About half of people suffering from schizophrenia since their youth
experience improvement in symptoms and functioning as they get older, but the
vast majority of older patients still face many difficulties in living a
satisfying life integrated into the community.
At a presentation at the American Association for Geriatric Psychiatry
annual meeting in Honolulu in March, Carl Cohen, M.D., a professor and
director of the Division of Geriatric Psychiatry at the State University of
New York (SUNY) Downstate Medical Center in Brooklyn, described five models of
evaluating clinical and psychosocial outcomes in older patients living with
schizophrenia that encompass (1) remission, (2) recovery, (3) community
integration, (4) objective successful aging, and (5) subjective successful
aging. Cohen noted that each individual model used was previously developed
and reported on by different researchers not involved in this study.
Based on published studies and research conducted in the New York City area
by Cohen and his SUNY colleagues, "about 50 percent of people with
schizophrenia reach older age ... and their symptoms generally improve from
younger age," Cohen noted. Most patients are diagnosed in their teens
and early 20s, he told Psychiatric News. Their health and social
status in older age tend to be somewhere between younger schizophrenia
patients and older adults in the general population without schizophrenia.
About 15 percent to 20 percent of older patients remain severely ill and more
or less institutionalized or get worse with age. The other 30 percent or so
patients remain in the social functioning level similar to their younger
As patients age, positive symptoms and negative symptoms tend to improve.
About half of the patients tend to have mild or no symptoms. Depressive
symptoms, which are common in schizophrenia, may stay the same or worsen:
about one-third of patients may have syndromal depression and one-third
subsyndromal depression, Cohen said. Adaptive functioning may improve in many
patients. Overall, however, only about one-tenth of these patients reach full
recovery with no symptoms or impairments.
Using the five models of outcomes, Cohen and colleagues assessed the
clinical and social indicators in two groups of adults 55 years or older who
were living in the community in New York City. The two groups consisted of 198
people with schizophrenia and 113 without schizophrenia who were matched in
age, gender, and income.
In terms of remission, half (49 percent) of the schizophrenia patients met
the clinical criteria, defined as a score of 3 or less on eight domains of the
Positive and Negative Syndrome Scale (PANSS) and no hospitalization in the
previous year. "So symptom remission is a realistic goal for many of our
older patients in the community," Cohen said.
The researchers defined recovery, the focus of the second outcome model, as
clinical remission and social functionality, including the ability to manage
medications and money independently, having at least one confidant, and
joining activities with others. According to these criteria, 17 percent of the
schizophrenia group had achieved recovery.
In the third outcome model, four areas of community integration are
assessed: the patient's independence, psychological integration, physical
integration, and social integration with the surrounding community. Based on
12 criteria of community integration in the four areas, the nonschizophrenic
community group scored an average of 8.85, compared with 7.55 for their peers
with schizophrenia. The difference was statistically significant.
Cohen and colleagues used a six-item scale for "successful
aging" based on a model proposed by Rowe and Kahn, which evaluates a
person's physical health, cognitive and physical functions, and engagement
with life; the last aspect was defined as having three or more confidants and
three or more instrumental linkages and/or working and/or does heavy and light
housework. The community group scored 4.35 on a scale of 0 to 6, and the
schizophrenia group scored 3.04; the difference was statistically
The last outcome model, subjective successful aging, also used a six-item
scale measuring a person's self-rated health status, activity level, ability
to think and care for self, and satisfaction with emotional support and
connection with others. The community group had a statistically significantly
higher score than the schizophrenia group (4.35 and 3.52, respectively).
Interestingly, statistical analyses showed that these five outcome
measurements had limited correlation with each other. "There was some
overlap, but the correlation was modest for the most part," Cohen
pointed out. "They seem to be somewhat different in what they were
Therefore, Cohen suggested that psychiatric and social interventions should"
be directed to improving the risk factors and ... components of these
measures such as health, adaptive functioning, and social engagement."
He also noted that because the components of outcomes in this population seem
to lack strong correlation, the deficiencies in certain components should be
specifically targeted in treatment and intervention, since symptom remission
alone may not necessarily improve community integration or successful
Subsequent to the annual meeting of AAGP, "Outcome Among
Community Dwelling Older Adults With Schizophrenia: Results Using Five
Conceptual Models" was published in the April 2 Community Mental
Health Journal. An abstract is posted at<www.springerlink.com/content/x7h68263r6114804/fulltext.pdf?page=1>.▪