Book Review

Schizophrenia into Later Life: Treatment, Research, and Policy

N Engl J Med 2003; 349:2370-2371December 11, 2003

Article

Schizophrenia into Later Life: Treatment, Research, and Policy
Edited by Carl I. Cohen. 322 pp. Washington, D.C., American Psychiatric Publishing, 2003. $36. ISBN: 1-58562-037-8

Schizophrenia is a worldwide public health problem that carries substantial personal and social burdens. As the fourth leading cause of disability among adults, schizophrenia compromises the social and occupational functions of those who have this disease. The life stories of young people troubled by unexplained cognitive and social impairments are poignant, and only somewhat less so is the public presentation of psychosis when perceptual abnormalities, disorganization of thought and behavior, and ideas of persecution begin to dominate the patient's experience. Many patients also have a pathologic restriction of affect. Stigma further complicates the schizophrenic patient's adaptation to society. The family members of a person who has schizophrenia are often the principal caretakers, since the health care system fails to address this illness with adequate knowledge and resources. Persons who have schizophrenia very often become homeless, and their abnormal behavior is often addressed by the justice system. The high rates of substance abuse and suicide indicate the personal toll among those who have schizophrenia.

The challenges in later life are profound for persons with schizophrenia. In Schizophrenia into Later Life, Carl I. Cohen has put together a succinct overview of current knowledge on treatment, research, and policy with regard to older persons who have schizophrenia. The first thing to note is that there is a general lack of research and policy attention to the effects of schizophrenia in elderly populations. That noted, it should also be recognized that several major conceptual issues have been resolved with empirical study. Among these issues is the question of whether schizophrenia is an early-onset, progressive neurodegenerative disease with a severe defect state as the late-life outcome. The answer is no. The disease progression usually occurs in the early stages, and there is little evidence of a substantial neurodegenerative process. Among a surprising proportion of patients who have schizophrenia, symptoms and life functions improve late in life. However, a subgroup of patients have a rapid cognitive and functional decline late in life, which may be associated with white-matter neuropathology.

Is late-onset schizophrenia the same disease as early-onset schizophrenia? Yes. At least, there is a substantial similarity in the symptoms, the responses to treatment, and the associated biologic variables. The prognosis for persons with late-onset disease is more favorable, perhaps because their coping skills and the social niche they occupy have been established before the onset of disease. Another subtype of the disease that is marked by deficits in affect, drive, and cognition and that has a poor prognosis develops less frequently in patients who have late-onset schizophrenia.

The chapters that address pharmacologic and biobehavioral treatment and rehabilitation review the few studies that have been conducted of elderly populations with schizophrenia. These studies present a rational adaptation of methods that have been validated in the treatment of younger populations with this disease to the special problems associated with aging and schizophrenia. For example, low doses of new-generation antipsychotic drugs have advantages in the treatment of elderly patients, who are at increased risk for adverse neurologic and cognitive effects of the first-generation antipsychotic drugs. The long-term consequences of some new-generation drugs (e.g., hyperlipidemia, weight gain, and diabetes) are a lesser concern in the treatment of aging patients.

The chapters on coexisting medical conditions, health services, patterns of care, and changes in the caregiving required for older persons who have schizophrenia deal with extraordinarily complex issues. Deinstitutionalization of the mentally ill placed a new burden on their parents, but what happens as the parents age? Nursing homes and alternative, supervised residential facilities are now the primary settings for the life care of older persons who have schizophrenia but are poorly prepared to cope with the special issues of psychosis and coexisting medical conditions. Persons with schizophrenia as a group have a high-risk lifestyle that may include smoking, substance abuse, and poor diet, as well as a lack of exercise, companionship, intellectual activities, and medical care. The contributors to Schizophrenia into Later Life make clear the shortfall in research, training, and resources that needs to be addressed in order to direct attention to these complex health care challenges. The critique of Medicare and Medicaid, managed care, and what are known as the carved-in and carved-out mental health services is informative. Health care planners will pay special attention to the discussion of innovative models of long-term care for this population.

Cohen addresses these issues with a distinguished group of contributors, who provide a broad overview of current knowledge and practice with respect to late-life schizophrenia. The book is an easy read and free of jargon, and it will prove informative to mental health administrators, citizen advocates for the mentally ill, and mental health clinicians. It will be important also to many general physicians who attend the elderly, especially in nursing facilities. In a book this broad, integration across topics is difficult, but in the final chapter Cohen draws from the field of gerontology to provide an integrative model that may be used to guide future research.

William T. Carpenter, M.D.
Maryland Psychiatric Research Center, Baltimore, MD 21228