Studying late-onset schizophrenia and non schizophrenia

Studying late-onset schizophrenia and non schizophrenia

psychosis in elderly Egyptian patientsHanan Husseina, Ahmed El Shafeia, Marwa Abd El Meguidb, Marwa El Missiryb

and Mahmoud Tamarac

Departments of aNeuropsychiatry,bNeuropsychychiatry and cGeriatric, Faculty ofMedicine, Ain Shams University, Cairo, Egypt

Correspondence to Marwa Abd El Meguid, MD,Department of Psychiatry, Institute of Psychiatry, 65 ElNozha Street, Heliopolis, Cairo, EgyptTel: + 002 0105752536; fax: + 202 22678032;e-mail: [email protected]

Received 19 May 2011Accepted 12 August 2011

Middle East Current Psychiatry

2012, 19:12–22

Background

In Egypt, the proportion of elderly people in the population is increasing markedly;

cases of late-life psychoses are increasing at a rapid pace as the population of the

world ages, and this will create a tremendous economic burden on the society

because of the increasing rates of disability.

Aim

The aim of this work was to compare the sociodemographic and clinical

characteristics, daily living functioning, and cognitive impairment between late-onset

schizophrenia and other late-onset psychotic disorders.

Patients and methods

A cross-sectional comparative study was conducted on 100 patients: 50 patients with

schizophrenia with onset after the age of 50 years (group A) and 50 patients with

nonschizophrenia late-onset psychoses (group B). All patients were interviewed using The

Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders

Axis-I diagnosis were assessed using the Positive and Negative Syndrome Scale, the

Functional Assessment of Activity of Daily Living scale, section B of the Cambridge Mental

Disorders of the Elderly Examination, and the Wechsler Adult Intelligence Scale.

Results

Patients in group A were significantly younger – they were mainly women (72%), the

majority were never married (54%), and 62% were living alone – compared with group

B, who were mainly married (46%) and lived more often with their families. Among

patients with late onset schizophrenia spectrum, 70% had paranoid subtype, 12% had

delusional disorder and the rest had either undifferentiated or schizoaffective subtype.

On the other hand, 70% of group B patients had psychotic symptoms due to dementia,

20% had mood disorder with psychotic symptoms; and the rest 10% had psychosis

secondary to medical illnesses. (Group B) patients had significantly lower scores on

items assessing positive symptoms and higher scores on general psychopathology

than did (Group A) patients, the scores on negative symptoms, and also the total

PANSS scores were almost similar in both groups and did not show any significant

differences. Group A patients scored significantly better in daily living functioning,

whereas a significant number of patients of group B needed partial and complete

support. Cognitive assessment revealed that group A patients scored almost within

norms, except for memory, apraxia, abstract, and perception items, compared with

group B patients who scored significantly lower in all cognitive items.

Conclusion

Patients with late-onset schizophrenia compared with patients with other late-onset

psychoses differ in a number of psychosocial and clinical variables, daily functioning,

and cognitive abilities. The results of this study contribute to the development of a

better understanding of the elderly patient population with different types of late-onset

psychoses, which have been largely ignored in research.

Keywords:

activities of daily living, cognitive functions, late-onset psychoses, late-onset

schizophrenia

Middle East Curr Psychiatry 19:12–22& 2012 Okasha Institute of Psychiatry, Ain Shams University2090-5408

Introduction

Worldwide, the number of persons aged 65 years or older

has increased from 17 million in 1900 to 342 million in

1992 and is expected to increase to 2.5 billion (compris-

ing 20% of the total population) by 2050 [1]. In other

words, the proportion of elderly people in this population

will increase by 65%. In the next 30 years, life expectancy

12 Original article

2090-5408 & 2012 Okasha Institute of Psychiatry, Ain Shams University DOI: 10.1097/01.XME.0000407866.00571.95

Copyright © Institute of Psychiatry, Ain Shams University. Unauthorized reproduction of this article is prohibited.

will increase markedly in western countries, and it is

expected to increase further [2]. In Egypt, there is

a marked increase in the proportion of elderly people in

the population; according to ‘The Statistical Year Book

2009,’ [3] people above 60 years of age constitute 6% of

the Egyptian population and this proportion is expected

to reach 11.5% by the year 2025 with the mean life

expectancy around 70.1 years [4].

Cases of late-life psychoses are increasing markedly as the

population of the world ages, and this will create a

tremendous economic burden on the society because of

the increasing rates of disability and institutionaliza-

tion [5]. It is worth mentioning that Khouzam et al. [6]

reported that up to 23% of the elderly population will

experience psychotic symptoms that may increase the

suffering of patients, family, and caregivers [5].

There is a growing awareness that late-onset psychoses

constitute a heterogenous group of serious disorders of a

complex nature, which present in different forms with

different etiologies [7,8]. These conditions include

delusional disorders, induced psychotic disorders, late-

onset schizophrenia, psychosis associated with dementia,

mood disorders with prevailing psychotic symptoms, and

others [9,10]; clinicians must remember the nonspecific

nature of psychotic symptoms to avoid errors in diagnosis

[11]. Controversy still surrounds the differential diag-

nosis of psychoses that begin late in life [12,13]. The

nosology, classification, and biological basis of psychoses

in the elderly have been much debated; primary and

secondary psychotic disorders of late life and their etiology

are commonly considered from the view point of risk

factors such as genetic predisposition triggering life events

and organic cerebral dysfunction [11]. In a recent study

by Woolley et al. [13], a total of 28.2% of patients with

a neurodegenerative disease received a prior psychiatric

diagnosis of a psychotic nature, as neurodegenerative

diseases are often misdiagnosed as psychiatric disorders.

Late-onset schizophrenia refers to schizophrenia or a

related disorder (schizoaffective, schizophreniform, or

delusional disorder) with onset of prodromal symptoms

after the age of 50 years [8]. According to Diagnostic andStatistical Manual of Mental Disorders (DSM)-III-R, the

onset of symptoms, including prodromal symptoms, must

be after the age of 45 years. DSM-IV, however, does not

specify the term ‘late onset,’ nor does it set an upper age

limit for the diagnosis of schizophrenia [9]. Although

DSM-IV and DSM-IV-TR criteria do not include codeable

diagnoses for late-onset schizophrenia, DSM-IV and

DSM-IV-TR mention differences between cases of

schizophrenia with onset after 50 years compared with

those with earlier onset. Moreover, DSM-III-R included a

late-onset category for patients with initial presentation

at the age of 50 years or later [10].

Different studies suggest that there are specific risk

factors for late-onset schizophrenia that could be identi-

fied; these include female sex, visual, auditory sensory

impairments, and premorbid schizoid personality [7].

In Egypt, with the increased longevity of life and the

change in family system toward a nuclear one, together

with the increased medical, psychiatric, and behavioral

problems in the aged population, there is a great

necessity to have carefully designed plans for mental

health promotion of the elderly [14]. There is clearly an

enormous need to clarify the clinical characteristics and

range of dysfunction in cases of late-onset psychoses to

streamline treatment recommendation for the already

complex and vulnerable elderly population, aiming to

minimize the cost of these devastating disorders through

early recognition and fast intervention.

Aim of the workThe aim of the current study was to compare the

sociodemographic and clinical characteristics, daily func-

tioning, and cognitive impairment between patients with

late-onset schizophrenia and those with other late-onset

psychotic disorders.

Patients and methodsDesign

The study design was cross-sectional and comparative in

nature, and the sample was selective. A total of 100

patients were enrolled in a 1-year period from March 2008

to February 2009; they were selected and divided into

two groups, A and B, as mentioned below.

Group A comprised 50 patients fulfilling the diagnosis of

schizophrenia and other psychotic disorders according to

DSM-IV. We also used the operational definition accord-

ing to the consensus statement by the International Late-

Onset Schizophrenia Group, which stated that the term

could be applied to those cases with onset of prodromal

symptoms after the age of 50 years and refers to

schizophrenia or a related disorder (schizoaffective,

schizophreniform, or delusional disorder) [8]. Both male

and female patients were recruited from among the

inpatients and outpatients attending the Geriatric

Hospital and Institute of Psychiatry, Ain Shams Uni-

versity Hospitals. Some cases were also recruited from

Abbasseya State Hospital because of the rarity of cases

fulfilling the following inclusion and exclusion criteria:

patients should have developed schizophrenia after the

age of 50 years; and patients should not have a life-time

history of schizophrenia, other psychoses including

schizoaffective disorder, paranoid disorder, or psychotic

symptoms secondary to other mental or general medical

disorders or dementia.

Group B comprised 50 male and female patients fulfilling

the diagnosis of late-onset nonschizophrenia psychoses

developed after the age of 50 years, including psychotic

disorders due to general medical conditions, mood

disorders with psychotic features, and dementia with

delusions and hallucinations. Patients with life-time history

of schizophrenia, schizoaffective disorder, mood disorder,

delirium, or late-stage dementia were excluded. Patients

Late-onset schizophrenia and nonschizophrenia psychosis Hussein et al. 13


were recruited mainly from inpatient and outpatient clinics

of Geriatric Ain Shams University Hospital.

Ethical issue

Ethical approval of the research protocol was obtained from

the Ain Shams University Ethical and Research Commit-

tee. The researchers described the study to the patients or

their guardians, ensured confidentiality of information, and

obtained their informed consent for participation. It was

stated that participation in the study was voluntary and

that they have the freedom to withdraw from the

assessment at any time. Informed written consent from

patients or their guardians was obtained. All 50 cases in

each study group who fulfilled the research criteria and

gave their consent were subjected to preliminary clinical

evaluation including history of illness obtained from the

patient and his or her family. Physical and neurological

examinations were conducted by a Gerontologist Specialist.

The research team also revised the medical files and

investigations of all patients.

Tools and procedures

All patients underwent the following examinations:

(a) clinical assessment, (b) assessment of daily function-

ing, (c) cognitive assessments, and (d) Fahmy and

El-Sherbini’s Social Classification Scale.

Clinical assessments included the Structured Clinical

Interview for DSM Axis-I diagnosis – clinical version [15]

and the Positive and Negative Syndrome Scale

(PANSS) [16]. The PANSS was designed to measure

the severity of psychopathology in adult patients with

schizophrenia, schizoaffective disorder, and other psycho-

tic disorders.

Assessment of daily functioning included activities of

daily living (ADL) and instrumental activities of daily

living (IADL).

The ADL scale [17] assesses certain basic abilities that a

person must possess to remain at home independently.

These abilities allow a person to perform basic self-care

tasks. Accordingly, patients were classified into the

following groups: needs no support (10), needs partial

support (six to nine), or needs full support (zero to five).

The Arabic standardized version was used [18]. The

IADL scale [17] measures two broad categories: (a) basic

self-maintenance behaviors such as feeding, dressing,

bathing, and mobility, and (b) more complex behaviors

such as managing finances, traveling, and taking medica-

tions. These abilities are higher-level abilities that allow a

person to function independently at home or in the

community. Accordingly, patients were classified into the

following groups: needs no support (10), needs partial

support (six to nine), or needs full support (zero to five).

We used the Arabic standardized version [18].

Cognitive assessments included Cambridge Mental Dis-

orders of the Elderly Examination (CAMDEX) scale [19]

and the Wechsler Adult Intelligence Scale (WAIS).

The CAMDEX scale [19] was developed to assess the

diagnosis and measurement of dementia among the

elderly. This scale assessed orientation, language (ex-

pression, comprehension), memory (both recent and

remote), and learning praxis, attention, abstract thinking,

perception, and calculation. It was translated into Arabic

and validated by Mahmoud et al. [20]. The WAIS [21] is

the most commonly administered general intelligence

test for adults, and it is also viewed as a broad assessment

of cognitive functions. The Wechsler scale provides

information about the important aspects of the patients’

intellectual functioning. We used the standardized Arabic

version of the test [22].

Fahmy and El-Sherbini’s Social Classification Scale [23] is

based on parameters such as education and work of the

father, education and work of the mother, income

crowding index, and sanitation.

Statistical analysis

Data were statistically analyzed using the Statistical

Package for Social Sciences program software version 17.0.

(SPSS Inc., Illinois, Chicago) Descriptive statistics were

obtained for numerical parametric data as means and SD and

for categorical data as number and percentage. Inferential

analyses were performed for quantitative variables using

Student’s t-test for independent data. Qualitative data were

analyzed using Pearson’s w2-test. The level of significance

was taken at P-value less than 0.05; otherwise, it was

considered nonsignificant.

ResultsTo fulfill the aim of the work, we compared the studied

groups with each other with regard to their socio-

demographic characteristics, clinical data, ADL, and

cognitive functioning.

Demographic data

Patients in group A were significantly younger (mean age

69.5 ± 3.39) – they were mainly women (72%), the

majority were never married (54%), and 62% were living

alone – compared with group B (mean age 72.5 ± 2.26),

who were mainly married (46%) and lived more often

with their families. Social class did not show any

statistical differences between the groups.

A total of 54% of group A patients graduated from

secondary schools and universities compared with only

38% of group B patients. Previous engagement in

different occupations showed striking differences, as a

higher percentage of group B patients were engaged in

jobs previously compared with group A patients

(P = 0.000). Details are illustrated in Table 1.

Age at onset, duration of illness, and family history of

psychiatric illness

Patients in group A developed their illness significantly

earlier (P = 0.001) and had longer duration of illness than

did patients in group B. Although group A patients had

higher frequency of positive family history of psychiatric

disorders compared with group B patients (8 and 4%,

14 Middle East Current Psychiatry


respectively), the difference was not statistically signifi-

cant (P40.05) (Table 1).

Medical history

Group A patients had significantly (P = 0.000) more

chest diseases (72%), auditory impairment (30%), and

musculoskeletal problems (66%) compared with group B

patients; in contrast, group B patients had significantly

(P = 0.000) more renal (56%) and neurological diseases

(50%) than group A patients. No statistically significant

difference was found between the two groups with regard

to diabetes mellitus, hypertension, cardiac diseases, and

visual impairment (Table 2).

Clinical data

Diagnostic categories

Data represented in Fig. 1a show that, among patients

with late-onset schizophrenia, 70% had paranoid subtype,

12% had delusional disorder, and the remaining had either

undifferentiated or schizoaffective subtype. In contrast,

70% of group B patients with other late-onset psychoses

had psychotic symptoms due to dementia, 20% had mood

disorder with psychotic symptoms, and the remaining 10%

had psychosis secondary to medical illnesses (Fig. 1b).

Assessment of psychotic symptoms using Positive and

Negative Syndrome Scale

Figure 2 illustrates clearly that group B patients had

significantly lower scores on items assessing positive

symptoms (including delusions, conceptual disorganiza-

tion, and hallucinatory behavior) and higher scores on

general psychopathology (including somatic concern,

anxiety, guilt feelings) than did group A patients; the

scores on negative symptoms (including blunted affect,

emotional withdrawal, poor rapport) and the total PANSS

scores were almost similar in both groups and did not

show any significant differences.

The nature and content of delusions differ from that of

group A patients who had more complex bizarre delusions

of control, passivity, and persecution in comparison with

group B patients with dementia who exhibited simple

paranoid delusion and also delusions of someone stealing or

Table 1 Sociodemographic variables

Group A Group B

Patients with late-onset schizophrenian = 50

Patients with nonschizophrenia late-onset psychosesn = 50

No % No % Test

Age, mean ± SD 69.5 ± 3.39 72.5 ± 2.26 Test used t-testP = 0.000 (VHS)

Age of onset, mean ± SD 57.24 ± 6.6 69.82Duration of illness, mean ± SD 14.06 2.68Sex

Females 36 72% 26 52% w2 = 6.0Males 14 28% 24 48% P = 0.014 (Sig)

Marital statusMarried 14 28% 23 46% w2 = 40.67Never married 27 54% 3 6% d.f. = 3Divorced 5 10% – – P = 0.000Widow 4 8% 24 48% (VHS)

Living statusSpouse 5 10% 19 38% w2 = 54.03Children 3 6% 16 32%Others 1 2% 8 16% d.f. = 4Family 10 20% 7 14% P = 0.000Alone 31 62% – – (VHS)

EducationIlliterate 7 14% 6 12% w2 = 6.52Read and write 8 16% 9 18% d.f. = 5.0Primary school 3 6% 10 20% P = 0.025Preparatory school 5 10% 6 12% (Sig)Secondary school 21 42% 12 24%University 6 12% 7 14%

Previous occupationNone 27 54% 7 14% w2 = 20.45Professional 8 16% 16 32% d.f. = 3.0Semiprofessional 4 8% 2 4% P = 0.000Skilled and others 11 22% 25 50% (VHS)

Social classHigh 9 18% 10 20% w2 = 1.124High middle 6 12% 3 6% d.f. = 3Low middle 8 16% 8 16% P = 0.771Low 27 54% 29 58% (Insig)

Family history of psychiatric illnessYes 4 8% 2 4% P40.05No 46 92% 48 96% (Insig)

d.f., degree of freedom; Insig, insignificant; Sig, significant; VHS, very highly significant.



hiding objects. Group B patients with depression described

somatic, hypochondriacal delusions. In addition, some

patients had delusions of guilt and nihilism, and others

had noncongruent delusions of persecution and reference.

The pattern of hallucinations in group A patients showed

multimodal hallucinations, mainly auditory, tactile, and

olfactory hallucinations. Schneiderian first-rank symptoms

such as hearing multiple voices or running commentary were

recorded in this group, whereas group B patients with

dementia had mainly visual hallucination. Group B patients

with mood disorder had auditory and olfactory hallucinations.

Functional assessment of the ADL scores revealed that

group A patients had significantly better ADL and IADL

scores, whereas a significant number of group B patients

needed partial and complete support compared with

group A patients (Table 3).

Cognitive assessment

Using section B (CAMCOG) of the CAMDEX it was

revealed that group A patients scored almost within

norms, except for memory, apraxia, abstract, and percep-

tion items, compared with group B patients who scored

lower in all cognitive items. Group A patients compared

with group B showed highly statistically significant dif-

ferences in the following parameters: language, memory,

abstract, and perception (P = 0.000). Their scores on

orientation, attention, and apraxia were significantly

lower at the following levels of significance: 0.004, 0.02,

and 0.001, respectively (Table 4).

On the WAIS, patients with late-onset schizophrenia

scored significantly better in all total and subitems of the

test. It was noticed that a very highly statistically significant

difference exists between both groups with regard to total,

performance, and verbal intelligence quotient scores, being

lower in group B than in group A. Both groups showed

discrepancy between verbal and performance intelligence

quotient, which denotes cognitive decline (Table 5).

DiscussionPsychotic manifestations constitute an important pro-

blem in the geriatric population. Some authors have

reported that psychosis was present in 26% of elderly

patients admitted to an inpatient geriatric unit and in

36% of patients admitted for the first time to a

psychiatric facility [24]. Within the psychiatric ward,

cases showing an onset after 40 years of age comprised

10.8% of the total population [25]. Early detection and

management of psychotic symptoms is associated with a

better psychosocial adjustment [24].

This study aimed to uncover some clinical aspects in a

sample of the Egyptian elderly population. The research

aimed to study a group of elderly patients with primary

psychotic disorders that appear for the first time after

the age of 50 years (group A), including schizophrenia,

delusional disorder, and schizoaffective disorders, and

compare them with a group of elderly patients

with psychotic disorders other than schizophrenia (group

B), which include psychosis associated with dementia,

Table 2 Medical history: a comparison between patients with late-onset schizophrenia and nonschizophrenia late-onset psychoses

Group A Group B


Patients with nonschizophrenia late onset psychosesn = 50

No % No % Test

Diabetes+ ve 19 38% 11 22% w2 = 3.04– ve 31 62% 39 78% P = 0.08 (Insig)

Cardio vascular diseases+ ve 21 42% 17 34% w2 = 0.679– ve 29 58% 33 66% P = 0.410 (Insig)

Chest diseases+ ve 36 72% 14 28% w2 = 19.36– ve 14 28% 36 72% P = 0.000 (VHS)

GIT diseases+ ve 25 50% 15 30% w2 = 4.167– ve 25 50% 35 70% P = 0.04 (Sig)

Renal diseases+ ve 6 12% 28 56% w2 = 21.569– ve 44 88% 22 44% P = 0.000 (VHS)

CNS diseases+ ve 8 16% 25 50% w2 = 13.07– ve 42 84% 25 50% P = 0.000 (VHS)

Visual impairment+ ve 18 36% 14 28% w2 = 0.735– ve 32 64% 36 72% P = 0.391 (Insig)

Auditory impairment+ ve 15 30% 5 10% w2 = 6.750– ve 35 70% 45 90% P = 0.01 (Sig)

Musculo skeletal problems+ ve 33 66% 12 24% w2 = 17.818– ve 17 34% 38 76% P = 0.000 (VHS)

Insig, insignificant; Sig, significant; – ve, negative; + ve, positive; VHS, very highly significant.



mood disorders, and psychosis secondary to medical

conditions.

Demographic variables

Late-onset schizophrenia affects women two to 10 times

more than it does men [8,10]. With regard to sex, 72% of

patients with late-onset schizophrenia were significantly

predominantly women compared with only 52% of patients

with late-onset other psychoses. This result was in

accordance with a previous study by Howard et al. [8]. In

the Egyptian community, Ashour et al. [26] found that the

ratio between men and women was 1 : 3 among the elderly

with different psychiatric morbidities in Cairo hostels. The

preponderance of female patients in the group of late-onset

schizophrenia was also recorded previously by Haiba [27],

who studied paranoid symptoms in the elderly population

in Egypt. Recently in China, Yasuda and Kato [25] found

that female patients comprised 16.3%, which was signifi-

cantly higher than that of male cases (2.0%). The

robustness of this finding, coupled with the higher

incidence rates of early-onset schizophrenia in men, led

to the estrogen hypothesis, which postulates that estradiol

has antidopaminergic properties that somehow protect

women to a certain degree from puberty to menopause.

As estradiol levels decrease at midlife, this protective factor

is lost, thus predisposing vulnerable women to a second

illness-onset peak after the age of 45 years because of the

decline in estrogen with relative excess of dopamine D2

receptors [28].

Social isolation has been linked to late-onset schizophrenia;

it either plays a role in causation or may be the

consequence [29]. In our research, we found that patients

with late-onset schizophrenia were predominantly never

married or were divorced; a significant proportion of them

were living alone compared with the group of nonschizo-

phrenia late-onset psychosis patients. Our results agreed

with those of previous national and international research-

ers who found that social isolation, living alone, having no

friends, and having no regular visitors are associated with

late-onset schizophrenia [27,29,30].

Genetic factors seem to play a smaller role in the etiology

of late-onset schizophrenia [8]. Our results showed that

there were no significant differences with regard to family

history of psychiatric disorders among both studied

groups, consolidating the above-mentioned findings.

Medical history

Late-life psychotic symptoms often have a medical

etiology and may be the first symptoms of undiagnosed

medical conditions. This is because elderly people usually

take several medications with possible side effects and

drug interactions, which may contribute to the appear-

ance of psychotic symptoms [6,7].

Group B patients had significantly more frequent renal

and neurological diseases. It was also reported in Egyptian

communities that cognitive and behavioral changes were

frequently encountered in elderly patients with renal

impairment [31]. In addition, Mostafa et al. [32] had

reported a high prevalence of neurological incidents among

elderly patients presenting with psychiatric symptoms.

Group A patients with late-onset schizophrenia compared

with their group B counterparts had significantly more

frequent chest diseases, probably because of excessive

smoking, more musculoskeletal problems, and auditory

impairment, which add to their social isolation. We are in

agreement with previous studies that found that some

evidence exists of an association between sensory deficits

and psychotic symptoms [33,34]; moreover, some have

Figure 1

0%

70%

4%

0%

12%

14%

0% 10% 20% 30% 40% 50% 60% 70% 80%

Residual Schizo.

Paranoia Schizo.

Undiff. Schizo.

Disorganized Schizo.

Delusional Dis.

Schizoaffective

(a)

(b)

Residual Schizo. Paranoid Schizo. Undiff. Schizo.Disorganized Schizo. Delusional Dis. Schizoaffective

20%

70%

10%

Mood dis. With psychotic featuresPsychosis due to dementiaOthers

(a) Diagnostic categories: late-onset schizophrenia. (b) Diagnosticcategories: late-onset other psychoses.

Figure 2

35.621.5

58.1

115.2 114.6

29.621.9

63.1

0

20

40

60

80

100

120

140

Positivesymptoms

Negativesymptoms

Generalpsychopathology

Total PANSS

Group (A) Group (B)

P=0.001 P=0.634Insig.

p=0.01Sig.Sig.

p=0.06Sig.

Assessment of psychotic symptoms by PANSS: a comparison betweenpatients with late-onset schizophrenia (group A) and nonschizophrenialate-onset psychoses (group B). PANSS, Positive and NegativeSyndrome Scale.



suggested that late-onset schizophrenia might reflect the

impact of sensory deprivation due to uncorrected visual

and hearing deficits associated with aging [35].

Diagnostic categories

The majority of group B patients (70%) had psychosis due

to dementia, whereas 20% had mood disorder with

psychotic features, and 10% had psychosis secondary to

medical illnesses. Our results are not in agreement with

the study by Barclay and Almeida [36], who reported that

the most frequent clinical diagnoses for elderly patients

with psychotic symptoms other than schizophrenia were

dementia (40%), depression (33%), psychosis secondary

to a medical condition (7%), bipolar disorder (5%), and

the remaining due to adverse reaction to medication. Jeste

and Finkel [37] stated that the incidence of psychosis

in dementia was 30–50%, whereas Paulsen et al. [38]

reported that approximately 50% of dementia patients will

have psychotic symptoms, predominantly delusions and

hallucinations. The difference between our results and

the above-mentioned findings could be attributed to the

difference in sampling methods and techniques.

The diagnosis of paranoid disorder was by far the most

diagnostic type of schizophrenia encountered in our late-

onset schizophrenia group (70%), whereas only 12% had

delusional disorder and 14% had schizoaffective disorder.

Only 4% had undifferentiated schizophrenia. In their

study, Yasuda and Kato [25] found that the paranoid type

comprised 55.3% of the total population of late-onset

Table 3 Functional assessment of daily living: a comparison between patients with late-onset schizophrenia and nonschizophrenia

late-onset psychoses

Group A Group B


Patients with nonschizophrenialate-onset psychoses

n = 50

No % No % Test

(a) ADLADL (mean ± SD) 12.8 ± 9.8 7.5 ± 2.2 t = 3.7

P40.000 (VHS)Need complete support (0–5) 2 4% 5 10% w2 = 48.33Need partial support (6–0.9) 4 8% 31 62% d.f. = 2No need for support (10–12) 44 88% 14 28% P = 0.000 (VHS)

(b) IADLIADL (mean ± SD) 12.31 ± 2.81 7.6 ± 3.1 t = 4.9

P40.000 (VHS)Need complete support (0–5) 2 4% 18 36% w2 = 49.86Need partial support (6–0.9) 8 16% 20 40% d.f. = 2No need for support (10–12) 42 84% 12 24% P = 0.000 (VHS)

ADL, activities of daily living; d.f.,degree of freedom; IADL, instrumental activities of daily living; VHS, very highly significant.

Table 4 Comparison between patients with late-onset schizophrenia and nonschizophrenia late-onset psychoses

Group AMean ± SD

Group BMean ± SD



n = 50 Test

Orientation 9.08 ± 1.00 5.32 ± 1.39 t = 15.47P = 0.004 (Sig)

Language 18.7 ± 2.18 15.26 ± 4.03 t = 14.61P = 0.000 (VHS)

Memory 17.20 ± 2.64 11.52 ± 5.45 t = 6.628P = 0.000 (VHS)

Attention 5.74 ± 2.38 3.1 ± 1.32 t = 12.03P = 0.02 (VHS)

Apraxia 9.45 ± 2.15 5.12 ± 2.0 t = 6.7P = 0.001 (Sig)

Abstract 4.46 ± 2.0 2.3 ± 0.7 t = 41.49P = 0.000 (VHS)

Perception 5.96 ± 1.3 4.02 ± 1.15 t = 7.76P = 0.000 (VHS)

Total 70.59 ± 13.65 46.64 ± 16.04 t = 17.0P = 0.00 (VHS)

Norms according to the Egyptian sampleOrientation Language Memory Attention Apraxia Abstract Perception9.2 ± 1.0 21.9 ± 2.6 20.7 ± 3.6 5.1 ± 1.9 10.1 ± 2.0 5.3 ± 3.2 7.8 ± 1.8

Sig, significant; VHS, very highly significant



cases. The higher prevalence of paranoid schizophrenia in

our sample compared with other studies could not be

interpreted because our sample is a selective sample

rather than a random one.

Clinical picture

Symptoms of psychosis associated with late-onset schizo-

phrenia were different from that of other late-onset

psychoses. Delusions reported in dementia patients were

typically simple, nonbizarre, and of the paranoid type, for

example, morbid jealousy and delusions related to someone

stealing or hiding objects. A number of researchers have

found that delusions and hallucinations are commonly

associated with aggression, agitation, and disruptive behav-

ior in patients with dementia [39–41]. Patients with late-

onset schizophrenia tended to have complex bizarre

systematized delusions, example persecutory delusions

and suffering from a disease or spouse infidelity. Delusions

in patients with mood disorders were characterized by

somatic, hypochondriacal, guilty, or nihilistic delusions, and

also by noncongruent delusions such as persecution and

reference. These results were similar to previous findings

in the elderly Egyptian population [42–44]. From the

clinical point of view, Alexopoulos et al. [45] stated that

depressive delusions can be distinguished from delusions in

patients with dementia, in that the latter are less system-

atized and less congruent to the affective disturbance.

Controversy surrounds the differential diagnosis of

hallucinations that begin late in life [40,46]. In our study,

we reported that hallucinations in dementia were more

frequently visual than auditory; the reverse is true for

patients with schizophrenia who had multimodal hallu-

cinations. Patients with psychotic symptoms associated

with depression had mainly auditory and olfactory

hallucinations.

The severity of positive, negative, and general psycho-

pathologic symptoms was measured with the respective

subscales of PANSS. Data revealed that patients with

late-onset schizophrenia had more severe positive symp-

toms and less severe general psychopathology in contrast

to patients who had nonschizophrenia psychoses. Cohen

et al. [39] stated that negative symptoms can be difficult

to distinguish from the confounding effects of depression,

medications, and institutionalization. In our study, using

the PANSS, it was evident that scores of negative

symptoms were similar in both groups studied and were

far lower than scores on positive symptom scales; these

results are in accordance with those of the San Diego

study, which proved that lower scores on negative

symptoms tended to be associated with the higher age

group having psychotic illness [40].

Assessment of daily functioning

Assessment of daily functioning revealed that patients

with late-onset schizophrenia had significantly better

ADL and IADL scores, whereas a significant number of

patients with late-onset nonschizophrenia psychoses

needed partial and complete support. This finding may

be attributed to the medical conditions of the latter

group, who had more frequent medical, neurological, and

cognitive impairment, which negatively impacted their

ability to perform daily activities compared with those

who suffered from late-onset schizophrenia. The deterio-

rated daily functioning reflects the devastating effects of

dementia on ADL and highlights the impact of this

disability on caregivers. These findings were in accor-

Table 5 Cognitive functions using the Wechsler Adult Intelligence Scale

Group AMean ± SD

Group BMean ± SD

Patients with late-onsetschizophrenia

n = 50


n = 50 Test

Comprehension 7.52 ± 3.54 2.52 ± 1.74 t = 8.94P = 0.000

Digit span 4.12 ± 2.55 1.12 ± 0.47 t = 10.89P = 0.000

Arithmetic 2.48 ± 1.18 1.5 ± 1.58 t = 10.63P = 0.000

Similarities 6.74 ± 1.18 3.64 ± 1.05 t = 10.00P = 0.000

Vocabulary 5.57 ± 1.30 3.5 ± 0.55 t = 10.44P = 0.00

Picture completion 6.06 ± 1.40 2.22 ± 0.99 t = 15.76P = 0.00

Block design 4.54 ± 0.99 2.84 ± 0.88 t = 14.31P = 0.00

Digit symbols 5.4 ± 12.00 1.12 ± 0.59 t = 3.10P = 0.002

Verbal IQ 80.56 ± 14.2 61.96 ± 3.86 t = 8.92P = 0.000

Performance IQ 84 ± 7.1 76.8 ± 2.6 t = 16.15P = 0.000

Total IQ 82.16 ± 13.7 63.0 ± 2.95 t = 9.65P = 0.000

IQ, intelligence quotient.



dance with those of previous studies, which found that

higher levels of daily functioning among elderly people

with schizophrenia were associated with better cognitive

functioning, fewer negative symptoms, better physical

health, and independent living in the community [47–49].

Cognitive assessment

Patients with a primary diagnosis of dementia suffer from a

number of psychotic symptoms, and patients with primary

functional disorders become cognitively impaired. Barclay

and Almeida [36] stated that schizophrenia does not

increase the risk of dementia. In contrast, individuals with

cognitive impairment in later life are at increased risk for

psychosis. Dementia is characterized by a progressive

decline in cognitive abilities. This was true in our research,

which illustrated that group B patients, in which 70% of

patients had a diagnosis of dementia, scored significantly

worse in all subitems of cognitive assessment according to

CAMCOG compared with group A patients. It is interest-

ing to note that several groups of investigators have

reported potentially relevant clinical, neuropsychological,

and neurobiological differences between dementia patients

with and without psychosis. Stern et al. [50] observed that,

among dementia patients, psychosis was associated with a

greater prevalence of rapid cognitive decline. Moreover, in a

study by Jeste and Finkels [37], it was noted that those

with psychosis had greater impairment on putative

neuropsychological tests of frontal lobe function compared

with dementia patients without psychosis.

The association between cognitive functions in dementia

cases with or without psychosis should be clarified in

future studies. There was much debate on this topic;

Linda et al. [51] reported that behavioral symptoms and

cognitive functions are independent dimensions, whereas

Hopkins and Libon [52] suggested a strong relationship

between severity of psychosis and poor performance on

some cognitive functions.

From the current research, the obtained results are

important in demonstrating that the cognitive deficits

associated with late-onset schizophrenia are different

from the cognitive declines associated with dementia.

The rate of decline observed among the dementia groups

in the present sample appears to be consistent with that

reported in the literature [53,54]. Thus, the onset of

schizophrenia late in life does not appear to be a mere by-

product of a dementia disorder. The same conclusion is

consistent with the findings from studies by the Mount

Sinai research group, which examined chronically insti-

tutionalized elderly schizophrenia patients. These in-

vestigators found that the pattern of cognitive deficits of

such patients was distinct from that associated with

dementia; moreover, their postmortem neuropathological

studies indicated that the prevalence of amyloid plaques

and neurofibrillary tangles was not different from that of

age-matched healthy control individuals [55]. Unfortu-

nately, in this study, we did not compare group A patients

with healthy controls; thus, we could not comment on

cognitive decline in the late-onset schizophrenia group in

comparison with the healthy elderly population.

ConclusionPatients with late-onset schizophrenia compared with

patients with other late-onset psychoses differ in a

number of psychosocial and clinical variables, daily

functioning, and cognitive abilities. The results of this

study contribute to the development of a better under-

standing of the elderly patient population with different

types of late-onset psychoses, which have been largely

ignored in research. These findings draw the attention of

policymakers and psychiatrists to the burden of psychotic

disorders in the elderly and the need for specialized

psychiatric care units providing intensified help and

rehabilitation.

Recommendations

In Egypt, research in the area of old-age psychosis is still

scarce and has been neglected. Thus, studies on this

topic on a large representative sample from different

geographical areas are highly recommended. In addition,

prospective cohort studies of elders with psychotic

disorders to determine the outcome of psychotic disorders

are mandatory. Studies addressing clarification of risk

factors to develop psychosis at later age, the impact of

psychotic symptoms on caregivers, and treatment outcome

of old-age psychosis are recommended. Future studies

should involve different disciplines. These disciplines

should cooperate together to provide evidence-based data

that can inform the public, help policymakers to make

informed decisions and plans, and stimulate further

research.

Strength and limitations of the study

One of the strengths of this study is that (according to

best of our knowledge) it is among the first studies to

compare late-onset schizophrenia with nonschizophrenia

late-onset psychoses. Although our findings shed light on

this poorly understood and investigated area of research,

the results should be considered preliminary data because

of the limitations of small size and type of sample, which

was a selective rather than a stratified random sample

representing different geographical areas in Egypt. Our

findings must be reviewed as provisional and will be

subjected to revision, as more studies are needed in the

field of elderly patients with psychotic disorders.

AcknowledgementsThe authors express their gratitude to Professor M. El Banouby, formerchair of the department of Geriatric Medicine, Ain Shams University, forhis support and guidance. The authors are grateful to Dr Hisham Sadek,Dr Ahmed El Missiry, Dr Abeer Mahmoud, Dr Hanan Hussein, Dr AhmedEl Shafie, and the other research participants from the department ofNeuropsychiatry, Ain Shams University, for their time, training on tools,guidance, advice, and efforts in completing the study assessment. Theauthors would also like to thank Dr Olfat Kahla, senior psychologist inGeriatric Hospital, Ain Shams University, for her help, and Dr MohamedHassan Taha from ‘TIT Solution’ for the statistical analysis.

Conflicts of interestsThere are no conflicts of interest.



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Documents

Studying late-onset schizophrenia and non schizophrenia