Schizophrenia Remission Unstable in Older Adults

WASHINGTON – One-fourth of older adults with schizophrenia shifted between remission and nonremission status in the first-ever large-scale longitudinal outcome study of older adults with schizophrenia spectrum disorder living in the community.

The 4-year longitudinal data revealed a lower persistent remission rate than had been suggested by earlier cross-sectional studies. "Our findings suggest that in addition to the increasingly recognized difficulties that older adults with schizophrenia face with respect to physical health, there is substantially more psychiatric instability than previously believed," said Dr. Carl I. Cohen, professor of psychiatry and director of the division of geriatric psychiatry at the State University of New York Downstate, Brooklyn.

Schizophrenia typically develops in the second or third decade of life, and increasing numbers of patients are surviving into old age with the disorder. Between 80% and 85% of people aged 55 years and over with schizophrenia developed it prior to age 45, with prevalence estimates for schizophrenia in adults aged between 45 and 60 of about 0.6% to 1%.

However, over the next two decades, there will be a doubling of the number of people aged 55 years and over with schizophrenia, from about 550,000 in 2005 to 1.1 million in 2025. By that time, about one-fourth of people with schizophrenia will be in this older age bracket. And in contrast to previous decades, most of these individuals are living in the community rather than in institutional settings, Dr. Cohen noted at the annual meeting of the American Association for Geriatric Psychiatry.

Recent cross-sectional studies of older adults have found remission rates of 49% (Am. J. Geriatr. Psychiatry 2008;16:966-73), 47% (J. Int. Neuropsychol. Soc. 2008;14:479-88), and 29% (Schizophr. Res. 2011;126:237-44). In longitudinal studies of remission and associated predictors in younger persons with schizophrenia, rates of clinical remission after an initial clinical episode ranged from 17% to 88% (Curr. Opin. Psychiatry 2011;24:114-21). On follow-up, the percentage of patients maintaining remission ranged from 50% to 89% (Rev. Epidemiol. Sante Publique 2009;57:25-32 and Schizophr. Res. 2009;115:58-66), with remission occurring in some of the originally nonremitted patients over time.

There have been no previous longitudinal studies in older adults, he said.

Dr. Cohen and his associates previously conducted a cross-sectional study of 198 community-dwelling adults with schizophrenia aged 55 years and over, and found that that 49% met the clinical criteria for remission, 66% met the Positive and Negative Syndrome Scale (PANSS) criteria of 3 or fewer of 8 domains, and 83% had had no hospitalizations in the past year (Am. J. Geriatr. Psychiatry 2008;16:966-73). Thus, "the study showed that symptom remission is a realistic goal for many patients," Dr. Cohen said.

In that study, four variables were associated with remission: fewer total network contacts, a greater proportion of intimates, fewer lifetime traumatic events, and higher Dementia Rating Scale scores. Type of residence, use of mental health services, and use of psychotropic medication had no significant association with remission, he said.

In the current longitudinal study, a total of 104 patients aged 55 years and older with schizophrenia spectrum disorders participated in follow-up interviews. They were followed for a mean of 52 months (range, 12-116 months). They had a mean age of 61 years, 55% were men, and 55% were white. Two-thirds (65%) lived in supported residences, while the other 35% lived independently or with family members.

To meet the criteria of remission, subjects had to score 3 or below on 8 symptom domains derived from the PANSS, and were required to have no hospitalizations during the previous year. The PANSS domains used were P1 (delusions), P2 (conceptual disorganization), P3 (hallucinatory behavior), N1 (blunted affect), N4 (passive/apathetic social withdrawal), N6 (lack of spontaneity and flow of conversation), G5 (mannerisms and posturing), and G9 (unusual thought content).

On follow-up, there were nonsignificant changes in the percentages meeting the outcomes of remission, including no hospitalizations in the past year (49% at baseline, 40% at follow-up), overall symptom remission (56% at baseline, 47% at follow-up), positive-type symptom remission (66% at baseline, 72% at follow-up), and negative-type symptom remission (64% at baseline, 68% at follow-up).

"If you look cross sectionally, you don’t see much change," Dr. Cohen noted.

However, a great deal of movement occurred between groups. Just 25% met remission criteria at both assessments, and an additional 35% did not meet remission criteria at either assessment. Another 25% went from meeting remission criteria at time 1 to not meeting remission criteria at time 2, and 16% went from not meeting remission criteria at T1 to meeting remission criteria at T2.

"Notably, half the persons in remission at time 1 were not in remission at time 2. These findings suggest that sustained remission is much less than suggested by cross-sectional studies, and optimism regarding outcome may need to be tempered.

"Secondly, [the results] suggest that symptoms in later life are not stagnant and that there is considerable flux in symptoms," he commented.

In bivariate analysis, 7 of 12 of the baseline predictor variables were significant at T1: baseline remission, total number of intimates, community integration, residential status, self-esteem score, number of psychiatric medications, and number of entitlements. Significant loss in the past 5 years at T2 also proved to be a significant predictor.

However, on logistic regression analysis, only 3 of the baseline predictors were found to predict readmission at follow-up: a higher community integration score (8.8 vs. 7.3; odds ratio, 1.52), higher number of entitlements (3.9 vs. 3.3; OR, 1.57), and a lower number of psychiatric medications (1.6 vs. 2.3; OR, 0.63). After network size at T1 was controlled for, remission at T1 was significantly correlated with network size at T2 (10.3 vs. 6.5 contacts for persons in remission at T1 vs. nonremission at T2). Baseline remission did not predict any other clinical or social variables at T2, after their baseline levels were controlled for.

"The fact that community integration can impact on subsequent clinical remission suggests that social interventions can be very important in older adults with respect to both clinical and social well-being. The significance of entitlements in this population underscores the need for older adults to secure and maintain various safety net supports as they grow older and more physically frail," Dr. Cohen said.

The finding that more psychotropic medications at baseline were associated with lower remission rates at follow-up is probably attributable to greater symptoms among the nonremission group, rather than the medications making patients worse. However, "it does suggest that the medications may not be as powerful in the older age group," he noted.

Post hoc analysis revealed that compared with the 36 patients who remained in nonremission, the 16 who improved showed higher Instrumental Activities of Daily Living scores at baseline (24.3 vs. 21.9), had a greater number of physical disorders at baseline (2.3 vs. 1.0), and had more persons in their network who could be counted on (7.3 vs. 4.6). When the investigators compared the 25 patients who remained in remission with the 25 who went from remission at baseline to nonremission at follow-up, they found that those who worsened showed lower rates of community integration scores (7.8 vs. 8.9), he said.

There were no significant changes in positive symptom remission (65% at baseline vs. 72% at follow-up), with 51% in remission at both assessments, 15% not in remission at either assessment, 14% going from remission to nonremission, and 20% from nonremission to remission. There were also no significant changes in negative symptom remission (64% at baseline vs. 68% at follow-up), with 54% in remission at both assessments, 23% not in remission at either assessment, 10% going from remission to nonremission, and 14% from nonremission to remission.

"Little is known about the factors that predict the movement from remission to nonremission status and vice versa. Our preliminary data – with a fairly small subsample – suggest that social and functional factors are important," Dr. Cohen concluded. "More studies are needed to identify those factors that move persons toward remission."

Dr. Cohen’s research was funded in part by a grant from the National Institute of General Medical Sciences. He reported no other disclosures.

WASHINGTON – One-fourth of older adults with schizophrenia shifted between remission and nonremission status in the first-ever large-scale longitudinal outcome study of older adults with schizophrenia spectrum disorder living in the community.

The 4-year longitudinal data revealed a lower persistent remission rate than had been suggested by earlier cross-sectional studies. "Our findings suggest that in addition to the increasingly recognized difficulties that older adults with schizophrenia face with respect to physical health, there is substantially more psychiatric instability than previously believed," said Dr. Carl I. Cohen, professor of psychiatry and director of the division of geriatric psychiatry at the State University of New York Downstate, Brooklyn.

Schizophrenia typically develops in the second or third decade of life, and increasing numbers of patients are surviving into old age with the disorder. Between 80% and 85% of people aged 55 years and over with schizophrenia developed it prior to age 45, with prevalence estimates for schizophrenia in adults aged between 45 and 60 of about 0.6% to 1%.

However, over the next two decades, there will be a doubling of the number of people aged 55 years and over with schizophrenia, from about 550,000 in 2005 to 1.1 million in 2025. By that time, about one-fourth of people with schizophrenia will be in this older age bracket. And in contrast to previous decades, most of these individuals are living in the community rather than in institutional settings, Dr. Cohen noted at the annual meeting of the American Association for Geriatric Psychiatry.

Recent cross-sectional studies of older adults have found remission rates of 49% (Am. J. Geriatr. Psychiatry 2008;16:966-73), 47% (J. Int. Neuropsychol. Soc. 2008;14:479-88), and 29% (Schizophr. Res. 2011;126:237-44). In longitudinal studies of remission and associated predictors in younger persons with schizophrenia, rates of clinical remission after an initial clinical episode ranged from 17% to 88% (Curr. Opin. Psychiatry 2011;24:114-21). On follow-up, the percentage of patients maintaining remission ranged from 50% to 89% (Rev. Epidemiol. Sante Publique 2009;57:25-32 and Schizophr. Res. 2009;115:58-66), with remission occurring in some of the originally nonremitted patients over time.

There have been no previous longitudinal studies in older adults, he said.

Dr. Cohen and his associates previously conducted a cross-sectional study of 198 community-dwelling adults with schizophrenia aged 55 years and over, and found that that 49% met the clinical criteria for remission, 66% met the Positive and Negative Syndrome Scale (PANSS) criteria of 3 or fewer of 8 domains, and 83% had had no hospitalizations in the past year (Am. J. Geriatr. Psychiatry 2008;16:966-73). Thus, "the study showed that symptom remission is a realistic goal for many patients," Dr. Cohen said.

In that study, four variables were associated with remission: fewer total network contacts, a greater proportion of intimates, fewer lifetime traumatic events, and higher Dementia Rating Scale scores. Type of residence, use of mental health services, and use of psychotropic medication had no significant association with remission, he said.

In the current longitudinal study, a total of 104 patients aged 55 years and older with schizophrenia spectrum disorders participated in follow-up interviews. They were followed for a mean of 52 months (range, 12-116 months). They had a mean age of 61 years, 55% were men, and 55% were white. Two-thirds (65%) lived in supported residences, while the other 35% lived independently or with family members.

To meet the criteria of remission, subjects had to score 3 or below on 8 symptom domains derived from the PANSS, and were required to have no hospitalizations during the previous year. The PANSS domains used were P1 (delusions), P2 (conceptual disorganization), P3 (hallucinatory behavior), N1 (blunted affect), N4 (passive/apathetic social withdrawal), N6 (lack of spontaneity and flow of conversation), G5 (mannerisms and posturing), and G9 (unusual thought content).

On follow-up, there were nonsignificant changes in the percentages meeting the outcomes of remission, including no hospitalizations in the past year (49% at baseline, 40% at follow-up), overall symptom remission (56% at baseline, 47% at follow-up), positive-type symptom remission (66% at baseline, 72% at follow-up), and negative-type symptom remission (64% at baseline, 68% at follow-up).

"If you look cross sectionally, you don’t see much change," Dr. Cohen noted.

However, a great deal of movement occurred between groups. Just 25% met remission criteria at both assessments, and an additional 35% did not meet remission criteria at either assessment. Another 25% went from meeting remission criteria at time 1 to not meeting remission criteria at time 2, and 16% went from not meeting remission criteria at T1 to meeting remission criteria at T2.

"Notably, half the persons in remission at time 1 were not in remission at time 2. These findings suggest that sustained remission is much less than suggested by cross-sectional studies, and optimism regarding outcome may need to be tempered.

"Secondly, [the results] suggest that symptoms in later life are not stagnant and that there is considerable flux in symptoms," he commented.

In bivariate analysis, 7 of 12 of the baseline predictor variables were significant at T1: baseline remission, total number of intimates, community integration, residential status, self-esteem score, number of psychiatric medications, and number of entitlements. Significant loss in the past 5 years at T2 also proved to be a significant predictor.

However, on logistic regression analysis, only 3 of the baseline predictors were found to predict readmission at follow-up: a higher community integration score (8.8 vs. 7.3; odds ratio, 1.52), higher number of entitlements (3.9 vs. 3.3; OR, 1.57), and a lower number of psychiatric medications (1.6 vs. 2.3; OR, 0.63). After network size at T1 was controlled for, remission at T1 was significantly correlated with network size at T2 (10.3 vs. 6.5 contacts for persons in remission at T1 vs. nonremission at T2). Baseline remission did not predict any other clinical or social variables at T2, after their baseline levels were controlled for.

"The fact that community integration can impact on subsequent clinical remission suggests that social interventions can be very important in older adults with respect to both clinical and social well-being. The significance of entitlements in this population underscores the need for older adults to secure and maintain various safety net supports as they grow older and more physically frail," Dr. Cohen said.

The finding that more psychotropic medications at baseline were associated with lower remission rates at follow-up is probably attributable to greater symptoms among the nonremission group, rather than the medications making patients worse. However, "it does suggest that the medications may not be as powerful in the older age group," he noted.

Post hoc analysis revealed that compared with the 36 patients who remained in nonremission, the 16 who improved showed higher Instrumental Activities of Daily Living scores at baseline (24.3 vs. 21.9), had a greater number of physical disorders at baseline (2.3 vs. 1.0), and had more persons in their network who could be counted on (7.3 vs. 4.6). When the investigators compared the 25 patients who remained in remission with the 25 who went from remission at baseline to nonremission at follow-up, they found that those who worsened showed lower rates of community integration scores (7.8 vs. 8.9), he said.

There were no significant changes in positive symptom remission (65% at baseline vs. 72% at follow-up), with 51% in remission at both assessments, 15% not in remission at either assessment, 14% going from remission to nonremission, and 20% from nonremission to remission. There were also no significant changes in negative symptom remission (64% at baseline vs. 68% at follow-up), with 54% in remission at both assessments, 23% not in remission at either assessment, 10% going from remission to nonremission, and 14% from nonremission to remission.

"Little is known about the factors that predict the movement from remission to nonremission status and vice versa. Our preliminary data – with a fairly small subsample – suggest that social and functional factors are important," Dr. Cohen concluded. "More studies are needed to identify those factors that move persons toward remission."

Dr. Cohen’s research was funded in part by a grant from the National Institute of General Medical Sciences. He reported no other disclosures.

WASHINGTON – One-fourth of older adults with schizophrenia shifted between remission and nonremission status in the first-ever large-scale longitudinal outcome study of older adults with schizophrenia spectrum disorder living in the community.

The 4-year longitudinal data revealed a lower persistent remission rate than had been suggested by earlier cross-sectional studies. "Our findings suggest that in addition to the increasingly recognized difficulties that older adults with schizophrenia face with respect to physical health, there is substantially more psychiatric instability than previously believed," said Dr. Carl I. Cohen, professor of psychiatry and director of the division of geriatric psychiatry at the State University of New York Downstate, Brooklyn.

Schizophrenia typically develops in the second or third decade of life, and increasing numbers of patients are surviving into old age with the disorder. Between 80% and 85% of people aged 55 years and over with schizophrenia developed it prior to age 45, with prevalence estimates for schizophrenia in adults aged between 45 and 60 of about 0.6% to 1%.

However, over the next two decades, there will be a doubling of the number of people aged 55 years and over with schizophrenia, from about 550,000 in 2005 to 1.1 million in 2025. By that time, about one-fourth of people with schizophrenia will be in this older age bracket. And in contrast to previous decades, most of these individuals are living in the community rather than in institutional settings, Dr. Cohen noted at the annual meeting of the American Association for Geriatric Psychiatry.

Recent cross-sectional studies of older adults have found remission rates of 49% (Am. J. Geriatr. Psychiatry 2008;16:966-73), 47% (J. Int. Neuropsychol. Soc. 2008;14:479-88), and 29% (Schizophr. Res. 2011;126:237-44). In longitudinal studies of remission and associated predictors in younger persons with schizophrenia, rates of clinical remission after an initial clinical episode ranged from 17% to 88% (Curr. Opin. Psychiatry 2011;24:114-21). On follow-up, the percentage of patients maintaining remission ranged from 50% to 89% (Rev. Epidemiol. Sante Publique 2009;57:25-32 and Schizophr. Res. 2009;115:58-66), with remission occurring in some of the originally nonremitted patients over time.

There have been no previous longitudinal studies in older adults, he said.

Dr. Cohen and his associates previously conducted a cross-sectional study of 198 community-dwelling adults with schizophrenia aged 55 years and over, and found that that 49% met the clinical criteria for remission, 66% met the Positive and Negative Syndrome Scale (PANSS) criteria of 3 or fewer of 8 domains, and 83% had had no hospitalizations in the past year (Am. J. Geriatr. Psychiatry 2008;16:966-73). Thus, "the study showed that symptom remission is a realistic goal for many patients," Dr. Cohen said.

In that study, four variables were associated with remission: fewer total network contacts, a greater proportion of intimates, fewer lifetime traumatic events, and higher Dementia Rating Scale scores. Type of residence, use of mental health services, and use of psychotropic medication had no significant association with remission, he said.

In the current longitudinal study, a total of 104 patients aged 55 years and older with schizophrenia spectrum disorders participated in follow-up interviews. They were followed for a mean of 52 months (range, 12-116 months). They had a mean age of 61 years, 55% were men, and 55% were white. Two-thirds (65%) lived in supported residences, while the other 35% lived independently or with family members.

To meet the criteria of remission, subjects had to score 3 or below on 8 symptom domains derived from the PANSS, and were required to have no hospitalizations during the previous year. The PANSS domains used were P1 (delusions), P2 (conceptual disorganization), P3 (hallucinatory behavior), N1 (blunted affect), N4 (passive/apathetic social withdrawal), N6 (lack of spontaneity and flow of conversation), G5 (mannerisms and posturing), and G9 (unusual thought content).

On follow-up, there were nonsignificant changes in the percentages meeting the outcomes of remission, including no hospitalizations in the past year (49% at baseline, 40% at follow-up), overall symptom remission (56% at baseline, 47% at follow-up), positive-type symptom remission (66% at baseline, 72% at follow-up), and negative-type symptom remission (64% at baseline, 68% at follow-up).

"If you look cross sectionally, you don’t see much change," Dr. Cohen noted.

However, a great deal of movement occurred between groups. Just 25% met remission criteria at both assessments, and an additional 35% did not meet remission criteria at either assessment. Another 25% went from meeting remission criteria at time 1 to not meeting remission criteria at time 2, and 16% went from not meeting remission criteria at T1 to meeting remission criteria at T2.

"Notably, half the persons in remission at time 1 were not in remission at time 2. These findings suggest that sustained remission is much less than suggested by cross-sectional studies, and optimism regarding outcome may need to be tempered.

"Secondly, [the results] suggest that symptoms in later life are not stagnant and that there is considerable flux in symptoms," he commented.

In bivariate analysis, 7 of 12 of the baseline predictor variables were significant at T1: baseline remission, total number of intimates, community integration, residential status, self-esteem score, number of psychiatric medications, and number of entitlements. Significant loss in the past 5 years at T2 also proved to be a significant predictor.

However, on logistic regression analysis, only 3 of the baseline predictors were found to predict readmission at follow-up: a higher community integration score (8.8 vs. 7.3; odds ratio, 1.52), higher number of entitlements (3.9 vs. 3.3; OR, 1.57), and a lower number of psychiatric medications (1.6 vs. 2.3; OR, 0.63). After network size at T1 was controlled for, remission at T1 was significantly correlated with network size at T2 (10.3 vs. 6.5 contacts for persons in remission at T1 vs. nonremission at T2). Baseline remission did not predict any other clinical or social variables at T2, after their baseline levels were controlled for.

"The fact that community integration can impact on subsequent clinical remission suggests that social interventions can be very important in older adults with respect to both clinical and social well-being. The significance of entitlements in this population underscores the need for older adults to secure and maintain various safety net supports as they grow older and more physically frail," Dr. Cohen said.

The finding that more psychotropic medications at baseline were associated with lower remission rates at follow-up is probably attributable to greater symptoms among the nonremission group, rather than the medications making patients worse. However, "it does suggest that the medications may not be as powerful in the older age group," he noted.

Post hoc analysis revealed that compared with the 36 patients who remained in nonremission, the 16 who improved showed higher Instrumental Activities of Daily Living scores at baseline (24.3 vs. 21.9), had a greater number of physical disorders at baseline (2.3 vs. 1.0), and had more persons in their network who could be counted on (7.3 vs. 4.6). When the investigators compared the 25 patients who remained in remission with the 25 who went from remission at baseline to nonremission at follow-up, they found that those who worsened showed lower rates of community integration scores (7.8 vs. 8.9), he said.

There were no significant changes in positive symptom remission (65% at baseline vs. 72% at follow-up), with 51% in remission at both assessments, 15% not in remission at either assessment, 14% going from remission to nonremission, and 20% from nonremission to remission. There were also no significant changes in negative symptom remission (64% at baseline vs. 68% at follow-up), with 54% in remission at both assessments, 23% not in remission at either assessment, 10% going from remission to nonremission, and 14% from nonremission to remission.

"Little is known about the factors that predict the movement from remission to nonremission status and vice versa. Our preliminary data – with a fairly small subsample – suggest that social and functional factors are important," Dr. Cohen concluded. "More studies are needed to identify those factors that move persons toward remission."

Dr. Cohen’s research was funded in part by a grant from the National Institute of General Medical Sciences. He reported no other disclosures.