better under-
standing of the elderly patient population with different
types of late-onset psychoses, which have been largely
ignored in research. These findings draw the attention of
policymakers and psychiatrists to the burden of psychotic
disorders in the elderly and the need for specialized
psychiatric care units providing intensified help and
rehabilitation.
Recommendations
In Egypt, research in the area of old-age psychosis is still
scarce and has been neglected. Thus, studies on this
topic on a large representative sample from different
geographical areas are highly recommended. In addition,
prospective cohort studies of elders with psychotic
disorders to determine the outcome of psychotic disorders
are mandatory. Studies addressing clarification of risk
factors to develop psychosis at later age, the impact of
psychotic symptoms on caregivers, and treatment outcome
of old-age psychosis are recommended. Future studies
should involve different disciplines. These disciplines
should cooperate together to provide evidence-based data
that can inform the public, help policymakers to make
informed decisions and plans, and stimulate further
research.
Strength and limitations of the study
One of the strengths of this study is that (according to
best of our knowledge) it is among the first studies to
compare late-onset schizophrenia with nonschizophrenia
late-onset psychoses. Although our findings shed light on
this poorly understood and investigated area of research,
the results should be considered preliminary data because
of the limitations of small size and type of sample, which
was a selective rather than a stratified random sample
representing different geographical areas in Egypt. Our
findings must be reviewed as provisional and will be
subjected to revision, as more studies are needed in the
field of elderly patients with psychotic disorders.
AcknowledgementsThe authors express their gratitude to Professor M. El Banouby, formerchair of the department of Geriatric Medicine, Ain Shams University, forhis support and guidance. The authors are grateful to Dr Hisham Sadek,Dr Ahmed El Missiry, Dr Abeer Mahmoud, Dr Hanan Hussein, Dr AhmedEl Shafie, and the other research participants from the department ofNeuropsychiatry, Ain Shams University, for their time, training on tools,guidance, advice, and efforts in completing the study assessment. Theauthors would also like to thank Dr Olfat Kahla, senior psychologist inGeriatric Hospital, Ain Shams University, for her help, and Dr MohamedHassan Taha from ‘TIT Solution’ for the statistical analysis.
Conflicts of interestsThere are no conflicts of interest.
References1 Olshansky SJ, Carnes BA, Cassel CK. The aging of the human species. Sci
Am 1993; 268:46–52.
2 Spar JE, La Rue A. Anxiety disorders and late onset schizophrenia. In: SparJE, La Rue A, editors. Clinical manual of geriatric psychiatry. 1st ed.American Psychiatric Publishing; 2006. p. 302–306.
3 Central Agency for Public Mobilization and Statistics. Egypt in figures. 2009;Available at: http://www.capmas.gov.eg/pdf/indicators/pages/preface.htm.
4 El Banouby MHHealth and aging in the Eastern Mediterranean region.. In:Robinson M, Novelli W, Pearson C, Norris L, editors. Global health andglobal aging. USA: The AARP Foundation; 2007. pp. 215–226.
5 Morris SK, Jeste DVSchizophrenia and other psychotic disorders.. In: Haz-zard WR, Blass JP, Ettinger WH, Halter JB, Ouslader JG, Ouslander JG,editors. Principles of geriatric medicine and gerontology. 4th ed. New York:Mcgraw-Hill; 1998. pp. 1341–1349.
6 Khouzam HR, Battista MA, Emes R, Ahles S. Psychoses in late life: eva-luation and management of disorders seen in primary care. Geriatrics2005; 60:26–33.
7 Harris MJ, Jeste DV. Late-onset schizophrenia: an overview. Schizophr Bull1988; 14:39–55.
8 Howard R, Rabins PV, Seeman MV, Jeste DV. Late-onset schizophrenia andvery-late-onset schizophrenia-like psychosis: an international consensus. TheInternational Late-Onset Schizophrenia Group. Am J Psychiatry2000; 157:172–178.
9 McClure FS, Gladsjo JA, Jeste DV. Late-onset psychosis: clinical, researchand ethical considerations. Am J Psychiatry 1999; 156:935–940.
10 Jeste DV, Dolder CR, Nayak GV, Salzman C. Atypical antipsychotics in el-derly patients with dementia or schizophrenia: review of recent literature.Harv Rev Psychiatry 2005; 13:340–351.
11 Fuchs T. Life events in late paraphrenia and depression. Psychopathology1999; 32:60–69.
12 Rabins PV, Lavrisha M. Long-term follow-up and phenomenologic differ-ences distinguish among late-onset schizophrenia, late-life depression andprogressive dementia. Am J Geriatr Psychiatry 2003; 11:589–594.
13 Woolley JD, Khan BK, Murthy NK, Miller BL, Rankin KP. The diagnosticchallenge of psychiatric symptoms in neurodegenerative disease: rates ofand risk factors for prior psychiatric diagnosis in patients with early neuro-degenerative disease. J Clin Psychiatry 2011; 72:126–133.
14 Omar AN, Haroun A, Nagy NE. Prevalence of depressive symptoms inphysically-ill elderly inpatients. Curr Psychiatry 1998; 5:145–155.
15 First MB, Gibbon M, Spitzer RL, Williams JBW, Benjamin LS. Structuredclinical interview for DSM-IV axis II personality disorders, (SCID-II).Washington, DC: American Psychiatric Press, Inc; 1997.
16 Kay SR. Positive-negative symptom assessment in schizophrenia: psycho-metric issues and scale comparison. Psychiatr Q 1990; 61:163–178.
17 Lawton MP, Brody EM. Assessment of older people: self-maintaining andinstrumental activities of daily living. Gerontologist 1969; 9:179–186.
18 El Okl MA. Prevalence of alzheimer’s disease and other types of dementia inthe Egyptian Elderly. Faculty of Medicine, Ain Shams University; 2002.
19 Kojo K. Late-onset schizophrenic syndromes in socially isolated situations: acomparison of Janzarik’s ‘Kontaktmangelparanoid’ and late paraphrenia.Psychogeriatrics 2010; 10:83–89.
20 Mahmoud A. Clinical profile of patients attending memory clinic in Ain ShamsUniversity, Institute of Psychiatry. Ain Shams University; 2002.
21 Wechsler D. Wechsler adult intelligence scale-revised. San Antonio, TX: ThePsychological Corporation; 1981.
22 Melika LK. The Wechsler Adult Intelligence scale.Dar El Nahda El Arabia,Egypt; 1996.
23 El Sherbini FM. The Egyptian classification of social class. Egypt: Faculty ofMedicine, Tanta University; 1986.
24 Girard C, Simard M. Clinical characterization of late- and very late-onset firstpsychotic episode in psychiatric inpatients. Am J Geriatr Psychiatry2008; 16:478–487.
25 Yasuda M, Kato S. Clinical psychopathological research on late-onsetschizophrenia – mainly patients with schizophrenia from a hospitalpsychiatric ward. Seishin Shinkeigaku Zasshi 2009; 111:250–271.
26 Ashour A, Okasha A, Sadek A, Hambali M, Lotaief F, Bishry Z. Portrait of oldpeople in Cairo hostels. Egypt J Psychiatry 1982; 5:75–94.
27 Haiba AAM. A community study of paranoid symptoms in the elderly popu-lation. Faculty of Medicine, Tanta University; 2002.
28 Lehmann SW. Psychiatric disorders in older women. Int Rev Psychiatry2003; 15:269–279.
29 Riecher Rossler A, Rossler W, Forstl H, Meise U. Late-onset schizophreniaand late paraphrenia. Schizophr Bull 1995; 21:345–354, discussion355–356.
30 Cohen CI, Vahia I, Reyes P, Diwan S, Bankole AO, Palekar N, et al. Schi-zophrenia in later life: clinical symptoms and social well-being. Psychiatr Serv2008; 59:232–234.
31 El Said SMS. Study of the effect of renal impairment on cognitive function inelderly patients. Faculty of Medicine, Tanta University; 2004.
32 Mostafa MM, Akram A. Clinical deterioration in vascular dementia: role ofnew ischemic lesions, hypoalbuminemia and hyponatremia. Egypt J NeurolPsychiat Neurosurg 2004; 41:401–412.
33 Prager S, Jeste DV. Sensory impairment in late-life schizophrenia. SchizophrBull 1993; 19:755–772.
34 Howard R, Cox T, Almeida O, Mullen R, Graves P, Reveley A, et al. Whitematter signal hyperintensities in the brains of patients with late paraphreniaand the normal, community-living elderly. Biol Psychiatry 1995; 38:86–91.
35 Almeida OP, Howard RJ, Levy R, David AS. Psychotic states arising in latelife (late paraphrenia) psychopathology and nosology. Br J Psychiatry1995; 166:205–214.
36 Barclay L, Almeida O. Schizophrenia in later life. Curr Opin Psychiatry2000; 13:423–427.
37 Jeste DV, Finkel SI. Psychosis of Alzheimer’s disease and related dementias.Diagnostic criteria for a distinct syndrome. Am J Geriatr Psychiatry2000; 8:29–34.
38 Paulsen JS, Salmon DP, Thal LJ, Romero R, Weisstein Jenkins C, Galasko D,et al. Incidence of and risk factors for hallucinations and delusions in patientswith probable AD. Neurology 2000; 54:1965–1971.
39 Cohen CI. Schizophrenia into later life: Treatment, research and policy.Library of Congress: American Psychiatric Publishing Inc.; 2003.
40 Jeste DV, Twamley EW, Eyler Zorrilla LT, Golshan S, Patterson TL, PalmerBW. Aging and outcome in schizophrenia. Acta PsychiatrScand2003; 107:336–343.
41 Quin RC, Clare L, Ryan P, Jackson M. ‘Not of this world’: the subjectiveexperience of late-onset psychosis. Aging Ment Health 2009; 13:779–787.
42 Metwally AS. Prevalence of depression among Egyptian geriatric community.Faculty of Medicine, Ain Shams University; 1998.
43 El Banoty M, Ghanem M, Mortagy A, Metwally A, El Nahas A, Sayed M.Prevalence of depression among the aged Egyptian community. Curr Psy-chiatry 1999; 6:3.
44 Asaad T. Recognizing depression in patients with dementia (a comparativestudy between Alzheimer’s disease and vascular dementia in a sample ofEgyptian patients). CurrPsychiatry 2002; 9:72–73.
45 Alexopoulos GS, Meyers BS, Young RC, Kalayam B, Kakuma T, Gabrielle M,et al. Executive dysfunction and long-term outcomes of geriatric depression.Arch Gen Psychiatry 2000; 57:285–290.
46 Vahia I, Bankole AO, Reyes P, Diwan S, Palekar N, Sapra M, et al. Schizo-phrenia in later life. Aging Health 2007; 3:383–396.
47 Gupta S, Steinmeyer C, Frank B, Lockwood K, Lentz B, Schultz K. Olderpatients with schizophrenia: nature of dwelling status and symptom severity.Am J Psychiatry 2003; 160:383–384.
48 Evans JD, Heaton RK, Paulsen JS, Palmer BW, Patterson T, Jeste DV. Therelationship of neuropsychological abilities to specific domains of functionalcapacity in older schizophrenia patients. Biol Psychiatry 2003; 53:422–430.
49 Viertio S, Tuulio Henriksson A, Perala J, Saarni SI, Koskinen S, Sihvonen M,et al. Activities of daily living, social functioning and their determinants inpersons with psychotic disorder. Eur Psychiatry 2011[In Press].
50 Stern Y, Albert M, Brandt J, Jacobs DM, Tang MX, Marder K, et al. Utility ofextrapyramidal signs and psychosis as predictors of cognitive and functionaldecline, nursing home admission and death in Alzheimer’s disease: pro-spective analyses from the Predictors Study. Neurology 1994; 44:2300–2307.
51 Linda CW, Nelson LS, Sl M, Victor WC, Agnes SY, Leung PY, et al. Apo-lipoprotein epsilon-4 allele and the two-year progression of cognitive func-tion in Chinese subjects with late-onset Alzheimer’s disease. Am J AlzheimerDis Other Demen 2006; 21:92–9.
53 Clarke R, Smith AD, Jobst KA, Refsum H, Sutton L, Ueland PM. Folate,vitamin B12 and serum total homocysteine levels in confirmed Alzheimerdisease. Arch Neurol 1998; 55:1449–1455.
54 Galasko DR, Gould RL, Abramson IS, Salmon DP. Measuring cognitivechange in a cohort of patients with Alzheimer’s disease. Stat Med2000; 19:1421–1432.
55 Palmer BW, Heaton RK, Gladsjo JA, Evans JD, Patterson TL, Golshan S,et al. Heterogeneity in functional status among older outpatients with schi-zophrenia: employment history, living situation and driving. SchizophrRes2002; 55:205–215.
Late-onset schizophrenia and nonschizophrenia psychosis Hussein et al. 21