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Dan I. Lubman, PhD David J. Castle, MD r. B, age 73, repeatedly complained to his landlord that
Senior research fellow
and consultant psychiatrist
Professorial fellow
M people were trying to poison him by pumping noxious
gas into his apartment. He barricaded himself inside,
University of Melbourne
taped up all air vents and windows, and left only when absolutely
Mental Health Research Institute necessary. At night, he could hear people working the apparatus
and Royal Melbourne Hospital that pumped the gas, and could smell the vapors.
Victoria, Australia
On examination, he was physically well but suffered from
mild neural deafness and myopia. He was suspicious and guarded
New evidence shows psychosis but oriented and not cognitively impaired. He expressed paranoid
beliefs and experienced auditory and olfactory hallucinations.
presents in later life more often than There was no evidence of affective disturbance.
At first he refused psychiatric care but eventually agreed to
was once believed. Very late-onset take risperidone, 0.5 mg at night. He tolerated the agent well, and
his psychotic symptoms slowly resolved.
schizophrenia remains underdiagnosed
As Mr. Bs case illustrates, schizophreniaonce thought
but responds well to treatment. to be strictly an early-onset disordercommonly manifests late
in life (Box). Too often, however, very late-onset schizophrenia
goes undiagnosed because older patients with the disorder tend
to be socially isolated. Their symptoms of paranoia and reluc-
tance by family members to intervene also can prevent them
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generally live longer than men, this predominance is still Sweet and Pollock15 found an average dosage of chlorpro-
greater than one would expect. It might also hide important mazine equivalents, 148 mg/d, to be effective in older patients,
clues regarding schizophrenia and related disorders across the compared with >300 mg/d in younger cohorts.
life span, including the fact that the brains of men and women Neuroleptic side effects. Older patients are more susceptible
show sex-specific patterns of aging.12 than their younger counterparts to side effects and adverse
reactions from typical neuroleptics, even at low dosages. Age-
Managing very late-onset schizophrenia related differences in pharmacokinetics and pharmacodynam-
Initial assessment. Patients who present with a new-onset psy- ics, combined with the increased incidence of comorbid physi-
chotic disorder at any age require careful evaluation to exclude cal disease and polypharmacy among older patients, often
an underlying organic cause. The following are strongly sug- complicate pharmacotherapy for late-onset schizophrenia.
gested in older patients with new-onset psychoses: Older patients taking antipsychotics face an increased risk
comprehensive history (including medications) of extrapyramidal symptoms (EPS), especially parkinsonism
physical (including neurologic) examination and akathisia.16 Anticholinergics are poorly tolerated and may
laboratory investigations cause urinary retention, constipation, blurred vision, exacerba-
CT neuroimaging tion of glaucoma, and delirium. Cardio-
and cognitive screening, such as the vascular side effects, especially orthostatic
Mini Mental State Examination. Cognitive-behavioral hypotension, may lead to falls and significant
Drug treatment. Despite the wealth of pub- therapy can help modify injury and may exacerbate coexisting cardio-
lished data on the psychopharmacologic man- delusional beliefs vascular disease.
agement of schizophrenia, few randomized, con- and gain control Neuroleptic-induced tardive dyskinesia
(TD) is another potential complication. Jeste
over hallucinations
et al found the cumulative annual incidence of
drug-induced TD to be five times greater
among older psychotic patients than among younger
ones (26% vs. 5% after 1 year).17 Duration of exposure and total
cumulative amount of prescribed neuroleptics remain signifi-
trolled trials have examined the use of drugs to treat the disor- cant risk factors for TD in older patients.
ders very late-onset form. Case reports or small open studies Atypical antipsychotics, with their less-adverse side-effect pro-
comprise the available literature. Significant flaws in treatment files and lower risk of EPS (and probably TD as well) are the
studies have included diagnostic heterogeneity, mixing of preferred first-line drugs for late-onset schizophrenia. These
early- and late-onset patients, inadequate outcome criteria, and agents also have been associated with improved cognition in
lack of control groups. 13
younger patients with schizophrenia, a potentially significant
As with early-onset schizophrenia, however, antipsy- benefit in the older patient.
chotics appear to improve the acute symptoms of very
late-onset schizophrenia and reduce the risk of relapse.14 Table 2
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