Schizophrenia and dementia Chris Perkins Alzheimers NZ Conference

Schizophrenia and dementia Chris Perkins Alzheimers NZ Conference 04/11/16

• 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 years difference. • This means that many men and women with schizophrenia will be reaching their 60 s and be at increasing risk for dementia. • By 2025 20% of people with schizophrenia will be 65 or older (Rajji et al. 2013)

Danish cohort study: Ribe et al ( 2015) Risk of dementia > 2 x 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”

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 S

Schizophrenia or dementia? It’s all in the history Negative symptoms of schizophrenia Frontotemporal dementia • Diminished emotional expression • Avolition • Reduced speech output • Loss of ability to experience pleasure • Lack of interest in social activities • Loss of sympathy or empathy • Apathy or inertia • Decline in language ability (language variant) • Decline in social cognition and /or executive abilities • Behavioural disinhibition • Compulsive / ritualistic behaviour

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 20/30 and 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…

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.

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 past Mood 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…

Dementia risk factors in L-T mental illness • Brain damage – reduced cognitive reserve from illness • Smoking and other substance use • Physical inactivity • Reduced 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)

• • Keeping Body and Mind Together: Improving the physical health and life expectancy of people with serious mental illness • RANZCP (2015)

Management MH Old age ID

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 schizophrenia

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– 108 • Harvey, P. (2001) Cognitive and functional Impairments in Elderly Patients with Schizophrenia: A Review of the recent Literature Harvard Rev Psychiatry, 9, 2 , 59 -68 • Jeste, D. , Wolkowitz, M. &Palmer, B. (2011) Divergent trajectories of Physical, Cognitive and Psychosocial Aging in Schizophrenia Bulletin 37, 3: 451 -455 • RANZCP (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 -01 • Yucel, M. , Bora 1, E. , Lubman D. et al. (2012) Impact of Cannabis Use on Cognitive Functioning in Patients With. Schizophrenia: A Meta-analysis of Existing Findings and New Data in a First-Episode Sample. Schizophrenia Bulletin vol. 38 no. 2 pp. 316– 330 doi: 10. 1093/schbul/sbq 079 • ,