Schizophrenia in the elderly: Guidelines for management

The treatment of schizophrenia in older populations poses special challenges for patients, family members and clinicians. These include changes in manifestation of schizophrenic illness in later life, age-related changes in response to pharmacological treatments and psychosocial issues associated with older life status. As with younger individuals, antipsychotic medications constitute the mainstay of treatment for schizophrenia in the elderly. However, the drug treatment of schizophrenia is substantially affected by the aging process. Medication sensitivity is pronounced in the elderly, largely due to age-related changes in the body's capacity to metabolise psychotropic and other drugs. Other relevant factors include higher rates of physical comorbidity, drug-drug interactions and age-related adverse effects. Generally, the appropriate starting dose of antipsychotic medication in the elderly is 25% of the adult dose. Total daily maintenance doses may be 30 to 50% of the adult dose. The use of conventional antipsychotics in the elderly is limited because of their association with extrapyramidal symptoms and anticholinergic and cardiovascular adverse effects. The advent of atypical antipsychotics has revolutionised the treatment of psychosis in the elderly. Based on the general psychiatric literature, the atypical agents have been found to be as efficacious as conventional agents in reducing positive symptoms, more efficacious against negative symptoms, and to have a much more benign adverse effect profile. Nonpharmacological issues in the management of schizophrenia in the elderly are at least as important as in younger individuals. Older individuals may face additional challenges that affect health outcome, such as living alone or being unable to drive. All drug treatments should be partnered with supportive approaches and psychosocial interventions that maximise treatment compliance and improve outcome.