Challenges in antipsychotic prescribing in older age. Schiz Bulletin. Sept.2013

13.09.2013

 The average life span of a person with schizophrenia is 20–23 years shorter than that of an unaffected person. People with schizophrenia in their 40s and 50 s may be comparable medically with those in the 60s and 70s in the general population and this has to be considered while formulating treatment plans.

Dilip V. Jeste and Jeanne e. Maglione from  Department of Psychiatry, University of California, San Diego describe the challenges in treating middle and older individuals (40-and above) with schizophrenia. These individuals have:   reduced hepatic protein synthesis (hence  more biological active free drug in blood), increased elimination half life ,increased permeability of BBB, decrease in number of D2 receptors, occurrence of EPSe at far less D2 occupancy, increased risk of falls and metabolic syndrome;  and these  are some of the key factors to consider while prescribing medications.

Late-onset schizophrenia is thought to have better prognosis and requires lower daily dosages of antipsychotics than early-onset illness.  Absolute reemission requiring to be on no medications/ significantly reduced doses is observed in a small minority (up to 8%). Reduction in dose or gradual tapering and discontinuation may be possible in later years in a minority. Discontinuation due to side effect is more among this age group. Authors advise to start very low initial dose (25%–50% of that used in a younger adult) and titrate more slowly. In stable patients,  consider  gradual and incremental dose decreases in order to determine the lowest effective dose, and occasionally could try for eventual discontinuation.Interventions like Cognitive Behavioral Social Skills Training and Functional Adaptation Skills Training are effective in functional recovery.

Conclusion:

Remission is possible even after decades of illness. Need and effects of medication should be monitored closely and frequently.

Treating older adults with schizophreniachallenges and opportunities.

Jeste DV, Maglione JE. Schizophr Bull. 2013 Sep;39(5):966-8.

 

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