CLINICAL HANDBOOK OF SCHIZOPHRENIA

38. Older Individuals 395rates (69%) of competitive, paid work among middle-aged and older adults with schizophreniawas found to be substantially better than two other forms of vocational rehabilitation.Overall, the ability of these various nonpharmacological treatments to improvethe functioning of older adults, who often have been affected by schizophrenia for decades,is impressive, but there is much room to build upon these results and expand thearmamentarium of psychosocial treatments for this population.SUMMARY OF TREATMENT GUIDELINES1. Antipsychotic medication is the mainstay of pharmacological treatment for olderadults with schizophrenia. There is no consensus on which specific antipsychotic shouldbe used as first-line therapy.2. Patients who have been treated successfully with a particular medication thatwas begun at a younger age may remain on that medication (with an explanation of therelative differences in side effect profiles associated with other available medications), althoughthe dose may need to be reduced in later life.3. Important side effect differences to highlight (whether continuing with an existingmedication or starting a new one) include (a) higher risk of movement disorders (includingpossibly persistent TD) with typical than with atypical antipsychotics, in an agedependentmanner; (b) possible elevated risk of metabolic disorders, such as diabetesmellitus and obesity, with certain atypical antipsychotics (e.g., clozapine, olanzapine);and (c) risk of death and cerebrovascular events when using atypical antipsychotics, if thepatient has comorbid dementia (and that current relevant data about these risks in olderadults with schizophrenia are scarce).4. Medications with the most data from controlled trials specifically for olderadults with schizophrenia include risperidone, olanzapine, and haloperidol.5. Initial antipsychotic doses for older adults with schizophrenia should be 25–50%of those used in younger adults. Whereas effective doses for older adults with early-onsetschizophrenia are usually 50–75% of those used in younger adults, doses may need to beonly 25–33% of younger adult doses for patients with late-onset schizophrenia or with“old-old” (over age 75) patients.6. Monitoring for medication-related side effects (irrespective of the specific medicationused) should include regular evaluation for extrapyramidal symptoms and TD(e.g., using the Abnormal Involuntary Movement Scale), as well as routine monitoring ofweight, blood pressure, blood glucose or hemoglobin A1C, and lipids.7. Patients should be offered psychosocial interventions as adjunctive therapy toantipsychotic medications. The most empirically validated psychosocial treatments formiddle-aged and older adults with schizophrenia include CBSST, FAST, and IPS vocationalrehabilitation.8. Other psychosocial interventions shown to help younger persons with schizophreniamight also be helpful for older adults. Examples include supportive psychotherapy,family therapy, psychoeducation, and case management/ACT.9. Due to increasing medical comorbidity associated with aging and traditionallyinadequate health care for persons with schizophrenia, clinicians should remain vigilantto ensure that older persons with schizophrenia receive appropriate treatment for activemedical problems, as well as standard preventive/screening procedures (including counselingfor applicable lifestyle modifications).10. Despite the relative stability of intrinsic cognitive deficits associated with schizophreniaover time, dementia may still co-occur with schizophrenia in aging individuals;