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Studying late-onset schizophrenia and non schizophrenia psychosis in elderly Egyptian patients

Hussein, Hanana; Shafei, Ahmed Ela; Meguid, Marwa Abd Elb; Missiry, Marwa Elb; Tamara, Mahmoudc

Middle East Current Psychiatry: January 2012 - Volume 19 - Issue 1 - p 12–22
doi: 10.1097/01.XME.0000407866.00571.95
Original articles
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Background In Egypt, the proportion of elderly people in the population is increasing markedly; cases of late-life psychoses are increasing at a rapid pace as the population of the world ages, and this will create a tremendous economic burden on the society because of the increasing rates of disability.

Aim The aim of this work was to compare the sociodemographic and clinical characteristics, daily living functioning, and cognitive impairment between late-onset schizophrenia and other late-onset psychotic disorders.

Patients and methods A cross-sectional comparative study was conducted on 100 patients: 50 patients with schizophrenia with onset after the age of 50 years (group A) and 50 patients with nonschizophrenia late-onset psychoses (group B). All patients were interviewed using The Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders Axis-I diagnosis were assessed using the Positive and Negative Syndrome Scale, the Functional Assessment of Activity of Daily Living scale, section B of the Cambridge Mental Disorders of the Elderly Examination, and the Wechsler Adult Intelligence Scale.

Results Patients in group A were significantly younger – they were mainly women (72%), the majority were never married (54%), and 62% were living alone – compared with group B, who were mainly married (46%) and lived more often with their families. Among patients with late onset schizophrenia spectrum, 70% had paranoid subtype, 12% had delusional disorder and the rest had either undifferentiated or schizoaffective subtype. On the other hand, 70% of group B patients had psychotic symptoms due to dementia, 20% had mood disorder with psychotic symptoms; and the rest 10% had psychosis secondary to medical illnesses. (Group B) patients had significantly lower scores on items assessing positive symptoms and higher scores on general psychopathology than did (Group A) patients, the scores on negative symptoms, and also the total PANSS scores were almost similar in both groups and did not show any significant differences. Group A patients scored significantly better in daily living functioning, whereas a significant number of patients of group B needed partial and complete support. Cognitive assessment revealed that group A patients scored almost within norms, except for memory, apraxia, abstract, and perception items, compared with group B patients who scored significantly lower in all cognitive items.

Conclusion Patients with late-onset schizophrenia compared with patients with other late-onset psychoses differ in a number of psychosocial and clinical variables, daily functioning, and cognitive abilities. The results of this study contribute to the development of a better understanding of the elderly patient population with different types of late-onset psychoses, which have been largely ignored in research.

aDepartments of Neuropsychiatry

bNeuropsychychiatry

cGeriatric, Faculty of Medicine, Ain Shams University, Cairo, Egypt

Correspondence to Marwa Abd El Meguid, MD, Department of Psychiatry, Institute of Psychiatry, 65 El Nozha Street, Heliopolis, Cairo, Egypt Tel: + 002 0105752536; fax: +202 22678032; e-mail: melmeguid@gmail.com

Received May 19, 2011

Accepted August 12, 2011

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Introduction

Worldwide, the number of persons aged 65 years or older has increased from 17 million in 1900 to 342 million in 1992 and is expected to increase to 2.5 billion (comprising 20% of the total population) by 2050 1. In other words, the proportion of elderly people in this population will increase by 65%. In the next 30 years, life expectancy will increase markedly in western countries, and it is expected to increase further 2. In Egypt, there is a marked increase in the proportion of elderly people in the population; according to ‘The Statistical Year Book 2009,’ 3 people above 60 years of age constitute 6% of the Egyptian population and this proportion is expected to reach 11.5% by the year 2025 with the mean life expectancy around 70.1 years 4.

Cases of late-life psychoses are increasing markedly as the population of the world ages, and this will create a tremendous economic burden on the society because of the increasing rates of disability and institutionalization 5. It is worth mentioning that Khouzam et al.6 reported that up to 23% of the elderly population will experience psychotic symptoms that may increase the suffering of patients, family, and caregivers 5.

There is a growing awareness that late-onset psychoses constitute a heterogenous group of serious disorders of a complex nature, which present in different forms with different etiologies 7,8. These conditions include delusional disorders, induced psychotic disorders, late-onset schizophrenia, psychosis associated with dementia, mood disorders with prevailing psychotic symptoms, and others 9,10; clinicians must remember the nonspecific nature of psychotic symptoms to avoid errors in diagnosis 11. Controversy still surrounds the differential diagnosis of psychoses that begin late in life 12,13. The nosology, classification, and biological basis of psychoses in the elderly have been much debated; primary and secondary psychotic disorders of late life and their etiology are commonly considered from the view point of risk factors such as genetic predisposition triggering life events and organic cerebral dysfunction 11. In a recent study by Woolley et al.13, a total of 28.2% of patients with a neurodegenerative disease received a prior psychiatric diagnosis of a psychotic nature, as neurodegenerative diseases are often misdiagnosed as psychiatric disorders.

Late-onset schizophrenia refers to schizophrenia or a related disorder (schizoaffective, schizophreniform, or delusional disorder) with onset of prodromal symptoms after the age of 50 years 8. According to Diagnostic and Statistical Manual of Mental Disorders (DSM)-III-R, the onset of symptoms, including prodromal symptoms, must be after the age of 45 years. DSM-IV, however, does not specify the term ‘late onset,’ nor does it set an upper age limit for the diagnosis of schizophrenia 9. Although DSM-IV and DSM-IV-TR criteria do not include codeable diagnoses for late-onset schizophrenia, DSM-IV and DSM-IV-TR mention differences between cases of schizophrenia with onset after 50 years compared with those with earlier onset. Moreover, DSM-III-R included a late-onset category for patients with initial presentation at the age of 50 years or later 10.

Different studies suggest that there are specific risk factors for late-onset schizophrenia that could be identified; these include female sex, visual, auditory sensory impairments, and premorbid schizoid personality 7.

In Egypt, with the increased longevity of life and the change in family system toward a nuclear one, together with the increased medical, psychiatric, and behavioral problems in the aged population, there is a great necessity to have carefully designed plans for mental health promotion of the elderly 14. There is clearly an enormous need to clarify the clinical characteristics and range of dysfunction in cases of late-onset psychoses to streamline treatment recommendation for the already complex and vulnerable elderly population, aiming to minimize the cost of these devastating disorders through early recognition and fast intervention.

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Aim of the work

The aim of the current study was to compare the sociodemographic and clinical characteristics, daily functioning, and cognitive impairment between patients with late-onset schizophrenia and those with other late-onset psychotic disorders.

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Patients and methods

Design

The study design was cross-sectional and comparative in nature, and the sample was selective. A total of 100 patients were enrolled in a 1-year period from March 2008 to February 2009; they were selected and divided into two groups, A and B, as mentioned below.

Group A comprised 50 patients fulfilling the diagnosis of schizophrenia and other psychotic disorders according to DSM-IV. We also used the operational definition according to the consensus statement by the International Late-Onset Schizophrenia Group, which stated that the term could be applied to those cases with onset of prodromal symptoms after the age of 50 years and refers to schizophrenia or a related disorder (schizoaffective, schizophreniform, or delusional disorder) 8. Both male and female patients were recruited from among the inpatients and outpatients attending the Geriatric Hospital and Institute of Psychiatry, Ain Shams University Hospitals. Some cases were also recruited from Abbasseya State Hospital because of the rarity of cases fulfilling the following inclusion and exclusion criteria: patients should have developed schizophrenia after the age of 50 years; and patients should not have a life-time history of schizophrenia, other psychoses including schizoaffective disorder, paranoid disorder, or psychotic symptoms secondary to other mental or general medical disorders or dementia.

Group B comprised 50 male and female patients fulfilling the diagnosis of late-onset nonschizophrenia psychoses developed after the age of 50 years, including psychotic disorders due to general medical conditions, mood disorders with psychotic features, and dementia with delusions and hallucinations. Patients with life-time history of schizophrenia, schizoaffective disorder, mood disorder, delirium, or late-stage dementia were excluded. Patients were recruited mainly from inpatient and outpatient clinics of Geriatric Ain Shams University Hospital.

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Ethical issue

Ethical approval of the research protocol was obtained from the Ain Shams University Ethical and Research Committee. The researchers described the study to the patients or their guardians, ensured confidentiality of information, and obtained their informed consent for participation. It was stated that participation in the study was voluntary and that they have the freedom to withdraw from the assessment at any time. Informed written consent from patients or their guardians was obtained. All 50 cases in each study group who fulfilled the research criteria and gave their consent were subjected to preliminary clinical evaluation including history of illness obtained from the patient and his or her family. Physical and neurological examinations were conducted by a Gerontologist Specialist. The research team also revised the medical files and investigations of all patients.

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Tools and procedures

All patients underwent the following examinations: (a) clinical assessment, (b) assessment of daily functioning, (c) cognitive assessments, and (d) Fahmy and El-Sherbini’s Social Classification Scale.

Clinical assessments included the Structured Clinical Interview for DSM Axis-I diagnosis – clinical version 15 and the Positive and Negative Syndrome Scale (PANSS) 16. The PANSS was designed to measure the severity of psychopathology in adult patients with schizophrenia, schizoaffective disorder, and other psychotic disorders.

Assessment of daily functioning included activities of daily living (ADL) and instrumental activities of daily living (IADL).

The ADL scale 17 assesses certain basic abilities that a person must possess to remain at home independently. These abilities allow a person to perform basic self-care tasks. Accordingly, patients were classified into the following groups: needs no support (10), needs partial support (six to nine), or needs full support (zero to five). The Arabic standardized version was used 18. The IADL scale 17 measures two broad categories: (a) basic self-maintenance behaviors such as feeding, dressing, bathing, and mobility, and (b) more complex behaviors such as managing finances, traveling, and taking medications. These abilities are higher-level abilities that allow a person to function independently at home or in the community. Accordingly, patients were classified into the following groups: needs no support (10), needs partial support (six to nine), or needs full support (zero to five). We used the Arabic standardized version 18.

Cognitive assessments included Cambridge Mental Disorders of the Elderly Examination (CAMDEX) scale 19 and the Wechsler Adult Intelligence Scale (WAIS).

The CAMDEX scale 19 was developed to assess the diagnosis and measurement of dementia among the elderly. This scale assessed orientation, language (expression, comprehension), memory (both recent and remote), and learning praxis, attention, abstract thinking, perception, and calculation. It was translated into Arabic and validated by Mahmoud et al.20. The WAIS 21 is the most commonly administered general intelligence test for adults, and it is also viewed as a broad assessment of cognitive functions. The Wechsler scale provides information about the important aspects of the patients’ intellectual functioning. We used the standardized Arabic version of the test 22.

Fahmy and El-Sherbini’s Social Classification Scale 23 is based on parameters such as education and work of the father, education and work of the mother, income crowding index, and sanitation.

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Statistical analysis

Data were statistically analyzed using the Statistical Package for Social Sciences program software version 17.0. (SPSS Inc., Illinois, Chicago) Descriptive statistics were obtained for numerical parametric data as means and SD and for categorical data as number and percentage. Inferential analyses were performed for quantitative variables using Student’s t-test for independent data. Qualitative data were analyzed using Pearson’s χ2-test. The level of significance was taken at P-value less than 0.05; otherwise, it was considered nonsignificant.

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Results

To fulfill the aim of the work, we compared the studied groups with each other with regard to their sociodemographic characteristics, clinical data, ADL, and cognitive functioning.

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Demographic data

Patients in group A were significantly younger (mean age 69.5±3.39) – they were mainly women (72%), the majority were never married (54%), and 62% were living alone – compared with group B (mean age 72.5±2.26), who were mainly married (46%) and lived more often with their families. Social class did not show any statistical differences between the groups.

A total of 54% of group A patients graduated from secondary schools and universities compared with only 38% of group B patients. Previous engagement in different occupations showed striking differences, as a higher percentage of group B patients were engaged in jobs previously compared with group A patients (P=0.000). Details are illustrated in Table 1.

Table 1

Table 1

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Age at onset, duration of illness, and family history of psychiatric illness

Patients in group A developed their illness significantly earlier (P=0.001) and had longer duration of illness than did patients in group B. Although group A patients had higher frequency of positive family history of psychiatric disorders compared with group B patients (8 and 4%, respectively), the difference was not statistically significant (P>0.05) (Table 1).

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Medical history

Group A patients had significantly (P=0.000) more chest diseases (72%), auditory impairment (30%), and musculoskeletal problems (66%) compared with group B patients; in contrast, group B patients had significantly (P=0.000) more renal (56%) and neurological diseases (50%) than group A patients. No statistically significant difference was found between the two groups with regard to diabetes mellitus, hypertension, cardiac diseases, and visual impairment (Table 2).

Table 2

Table 2

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Clinical data

Diagnostic categories

Data represented in Fig. 1a show that, among patients with late-onset schizophrenia, 70% had paranoid subtype, 12% had delusional disorder, and the remaining had either undifferentiated or schizoaffective subtype. In contrast, 70% of group B patients with other late-onset psychoses had psychotic symptoms due to dementia, 20% had mood disorder with psychotic symptoms, and the remaining 10% had psychosis secondary to medical illnesses (Fig. 1b).

Figure 1

Figure 1

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Assessment of psychotic symptoms using Positive and Negative Syndrome Scale

Figure 2 illustrates clearly that group B patients had significantly lower scores on items assessing positive symptoms (including delusions, conceptual disorganization, and hallucinatory behavior) and higher scores on general psychopathology (including somatic concern, anxiety, guilt feelings) than did group A patients; the scores on negative symptoms (including blunted affect, emotional withdrawal, poor rapport) and the total PANSS scores were almost similar in both groups and did not show any significant differences.

Figure 2

Figure 2

The nature and content of delusions differ from that of group A patients who had more complex bizarre delusions of control, passivity, and persecution in comparison with group B patients with dementia who exhibited simple paranoid delusion and also delusions of someone stealing or hiding objects. Group B patients with depression described somatic, hypochondriacal delusions. In addition, some patients had delusions of guilt and nihilism, and others had noncongruent delusions of persecution and reference.

The pattern of hallucinations in group A patients showed multimodal hallucinations, mainly auditory, tactile, and olfactory hallucinations. Schneiderian first-rank symptoms such as hearing multiple voices or running commentary were recorded in this group, whereas group B patients with dementia had mainly visual hallucination. Group B patients with mood disorder had auditory and olfactory hallucinations.

Functional assessment of the ADL scores revealed that group A patients had significantly better ADL and IADL scores, whereas a significant number of group B patients needed partial and complete support compared with group A patients (Table 3).

Table 3

Table 3

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Cognitive assessment

Using section B (CAMCOG) of the CAMDEX it was revealed that group A patients scored almost within norms, except for memory, apraxia, abstract, and perception items, compared with group B patients who scored lower in all cognitive items. Group A patients compared with group B showed highly statistically significant differences in the following parameters: language, memory, abstract, and perception (P=0.000). Their scores on orientation, attention, and apraxia were significantly lower at the following levels of significance: 0.004, 0.02, and 0.001, respectively (Table 4).

Table 4

Table 4

On the WAIS, patients with late-onset schizophrenia scored significantly better in all total and subitems of the test. It was noticed that a very highly statistically significant difference exists between both groups with regard to total, performance, and verbal intelligence quotient scores, being lower in group B than in group A. Both groups showed discrepancy between verbal and performance intelligence quotient, which denotes cognitive decline (Table 5).

Table 5

Table 5

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Discussion

Psychotic manifestations constitute an important problem in the geriatric population. Some authors have reported that psychosis was present in 26% of elderly patients admitted to an inpatient geriatric unit and in 36% of patients admitted for the first time to a psychiatric facility 24. Within the psychiatric ward, cases showing an onset after 40 years of age comprised 10.8% of the total population 25. Early detection and management of psychotic symptoms is associated with a better psychosocial adjustment 24.

This study aimed to uncover some clinical aspects in a sample of the Egyptian elderly population. The research aimed to study a group of elderly patients with primary psychotic disorders that appear for the first time after the age of 50 years (group A), including schizophrenia, delusional disorder, and schizoaffective disorders, and compare them with a group of elderly patients with psychotic disorders other than schizophrenia (group B), which include psychosis associated with dementia, mood disorders, and psychosis secondary to medical conditions.

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Demographic variables

Late-onset schizophrenia affects women two to 10 times more than it does men 8,10. With regard to sex, 72% of patients with late-onset schizophrenia were significantly predominantly women compared with only 52% of patients with late-onset other psychoses. This result was in accordance with a previous study by Howard et al.8. In the Egyptian community, Ashour et al.26 found that the ratio between men and women was 1 : 3 among the elderly with different psychiatric morbidities in Cairo hostels. The preponderance of female patients in the group of late-onset schizophrenia was also recorded previously by Haiba 27, who studied paranoid symptoms in the elderly population in Egypt. Recently in China, Yasuda and Kato 25 found that female patients comprised 16.3%, which was significantly higher than that of male cases (2.0%). The robustness of this finding, coupled with the higher incidence rates of early-onset schizophrenia in men, led to the estrogen hypothesis, which postulates that estradiol has antidopaminergic properties that somehow protect women to a certain degree from puberty to menopause. As estradiol levels decrease at midlife, this protective factor is lost, thus predisposing vulnerable women to a second illness-onset peak after the age of 45 years because of the decline in estrogen with relative excess of dopamine D2 receptors 28.

Social isolation has been linked to late-onset schizophrenia; it either plays a role in causation or may be the consequence 29. In our research, we found that patients with late-onset schizophrenia were predominantly never married or were divorced; a significant proportion of them were living alone compared with the group of nonschizophrenia late-onset psychosis patients. Our results agreed with those of previous national and international researchers who found that social isolation, living alone, having no friends, and having no regular visitors are associated with late-onset schizophrenia 27,29,30.

Genetic factors seem to play a smaller role in the etiology of late-onset schizophrenia 8. Our results showed that there were no significant differences with regard to family history of psychiatric disorders among both studied groups, consolidating the above-mentioned findings.

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Medical history

Late-life psychotic symptoms often have a medical etiology and may be the first symptoms of undiagnosed medical conditions. This is because elderly people usually take several medications with possible side effects and drug interactions, which may contribute to the appearance of psychotic symptoms 6,7.

Group B patients had significantly more frequent renal and neurological diseases. It was also reported in Egyptian communities that cognitive and behavioral changes were frequently encountered in elderly patients with renal impairment 31. In addition, Mostafa et al.32 had reported a high prevalence of neurological incidents among elderly patients presenting with psychiatric symptoms.

Group A patients with late-onset schizophrenia compared with their group B counterparts had significantly more frequent chest diseases, probably because of excessive smoking, more musculoskeletal problems, and auditory impairment, which add to their social isolation. We are in agreement with previous studies that found that some evidence exists of an association between sensory deficits and psychotic symptoms 33,34; moreover, some have suggested that late-onset schizophrenia might reflect the impact of sensory deprivation due to uncorrected visual and hearing deficits associated with aging 35.

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Diagnostic categories

The majority of group B patients (70%) had psychosis due to dementia, whereas 20% had mood disorder with psychotic features, and 10% had psychosis secondary to medical illnesses. Our results are not in agreement with the study by Barclay and Almeida 36, who reported that the most frequent clinical diagnoses for elderly patients with psychotic symptoms other than schizophrenia were dementia (40%), depression (33%), psychosis secondary to a medical condition (7%), bipolar disorder (5%), and the remaining due to adverse reaction to medication. Jeste and Finkel 37 stated that the incidence of psychosis in dementia was 30–50%, whereas Paulsen et al.38 reported that approximately 50% of dementia patients will have psychotic symptoms, predominantly delusions and hallucinations. The difference between our results and the above-mentioned findings could be attributed to the difference in sampling methods and techniques.

The diagnosis of paranoid disorder was by far the most diagnostic type of schizophrenia encountered in our late-onset schizophrenia group (70%), whereas only 12% had delusional disorder and 14% had schizoaffective disorder. Only 4% had undifferentiated schizophrenia. In their study, Yasuda and Kato 25 found that the paranoid type comprised 55.3% of the total population of late-onset cases. The higher prevalence of paranoid schizophrenia in our sample compared with other studies could not be interpreted because our sample is a selective sample rather than a random one.

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Clinical picture

Symptoms of psychosis associated with late-onset schizophrenia were different from that of other late-onset psychoses. Delusions reported in dementia patients were typically simple, nonbizarre, and of the paranoid type, for example, morbid jealousy and delusions related to someone stealing or hiding objects. A number of researchers have found that delusions and hallucinations are commonly associated with aggression, agitation, and disruptive behavior in patients with dementia 39–41. Patients with late-onset schizophrenia tended to have complex bizarre systematized delusions, example persecutory delusions and suffering from a disease or spouse infidelity. Delusions in patients with mood disorders were characterized by somatic, hypochondriacal, guilty, or nihilistic delusions, and also by noncongruent delusions such as persecution and reference. These results were similar to previous findings in the elderly Egyptian population 42–44. From the clinical point of view, Alexopoulos et al.45 stated that depressive delusions can be distinguished from delusions in patients with dementia, in that the latter are less systematized and less congruent to the affective disturbance.

Controversy surrounds the differential diagnosis of hallucinations that begin late in life 40,46. In our study, we reported that hallucinations in dementia were more frequently visual than auditory; the reverse is true for patients with schizophrenia who had multimodal hallucinations. Patients with psychotic symptoms associated with depression had mainly auditory and olfactory hallucinations.

The severity of positive, negative, and general psychopathologic symptoms was measured with the respective subscales of PANSS. Data revealed that patients with late-onset schizophrenia had more severe positive symptoms and less severe general psychopathology in contrast to patients who had nonschizophrenia psychoses. Cohen et al.39 stated that negative symptoms can be difficult to distinguish from the confounding effects of depression, medications, and institutionalization. In our study, using the PANSS, it was evident that scores of negative symptoms were similar in both groups studied and were far lower than scores on positive symptom scales; these results are in accordance with those of the San Diego study, which proved that lower scores on negative symptoms tended to be associated with the higher age group having psychotic illness 40.

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Assessment of daily functioning

Assessment of daily functioning revealed that patients with late-onset schizophrenia had significantly better ADL and IADL scores, whereas a significant number of patients with late-onset nonschizophrenia psychoses needed partial and complete support. This finding may be attributed to the medical conditions of the latter group, who had more frequent medical, neurological, and cognitive impairment, which negatively impacted their ability to perform daily activities compared with those who suffered from late-onset schizophrenia. The deteriorated daily functioning reflects the devastating effects of dementia on ADL and highlights the impact of this disability on caregivers. These findings were in accordance with those of previous studies, which found that higher levels of daily functioning among elderly people with schizophrenia were associated with better cognitive functioning, fewer negative symptoms, better physical health, and independent living in the community 47–49.

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Cognitive assessment

Patients with a primary diagnosis of dementia suffer from a number of psychotic symptoms, and patients with primary functional disorders become cognitively impaired. Barclay and Almeida 36 stated that schizophrenia does not increase the risk of dementia. In contrast, individuals with cognitive impairment in later life are at increased risk for psychosis. Dementia is characterized by a progressive decline in cognitive abilities. This was true in our research, which illustrated that group B patients, in which 70% of patients had a diagnosis of dementia, scored significantly worse in all subitems of cognitive assessment according to CAMCOG compared with group A patients. It is interesting to note that several groups of investigators have reported potentially relevant clinical, neuropsychological, and neurobiological differences between dementia patients with and without psychosis. Stern et al.50 observed that, among dementia patients, psychosis was associated with a greater prevalence of rapid cognitive decline. Moreover, in a study by Jeste and Finkels 37, it was noted that those with psychosis had greater impairment on putative neuropsychological tests of frontal lobe function compared with dementia patients without psychosis.

The association between cognitive functions in dementia cases with or without psychosis should be clarified in future studies. There was much debate on this topic; Linda et al.51 reported that behavioral symptoms and cognitive functions are independent dimensions, whereas Hopkins and Libon 52 suggested a strong relationship between severity of psychosis and poor performance on some cognitive functions.

From the current research, the obtained results are important in demonstrating that the cognitive deficits associated with late-onset schizophrenia are different from the cognitive declines associated with dementia. The rate of decline observed among the dementia groups in the present sample appears to be consistent with that reported in the literature 53,54. Thus, the onset of schizophrenia late in life does not appear to be a mere by-product of a dementia disorder. The same conclusion is consistent with the findings from studies by the Mount Sinai research group, which examined chronically institutionalized elderly schizophrenia patients. These investigators found that the pattern of cognitive deficits of such patients was distinct from that associated with dementia; moreover, their postmortem neuropathological studies indicated that the prevalence of amyloid plaques and neurofibrillary tangles was not different from that of age-matched healthy control individuals 55. Unfortunately, in this study, we did not compare group A patients with healthy controls; thus, we could not comment on cognitive decline in the late-onset schizophrenia group in comparison with the healthy elderly population.

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Conclusion

Patients with late-onset schizophrenia compared with patients with other late-onset psychoses differ in a number of psychosocial and clinical variables, daily functioning, and cognitive abilities. The results of this study contribute to the development of a better understanding of the elderly patient population with different types of late-onset psychoses, which have been largely ignored in research. These findings draw the attention of policymakers and psychiatrists to the burden of psychotic disorders in the elderly and the need for specialized psychiatric care units providing intensified help and rehabilitation.

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Recommendations

In Egypt, research in the area of old-age psychosis is still scarce and has been neglected. Thus, studies on this topic on a large representative sample from different geographical areas are highly recommended. In addition, prospective cohort studies of elders with psychotic disorders to determine the outcome of psychotic disorders are mandatory. Studies addressing clarification of risk factors to develop psychosis at later age, the impact of psychotic symptoms on caregivers, and treatment outcome of old-age psychosis are recommended. Future studies should involve different disciplines. These disciplines should cooperate together to provide evidence-based data that can inform the public, help policymakers to make informed decisions and plans, and stimulate further research.

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Strength and limitations of the study

One of the strengths of this study is that (according to best of our knowledge) it is among the first studies to compare late-onset schizophrenia with nonschizophrenia late-onset psychoses. Although our findings shed light on this poorly understood and investigated area of research, the results should be considered preliminary data because of the limitations of small size and type of sample, which was a selective rather than a stratified random sample representing different geographical areas in Egypt. Our findings must be reviewed as provisional and will be subjected to revision, as more studies are needed in the field of elderly patients with psychotic disorders.

Figure

Figure

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Acknowledgements

The authors express their gratitude to Professor M. El Banouby, former chair of the department of Geriatric Medicine, Ain Shams University, for his support and guidance. The authors are grateful to Dr Hisham Sadek, Dr Ahmed El Missiry, Dr Abeer Mahmoud, Dr Hanan Hussein, Dr Ahmed El Shafie, and the other research participants from the department of Neuropsychiatry, Ain Shams University, for their time, training on tools, guidance, advice, and efforts in completing the study assessment. The authors would also like to thank Dr Olfat Kahla, senior psychologist in Geriatric Hospital, Ain Shams University, for her help, and Dr Mohamed Hassan Taha from ‘TIT Solution’ for the statistical analysis.

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Conflicts of interests

There are no conflicts of interest.

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Keywords:

activities of daily living; cognitive functions; late-onset psychoses; late-onset schizophrenia

© 2012 Okasha Institute of Psychiatry, Ain Shams University