Transcript Decreased functional status in outpatients with chronic

Decreased functional status in
outpatients with chronic
schizophrenia
Kushik Jaga, MBBS, MPH1,2, Cecile Sison, PhD2,
Edward R. Allan, MD2, Christopher R. Bowie, PhD1,
Philip D. Harvey, PhD1
Mount Sinai School of Medicine, Dept. of
Psychiatry, New York, NY
2 VA Hudson Valley Health Care System,
Research and Development, Montrose, NY
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Abstract
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Introduction:
The course of illness in chronic schizophrenics is known to affect the functional status of patients
over time. Psychotic symptoms also vary with age and determine the health outcome of patients
such as; well being and physical functioning. In this study, functional status of outpatients with
chronic schizophrenia was compared across age groups.
Methods:
Outpatients aged 50 and above diagnosed with schizophrenia or schizoaffective disorder were
included (196). Symptom severity was measured by the positive and negative syndrome scale
(PANSS). Functional status was assessed with both a performance-based (UPSA) and observer
rated Specific Level of Functioning (SLOF) measures. Mean scores of the PANSS, UPSA and
SLOF were compared between 4 age groups; 50-54, 55-59, 60-64, >= 65, using Analysis of
variance (ANOVA). Correlation analysis examined relationships between PANSS, UPSA and
SLOF categories.
Results:
Functional performance declined significantly with increasing age – UPSA (p = 0.001), SLOF
(p=0.04). The PANSS general psychopathology symptoms improved significantly in ages 65 and
above (p=0.05). Increasing age correlated with declining UPSA and SLOF scores (p < 0.01). The
PANSS negative scale correlated with lower SLOF scores (p < 0.01). The mini-mental status
(MMSE) mainly predicted performance on the UPSA and SLOF (p < 0.01). Negative symptoms
predicted outcome of SLOF more than age.
Conclusion:
With increasing age schizophrenic patients are more likely to demonstrate poorer functional
abilities and have increasingly impaired functional ("real world") performance. Older schizophrenia
patients might have different community-based and home care needs.
Course of Cognitive and Functional Deficits in
Older Schizophrenic Patients
Supported by: National Institute of Mental Health (NIMH)
Grant MH 63116
Principal Investigator: Philip D. Harvey
Co-Investigator: Cecile Sison, PhD
Study Manager: Christopher R. Bowie, PhD.
Clinical Research Coordinator: Kushik Jaga, MBBS, MPH
Introduction
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Schizophrenia: Severe psychiatric disorder,
Psychotic symptoms; hallucinations and delusions
Cognitive and functional impairment – major cause
of disability1,2
Affects more than 2 million people in the US
98,000 veterans received care for schizophrenia in
the VA in 20033.
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Figure 1: Longitudinal Course of Schizophrenia (Lieberman)4
Premorbid Stage
Prodromal Onset/
Progression
Birth
Puberty -20 yrs
Clinical
Deterioration
Psychotic symptoms
30 yrs
Chronic/ Residual
Stage
40 yrs and above
Functional Decline
(Cognitive Impairment)1,5
Outcome of Illness:
Functional impairment - Social, occupational, independent living,
rehabilitation skills1,2
" Not able to manage their way in the world"
" Not able to function in a gainful way"4
Quality of life
Measurement of Functional Status
Standardized neurocognitive tests – neuropsychological performance
Functional capacity
– "real world outcome"
What the person can do
What the person does1
Objective:
To compare the functional status across age groups in outpatients with
chronic schizophrenia.
Methods
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Study population: Outpatients with chronic schizophrenia; aging population
in community dwelling or care, or independent living
(changed environment from in-patients)
On active treatment with antipsychotic medications
Inclusions: schizophrenia or schizoaffective disorder
age 50 years and above
Exclusions: Other Axis I psychotic disorders; bipolar, psychosis NOS,
Major Depressive Disorder (MDD) with psychotic features
Medical illness known to affect cognitive functioning
(dementia, head trauma)
Mini-mental score < 17.
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Selection: 196 patients were selected from VA, New York State, or
academic research sites.
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Measurements
Mini-Mental Status Exam (MMSE)
Positive and Negative Symptom Scale (PANSS)
Functional Skills Assessment; USCD performance based (UPSA)
comprehension and planning, finance,
communication, mobility
Specific Level of Functioning (SLOF) (observer rated)
physical functioning, interpersonal relationships,
social acceptability, activities, work skills
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Statistical Analysis
Comparison of mean scores of PANSS, UPSA, and SLOF between 4 age
groups;
50-54, 55-59, 60-64, >=65 years
- One Way Analysis of Variance (ANOVA)
Correlation analysis between; age and UPSA, SLOF,
PANSS and UPSA, SLOF. (Pearson's Correlation)
Regression of MMSE, negative symptoms, and age to determine how well
they predict variability on the UPSA and SLOF.
Results
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N=196; veterans 91 (46.4%)
males 143 (73%),
females 52 (27%)
Table 1 Demographics of schizophrenic patients
Characteristic
Mean + SD
Age (years)
MMSE
Education (years)
Age distribution:
50-54 yrs
55-59 yrs
60-64 yrs
>= 65 yrs
59.1 + 9.4
26.9 + 3.1
12.2 + 3.8
73 (37.2%)
57 (29.1%)
28 (14.3%)
38 (19.4%)
Figure 2 Comparison of PANSS scores across Age groups
PANNS P
PANSS N
PANSS G
30
25
Mean
Scores
20
15
10
5
0
50-54
55-59
60-64
>65
Age Groups (years)
• PANSS positive and negative symptoms did not change across age groups
• The PANSS general psychopathology symptoms improved significantly
in older patients, 65 years and above (F=2.53, p=0.05).
Figure 3 Comparison of UPSA scores across age groups
50
40
Mean
Scores
30
20
10
0
50-54
55-59
60-64
> 65
Age Groups (years)
• Significant decline in UPSA scores in patients 65 years and older
- comprehension and planning, communication, mobility (F=5.67, p=0.001)
Figure 4 Comparison of SLOF scores across age groups
210
200
Mean
Scores
190
180
170
160
50-54
55-59
60-64
> 65
Age Group (years)
• Patients 65 years and above had a significant decline in the SLOF
– physical functioning, activity, work skills (F=4.64, p=0.04)
Correlations
• Increasing age correlated with declining scores of UPSA and SLOF
respectively (r = -0.29, p < 0.001; r = -0.27, p < 0.001).
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Correlation between PANSS negative symptoms and decreasing SLOF
scores
(r = -0.307, p < 0.001).
Regression Analysis
• Lower MMSE scores was a predictor of the decline in functional status;
21% of the variance on UPSA (p < 0.01, 95%CI: 1.23 – 2.19)
20% of the variance on SLOF (p < 0.01, 95%CI: 1.8-3.6)
• Negative symptoms accounted for 4.0% of the variance on the SLOF
(p=0.06).
• Older age accounted for 3.0% of the variance on UPSA (p < 0.01),
and 3.2% on the SLOF (p < 0.01).
Conclusions
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Community dwelling patients with chronic schizophrenia are more likely to
demonstrate poorer functional abilities with increasing age – impaired
functional "real world" performance.
The level of impairment in older schizophrenics is related to cognitive
impairment and negative symptoms.
Older schizophrenics might have different community-based and home care
needs, requiring treatment targeted at cognitive and functional
improvement.
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