Psychotic Disorders in Late Life: Implications for Treatment and Future Directions for Clinical Services

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Mental Health and Mental Illness in Later Life

Helping a highly vulnerable population.

Psychotic disorders are among the most costly medical disorders, whether judged in terms of their impact on the lives of patients and their family members or judged solely in terms of monetary considerations. Schizophrenia is the disorder that accounts for the largest proportion of federally funded mental health expenditure in the United States (Wasylenki, 1994). Moreover, the cost associated with schizophrenia is highest in the oldest age group (Cuffel et al.,1996). The anticipated increase in the number of older individuals with psychotic disorders over the next few decades will have a profound impact on the mental health care system (Administration on Aging, 2001; Jeste et al., 1999). As part of the effort to analyze and meet this challenge, this article provides a brief overview of the relevant issues and their implications for clinicians and policy makers.

AGE OF ONSET, GENDER, AND ETHNICITY

Although psychosis can occur as a secondary syndrome in a variety of disorders including Alzheimer's disease, this discussion focuses on primary psychotic conditions. These are schizophrenia, schizoaffective disorder, delusional disorder, mood disorders with psychotic features, and psychotic disorder not otherwise specified. Although approx- imately 80 percent of older people with schizophrenia developed the disorder as young adults (early-onset schizophrenia), about 20 percent developed schizophrenia in middle-age (late-onset schizophrenia) (Howard et at., 2000). Compared to older adults with early-onset schizophrenia, older people with late-onset schizophrenia show less formal thought disorder and higher pre-- onset rates of marriage, parenthood, and having held a job (Harris and Jeste, 1988).

On average, women have a later age of onset of schizophrenia than men (Bleuler, 1911; Hafner et al., 1998; Lindamer et al., 1997). While considerable heterogeneity exists among older women with schizophrenia, on average women tend to have less severe forms of schizophrenia than men, including a tendency toward better psychosocial functioning and a greater preponderance of positive and affective symptoms relative to negative symptoms (Lindamer, Dunn, and Jeste, in press). The later age of onset of schizophrenia in women may have a protective effect because it allows a longer time of normal function prior to onset of the condition and thus more time to establish social networks, for example. The later age of onset has been hypothesized to be associated with hormonal differences. Based on the hypothesis that estrogen protects some women from psychosis until the onset of menopause, researchers have recently become interested in the possible therapeutic benefits of estrogen augmentation in postmenopausal women with schizophrenia (Kulkarni et al., 1996; Lindamer et al., 2001; Seeman,1996).

The interaction between ethnicity and diagnosis, severity, and treatment of psychotic conditions is complex, and relatively little attention has been devoted to the interactions between culture, ethnicity, and psychosis in older patients. Studies of middle-aged and older clinically stable outpatients indicate no differences between white and African American schizophrenia patients in terms of severity of psychopathology or in terms of the maintenance dose of conventional neuroleptic medications (Jeste et al., 1996). There are, however, data suggesting that African Americans are at greater risk for development of tardive dyskinesia (involuntary muscle movement) as a side effect of conventional neuroleptic medications (Jeste et al.,1996; Lindamer, Lacro, and Jeste, 1999).

IMPACT OF LATE-LIFE PSYCHOSIS

There is considerable heterogeneity among older patients with psychotic disorders with respect to functioning and need for supports. While the precise percentages are not known, our research suggests that some older schizophrenia patients are able to maintain relative independence in important spheres of everyday functioning (Palmer et al. …