CLINICAL HANDBOOK OF SCHIZOPHRENIA

38. Older Individuals 393answer, and all of these previously mentioned factors must be weighed in light of eachindividual patient’s unique history. One notable difference among various antipsychoticagents that may have both clinical and systemwide relevance is cost (e.g., from the perspectiveof older adults on fixed incomes, or from the perspective of administrators regardingthe impending difficulty in financing health care for the growing number of olderadults). Aside from cost issues, the various available antipsychotic medications differ primarilyin side effect profiles, though individual patients may preferentially respond to onemedication or another for unclear reasons. Some of these side effect differences, as previouslydescribed, may be generalized by antipsychotic “class” (i.e., typical vs. atypical).Other differences in side effect profiles vary from one agent to another, both within andbetween classes, and these differences may also be important to consider when treatingspecial subpopulations, such as older adults. For example, medications that stronglyblock acetylcholine receptors are generally poorly tolerated in older adults, who are especiallyprone to develop anticholinergic side effects such as cognitive impairment, constipation,and urinary retention. Likewise, many antipsychotic medications antagonize alpha-adrenergicreceptors, sometimes resulting in postural hypotension. This side effectmay be especially problematic in older adults, who often are taking antihypertensivemedications that may add to this effect, and who may be prone to hypotension-relatedfalls (with falls being a major cause of morbidity and mortality in older adults). Excess sedationand parkinsonism may also be antipsychotic side effects that contribute to falls inolder adults. Antipsychotic medications also differ in their effects on cardiac conduction(e.g., QT interval prolongation). Whereas the increased rates of cardiac disease in olderadults may heighten the relevance of cardiac conduction effects, the clinical significanceof these different effects among antipsychotics is unknown.Once a specific antipsychotic agent has been chosen, it is important to adjust medicationdosage based on the person’s age. Older adults generally respond to lower doses ofantipsychotic medication and are more sensitive to the side effects. Aging brings aboutchanges in both pharmacokinetics (e.g., reduced renal and hepatic clearance of drugs)and pharmacodynamics (e.g., dopaminergic neuronal cell loss or altered receptor density)related to antipsychotic medications. As a general rule, older adults with schizophreniaoften require only 50–75% of the usual antipsychotic dose given to younger adults withthe same disorder. It may be helpful in less urgent situations to begin therapy with 25%or less of the usual adult dosage, then titrate up as necessary. Certain subgroups, includingthe “old-old” (those over age 75) and persons with middle-age or very-late-onsetschizophrenia, may respond to even lower doses (e.g., 25–33% of the usual adult dosage).The most evidence regarding effective daily doses from controlled trials exists forrisperidone (ca.2 mg/day) and olanzapine (ca.10 mg/day) among relatively “young-old”adults (average age 65–70).Although antipsychotic medications are pivotal in the treatment of late-life schizophrenia,clinicians, patients, and families often recognize their limitations. Even whenthey are well-tolerated and effective, antipsychotic medications may not be sufficientlyeffective to return older adults with schizophrenia to “normal” functioning. Also, medicationshave little effect on certain aspects of schizophrenia (e.g., social skills deficits,cognitive impairment). Many psychosocial interventions investigated as treatment augmentationto pharmacotherapy in general schizophrenia populations have had varyingdegrees of success. Examples include cognitive-behavioral therapy (CBT), psychoeducation,family therapies, vocational rehabilitation, cognitive training, social skills training,and assertive community treatment (ACT). As with medication trials, these psychosocialtrials frequently include relatively few older adults. Often there is an unspoken (or evenspoken) assumption about the inappropriateness of psychosocial interventions for older