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u majority live in the community, where most receive little or no treatment beyond medication despite continued need. As the number of patients with late-life schizophrenia increases over the coming decades, the challenges of treating this population will also increase.

Treatment Issues

Given the complexities of managing patients in the late phase of schizophrenia, a coordinated, biopsychosocial approach to treatment is advisable (32). Patients in this phase require treatment for medical conditions that typically accompany aging. Symptoms and functional impairments may be associated with many causes in contrast to those found in earlier phases of the illness. Differential diagnosis of emerging physical problems or changes in mental status is critical. For example, elderly schizophrenia patients are at greater risk of developing delirium secondary to neuroleptics with anticholinergic properties than during earlier stages. These symptoms may mimic other conditions that accompany late life, and optimal, safe treatment requires accurate diagnosis.

Late-life schizophrenia patients demonstrate greater variability in tolerability and sensitivity to neuroleptics than patients in earlier phases. For example, akathesia, parkinsonian symptoms, and tardive dyskinesia tend to be more prevalent with increasing age (33). Side effects tend to occur more commonly in older schizophrenia patients, including sedation, orthostatic hypotension, anticholinergic reactions, and EPS. Additionally, absorption, metabolism, and excretion of antip-sychotic medications differ considerably for late-life schizophrenia. While antipsychotics are the mainstay of treatment, dosages of neuro-leptics for older patients are usually much lower (even one-third or less) than those used in younger adults (34).

The use of atypical medications has not yet been adequately evaluated in older adults. Clozapine may be especially problematic for older adults because of potential side effects (postural hypotension and sedation) and the frequent blood tests that are required. Given the gradual improvements that often accompany the late phase of schizophrenia, it may be appropriate to consider withdrawing antipsychotic medications under close clinical supervision. Unfortunately, there is little empirical information to guide this decision-making process.

The level of depression among community-residing older adults with schizophrenia is approximately 1.5 to 3 times the level in the general elderly population (31). Clinicians must pay attention to issues

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Table 5

Summary of Clinical Strategies for the Late Phase of Schizophrenia

1. Assessment and coordination of medical health-care needs

2. Careful monitoring of medication dosages and side effects

3. Monitoring of potential adverse interactions with medications of medical conditions

4. Assessment of appropriate level of care based on cognitive, medical, and social-support factors

5. Careful differential diagnosis and treatment of emerging symptoms (e.g., depressive symptoms)

6. Facilitation of access to services (e.g., Meals on Wheels)

of possible medical etiology, and address whether such symptoms are caused or exacerbated by medication toxicity or medical conditions.

Clinicians must also deal with the issue of appropriate residential placement during this stage of the illness. In patients with severe cognitive deficits or debilitating medical problems, placement in a nursing home where constant care is available may be required. Many older persons with schizophrenia do not have family care providers available and are less socially connected than those without mental illness (35). For example, the death of parents, who are key caretakers for many persons with schizophrenia, frequently leaves middle-aged to elderly individuals with a dramatic reduction of social and financial support and at risk for decompensation and loss of residence in the community. The availability of social supports and the need to bolster this capacity are important considerations in treatment planning. Supported housing or residential treatment facilities may be appropriate for patients requiring supervision, and facilitating access to services such as transportation, home-care assistance, or Meals on Wheels may be indicated for aging patients living independently in the community.

Several individual psychological approaches with demonstrated efficacy in younger populations may be useful in treating older persons with schizophrenia (32). Capacity for communication, awareness of a problem, and capacity for retention and carryover should be considered when evaluating the appropriateness of psychotherapy. Psychological intervention should be matched to patients' level of need and ability, and should not create stress or cognitive overload.

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