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Dementia in Schizophrenia Raghavakurup Radhakrishnan, Robert Butler & Laura Head

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Dementia in Schizophrenia Raghavakurup Radhakrishnan, Robert Butler & Laura Head Advances in psychiatric treatment (2012), vol. 18, 144–153 doi: 10.1192/apt.bp.110.008268 ARTICLE Dementia in schizophrenia Raghavakurup Radhakrishnan, Robert Butler & Laura Head Raghavakurup Radhakrishnan domains, including current IQ, category fluency, SUMMR A Y is an ST6 in old age psychiatry at verbal memory, abstract thinking, language, St Clement’s Hospital, Ipswich. A growing body of evidence suggests that the most sustained attention and response inhibition. His research interests include common type of dementia in schizophrenia differs cognition and memory in dementia, Symbol coding tasks yielded some of the most from Alzheimer’s disease in its clinical features, depression, schizophrenia in late robust evidence, with very large effect sizes. natural course, neuropathology, neuroanatomical life and cognitive functioning after However, Hyde et al (1994) performed a cross- electroconvulsive therapy. Robert substrates and prognosis. Furthermore, there Butler is a consultant old age is some evidence that the risk of developing sectional study to assess cognitive performance psychiatrist with Suffolk Mental cognitive impairment and its progression in early- in schizophrenia across a wide age range. A Health Partnership NHS Trust, at onset schizophrenia differ compared with late- or comparison of scores on cognitive measures St Clement’s Hospital, Ipswich. very-late-onset schizophrenia. The diagnosis recorded for five age-derived cohorts showed His interests include dementia, depression in later life and service and management of dementia in schizophrenia no evidence of accelerated decline on the Mini- provision. Laura Head is a is challenging for both general adult and old age Mental State Examination (MMSE), the Dementia consultant old age psychiatrist with psychiatrists. This article reviews the evidence Rating Scale, list learning, semantic fluency Suffolk Mental Health Partnership base regarding dementia in schizophrenia. It or perseverative errors on the Wisconsin Card NHS Trust, working at Minsmere discusses the diagnosis of dementia in schizo- Sorting Test. House, Ipswich. Her interests phrenia, its management and prognosis, and include crisis and in-patient care identifies some future research opportunities. of older people with mental health Do people with schizophrenia develop problems, and medical management. D ECLARATION OF INTEREST Correspondence Dr Robert Butler, dementia? Consultant Old Age Psychiatrist, L. H. has undertaken commercial drug trials. In his Lehrbuch der Psychiatrie of 1893, Kraepelin St Clement’s Hospital, Foxhall used the term ‘dementia praecox’ (premature Road, Ipswich IP3 8LS, UK. Email: dementia) for schizophrenia because of its onset [email protected] Cognitive impairment is a well-recognised and in early life and the characteristic development cardinal feature of schizophrenia (Keefe 2007). of ‘mental enfeeblement’. He emphasised the Given the biological effects of ageing on the progressive deterioration of cognition but noted brain, it is important to consider the cognitive that memory was spared. He distinguished this manifestations of schizophrenia in the context condition from paraphrenia in which cognitive of ageing. Significant issues include the natural impairment did not occur. history of cognitive dysfunction over the lifespan, Over a century later, there is uncertainty about its progression to dementia, and the temporal the course of cognitive function with ageing in relationship between psychosis and cognitive schizophrenia. Early studies of the progression deficits. In this context, it helps to have a precise of dementia over the lifespan in individuals definition of cognitive impairment, and we find the with schizophrenia have shown inconsistent following useful: ‘a level of cognitive functioning results, although they were limited by a lack of suggesting a consistent severe impairment and/ standardised diagnostic criteria and specific or a significant decline from premorbid levels evaluation techniques. considering patients’ educational, familial In a study of long-term in-patients with schizo- and socioeconomic background’ (Keefe 2007). phrenia who had survived into old age, Harvey Cognitive impairment has a trajectory over the et al (1999a) followed up a group for 30 months course of schizophrenia that is different from using the Clinical Dementia Rating (CDR). Over that of psychotic symptoms and it may contribute this period, 30% of the patients deteriorated, to a poor functional outcome in older patients from a baseline of minimal or mild cognitive and (Davidson 1995). functional impairment to impairments severe enough to warrant a secondary diagnosis of Cognitive impairment in schizophrenia dementia. A number of meta-analyses have examined the Although many studies suggest a model of extent of cognitive impairment in people with schizophrenia as a progressive dementing illness, schizophrenia (Heinrichs 1998; Aleman 1999; others have supported the view that cognitive Bokat 2003). Large effect sizes (between 1 and impairment in schizophrenia fits the model of 1.5), representing robust evidence of impairment, a static encephalopathy (Goldberg 1993; Hyde have been reported across a multitude of cognitive 1994). 144 Advances in psychiatric treatment (2012), vol. 18, 144–153 doi: 10.1192/apt.bp.110.008268 Dementia in schizophrenia Evidence from international studies despite low MMSE scores at initial assessment. The authors concluded that cognitive functioning Studies examining cognitive impairment in older in older people with schizophrenia is different people with schizophrenia from that seen in Alzheimer’s disease. Ciompi (1980) described evaluations of mostly Heaton et al (1994) compared three groups of elderly people surviving from a large sample of people with schizophrenia (young people with patients with schizophrenia. He estimated that early-onset schizophrenia, older people with early- 25% had moderate to severe cognitive deficits, onset disorder, and people with late-onset, i.e. including memory disturbance and disorientation. after age 45, disorder) with ambulatory patients This study of chronically institutionalised older with Alzheimer’s disease and normal controls. patients demonstrated the presence of age- They concluded that cognitive impairment in related impaired global cognitive performance as schizophrenia is unrelated to current age, age at measured by the MMSE. Other researchers have onset or duration of illness. They also suggested estimated that more than 80% of older people that there is an encephalopathy associated with with schizophrenia show significant cognitive schizophrenia that is non-progressive and that impairment (Keefe 2007). has a different pattern of deficits from that seen in Studies showing a significant decline in cognition Alzheimer’s disease. over time The risk of dementia in late-onset and very-late- In a re-evaluation of the IOWA 500 study of a onset schizophrenia cohort of people with hebephrenic or catatonic schizo phrenia followed up for 40 years, Winokur Late-onset schizophrenia is usually defined as et al (1987) found that the subgroup of older onset after 40 years of age, and very-late-onset as participants was significantly more likely to have after 60 years of age. Studies of schizophrenia of worsened orientation and memory. late and very late onset are few and inconsistent In a follow-up of older patients with schizo - in their results. phrenia after discharge from long-term care in Palmer et al (2003) compared changes in cog - psychiatric hospital, Harvey et al (1999b) noted nition over 1 and 2 years for out-patients with an average reduction of 3.8 points on the MMSE late-onset schizophrenia-spectrum disorders, over a period of 2.5 years. Friedman et al (2001) earlier-onset schizophrenia-spectrum disorders, evalu ated the cognitive and functional status Alzheimer’s disease with psychosis, or Alzhei- of people with schizophrenia aged between 20 mer’s disease with baseline MMSE scores and 80 years in a 6-year follow-up study, and >25, and healthy comparison participants. compared the sub group of patients aged 50 and Cognitive changes among participants in the two over with healthy individuals and patients with schizophrenia-spectrum disorder groups were Alzheimer’s disease, also aged 50 and over. They similar to those in the healthy controls, whereas measured cognitive and functional decline using both Alzheimer’s disease groups showed greater CDR scores. They found a significant age-group declines in cognition. The authors concluded that effect on the magnitude of cognitive decline for late-onset schizophrenia is a neurodegenerative participants with schizophrenia. For those under disorder and, in agreement with earlier studies, a the age of 65, the proportional risk of cognitive and static encephalopathy. functional decline in schizophrenia was negligible. In another study (Laks 2006), involving a small However, the proportional risk rose from 38% for number of Brazilian patients with late-onset those aged 65–70, to 75% for the 70–75 age group schizophrenia, none of the participants developed and reached 100% for those aged 75–80. Neither observable dementia during 1-year follow-up. prior leucotomy, electroconvulsive therapy (ECT) Cognition and activities of daily living remained or insulin coma therapy, nor current exposure to stable over the course of the year. However, a antipsychotics showed adverse effects on current longer-term Australian follow-up study, also with a cog nitive functioning. The limitations
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