Annals of Long Term Care

Schizophrenia is a disease marked by delusions, hallucinations, and disordered thinking. Currently, the overall worldwide prevalence of schizophrenia is 1%, with two-thirds of cases becoming chronic. As more people survive into their later years, the number of people over age 65 years with schizophrenia is likely to increase.

Below we describe a case of an elderly single female, living in a supportive residence, with a history of many hospitalizations from chronic paranoid schizophrenia. Her case illustrates the factors influencing the prognosis of aging persons with schizophrenia, including cognitive dysfunction, medical comorbidities, and the adverse effects of antipsychotics. These factors, in part, may explain the heterogeneous course of this disease.

Case Presentation

Ms. Z is a 66-year-old single, retired, overweight, Jewish female on Social Security Disability (SSD) and Medicare residing in a supportive psychiatric residence with Intensive Case Management (ICM) services. She presented to an inner-city hospital psychiatric emergency room (ER) in July 2008, complaining of not being in control and saying, “I feel like strangling someone.” She had a long history of schizophrenia and multiple prior hospitalizations.

On arrival to the ER, Ms. Z was feeling depressed secondary to poor relationships with people at her residence. She also reported feelings of guilt, hopelessness, and anxiety. She had thought of committing suicide by overdosing on clozapine, and she was concerned she would have to go to a state hospital. She was actively compliant with clozapine 550 mg at bedtime, with monthly blood draws; however, she had a history of intermittent noncompliance and paranoia about medication.

The patient was taking aspirin, esomepazole, simvastatin, docusate, clozapine, and calcium carbonate. Although her first psychiatric hospitalization occurred at age 20, she was not diagnosed with schizophrenia until age 30. She had a history of lengthy psychiatric hospitalizations at state facilities. Her last acute psychiatric hospitalizations were in January and April 2008. Her last psychiatric admission prior to that was in 2001, meaning that she had a period of 7 years of relative stability. She developed tardive dyskinesia (TD), consisting of abnormal and involuntary movements, in association with exposure to haloperidol approximately 15 years previously. At that time she was switched to clozapine, resulting in stabilization of psychiatric symptoms with residual TD. Ms. Z had been tried on several antidepressants including fluoxetine, paroxetine, and bupropion, with modest therapeutic effect. She had a history of overdosing on diazepam in the context of alcohol abuse in the late 1970’s. She smoked one pack of cigarettes a day.

The patient’s family psychiatric history includes a sister with major depressive disorder and a mother who had a possible history of schizophrenia. Ms. Z has an extensive medical history including gastro-esophageal reflux disease, hypercholesterolemia, coronary artery disease, osteoporosis, vitamin B12 deficiency, obesity, and a left mastectomy secondary to left localized breast cancer in 1997. The patient experienced great anxiety surrounding medical appointments, and therefore had difficulty with compliance.

Ms. Z was born in New York and has two sisters. She reports having had a poor relationship with her mother. After earning a bachelor’s degree in philosophy, she worked as a secretary for 15 years. She was never married and has no children. She has lived in supportive housing for ten years. She changed supportive residences several times, at one point requiring a five-month, acute inpatient psychiatric hospitalization because of paranoia about her housing.

The patient presented to the ER alert and fully oriented. She was oddly related and appeared disheveled, with poor eye contact.