Late schizophrenia

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As late schizophrenia is called a subgroup of schizophrenia with onset in old age. This article presents the results of a 1999 consensus conference.

Historical aspects

The first publication on late schizophrenia can be found by Manfred Bleuler in 1943. M. Bleuler examined 126 patients whose disease appeared after the age of 40. He estimated about 15% of the total proportion of late schizophrenia. 4% of the patients were older than 60 years. In half of the cases, the symptoms were indistinguishable from those with the onset of the disease at a young age.

In the English literature, late schizophrenia is defined as the onset of the disease from the age of 55 or 60. The disease is then called "late paraphrenia" based on Emil Kraepelin to differentiate it from chronic schizophrenia. Kraepelin did not see paraphrenia ( delusion and hallucinations without influencing the affects) as a disease of old age. In connection with the emergence of geriatric psychiatry, the concept of late paraphrenia was quickly adopted. The most important diagnostic criteria were: predominantly women, abnormal premorbid personality, deafness .

For the American discussion, it is noteworthy that there is agreement in the fact that there were no codable diagnoses for late schizophrenia, neither in the DSM nor in the ICD . It was assumed that late schizophrenia would not differ from the usual forms of the disease. DSM-IV stipulated: From the onset of the disease beyond the age of 45, women predominate; their anamnesis is milder, there is more paranoid content and less disorganized behavior and fewer negative symptoms . A more frequent occurrence of sensory deficits in very old patients (over 60) is emphasized.

Clinical features

Bleuler already reported on some peculiarities in late schizophrenia. Half of the patients had “paraphrenia-like” symptoms, were depressed-anxious, catatonic or confused-agitated. The other part of Bleuler's patient collective had symptoms that were similar to those of schizophrenia with typical onset, but the patients were less affected and had a better prognosis.

In later studies, the following constellation of symptoms was shown: the patients more frequently show visual, tactile or olfactory hallucinations, paranoia, spatial delusion (permeable walls, doors, floors and ceilings), acoustic hallucinations of persistent commentary, accusatory and abusive character. Patients are less likely to have formal thought disorders, flattening or dulling of affects. Patients with a very late onset of the disease (older than 60 years) very rarely have formal thought disorders or negative symptoms.

Epidemiology

Since some diagnostic criteria rule out the presence of schizophrenia in later years, older patients are not represented in the epidemiological studies. The point prevalence of delusions in old age is estimated at 4–6%, with most of these patients likely to be demented . The total proportion of late schizophrenia is estimated at around 20%. For people older than 65 years, the overall prevalence (community prevalence) is estimated to be 0.1 to 0.5%. There are data for the incidence of 12 / 100,000 per year for schizophrenias with onset over 44 years of age. The incidence seems to increase with age.

Risk factors

The predominance of women in late schizophrenia is a "robust" finding. It is not due to secondary factors, although certain stressors may play a role (retirement, death of loved one, financial hardship and physical disability). The risk of relatives of patients with late-stage schizophrenia also developing schizophrenia appears to be lower. In patients with an onset of the disease over 65 years of age (very late-onset ), hearing loss is very common . This is a rarer finding in patients with an age of onset 40 years and over. Patients with late-stage schizophrenia are less likely to have premorbid abnormalities in the areas of work, education and social functioning. Nonetheless, premorbid schizoid or paranoid personality traits that do not meet the criteria for a personality disorder are more common .

Imaging

The morphological findings from CCT and MRT studies typical for younger patients can also be found in patients with late schizophrenia: ventricular asymmetry, volume reduction of the left temporal lobe , the left superior temporal gyrus. Reductions in volume of the thalamus have also been reported. Cerebrovascular changes do not contribute significantly to the disease. Findings for the known hypofrontality could be replicated in the functional imaging . Receptor PET studies did not show consistent results with regard to the D2 receptor density. Studies on event-correlated potentials showed similar findings as in younger patients.

Neuropsychological impairments

There are no uniform findings in studies of the neuropsychological impairments of aged schizophrenics. However, these patients never show such impairments as are typical for neurodegenerative diseases. Young schizophrenics have limitations in most cognitive tasks. When compared within the age group, patients with late schizophrenia have clear limitations in the areas of: executive functions (planning action), learning, motor skills and language. However, they show no restrictions in the Wisconsin Card Sorting Test (frontal lobe functioning) or in the California Verbal Learning Test.

Response to therapy

Patients with late schizophrenia generally receive lower doses of typical neuroleptics . It is reported that half of the patients experience complete remissions. Atypicals do not seem to eliminate all symptoms.

Consensus statement

The international "Late-Onset Schizophrenia" group made the following recommendations in 1999:

Introduction: Schizophrenia is a heterogeneous disease and probably consists of a group of related diseases. It is therefore suggested to differentiate between two types of disease:

  • Late-onset schizophrenia (> 40 years)
  • Very late onset of schizophrenia-like psychosis

Diversity of symptoms (heterogeneity) in late schizophrenia: Schizophrenia-like psychoses can manifest themselves at any point in life from childhood to old age. The diversity of symptoms is greatest in the extremes of childhood and later old age.

Epidemiology: In general, women fall ill later than men. There are three main age groups for the incidence of schizophrenia: early adulthood (<25 years), middle age (~ 40 years) and older age (> 60 years). A very late onset of the disease (> 60 years) seems to be related to sensory deficits (deafness) and social isolation.

Symptomatology: Patients with schizophrenia with a late and very late onset are similar, especially in terms of positive symptoms. In patients older than 60 years, formal thought disorders, less affective impairments and more frequent visual hallucinations were surprisingly found. It is not clear whether these peculiarities of the symptoms indicate an independent pathophysiological cause.

Pathophysiology: There is no evidence of comorbidity of dementia and late schizophrenia. Old patients with late schizophrenia do not differ in their cognitive abilities from the young patients when adjusted for age. The imaging findings also do not differ in the age groups.

Etiology: So far there is no evidence of a familial accumulation in late schizophrenia, similar to the findings as in schizophrenia with typical onset. There is no accumulation of diseases such as Alzheimer's disease , vascular dementia or Lewy body dementia among the relatives of patients with late schizophrenia .

Age thresholds: On the basis of epidemiological data and for reasons of research organization, the consensus group recommends an age threshold of 60 years for the definition of schizophrenia with a very late onset. The age threshold of 40 years for defining schizophrenia with late onset remained controversial.

Nomenclature: The consensus group recommended the term “late-onset schizoprenia” (late schizophrenia) for patients in the age group 40–60 years and the term “very late-onset schizophrenia-like psychosis” (late schizophrenia +) for patients in the age group over 60 years.

Treatment guidelines: A prerequisite for any treatment of late schizophrenia is a careful diagnostic procedure (Volhard: “Before the therapy, the gods made the diagnosis”). Organic causes of psychosis must be carefully excluded in old age. Treatment without medication in late schizophrenia has not yet been the subject of systematic studies. Psychosocial treatment approaches must be aimed at reducing disease-associated stress. Treatment with neuroleptics is the most important part of the treatment concept for late schizophrenia. One should start with very low doses and adjust the dose very slowly. Usually ¼ to ½ of the conventional doses are effective in patients over 40 years of age and 1/10 of the dose used in young patients in patients over 60 years of age. In the elderly, depot medication should be dosed very low, clozapine should be avoided, and atypical drugs have clear advantages in treatment.

Research perspectives: For epidemiological studies, the consensus group recommends adjusting the diagnostic criteria so that the existence of late schizophrenia is not excluded. Since the condition is rare, multi-center studies are essential. Since women are more likely to get the disease, studies should take into account that systematic errors will occur when assessing the prevalence of symptoms such as social activity if data are not corrected against the gender of the test subjects. To assess cognitive deficits in late schizophrenia, psychological tests must be adjusted according to age. The role of estrogen deprivation should be further investigated in the development of late schizophrenia. In order to clarify the question of adequate psychopharmacological treatment, receptor PET studies of the corresponding age group are desirable.

See also

literature

  • Niall Boycea, Zuzana Walke: Late-onset schizophrenia and very late-onset schizophrenia-like psychosis. In: Psychiatry. 2008, 7 (11), pp. 463-466.
  • Howard, Robert: Late-onset schizophrenia and very late-onset schizophrenia-like psychosis. In: Reviews in Clinical Gerontology. 2001, 11 (4), pp. 337-352.
  • G. Huber, G. Gross, R. Schüttler: Late schizophrenia. In: European Archives of Psychiatry and Clinical Neuroscience. 1975, 221 (1), pp. 197-217.
  • Stefan Leucht, Werner Kissling: Late schizophrenia and chronic schizophrenia in old age. In: Hans Förstl (Ed.): Dementia in theory and practice. 3rd, updated and revised Edition. Springer, Berlin et al. 2011, ISBN 978-3-540-35485-7 , pp. 241-262.
  • Anita Riecher-Rössler: 50 years after Manfred Bleuler: What do we know today about late schizophrenia (s)? In: The neurologist. 1997, 68 (3), pp. 159-170.

Individual evidence

  1. ↑ Robert Howard et al: Late-Onset Schizophrenia and very-late-onset Schizophrenia-like Psychosis: An International Consensus. In: Am. J. Psychiatry. 2000; 157, pp. 172-178. PMID 10671383 .
  2. ↑ M. Bleuler: The late schizophrenic clinical pictures. In: Advances Neurolo. Psychiatry. 1943; 15, pp. 259-290.