OCEBHA Quarterly Newsletter:
Older Adults and Schizophrenia |
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The Oregon Center of Excellence for Behavioral Health & Aging (OCEBHA) quarterly newsletter highlights key topics related to behavioral health and aging, with special emphasis on emerging research and innovative programs that address the behavioral health needs of older adults. In this edition, we highlight some of the latest research related to older adults and schizophrenia. Despite the unique impacts schizophrenia has on this population, less than 1% of published research on schizophrenia is devoted to adults over the age of 65 (Cohen et al., 2015).
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By 2050, it is expected that adults aged 55 and older will make up one-quarter of individuals with schizophrenia globally (Cohen et al., 2015). The all-cause mortality rate among older adults with schizophrenia is nearly three times that of the general population, especially for metabolic and respiratory conditions (Talaslahti et al., 2012; Caspi, 2024). Compared to their peers, older adults with schizophrenia also have a higher mortality rate from cardiovascular disease (Caspi, 2024). Contributing factors to the unique aging process observed in people with schizophrenia include long-term neuroleptic medication use, smoking, and sedentary behavior.
Suicidality is more common in this group—particularly among women—and more than two-fifths of older individuals with schizophrenia exhibit signs of clinical depression (Cohen, 2000). Depression increases the frequency of emergency department (ED) readmissions and substance use. Further, there is a low detection rate of depression among people with schizophrenia due to a lack of clear diagnostic criteria and difficulties determining depressive symptoms and medication side-effects. Depressive symptoms among people with schizophrenia may be reduced by reviewing and adjusting medications that may cause depressive symptoms (Mosolov, 2020), and psychosocial interventions such as social skills training and cognitive behavioral health (McDonagh et al., 2017). Loneliness is also more prevalent among older adults with severe mental disorders such as schizophrenia than in the general population (Eglit et al., 2018).
Approximately 1 in every 11 older adults have a substance use disorder, with rising rates of alcohol and cannabis use (SAMHSA, 2024). There is a high prevalence (41.7%) of comorbidity between substance use disorders (SUDs) and schizophrenia, which is associated with adverse consequences such as increased morbidity, mortality, non-compliance with treatment; higher rates of hospitalization, homelessness, violence, incarceration and suicidality than those without a substance use disorder (Hunt, et al, 2018). The most common substances used among people with schizophrenia are illicit drugs (27.5%), cannabis (26.2%), and alcohol (24.3%) (Hunt, et al., 2018). Studies show that high rates of cannabis use is associated with an increased risk for psychosis (Marconi et al., 2016). Older adults have less substance use than younger adults (Jeste, 2011).
People ages 65 and older are the fastest growing homeless demographic and by 2030 their numbers will triple (American Society on Aging, 2020). Among homeless people of all ages, a high percent experience overall psychosis, schizophrenia (10.29%), and schizophreniform disorder (2.48%), schizoaffective disorder (3.53%) (Ayano, et al., 2019).
Schizophrenia is a common cause of frequent ED visits due multiple factors, including lack of access to primary and specialty care (Talaslahti et al., 2012) non-adherence to medication (Harvey & Rosenthal, 2016), suicidality (Mosolov, 2020) and housing instability (Cohen, 2000), resulting in the ED becoming the default point of care when symptoms escalate. In Oregon, 9% of older adults admitted to the ED have a diagnosis of schizophrenia or another psychiatric disorder (Apprise Health Insights, 2022).
Age-related changes in how the body processes medications mean that older adults require lower doses of antipsychotics and are at a higher risk for side effects, including metabolic syndrome and movement disorders (Jeste & Maglione, 2013). Positive symptoms of schizophrenia often become less severe with age, while substance use decreases and overall mental health functioning frequently improves (Jeste & Maglione, 2013).
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What the research is telling us |
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Functional recovery in older adults with schizophrenia: A national interRAI study (Barak et al., 2024).
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A New Zealand study using global data (N = 2,620) from interRAI mental health assessments found that while the aging process in older adults with schizophrenia varies depending on treatment and disease factors, social wellbeing plays a key role in functional recovery. Among participants, 33% had good social wellbeing and 67% did not. The study found that depression and disruptive behavior were the strongest predictors of poor social wellbeing, while strong communication skills, physical activity, intact decision-making capability, and adherence to medication were the strongest predictors of good wellbeing. Researchers noted that depression, loneliness, and disruptive behaviors appear to be interconnected and suggest that addressing comorbid depression may significantly improve the wellbeing of older adults with schizophrenia (Barak et al., 2024).
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Good Cop, Better Cop: Evaluation of a Geriatrics Training Program for Police (Brown, et al., 2017)
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Researchers developed and evaluated a two-hour geriatrics training program for 143 San Francisco police officers to improve their knowledge and skills when interacting with older adults in the community. Officers reported that approximately 19% of their encounters were with older adults. The training included a 45-minute interactive session on aging-related health conditions and three 15-minute experiential simulation exercises, allowing officers to experience challenges associated with aging.
Following the training, officers anticipated having increased empathy and patience for older adults, greater awareness of aging-related conditions and their impact on police work, and an improved ability to provide appropriate community resource referrals. The training was incorporated into the San Francisco Police Department's mandatory Crisis Intervention Training (CIT) program, which promotes more effective interactions between law enforcement and individuals with mental illness, including psychotic disorders. This makes San Francisco one of the first jurisdictions to include general aging-related health education in police crisis training. The study supports the 2015 President’s Task Force on 21st Century Policing recommendation that departments develop policies and procedures for working with older adults.
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Changes in Cognitive Function After a 12-Week POWER Rehabilitation in Older Adults with Schizophrenia and Frailty (Chan et al., 2024)
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This study assessed the effects of a 12-week resistance training program called POWER (Produce Outcome Worthwhile for the Elderly Rehabilitation) on cognitive and physical function in older adults with schizophrenia and frailty. Participants were randomized into either an intervention group receiving POWER training or a control group without additional exercise. Cognitive outcomes were evaluated using tools such as the Mini-Mental State Examination (MMSE).
Those who participated in the POWER training program showed significant improvements in processing speed and sustained attention compared to the control group. The study supports the use of resistance training as a promising non-pharmacological intervention to enhance cognitive and physical functioning in older adults with schizophrenia and frailty.
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Loneliness in schizophrenia: Construct clarification, measurement, and clinical relevance (Eglit et al., 2018)
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This study explored the connection to how external factors related to loneliness, such as depression, anxiety, and well-being, differ and align among people with schizophrenia and those without schizophrenia. Researchers administered the third version of the UCLA Loneliness Scale (UCLA-3) to two groups: individuals with schizophrenia or schizoaffective disorder and non-psychiatric participants. They also collected demographic data, clinical measures, and assessments of positive psychological traits.
Individuals with schizophrenia reported significantly higher levels of loneliness compared to the non-psychiatric group; however, the pattern and strength of relationships between loneliness and other variables were largely similar across both groups. Loneliness was positively associated with depression, anxiety, and perceived stress, and negatively associated with mental well-being, happiness, and resilience. The study found that positive symptoms of loneliness (depression, anxiety and perceived stress) were higher among older adults without schizophrenia. The authors suggest that one explanation may be related to socio-economic factors associated with age and loneliness that may be less common among those with schizophrenia, such as losing a spouse. The study found that these symptoms diminish over the course of the linespan for individuals with schizophrenia, indicating that older age may reduce the correlation of loneliness.
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Cardiovascular disease, metabolic syndrome, and respiratory illness (often worsened by long-term antipsychotic use, sedentary behavior, poor nutrition, and high rates of smoking)
- Greater cognitive impairment, including early-onset dementia
- Depression & Suicidality, especially among older women
- Loneliness
- Lower functional independence, including areas of daily living
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Antipsychotic side effects, including extrapyramidal symptoms, sedation, falls, and metabolic disturbances
- Substance use, especially illicit drugs, cannabis and alcohol.
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Sources: (Caspi, A, 2024), (Harvey, P. D., & Rosenthal, J. B. 2016), (Cohen, C. I., 2000), (Eglit et al., 2018), (Barak et al., 2024), (Jeste & Maglione 2013), (Hunt et al., 2018)
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| - Strong social networks
- Resilience, optimism, hope, and perceived life satisfaction
- structured cognitive and physical activities
- Consistent adherence to prescribed antipsychotic and adjunctive medications
- Access to stable, supportive housing
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Sources: (Barak, et al., 2024), (Chan, et al., 2024), (Jeste & Maglione 2013), (Cohen et al., 2015)
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Screening Tools & Interventions for Older Adults with Schizophrenia |
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American Society on Aging. (2020). Homelessness, older adults, poverty & health. Generations: Journal of the American Society on Aging. https://generations.asaging.org/homelessness-older-adults-poverty-health/
Apprise Health Insights. (2022). Emergency department utilization data for Oregon seniors. Apprise Health Insights.
Barak, Y., Sajjadi, S. F., Hobbs, L., & Patterson, T. (2024). Functional recovery in older adults with schizophrenia: A national interRAI study. International Journal of Social Psychiatry, 70(4), 792–800. https://doi.org/10.1177/00207640241230837
Brown, R. T., Ahalt, C., Rivera, J., Stijacic Cenzer, I., Wilhelm, A., & Williams, B. A. (2017). Good cop, better cop: Evaluation of a geriatrics training program for police. Journal of the American Geriatrics Society, 65(9), 2034–2037. https://doi.org/10.1111/jgs.14899
Caspi, A. (2024). Cardiovascular and respiratory mortality in older adults with schizophrenia: A population-based analysis. American Journal of Geriatric Psychiatry, 32(2), 123–132.
Chan, J., Lee, H. Y., Wong, A., & Ng, K. (2024). Changes in cognitive function after a 12-week POWER rehabilitation in older adults with schizophrenia and frailty. Aging & Mental Health, 28(1), 101–109. https://doi.org/10.1080/13607863.2023.2298765
Cohen, C. I. (2000). Aging and schizophrenia: Research directions and treatment implications. Psychiatric Services, 51(8), 1013–1017. https://doi.org/10.1176/appi.ps.51.8.1013
Cohen, C. I., Pathak, R., Ramirez, P. M., & Vahia, I. (2015). Schizophrenia in later life: Emerging issues. Psychiatric Clinics of North America, 38(3), 519–535. https://doi.org/10.1016/j.psc.2015.05.001
Eglit, G. M. L., Palmer, B. W., Martin, A. S., Tu, X., Jeste, D. V., & Depp, C. A. (2018). Loneliness in schizophrenia: Construct clarification, measurement, and clinical relevance. PLoS ONE, 13(3), e0194021. https://doi.org/10.1371/journal.pone.0194021
Harvey, P. D., & Rosenthal, J. B. (2016). Cognitive and functional deficits in people with schizophrenia: Evidence for accelerated or exaggerated aging? Schizophrenia Research, 186, 41–45.
Hunt, G. E., Large, M. M., Cleary, M., Lai, H. M. X., & Saunders, J. B. (2018). Prevalence of comorbid substance use in schizophrenia spectrum disorders in community and clinical settings, 1990-2017: Systematic review and meta-analysis. Drug and alcohol dependence, 191, 234–258. https://doi.org/10.1016/j.drugalcdep.2018.07.011
Jeste, D. V., Wolkowitz, O. M., & Palmer, B. W. (2011). Divergent trajectories of physical, cognitive, and psychosocial aging in schizophrenia. Schizophrenia bulletin, 37(3), 451–455. https://doi.org/10.1093/schbul/sbr026
Jeste, D. V., & Maglione, J. E. (2013). Treating older adults with schizophrenia: Challenges and opportunities. Schizophrenia Bulletin, 39(5), 966–968. https://doi.org/10.1093/schbul/sbt043
Marconi, A., Di Forti, M., Lewis, C. M., Murray, R. M., & Vassos, E. (2016). Meta-analysis of the Association Between the Level of Cannabis Use and Risk of Psychosis. Schizophrenia bulletin, 42(5), 1262–1269. https://doi.org/10.1093/schbul/sbw003
McDonagh, M. S., Dana, T., Selph, S., Devine, B., Cantor, A., Bougatsos, C., & Blazina, I. (2017). Treatments for schizophrenia in adults: A systematic review (Comparative Effectiveness Reviews, No. 198). Agency for Healthcare Research and Quality. https://www.ncbi.nlm.nih.gov/books/NBK487620/
Mosolov, S. N. (2020). Diagnosis and treatment of depression in schizophrenia. Consortium Psychiatricum, 1(2), 29–42. https://doi.org/10.17650/2712-7672-2020-1-2-29-42
Substance Abuse and Mental Health Services Administration. (2024/2025). Behavioral health among older adults: Results from the 2021 and 2022 National Surveys on Drug Use and Health (SAMHSA Publication No. PEP24-07-018). Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. https://www.samhsa.gov/data/report/older-adult-behavioral-health-report-2021-2022
Talaslahti, T., Alanen, H. M., Leppävuori, A., Luukkaala, T., & Kautiainen, H. (2012). Increased mortality in schizophrenia among elderly patients. International Journal of Geriatric Psychiatry, 27(12), 1231–1237. https://doi.org/10.1002/gps.3772
Walker, V. G., & Harrison, T. C. (2024). Life course perspectives of aging with schizophrenia spectrum disorders in psychiatric and long-term care facilities. The Gerontologist, 64(5), gnad149. https://doi.org/10.1093/geront/gnad149
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OCEBHA supports the behavioral health of older adults in Oregon by growing and nourishing the network of aging and behavioral health care partners.
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Portland State University | Institute on Aging | Portland, OR 97201-0751 US
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