M. Jackuelyn Harris

Is it possible to be schizophrenic yet neuropsychologically normal

This study identified and characterized a group of schizophrenic patients without neuropsychological (NP) impairment. A comprehensive NP battery was administered to 171 schizophrenic outpatients and 63 normal comparison participants. Each participants NP status was classified through blind clinical ratings by 2 experienced neuropsychologists; 27% of the schizophrenics were classified as NP normal. The NP-normal and NP-impaired schizophrenics were similar in terms of most demographic, psychiatric, and functional characteristics, except that NP-normal patients had less negative and extrapyramidal symptoms, were on less anticholinergic medication, socialized more frequently, and were less likely to have had a recent psychiatric hospitalization. The existence of NP-normal schizophrenics suggests that the pathophysiology underlying the cognitive deficits often associated with schizophrenia may be distinct from that causing some of its core psychiatric features.

Lower Incidence of Tardive Dyskinesia with Risperidone Compared with Haloperidol in Older Patients

OBJECTIVE: To compare the 9‐month cumulative incidence of tardive dyskinesia (TD) with risperidone to that with haloperidol in older patients.

Conventional vs. Newer Antipsychotics in Elderly Patients

Elderly patients with schizophrenia and dementia patients with agitation are frequently candidates for antipsychotic treatment. Conventional neuroleptics have relatively little effect on negative symptoms and may cause considerable side effects, especially in elderly patients. The authors have found a 29% cumulative annual incidence of tardive dyskinesia (TD) in middle-aged and elderly outpatients treated with relatively low doses of conventional neuroleptics Newer antipsychotics are less likely to cause extrapyramidal symptoms and may be associated with a lower risk of TD. They are generally effective for both positive and negative symptoms and may also improve some aspects of cognition, but these drugs have their own side effects. Dosing requirements for elderly patients tend to be much lower than those for younger adults.

Nondementia Nonpraecox Dementia Praecox?: Late-Onset Schizophrenia

Schizophrenia has traditionally been viewed as a psychotic disorder with onset in adolescence or early adulthood and a deteriorating course. Over the past decade, the authors have been studying patients meeting DSM-III-R as well as specified research criteria for late-onset schizophrenia (onset after age 45) and several comparison groups with psychiatric, neurologic, neuropsychologic, brain-imaging, psychophysiological, and psychosocial assessments. Results to date suggest a number of similarities and differences between late-onset schizophrenia and comparison groups of other older patients with psychoses (including earlier-onset schizophrenia). Later-onset schizophrenia is probably a neurobiologically distinct subtype of schizophrenia. Differential involvement of cortico-striato-pallido-thalamic circuitry may explain differences in age at onset. The authors propose a new conceptual model for level of functioning at different stages of life in late-onset schizophrenia.

Sleep-disordered breathing and periodic limb movements in sleep in older patients with schizophrenia

BACKGROUND Since the prevalence of both sleep-disordered breathing (SDB) and periodic limb movements in sleep (PLMS) increase with age, we explored whether older schizophrenia patients would have a high incidence of SDB and PLMS. Correlations between sleep and clinical variables were also examined. METHODS Fifty-two patients (mean age = 59.6 years, SD = 8.9) had their sleep/wake, respiration, and leg movements recorded using a modified Medilog/Respitrace portable recording system plus oximetry. A battery of clinical, psychosocial, and motor disturbance variables were collected by research center staff. RESULTS Forty-eight percent of these patients had at least 10 respiratory events per hour of sleep. These patients reported more symptoms of daytime sleepiness than patients with fewer than 10 events per hour. The relatively high prevalence of SDB in this group may contribute to overall sleep disturbances, and does not appear to be a result of high body mass index. Only 14% of the patients had at least five limb movements per hour of sleep, suggesting the prevalence of PLMS is much lower than expected in this age group. The number of leg jerks was inversely related to symptoms of tardive dyskinesia. CONCLUSIONS The disturbance of sleep in these patients may be due, in part, to SDB, but is unlikely due to PLMS.

Health-related quality of life in older patients with schizophrenia and other psychoses: relationships among psychosocial and psychiatric factors.

Objective. Few multivariate studies relating psychosocial factors to symptoms of psychosis among older patients exist. We assessed environmental stressors, satisfaction with emotional support, coping responses and psychiatric symptoms, and sought to relate these factors to quality of well‐being among older patients with schizophrenia and other psychoses.

Minor Physical Anomalies in Older Patients With Late-Onset Schizophrenia, Early-Onset Schizophrenia, Depression, and Alzheimer's Disease

The authors assessed five groups of older subjects (age > 45) for evidence of minor physical anomalies. The groups were patients with early-onset schizophrenia (onset at age < 45; n = 15), late-onset schizophrenia (onset at age > 45; n = 8), Alzheimers disease (AD; n = 11), and unipolar depression (n = 11), and normal comparison (NC) subjects (n = 15). Patients with late- and early-onset schizophrenia, and unipolar depression were found to have significantly more anomalies than NC subjects. Patients with AD did not have significantly more anomalies than NC subjects, although the patients with AD were significantly older than the NC subjects. The authors discuss implications of these findings on the pathophysiology of schizophrenia.

Late-Onset Psychotic Disorder, Not Otherwise Specified: Clinical and Neuroimaging Findings

Utilizing current neuroimaging technology, recent relC~rts suggest that in psychotic and mood disorders, particularly when these present in the elderly, there is a higher prevalence of cerebral atrophy~ ventricular enlargement, and white matter lesions (WML) compared with control subjects (Miller and Lesser 1988; Jeste et al !988b; Nasrallah et al 1989; Andreasen et al 1990; Coffey et al 1990; Breitner et al 1990; Lesser et al 1991; Miller et al 1991; Krull et al 1991). Although schizophrenic and mood disorders in the elderly have been studied, little attention has been given to the residual diagnosis of psychotic disorder, not otherwise specified (PDNOS) (American Psychiatric Association 1987). As part of a larger study of late-onset psychotic disorder, we now report the results of clinical and neuroimaging evaluations of patients diagnosed as having PDNOS, with symptom onset after the age of 45.

Neuroleptic discontinuation in clinical and research settings: scientific issues and ethical dilemmas

The ethics of neuroleptic discontinuation in clinical and research settings are currently a topic of much discussion. The issues underlying this debate are complicated by the fact that these medications can be fairly effective in managing the symptoms and preventing relapse in schizophrenia and other psychotic disorders, yet these drugs have therapeutic limitations and their prolonged use is associated with a risk of serious, potentially persistent side-effects such as tardive dyskinesia. Over the past 47 years, the public perception about the value of neuroleptics has undergone dramatic shifts, based partly on the data available at different time periods. The risk-benefit ratio is better for the atypical antipsychotics compared to the conventional ones, but long-term experience with the newer agents has been limited. At present, a prudent strategy for most clinical and research purposes is to gradually taper the medications in clinically stable, carefully selected, consenting subjects to the lowest doses on which individual patients can be effectively maintained. In this article we discuss clinical, research, and ethical aspects of neuroleptic discontinuation. It is critical to protect potentially vulnerable patients with serious mental illnesses, while allowing them to benefit from appropriate investigations.

Neuroleptic dose reduction in older psychotic patients

We conducted a non-randomized, rater-blind study to safely determine the lowest effective neuroleptic dosage in older psychotic patients and to evaluate the clinical, neuropsychological, and psychosocial effects of neuroleptic dosage reduction. Twenty-seven carefully selected patients with schizophrenia and related psychotic disorders over the age of 45 had their dosage tapered by 25% each month to determine their lowest effective dosage. These patients were compared with patients similar in age, gender, and education who were currently off neuroleptics (n = 19) or maintained on neuroleptics (n = 22). All groups were followed for 11 months. Over the follow-up period, 29% of patients in the taper group, 8% of neuroleptic-free patients, and 0% of patients in the maintenance group experienced some increase in psychopathology, although there was no significant change in mean PANSS score in any group, and no patient required hospitalization. Patients in the taper group were maintained on approximately 60% of their original neuroleptic dosage after restabilization. Extrapyramidal symptoms continued to improve over time in the taper group. Neuropsychological testing did not change significantly over time except for those in the taper group who experienced a decrease in memory-retention on the Hopkins Verbal Learning Test and a significant improvement in digit vigilance and Stroop Interference Index. Carefully selected middle-aged and elderly psychotic patients can have their neuroleptic medications reduced without a significant change in psychopathology. Extrapyramidal symptoms may continue to improve gradually over time. The impact on cognition functioning needs further investigation.