Schizophrenia Treatment South Florida
Schizophrenia In the Nursing Home
By Bruce L. Saltz, M.D.
(Nursing Home Medicine, 1995; Volume 3: page 248)
Nursing home residents often have complex problems, and nursing home staff members appreciate assistance from capable practitioners. Despite population misconceptions, many psychiatric disturbances seen in nursing home residents are treatable. However, treating these problems can be frustrating and difficult. Often medical record documentation of prior behavioral problems and previous psychotropic and non-psychotropic medication treatment is insufficient. Also, nursing care by experienced psychiatric nurses usually is available for only a short period of time. However, recent epidemiologic studies report that as many as 60% to 94% of nursing home residents have some form of medical disturbance. An estimated 40% to 80% suffer from dementia, and 50% to 75% of these are also agitated; 5% to 25% suffer from depression, and up to 50% of these have psychotic depressions. Two percent to 12% of nursing home residents suffer from schizophrenia. Although schizophrenia is seen in only a small number of nursing home residents, schizophrenia must be diagnosed and treated properly to ensure maximum safety and quality of life for the resident with schizophrenia and other facility residents.
INCIDENCE AND PREVALENCE
The prevalence of schizophrenia among Americans over age 65 is estimated to be 0.1% to 1.1%, meaning that up to 300,000 people in this older age group may have schizophrenia. The incidence of schizophrenia in the populations-at-large is estimated to be 0.2 to 0.3 per 1000, compared with an estimated incidence of affective psychoses of 0.8 to 3.0 per 1000. This wide range is due to variability in-diagnostic precision. Thirty-five percent of elderly individuals requiring treatment in public psychiatric hospitals and 12% of those requiring treatment in nursing homes have schizophrenia.
UTILIZATION OF SERVICES
Kay and Bergmann found that the number of patients age 65 and over in state and county mental hospitals decreased by 36.6% between 1969 and 1973. This coincides with declines in private and Veteran's Administration hospitals. During the same time period, the number of persons over the age 65 treated in nursing homes increased by 101%.
One study reflecting the vigorous growth in nursing home services during this period analyzed psychiatric service utilization from data from the Monroe County (a small urban county in New York) psychiatric case register. This showed that in 1975, in the psychiatric service system of all persons having the most frequent diagnosis of psychosis, nearly 60% of elderly psychotics had their first contact with the system prior to 1961. Fewer than 10% had their first contact in 1975. At the same time, psychosis persons aged 15-44 demonstrated a modest decrease in utilization of state facility inpatient programs. In contrast, hospitalization rates at the state facility decreased sharply for psychotic persons over age 45 during the 10-year period from 1965 to 1975. It is possible that this reflects he vigorous growth in nursing home services for the disease during this period.
Some evidence from the Monroe County register shows that elderly persons with schizophrenic or affective psychoses exhibit a mortality risk that is slightly but significantly higher than those in general population. Both older groups were considerably greater risk of death by suicide than the general population. The psychotic population died from respiratory and digestive disorders at about twice the rate found in the general population. The risk of neoplasm was lower in schizophrenia and affective illness, excess morality was greatest in the 15 to 34 year old age group, ranging from two to three times the rate in the overall general population.
The essential features of schizophrenia are a mixture of characteristic signs and symptoms (positive and negative), which persist for at least 6 months. These signs and symptoms are associated with marked social and occupational dysfunction. Positive symptoms are delusions, hallucinations, distorted language and communication patterns, and disorganized or catatonic behavior. Negative symptoms are restrictions in the range and intensity of emotional expression, changes in the fluency and productivity of thought and speech, and changes in the initiation of goal-directed behavior. The illness generally is sub-typed into one of the following five categories: paranoid type, disorganized type, catatonic type, undifferentiated type, and residual type.
No laboratory findings are diagnostic of schizophrenia, although various findings are noted to be abnormal in groups of individuals with schizophrenia relative to control subjects. Clinicians have found structural abnormalities, including ventricular enlargement and cortical prominence, decreased temporal and hippocampal size, and increased basal ganglia size. Neuropsychological and neurophysiological assessments show a wide range of impairments such as difficulty in changing response set, focusing attention, and formulating abstract concepts; slowing in reaction times; eye tracking abnormalities; and sensory gating impairments. Some schizophrenic persons drink excessive amounts of fluids, resulting in water intoxication. Others have spontaneous or idiopathic dyskinesias without prior exposure to antipsychotic medication.
The onset of schizophrenia after age 30 in uncommon, and the late-onset variety often involves hallucinations and paranoia without disintegration of the personality. Jeste and colleagues reported that late schizophrenics less frequently exhibit negative symptoms, looseness of associations, and inappropriateness of affect, and are more likely to be women and unmarried.
Paranoid and schizoid characteristics are commonly found in both early-onset and late-onset schizophrenics. Kay and colleagues demonstrated a close relationship between premorbid personality and illness. They showed that six independent variables predicted 40% of the variance in distinguishing schizophrenic disorders from affective illnesses: (1) schizoid premorbid personality, (2) few surviving children, (3) deafness, (4) low social class, (5) presence of precipitating factors, and (6) family history of affective illness. The last two variables were predictive of affective illness. Family history of patients with late-onset schizophrenia suggests that 20% of patients have a first-degree relative with schizophrenia, which is substantially lower than among first-degree relatives of early-onset schizophrenics. Kay and colleagues reported that these individuals tend to respond to neuroleptics at lower doses than their early-onset counterparts.
According to studies by otologists and ophthalmologists in Great Britain, patients with late-onset and schizophrenia have a higher percentage of deafness and blindness than age-matched controls with affective illness. At the same time, some researchers have reported that elderly patients with paranoid psychoses have a more severe degree of hearing loss and more often "socially deaf" than their counterparts with affective illness. Sir Martin Roth developed the term "late paraphrenia" to emphasize the "late onset and schizophrenic-like characteristics of patients with paranoid delusions, with or without hallucinations, usually with preservation of personality and affective response." Others have labeled this group of maladies late schizophrenia, paraphrenia, involuntional psychotic reaction, and late-onset schizophrenia.
Disease Course and Outcome
The course of schizophrenia is variable and heterogeneous. The early work of Kraeplin Bleuler, with their respective conceptualizations of "dementia praecox" and "schizophrenia," suggested that this group of mental disorders is characterized by progressive deterioration and loss of function. However, their work with patients who were continuously institutionalized-with possible loss of follow-up among those with a better prognosis-may have influenced their findings. Several major longitudinal studies have demonstrated recovery rates ranging from 46% to 68%. Whether the illness starts early in life and persists into older adulthood or whether it begins later in life, clearly some persons improve with time and treatment and some deteriorate in symptom severity, personality structure, and surrounding environmental circumstances. Muller and Ciompi found that 10% to 15% of patients with a chronic course of schizophrenia become more calm with advancing age, with a few cases making a "striking improvement" after decades of illness. Harding and associates found in their Vermont study a surprisingly good 20-year outcome with a strong tendency toward independent living and diminished social pathology and psychopathology.
Many characteristics or domains of function have been examined with respect to outcome, including "positive symptoms" such as apathy and flat effect; cognitive function; social function; and neurological function such as attention, memory, abstract ability, perceptual motor skills, and initiative. Several long-term studies suggest that women exhibit a less deteriorative course than men. This may be confounded by another risk factor associated with outcome, namely, premorbid social function. Strauss and Carpenter dismissed the notion of schizophrenic outcome as a unitary process, suggesting that a system of characteristics linking social competence, occupational function, and psychopathology operate semi-independently in influencing outcome. However, the criteria to measure these characteristics have varied widely across studies.
Ciompi reported that dementia appears more frequently among older schizophrenics. In addition, although older schizophrenics exhibit cognitive impairments, particularly on memory and construction scales, their cognitive deficits are not typical of those seen in persons with Alzheimer's disease.
The brains of patients with paraphrenia and affective disorders do not have abnormal amounts of senile plaques or neurofibrillary tangles. However, 5% to 10% have standard cerebral lesions due to stroke. The course and outcome of paraphrenia are different from those seen in patients with Alzheimer's disease and vascular dementia. Heaton and Drexler conducted an extensive review of 100 cross-sectional studies and 14 longitudinal studies of the neuropsychological functioning schizophrenics. Almost all study participants were long-term care facility residents. Five longitudinal studies indicated diminishing function, four showed an increase in function, three showed no change, and two showed varying results, depending on diagnostic and clinical status. However, note that there were numerous methodologic limitations. At the same time, Ciompi reported that true dementia occurs more frequently in older schizophrenics than in normal older adults and that such dementias were more common in those schizophrenics with an unfavorable course and outcome.
Neuroleptic drugs are the mainstay of treatment for elderly persons with schizophrenia, as is true for younger schizophrenics. Neuroleptics are useful because of their benefits in treating symptoms such as agitation and assaultive or belligerent behavior, and they have specific function in treating perceptual disturbances such as delusions and hallucinations. Sedatives and anxiolytic agents are less useful because of their potential to aggravate underlying cognitive impairments that may be present; in addition, these drugs are not specific for the psychotic elements of the illness.
There is also a clear role for other types of psychotropic medications in treatment of patients with schizophrenia, particularly when concurrent symptom or behavioral profiles such as depression, mania, obsessive and compulsive features, and insomnia are present. Thus, clinicians often use antidepressant, antimanic, and other types of medication as an adjunctive form of treatment in combination with neuroleptics medication.
According to some researches, response to neuroleptics treatment may be even more favorable in patients with paraphrenia than in early-onset schizophrenics. In a study by Post, for example, 20% of 71 patients made a full recovery, 41% recovered with out insight, 31% achieved social recovery with some persistent abnormal ideas, and 8% had no response.
Most of the pharmacokinetic processes that determine the disposition of antipsychotic drugs may be altered by advancing age. In general, older patients have a variable rate of absorption, a larger volume of distribution of lipophilic substances, a slower metabolic rate, and reduced renal clearance-all of which may result in increased or reduced concentrations I plasma and at central nervous system receptors. It is unclear whether the increased sensitivity to neuroleptics in the elderly in primarily related to altered pharmacokinetic or pharmacodynamic mechanisms. In any event, a good guideline is to start with low doses and titrate the dosage slowly.
The clinician should monitor carefully for the development of akathisia, treatment-emergent parkinsonism, dystonia, dyskinesias, constipation, cardiac arrhythmias, postural hypotension or gait instability, liver function abnormalities, and neuroleptics malignant syndrome.
CRITERIA FOR TREATMENT WITH NEUROLEPTIC DRUGS
Selection of neuroleptics drugs for treatment usually is based on the patient's personal and family history of tolerance and responsiveness. High-potency agents such as haloperidol and fluphenazine can cause less sedation and fewer anticholinergic and cardiovascular side effects, but more tremor, bradykinesia, and other extrapyramidal side effect. Low-potency agents produce the opposite profile. There is no evidence that either high or low-potency agents are associated with a greater or lesser risk of producing tardive dyskinesias (TD), but the higher overall incidence of TD in older adults is well documented. The adverse effects of antipsychotic medication, particularly the neuromuscular ones, may limit the benefits of these medications profoundly, and the need to monitor them carefully cannot be overemphasized. It is not worth treating a psychotic septuagenarian, for example, if treatment-emergent tremor and bradykinesia subject the resident to a fractured hip secondary to a fall from an unsteady gait.
Conversely, if a resident develops a mild tremor but other wise is improved enough to continue residing in his or her residential facility, the outcome is considered successful and worth the risk of mild side effects.
Before prescribing a neuroleptics agent, a comprehensive medical, psychiatric, and psychosocial evaluation should be conducted, with a special focus on current medications. These steps are usually the most difficult to accomplish in the nursing home setting, since residents often are transferred to nursing homes from acute inpatient medical and surgical facilities with very little appropriate medical documentation accompanying them. Without such information, it is much more difficult to make accurate diagnosis and determine the best mode of treatment. For example, adverse drug effects are a common cause of psychotic signs and symptoms that may masquerade as "schizophrenia." If a psychotic patient was discontinued from daily of opiate analgesics just prior to transfer from an inpatient facility to a nursing home, a nursing home-based consultant psychiatrist would not be able to readily identify the cause of the psychosis. Inexperienced clinicians may over diagnose dementia, delirium, or schizophrenia in such cases or may admit nursing home residents to acute-care psychiatric units when simple drug toxicities-which can be resolved in the nursing home-are the cause of the problem. For example, Learoyd noted that 16% of 236 patients who received psychotropic agents prior to admission to a psychogeriatric unit had disorders directly attributable to the deleterious effects of these drugs, with symptom abatement after the psychotropics were discontinued.
The clinician must differentiate between major diagnostic groups, such as psychosis secondary to OMS (presenting primarily with dementia), psychosis secondary to OMS presenting with delirium, late-life paranoid disorder, chronic schizophrenia, major affective disorder (manic or depressed), or related illnesses such as Huntington's disease. He or she then must use this information to make an accurate diagnosis. Dementia causes affected individuals to decline from higher levels of intellectual function and may or may not be due to such reversible diseases as substance abuse, normal pressure hydrocephalus, thyroid disease, depression, or mania. However, most dementias are due to Alzheimer's disease or cerebrovascular disease.
GUIDELINES FOR DRUG TREATMENT
The federal guidelines that went into effect on July 1, 1995, dictate that although the facility can refer to a physician's justification as a valid justification for use of a drug, it may not justify the use of the drug, its dose, its duration, etc., solely on the basis that "the doctor ordered it."
Therefore, if elimination or gradual dose reduction of an antipsychotic medication cannot be attempted because of a resident's schizophrenia, this fact must be documented. An acceptable justification would include a physician's note indicating that the use of the drug, or continued use of the drug, is clinically appropriate and the reasons why this use is clinically appropriate. This note must demonstrate that the physician has carefully considered the risk/benefit to the resident in using drugs outside these guidelines.
A number of steps can help to ensure that schizophrenia in nursing home residents is diagnosed and treated accurately, and documentation of these steps can help the medical director to ensure that neuroleptics and other medications are used properly. These steps, which can be part of the facility's policies and procedures, including the following:
1. Require that all individuals be accompanied by copies of their most recent hospital admission and discharge summaries, laboratory studies, and consultants' reports (especially psychiatric reports) on their transfer or admission to the nursing home.
2. Use one or more brief psychiatric screening tools, which nurses or social workers can administer within 48 hours of the resident's arrival at the facility.
3. Require that the physician, provider organization, or family member who arranges for admission specify clearly the dose, duration of use, blood levels (when appropriate), and initial identification for use of all psychotropic medications currently (or within a 2- to 4-week period) being taken by the resident.
4. Require that all residents taking psychotropic medication be reevaluated by a psychiatrist or other competent mental health professional within 3 weeks of admission.
Psychoses are not uncommon in the elderly, and they may appear in many types of illness, including but not limited to dementia, delirium, drug toxicity, depression, mania, and schizophrenia. Since growing proportions of the population are over age 65, it is increasingly important for physicians-particularly those practicing in long-term care settings-to be aware of the diagnostic and treatment characteristics of schizophrenia. The provision of psychiatric services to schizophrenic residents in nursing homes can be rewarding, because many of these persons are responsive to treatment. However, the logistics can be complicated in settings where there is often a paucity of appropriate medical record documentation and relative lack of continuity of nursing care by personnel who are well trained in psychiatric illnesses.
Nursing home administrators should require a minimal amount of medical record information to accompany all new admissions. All physicians who take on the responsibility of evaluating psychosis in such settings should become aware of the residents recent and remote medical histories before prescribing psychotropic medications. In addition appropriate physical and laboratory examinations must be conducted to identify a discrete differential diagnosis. Physicians should note the presence or absence of parkinsonian, dystonic, or dyskeinetic features prior to initiating new medications. If physicians select neuroleptics medication, they should pay special attention to the emergence of adverse reactions such as tremor, bradykinesia, gait instability, and tardive dyskinesias so that appropriate interventions can be made in a timely manner.
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