CLINICAL HANDBOOK OF SCHIZOPHRENIA

38. Older Individuals 391TABLE 38.1. Clinical Comparisons of Schizophrenia According to Age of Illness OnsetEarly (typical)onsetMiddle-ageonsetAge of onset (years) < 40 40–65 > 65Family history of schizophrenia + + –Frequent prodromal childhood difficulties + + –Female preponderance – + ++Negative symptoms ++ + –Cognitive impairments ++ + ++Abnormal brain magnetic resonance imaging –/+ –/+ ++Require lower than usual dose of antipsychotics – + ++Very-late onset(schizophrenia-likepsychosis)Note. ++, usually true; +, often true; –/+, possibly observed; –, usually not true. From Palmer, McClure, and Jeste(2001). Copyright 2001 by InformaWorld. Adapted by permission.females, more paranoid and less disorganized subtypes, better premorbid functioning,and fewer negative and cognitive symptoms.Émil Kraepelin was amazingly ahead of his time in characterizing many aspects ofthe illness we now call schizophrenia; however, some important discoveries about olderadults with schizophrenia over the last few decades stand in contrast to presumptionsabout the illness that Kraepelin termed dementia praecox. For many years, in accordancewith this terminology of dementia, ideas about aging with schizophrenia were largelynegative in connotation, including expectations of a progressive, downhill course insymptoms and functioning, as well as notably shorter lifespans for persons with schizophreniacompared to the general population. However, schizophrenia is not typically a“neurodegenerative” disease in the same sense as Alzheimer’s or Parkinson’s diseases.Certainly older adults with schizophrenia face considerable and unique challenges, butthe overall message from recent years of research in this population has been one of hopefor meaningful quality of life among aging persons with this disorder. The increased studyof persons with schizophrenia outside of institutional settings may partially explain themore optimistic outcomes.There is notable heterogeneity in the clinical course that schizophrenia takes overseveral decades, with a minority of persons experiencing the extremes of sustained remissionor progressive deterioration. Psychosocial supports and early treatment are two importantfactors that may contribute to the relatively uncommon state of sustained remission.Nonetheless, the majority of persons with schizophrenia appear to have relativelystable to slightly improved symptom severity after the first few years of the illness. In particular,older adults with schizophrenia may experience less severe positive symptoms(i.e., delusions and hallucinations), although negative symptoms (e.g., apathy) may commonlypersist. Cognitive impairment (e.g., impaired attention and working memory) is acore feature of schizophrenia and a frequent problem associated with aging in general.Thus, one might expect cognitive decline to be accentuated in aging persons with schizophrenia.Although older adults with schizophrenia generally experience more problemswith cognition than do normal older adults, the rates of age-associated cognitive declineare similar between the two groups. Thus, on the whole, the prognosis for older adultswith schizophrenia is not as bleak as previously thought. Nonetheless, it should be notedthat even older adults whose symptoms improve with aging often do not achieve the samelevel of daily functioning or quality of life as never-affected older persons, and that treatinglate-life schizophrenia still requires considerable diligence and skill.