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Management of Schizophrenia in Late Life with Antipsychotic Medications

A Qualitative Review

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Abstract

Although patients with schizophrenia are reported to have excess mortality compared with the general population, many affected patients will nonetheless survive and continue to have the disorder in later life. Consequently, geriatric schizophrenia will be a significant public health concern in the years to come, and evidence-based treatment of schizophrenia in older patients is becoming an urgent issue. However, there has been a paucity of comparative data to guide selection of antipsychotics for schizophrenia in late life.

The primary aim of this review was to synthesize the available evidence on management of late-life schizophrenia with antipsychotic medications; a secondary aim was to evaluate treatment resistance in this population. Accordingly, PubMed and EMBASE were searched using the keywords ‘antipsychotics’, ‘age’ and ‘schizophrenia’ to identify psychopharmacological studies of antipsychotics in late-life schizophrenia (last search 30 April 2011). The literature search identified 23 prospective studies of use of antipsychotics for schizophrenia in older patients (generally age ≥65 years), including eight double-blind trials. The sample size was smaller than 40 patients for 52% of the studies. Two of the double-blind studies were post hoc analyses and one was a placebo-controlled trial. In the largest double-blind study, olanzapine (n = 88, median dose 10mg/day) and risperidone (n = 87, median dose 2 mg/day) were compared in patients not resistant to these therapies, with similar effects. There have also been several open-label trials of these two agents that have shown efficacy and tolerability in non-resistant patients. Evidence on other antipsychotics has been scarce and less robust.

The gold standard for treatment-resistant schizophrenia is clozapine. However, almost all of the studies of clozapine to date have effectively excluded older patients with schizophrenia. Only one small study has evaluated clozapine (n = 24, mean dose 300 mg/day) in comparison with chlorpromazine (n = 18, mean dose 600 mg/day) in a difficult-to-treat older population; the investigators reported that both treatments were similarly efficacious. Furthermore, there has been little compelling evidence in favour of or against augmentation of antipsychotics with other psychotropic medications in the older age group.

Treatment of non-resistant, late-life schizophrenia with olanzapine and risperidone appears to be supported by the available evidence. However, data on geriatric patients with schizophrenia are generally scarce, particularly for treatment-resistant subpopulations, underscoring the need for more research in this important area.

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Acknowledgements

This work was performed independent from any financial support.

Dr Suzuki has received fellowship grants from the Government of Canada Post-Doctoral Research Fellowships, the Japanese Society of Clinical Neuropsychopharmacology, the Kanae Foundation and the Mochida Memorial Foundation, and manuscript fees from Dainippon Sumitomo Pharma and Kyowa Hakko Kirin. Dr Remington has received research support (principal investigator) from the following funding agencies: Schizophrenia Society of Ontario and the Canadian Diabetes Association. As a principal investigator, he has also received research support from Novartis Canada, Medicure Inc. and Neurocrine. As a co-investigator, he has received research support from the following funding agencies: the Canadian Institutes of Health Research (CIHR) and the Canadian Psychiatric Research Foundation (CPRF). He is also a co-investigator in research sponsored by Pfizer Inc. He has also received consultant fees from CanAm Bioresearch Inc., Roche, Neurocrine and Medicure Inc., and speaker’s fees from Novartis. Dr Uchida has received grants, speaker’s honoraria, or manuscript fees from Pfizer Health Research Foundation, GlaxoSmithKline, Otsuka Pharmaceutical, Dainippon Sumitomo Pharma and Janssen Pharmaceuticals. Dr Rajji has received research support from CIHR, the Ontario Ministry of Health and Long-Term Care, and the US Department of Veterans Affairs. Dr Graff-Guerrero has received professional services compensation from Abbott Laboratories, Janssen-Cilag and Lilly. Dr Mamo has received grants or consultant fees from Bristol-Myers Squibb and Pfizer and has received speaker’s honoraria from AstraZeneca.

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Authors and Affiliations

  1. Geriatric Mental Health Program, Unit 4-2, Centre for Addiction and Mental Health, 1001 Queen Street West, Toronto, ON, M6J 1H4, Canada

    Takefumi Suzuki, Hiroyuki Uchida, Tarek K. Rajji &  David C. Mamo

  2. Department of Psychiatry, University of Toronto, Toronto, ON, Canada

    Takefumi Suzuki, Gary Remington, Ariel Graff-Guerrero &  David C. Mamo

  3. Multimodal Imaging Group, PET Centre, Centre for Addiction and Mental Health, Toronto, ON, Canada

    Takefumi Suzuki, Ariel Graff-Guerrero &  David C. Mamo

  4. Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan

    Takefumi Suzuki & Hiroyuki Uchida

  5. Schizophrenia Program, Centre for Addiction and Mental Health, Toronto, ON, Canada

    Gary Remington

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  1. Takefumi Suzuki
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  2. Gary Remington
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  3. Hiroyuki Uchida
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  4. Tarek K. Rajji
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  6. David C. Mamo
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Correspondence to David C. Mamo.

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Suzuki, T., Remington, G., Uchida, H. et al. Management of Schizophrenia in Late Life with Antipsychotic Medications. Drugs Aging 28, 961–980 (2011). https://doi.org/10.2165/11595830-000000000-00000

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