Chris Perkins Alzheimers NZ Conference 041116 Increased life expectancy Challenge of diagnosing dementia Risk reduction Management Life expectancy Schizophrenia Life expectancy lags by 12 years in women and 15 years in men with schizophrenia Casey et al 2011 Some others say 20 year ID: 622165
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Slide1
Schizophrenia and dementia
Chris Perkins
Alzheimers NZ Conference
04/11/16Slide2
Increased life expectancy
Challenge of diagnosing dementia
Risk reduction
Management Slide3
Life expectancy
Schizophrenia
Life expectancy lags by 12 years in women and 15 years in men with schizophrenia (Casey et al , 2011) Some others say 20 years difference.
This means that many men and women with schizophrenia will be reaching their 60s and be at increasing risk for dementia.
By 2025 20% of people with schizophrenia will be 65 or older (
Rajji
et al. 2013)Slide4
Danish cohort study: Ribe
et al ( 2015)
Risk of dementia > 2x greater in people with schizophrenia
“Individuals with schizophrenia, especially those younger than 65 years, had a markedly increased relative risk of dementia that could not be explained by established dementia risk factors”Slide5
Cognitive changes in schizophrenia / dementia praecox
Schizophrenia
= neurodevelopmental disorder
Premorbid
cognitive deficit of 5-10 IQ points (risk factor or consequence of disease?), then mild decline to post-onset period). Thereafter, very stable (Heaton et al 2001 in
Jeste
et al 2011).
N
SSlide6
Schizophrenia or dementia?
It’s all in the history
Negative symptoms of schizophreniaDiminished emotional expression
Avolition
Reduced speech output
Loss of ability to experience pleasure
Lack of interest in social activities
Frontotemporal dementia
Loss of sympathy or empathy
Apathy or inertia
Decline in language ability (language variant)
Decline in social cognition and /
o
r executive abilities
Behavioural disinhibitionCompulsive / ritualistic behaviourSlide7
Challenges in diagnosis: 1.
Ongoing psychosis
Mrs A. 57,
undergoing clozapine
trial in the adult inpatient ward
Chronic schizophrenia- thought disorder, delusions, hallucinations- unchanged over years.
Family report recent deterioration from usual coping abilities and doubts about self-care
MMSE 20/30and 21/30 as inpatient- too thought-disordered for fuller cognitive testing
C-T head, labs normal
Tentative diagnosis of dementia
Placed in residential
care -- and then…Slide8
Challenges to diagnosis: 2.
No cooperation
Lack of collateral history
Mrs
B. Long history of paranoid schizophrenia
Remains delusional, mistrustful
Losing things
increasing paranoia multiple calls to
police, ?poor self-care
MOCA one year prior
13/30
Refuses more cognitive
testing
Won’t allow us to contact others for collateral ( not sure if there is anyone)
Try
increasing
antipsychotic medication but tentative diagnosis
of dementia. Wait and
see.Slide9
Challenges to diagnosis 3.
Effects of medication
Mrs C. Brittle schizoaffective disorder with recent acute admission in depressed
state. Husband says her memory is failing and she always talks of the pastMood still a bit low but not bad for
her. ACEIII
67/100
Medication:
lorazepam, quetiapine, olanzapine, venlafaxine.
Changing meds even the tiniest bit can throw her off…Slide10Slide11
Dementia risk factors in L-T mental illness
Brain damage – reduced cognitive
reserve from illness
Smoking and other substance usePhysical inactivityReduced socialisation
Poorly
educated (often)- little cognitive stimulation
Poor physical health –metabolic
syndrome(obesity, diabetes, hyperlipidaemia) often related to medication.
Reduced GP contact
Poverty: cost of medication and GP (Care Plus)Slide12
Keeping Body and Mind
Together: Improving
the physical health and life expectancy of people with serious mental illnessRANZCP (2015)Slide13
Management
MH
Old age
IDSlide14Slide15
Summary
There will be more people with schizophrenia ageing and getting dementia
This is not a straightforward diagnosis to make
Our adult colleagues are aware of the need to attend to the physical health of their patients
We need to work together to ensure
the best care for people ageing with
schizophreniaSlide16Slide17
References
Casey, D., Rodriguez, M.,
Northcott
, C. Vickar, G & Shihabuddin, L. (2011) Schizophrenia – Medical illness, mortality and aging INT’L. J. PSYCHIATRY IN MEDICINE, Vol. 41(3) 245-251
,
Vasilis P.
Bozikas
, Christina
Andreou
(2011)
Longitudinal studies of cognition in first episode psychosis: a systematic review
of the literature
Australian and New Zealand Journal of Psychiatry
2011; 45:93–108Harvey,P. (2001) Cognitive and functional Impairments in Elderly Patients with Schizophrenia: A Review of the recent Literature Harvard Rev Psychiatry, 9, 2 , 59-68Jeste, D., Wolkowitz, M. &Palmer, B. (2011) Divergent trajectories of Physical, Cognitive and Psychosocial Aging in Schizophrenia. Schizophrenia Bulletin 37,
3:451-455RANZCP (2015) Keeping Body and Mind Together: Improving the physical health and life expectancy of people with serious mental illness
Ribe et al ( 2015) Long-term risk of dementia in persons with schizophrenia: a Danish population-based cohort study. JAMA Psychiatry 72 (11): 1095-01Yucel, M., Bora1, E., Lubman D. et al. (2012) Impact of Cannabis Use on Cognitive Functioning in Patients
WithSchizophrenia: A Meta-analysis of Existing Findings and New Data in a First-Episode SampleSchizophrenia Bulletin vol. 38 no. 2 pp. 316–330 doi:10.1093/schbul/sbq079
, Slide18