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

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Decreased functional status in outpatients with
chronic schizophreniaKushik Jaga, MBBS, MPH1,2,
Cecile Sison, PhD2, Edward R. Allan, MD2,
Christopher R. Bowie, PhD1, Philip D. Harvey,
PhD1

• 1 Mount Sinai School of Medicine, Dept. of
  Psychiatry, New York, NY
• VA Hudson Valley Health Care System,
• Research and Development, Montrose, NY

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Abstract

• 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, gt 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 (p0.04). The PANSS general
  psychopathology symptoms improved significantly
  in ages 65 and above (p0.05). Increasing age
  correlated with declining UPSA and SLOF scores (p
  lt 0.01). The PANSS negative scale correlated with
  lower SLOF scores (p lt 0.01). The mini-mental
  status (MMSE) mainly predicted performance on the
  UPSA and SLOF (p lt 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.

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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
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Introduction

• 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.
• Figure 1 Longitudinal Course of Schizophrenia
  (Lieberman)4
• Premorbid Stage Prodromal Onset/
  Clinical Chronic/ Residual
• 
  Progression Deterioration
  Stage
• 
  Psychotic symptoms
• Birth Puberty -20 yrs
  30 yrs 40
  yrs and above
• 
  
  Functional Decline
• 
  (Cognitive
  Impairment)1,5

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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.
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Methods

• 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 lt 17.
• 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
• Statistical Analysis
• Comparison of mean scores of PANSS, UPSA,
  and SLOF between 4 age groups 50-54,
  55-59, 60-64, gt65 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.

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Results

• N196 veterans 91 (46.4)
• males 143 (73),
  females 52 (27)
• Table 1 Demographics of schizophrenic patients
• Characteristic
  Mean SD
• Age (years)
  59.1 9.4
• MMSE
  26.9 3.1
• Education (years)
  12.2 3.8
• Age distribution 50-54 yrs 73 (37.2)
• 55-59
  yrs 57 (29.1)
• 60-64
  yrs 28 (14.3)
• gt 65
  yrs 38 (19.4)

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Figure 2 Comparison of PANSS scores across Age
groups

• 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
  (F2.53, p0.05).

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Figure 3 Comparison of UPSA scores across age
groups

• Significant decline in UPSA scores in patients
  65 years and older
• - comprehension and planning, communication,
  mobility (F5.67, p0.001)

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Figure 4 Comparison of SLOF scores across age
groups

• Patients 65 years and above had a significant
  decline in the SLOF
• physical functioning, activity, work
  skills (F4.64, p0.04)

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• Correlations
• Increasing age correlated with declining scores
  of UPSA and SLOF respectively (r -0.29, p lt
  0.001 r -0.27, p lt 0.001).
• Correlation between PANSS negative symptoms and
  decreasing SLOF scores (r -0.307, p lt
  0.001).
• Regression Analysis
• Lower MMSE scores was a predictor of the decline
  in functional status
• 21 of the variance on UPSA (p lt 0.01,
  95CI 1.23 2.19)
• 20 of the variance on SLOF (p lt 0.01,
  95CI 1.8-3.6)
• Negative symptoms accounted for 4.0 of the
  variance on the SLOF (p0.06).
• Older age accounted for 3.0 of the variance on
  UPSA (p lt 0.01),
• and 3.2 on the SLOF (p lt 0.01).

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Conclusions

• 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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