Treating older adults with schizophrenia: challenges and opportunities.

Schizophrenia affects people of all age groups. Treatment plans for older adults with schizophrenia must consider the effects of age on the course of the illness as well as on the response to antipsychotics and to psychosocial interventions. Positive symptoms of schizophrenia tend to become less severe, substance abuse becomes less common, and mental health functioning often improves. Hospitalizations are more likely to be due to physical problems rather than psychotic relapses. Physical comorbidity is a rule, however, and older age is a risk factor for most side effects of antipsychotics, including metabolic syndrome and movement disorders. We recently reported high rates of adverse events and medication discontinuation along with limited effectiveness of commonly used atypical antipsychotics in older adults. Psychosocial interventions such as cognitive behavioral social skills training are efficacious in improving functioning in older adults with schizophrenia. In formulating treatment plans for this population, a balanced approach combining cautious antipsychotic medication use with psychosocial interventions is recommended. Antipsychotic medications should generally be used in lower doses in older adults. Close monitoring for side effects and effectiveness of the medications and a watchful eye on their risk:benefit ratio are critical. In a minority of patients it may be possible to discontinue medications. Sustained remission of schizophrenia after decades of illness is not rare, especially in persons who receive appropriate treatment and psychosocial support-there can be light at the end of a long tunnel.