Annals of Long Term Care

Treating elderly persons with schizophrenia poses several challenges for clinicians. Antipsychotic side-effect profiles, medical conditions, physiologic effects of aging, and government regulations can complicate the clinical scenario. Important guidelines for use of antipsychotics in the elderly population include starting at low doses and increasing slowly, checking basic laboratory studies periodically and doing routine physical examinations, and weighing the risks versus benefits of discontinuing treatment with an antipsychotic medication. Schizophrenia is a chronic mental illness that in most all cases requires lifelong treatment. Discontinuation of antipsychotic medication can result in worsening psychosis and, ultimately, behaviors that place patients at high risk of self-harm. This article presents four cases of elderly persons with schizophrenia, each illustrating clinical points to consider in the treatment of this patient population. (Annals of Long-Term Care: Clinical Care and Aging 2009;17[9]:26-30)

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Introduction

The use of antipsychotic medications in the geriatric population can lead to many challenges for the prescribing physician. As patients with schizophrenia age, they may develop medical illnesses and cognitive changes that neuroleptic medications may adversely affect. Weight gain, metabolic syndrome, sedation, and movement disorders are just a few of the potential complications that need to be considered when treating psychosis in the elderly. In this article, we present several cases illustrating important clinical concepts to be considered in the treatment of geriatric schizophrenia.

Case 1

Ms. A is a 72-year-old woman with a long-standing history of paranoid schizophrenia successfully treated with risperidone 3 mg daily at bedtime. She also has a history of diabetes and coronary artery disease. Her diabetes had been under good control with diet and oral hypoglycemic agents. Ms. A had been residing at a nursing home (NH) for approximately 2 years and had been stable in terms of her psychotic symptoms. Following pharmacy medication review, it was recommended that her risperidone be tapered and discontinued. The medication was tapered gradually over a 3-month period. Approximately 2 weeks after discontinuing the medication, the patient was noted to become more agitated and withdrawn, and she began experiencing vivid auditory hallucinations. She became physically aggressive with a care provider in the facility and was emergently hospitalized on a psychiatric unit.

Ms. A was hospitalized for 12 days. The risperidone was reinitiated first at a 1-mg dose and then titrated to her former dose of 3 mg at bedtime. Her symptoms gradually remitted, and she returned to her baseline behavior and mental status after approximately 10 days of hospitalization. She tolerated the risperidone well, and there was no evidence of parkinsonism, undue sedation, gait instability, or exacerbation of her diabetes status.

Case 1 – Discussion

In 1987, President Reagan signed the Omnibus Budget Reconciliation Act (OBRA ‘87), which contained national standards for NH resident care and resident rights. Included in OBRA ‘87 was a set of standards aimed at reducing physical and chemical restraints in NHs. Under OBRA ’87, all psychopharmacologic drugs must be prescribed for the treatment of a specific condition, and an independent review must occur annually.1 As a result, psychopharmacologic medications are often tapered in medication reduction/elimination trials.