Research Article - Clinical Schizophrenia & Related Psychoses ( 2022) Volume 0, Issue 0
Does the Clinical Presentation of Schizophrenia Differ in Elders from Adults? A Cross Sectional Study
Arash Mowla1* and Zohre Zareizadeh22Department of Mental Health, Shiraz University of Medical Sciences, Shiraz, Iran
Arash Mowla, Department of Psychiatry, Shiraz University of Medical Sciences, Shiraz, Iran, Email: mowlaar@gmail.com
Received: 13-Jun-2022, Manuscript No. CSRP-22-66470; Editor assigned: 15-Jun-2022, Pre QC No. CSRP-22-66470 (PQ); Reviewed: 29-Jun-2022, QC No. CSRP-22-66470; Revised: 06-Jul-2022, Manuscript No. CSRP-22-66470 (R); Published: 15-Jul-2022, DOI: 10.3371/ CSRP.MAZZ.071522
Abstract
Introduction: As the population is aging, better understanding of the clinical presentation of schizophrenia in later life seems to be a clinical priority. Our aim is to study the clinical manifestations of schizophrenia in the older adult patients.
Methods: 102 schizophrenia patients met our inclusion criteria and entered the study. They were divided to two groups based on their age: group 1(18 years old to 64 years old) and group 2 (65 years old and older). There were 53 patients in group 1 and 49 patients in group 2. The patients were evaluated for schizophrenia pattern of presentation and clinical profile by Positive and Negative Syndrome Scale (PANSS). The two groups were compared according to their total score and subscale scores of PANSS.
Results: The mean age of the patients in group 1 (Age<65) was 35.5 ± 7.9 and in group 2 (age ≥ 65) was 72.1 ± 6.1. The total PANSS score and average positive subscale score were significantly lower in the older adult group. But the average negative subscale score and average general psychopathology subscale score did not differ significantly between the two groups.
Conclusion: Our study demonstrates that with aging, schizophrenia patients have improvements in positive symptoms especially disorganization, but negative and cognitive symptoms rates are similar in elderly and younger schizophrenia patients. Furthermore, we found that rate of depressive symptoms was higher in elders with schizophrenia.
Keywords
Schizophrenia • Positive symptoms • Negative symptoms • Elders
Introduction
Schizophrenia is a complex, chronic, and disabling illness that presents with heterogeneity in its clinical appearance, in patterns of psychopharmacological response and in long-term outcomes [1,2]. The prognosis for patients presenting with a first episode of schizophrenia is unclear, however various studies suggest that while up to a third make a good recovery, the remainder suffer from persistent symptoms or a relapsing and remitting course requiring on-going treatment [3,4]. It is estimated that 0.1% to 1.0% of the over 65 population has schizophrenia including up to 12% of all nursing home residents [5,6]. Schizophrenia classically begin in late adolescence and young adult age and the life course of schizophrenia into later adulthood is not well studied, but it is generally recognized that, whereas psychotic symptoms and disorganization tend to remit with time, negativity such as social withdrawal and emotional apathy, increase in frequency and intensity with aging [6,7].
As the population is aging and more schizophrenia patients reach the older adulthood, better understanding of the clinical presentation of this disease in later life seems to be a clinical priority. More knowledge on the clinical profile of older adult patients with schizophrenia would lead to better treatment plans and medication administration.
In this research, our aim is to study the clinical manifestations of schizophrenia in the older adult patients (age more than 65 years old).
Materials and Methods
Participants
All the patients with diagnosis of schizophrenia that were referred to Ebnesina psychiatry center were evaluated. To enter the study, they must meet the following criteria: 1-Diagnosis of schizophrenia according to DSM-5 criteria; 2- Age more than 18. A board-certified psychiatrist did the beginning evaluations. The patients were excluded if 1- They were on psychiatry medications; 2-They abused substances; 3-They were pregnant; 4-They had uncontrolled medical problems; and 5-They had other psychiatry disorders.
If the patients were on psychiatry medications or if they had used psychiatry medications in the past month, they were excluded. All the patients and their caregiver gave written consent to enter the study. The study protocell was approved by Shiraz medical school ethic committee.
Measurements
To study schizophrenia manifestation and clinical profile, we used the Positive and Negative Syndrome Scale (PANSS). This scale in addition to assessing psychosis-related symptoms, would evaluate general psychopathology (including depression and anxiety) and cognitively related features including “poor attention” and “difficulty in abstract thinking” and involves the use of data from patient reports, caregiver reports, and clinical observations [8,9]. It contains inquiries about some (not all) specific PANSS symptoms in a flexible semi-structured format. It is not a diagnostic tool, but a severity rating tool that rates 30 symptoms of schizophrenia, divided into positive, negative and general psychiatric symptoms, over the most recent week. Each item of this scale would be scored from 1(not present) to 7 (severe).
Procedure
102 schizophrenia patients met our inclusion criteria and entered the study. They were divided to two groups based on their age: group 1(18 years old to 64 years old) and group 2 (65 years old and older). There were 53 patients in group 1 and 49 patients in group 2. The patients were evaluated for schizophrenia pattern of presentation and clinical profile by PANSS. A trained clinical psychologist administers the test to all the patients. The two groups were compared according to their total score and subscale scores of PANSS.
Statistical analysis
All analyses were performed using Statistical Package for the Social Sciences (SPSS), 25.0 software (SPSS Inc., Chicago, IL). P value less than 0.05 were considered significant. Characteristics of the whole study group are presented using descriptive statistics including number of observations, means and SD for continuous variables. Frequencies and percentages are presented for categorical variables. For these, Pearson’s χ2-test was used for categorical variables and Mann-Whitney U-test or T-test was used for continuous variables. Normality was assessed by kolmogorow-smirnov test.
Results
Of 102 patients with schizophrenia that entered our study 53 patients were in group 1 (Age<65) and 49 were in group 2 (age ≥ 65). The mean age of the patients in group1 was 35.5 ± 7.9 and in group 2 was 72.1 ± 6.1. The demographic data of the patients are depicted in Table 1. The total PANSS score and positive subscale score were significantly lower in the older adult group. But the negative subscale scores and general psychopathology subscale scores did not differ significantly between the two groups (Table 2).
| Age ≥ 65 | Age<65 | P value | |
|---|---|---|---|
| Sex, female (%) | 45 | 51 | 0.65 |
| Years of education (n) | 8.5 | 14.4 | 0.00 |
| Marital Status, married (%) | 56 | 23 | 0.00 |
| Pervious admissions(n) | 6.3 | 2.1 | 0.00 |
| Age≥65 | Age<65 | P value | |||
|---|---|---|---|---|---|
| Mean | SD | Mean | SD | ||
| PANSS total Score | 125.5 | 15.8 | 136.9 | 12.6 | 0.016 |
| Positive symptoms subscale | 33.4 | 7.6 | 39.3 | 5.6 | 0.008 |
| Negative symptoms subscale | 34.8 | 7.4 | 33.4 | 5.7 | 0.989 |
| General psychopathology subscale | 57.1 | 8.8 | 60.5 | 5.8 | 0.153 |
| Note: PANSS: Positive and Negative Syndrome Scale | |||||
The clinical profile of the schizophrenia patients is depicted in Table 3. Among the positive symptoms studied, conceptual disorganization (P<0.000), Excitement (P<0.000) and Hostility (P=0.009) were significantly lower in the older adult group. Among the negative symptoms, blunted affect (P=0.019) was more observed in the older adult group. In the general psychopathology subscales, somatic concern (P=0.017), Depression (P=0.022), Motor retardation (P=0.009) and Disorientation (P=0.013) were more common in elders, while Poor impulse control (P<0.000) and Preoccupation (P<0.000) were more detected in adult group. The mean score of the rest of the symptoms were not significantly different between the groups.
|
|
Age≥65 | Age<65 | P value | |||
|---|---|---|---|---|---|---|
| Mean | SD | Mean | SD | |||
| Positive Symptoms Subscale | Delusion | 6.2 | 1.7 | 6.6 | 1.2 | 0.148 |
| Conceptual disorganization | 4.0 | 2.3 | 6.3 | 1.6 | 0.000 | |
| Hallucinatory behavior | 4.6 | 2.9 | 5.1 | 2.7 | 0.526 | |
| Excitement | 4.6 | 1.6 | 5.8 | 2.1 | 0.000 | |
| Grandiosity | 2.0 | 2.0 | 1.8 | 1.5 | 0.43 | |
| Suspiciousness/Persecution | 6.1 | 1.3 | 6.5 | 0.9 | 0.076 | |
| Hostility | 5.1 | 1.4 | 6.5 | 1.4 | 0.009 | |
| Negative Symptoms Subscale | Blunted Affect | 3.3 | 1.9 | 2.7 | 1.8 | 0.019 |
| Emotional withdrawal | 4.5 | 1.7 | 4.2 | 1.5 | 0.945 | |
| Poor rapport | 5.1 | 1.7 | 5.3 | 1.6 | 0.417 | |
| Passive/Apathetic social withdrawal | 5.9 | 1.7 | 6.3 | 1.0 | 0.663 | |
| Difficulty in abstract thinking | 6.8 | 0.7 | 6.7 | 0.8 | 0.463 | |
| Lack of spontaneity in flow of conversation | 5.1 | 1.6 | 4.9 | 1.4 | 0.695 | |
| Stereotypal thinking | 4.7 | 2.0 | 4.9 | 1.7 | 0.750 | |
| General Psychopathology Subscale | Somatic Concern | 2.6 | 1.6 | 1.2 | 0.9 | 0.017 |
| Anxiety | 2.4 | 2.6 | 2.2 | 2.0 | 0.445 | |
| Guilt feelings | 1.0 | 0.3 | 1.0 | 0.0 | 0.298 | |
| Tension | 1.6 | 1.5 | 1.0 | 1.4 | 0.562 | |
| Mannerism and posturing | 1.8 | 1.8 | 1.6 | 1.4 | 0.910 | |
| Depression | 2.5 | 2.1 | 1.7 | 1.5 | 0.022 | |
| Motor Retardation | 2.8 | 1.8 | 1.5 | 1.1 | 0.009 | |
| Uncooperativeness | 5.7 | 1.7 | 5.6 | 1.6 | 0.652 | |
| Unusual thought content | 1.9 | 1.7 | 1.8 | 1.8 | 0.212 | |
| Disorientation | 2.6 | 0.9 | 1.1 | 0.3 | 0.013 | |
| Poor attention | 4.0 | 1.2 | 3.8 | 1.1 | 0.127 | |
| Lack of judgment and insight | 7.0 | 0.1 | 7.0 | 0.0 | 0.298 | |
| Disturbance of volition | 6.9 | 0.5 | 6.9 | 0.4 | 0.358 | |
| Poor impulse control | 4.3 | 1.7 | 6.3 | 1.4 | 0.000 | |
| Preoccupation | 4.1 | 1.9 | 6.4 | 1.0 | 0.000 | |
| Active social avoidance | 6.2 | 1.6 | 6.5 | 0.5 | 0.110 | |
Discussion
In our cross-sectional study, we compared the clinical manifestation of schizophrenia in elders (mean age: 72.1) with adults (mean age: 35.5). We found that overall positive symptoms were less severe in elders (P=0.008). The negative symptoms and general psychopathology did not differ significantly.
In review of literature, we found several studies indicating positive symptom improvement in schizophrenia patients on long-term follow-up into later life [10-15]. In line with these studies, our result demonstrates that elders with schizophrenia had lower rate of positive symptoms. Among the positive symptoms, especially disorganization has been shown to decrease with age [16]. Consistently, we found conceptual disorganization to be significantly less in our older adult patients. A study on one hundred ninety-eight persons aged 55 and older living in the community who had developed schizophrenia before age 45 years, found that Thirty-two percent experienced auditory verbal hallucination that is lower than reported in younger adults [17]. Another study has shown a stable rate of hallucination over time in follow ups in schizophrenia patients [18]. In our study, the elderly had the same rate of auditory hallucinations than the younger participants.
Several studies have reported that positive symptoms of schizophrenia decline in later life and negative symptoms dominate the presentation in elders [5,11,12]. On the other hand, there are research indicating that negative symptoms in older patients with schizophrenia expresses in similar magnitude seen in patients with younger age [10,19]. Our results showed no significant difference in the rate of negative symptoms between the older adult and adult groups.
Raji, et al. in their study compared people with schizophrenia. Age 19 years to 79 years, with their healthy age peers. They concluded that cognitive deficits occur around the time of onset and do not progress beyond what is observed due to effect of aging over the entire span of adult life [20]. Consistently, our results shows that the cognitive subscales (Attention, Abstract thinking, Emotional expression) are not more declined in elders with schizophrenia.
Chen and Li in their study found that the prevalence of depressive symptoms in elderly patients with schizophrenia was 48.5% which is higher than the prevalence of depressive symptoms reported in younger schizophrenia patients [21-24]. In line with their study, our results show that depressive symptoms are more common in elders with schizophrenia.
Conclusion
Our study demonstrates that with aging, schizophrenia patients have improvements in positive symptoms especially disorganization, but negative and cognitive symptoms rates are similar in elderly and younger schizophrenia patients. All patients with schizophrenia who were referred to the Ebnesina psychiatry centre were evaluated. Furthermore, we found that rate of depressive symptoms was higher in elders with schizophrenia when compared to the adults with schizophrenia.
Limitations
Our study is a cross-sectional survey. Longitudinal research that follow schizophrenia patients from younger age to elderly are more reliable to study the effects of age on schizophrenia’ characteristics. Our sample size is small. Furthermore, our research has been done only in one site.
Acknowledgements
This study was performed as postgraduate thesis for graduation of Dr. Zohre Zareizadeh in Shiraz University of Medical Sciences and was financially supported by Shiraz University of Medical Sciences with grant number of 18301. All the authors declare no conflict of interest.
References
- Altamura, A. Carlo. "A Multidimensional (Pharmacokinetic and Clinical-Biological) approach to Neuroleptic Response in Schizophrenia: With Particular Reference to Drug Resistance." Schizophr Res 8 (1993): 187-98.
[Crossref] [Google scholar] [pubmed]
- Conley, Robert R. and Robert W. Buchanan. "Evaluation of Treatment-Resistant Schizophrenia." Schizophr Bull 23 (1997): 663-74.
[Crossref] [Google scholar] [pubmed]
- Bleule, Manfred. "The Long-Term Course of the Schizophrenic Psychoses." Psychol Med 4 (1974): 244-54.
[Crossref] [Google scholar] [pubmed]
- Ciompi, Luc. "Three Lectures on Schizophrenia: The Natural History of Schizophrenia in the Long Term." Br J Psychiatry 136 (1980): 413-20.
[Crossref] [Google scholar] [pubmed]
- Sajatovic, Martha, Subramoniam Madhusoodanan and Peter Buckley. "Schizophrenia in the Elderly." Mol Diag Ther 13 (2000): 103-15.
- Blazina, Linda. "Mental Disorders in the Nursing Home: Another Perspective." Am J Psychiatry 150 (1993): 1063-9.
[Crossref] [Google scholar] [pubmed]
- Harrop, Chris and Peter Trower. "Why does Schizophrenia Develop at Late Adolescence?" Clin Psychol Rev 21 (2001): 241-65.
[Crossref] [Google scholar] [pubmed]
- Leucht, Stefan, John M. Kane, Werner Kissling and Johannes Hamann, et al. "What does the PANSS Mean?" Schizophr Res 79 (2005): 231-8.
[Crossref] [Google scholar] [pubmed]
- Kay, Stanley R., Abraham Fiszbein and Lewis A. Opler. "The Positive and Negative Syndrome Scale (PANSS) for Schizophrenia." Schizophr Bull 13 (1987): 261-76.
[Crossref] [Google scholar] [pubmed]
- Harrison, Glynn, K. I. M. Hopper, Thomas Craig and Eugene Laska, et al. "Recovery from Psychotic Illness: A 15-and 25-year International Follow-up Study." Br J Psychiatry 178 (2001): 506-17.
[Crossref] [Google scholar] [pubmed]
- Harding, Courtenay M., George W. Brooks, Takamaru Ashikaga and John S. Strauss, et al. "The Vermont Longitudinal Study of Persons with Severe Mental Illness, II: Long-term Outcome of Subjects who Retrospectively Met DSM-III Criteria for Schizophrenia." Am J Psychiatry 144 (1987): 727-35.
[Crossref] [Google scholar] [pubmed]
- Huber, Gerd, Gisela Gross, Reinhold Schüttler and Maria Linz. "Longitudinal Studies of Schizophrenic Patients." Schizophr Bull 6 (1980): 592-605.
[Crossref] [Google scholar] [pubmed]
- Ciompi, Luc. "Catamnestic Long-term Study on the Course of Life and Aging of Schizophrenics." Schizophr Bull 6 (1980): 606-18.
[Crossref] [Google scholar] [pubmed]
- Mason, Peter, Glynn Harrison, Cristine Glazebrook and Ian Medley, et al. "Characteristics of Outcome in Schizophrenia at 13 years." Br J Psychiatry 167 (1995): 596-603.
[Crossref] [Google scholar] [pubmed]
- Marriott, Richard, Wendy Neil and Susie Waddingham. "Antipsychotic Medication for Elderly People with Schizophrenia." Cochrane Database Syst Rev 1 (2006): CD005580.
[Crossref] [Google scholar] [pubmed]
- Häfner, H., M. Hambrecht, W. Löffler and P. Munk-Jørgensen, et al. "Is Schizophrenia a Disorder of all Ages? A Comparison of First Episodes and Early Course across the Life-Cycle." Psychol Med 28 (1998): 351-65.
[Crossref] [Google scholar] [pubmed]
- Cohen, Carl I., Ifeanyi Izediuno, Audra M. Yadack and Biswarup Ghosh, et al. "Characteristics of Auditory Hallucinations and associated Factors in Older Adults with Schizophrenia." Am J Geriatr Psychiatry 22 (2014): 442-49.
[Crossref] [Google scholar] [pubmed]
- Yadack, Audra, Ifeanyi Izediuno, Biswarup Ghosh and Carl I. Cohen, et al. "Hallucinations in Older Adults with Schizophrenia on 4.5 Year Follow-up." Am J Geriatr Psychiatry 21 (2013): S122.
- Putnam, Katherine M. and Philip D. Harvey. "Cognitive Impairment and Enduring Negative Symptoms: A Comparative Study of Geriatric and Nongeriatric Schizophrenia Patients." Schizophr Bull 26 (2000): 867-78.
[Crossref] [Google scholar] [pubmed]
- Rajji, Tarek K., Aristotle N. Voineskos, Meryl A. Butters and Dielle Miranda, et al. "Cognitive Performance of Individuals with Schizophrenia across Seven Decades: A Study using the MATRICS Consensus Cognitive Battery." Am J Geriatr Psychiatry 21 (2013): 108-18.
[Crossref] [Google scholar] [pubmed]
- Chen, Yaopian and Wei Li. "Prevalence, Influencing Factors, and Cognitive Characteristics of Depressive Symptoms in Elderly Patients with Schizophrenia." Neuropsychiatr Dis Treat 17 (2021): 3645-54.
[Crossref] [Google scholar] [pubmed]
- Fond, G., M. Faugere, R. Richieri and M. Cermolacce, et al. "Depressive Symptoms and Chronic Peripheral Inflammation are associated with Impaired Functional Remission in Schizophrenia Independently of Psychotic Remission." J Affect Disord 280 (2021): 267-71.
[Crossref] [Google scholar] [pubmed]
- Baynes, David, Ciaran Mulholland, S. J. Cooper and R. C. Montgomery, et al. "Depressive Symptoms in Stable Chronic Schizophrenia: Prevalence and Relationship to Psychopathology and Treatment." Schizophr Res 45 (2000): 47-56.
[Crossref] [Google scholar] [pubmed]
- Sher, Leo and René S. Kahn. "Suicide in Schizophrenia: An Educational Overview." Medicina 55 (2019): 361.
[Crossref] [Google scholar] [pubmed]
Citation: Mowla, Arash and Zohre Zareizadeh. “Does the Clinical Presentation of Schizophrenia Differ in Elders from Adults? A Cross Sectional Study.” Clin Schizophr Relat Psychoses 16S (2022). Doi: 10.3371/ CSRP.MAZZ.071522.
Copyright: © 2022 Mowla A, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.