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Learning Objectives

  • Understand the epidemiology, etiopathogenesis, definition, and clinical presentations of schizophrenia in older adults.

  • Learn about the differential diagnosis, atypical presentations, and nonpsychotic conditions commonly confused with schizophrenia in the older population.

  • Acquire new knowledge about drugs and psychosocial strategies used to treat scizophrenia.

Key Clinical Points

  1. Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) defines schizophrenia as continued presence from a minimum of 1 to 6 months of the classic positive or negative symptoms of the disease.

  2. Presence of psychotic symptoms in older adults does not directly imply a diagnosis of schizophrenia. Patients should undergo full evaluation to exclude other diagnoses such as dementia, medication side effects, schizoaffective disorders, and delirium before a diagnosis of schizophrenia is made.

  3. Antipsychotics are the mainstay of therapy; however, psychosocial interventions are effective and should be considered along with the drug therapy.


Schizophrenia is a chronic, debilitating disease characterized by positive symptoms of hallucinations, delusions, and thought disorder (also referred to as psychosis), and negative symptoms of chronic social dilapidation. Emil Kraepelin first distinguished schizophrenia (then termed dementia praecox) from bipolar psychosis more than 100 years ago, by contrasting the long-term deteriorating course of delusions and hallucinations characteristic of schizophrenia to the intermittent course and lack of permanent social and occupational deterioration in bipolar illness. Schizophrenia remains a clinical diagnosis made on the basis of the individual’s psychiatric history and mental status examination, as no laboratory or imaging studies can validly diagnose it.

Inclusion Criteria

Schizophrenia is described in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders as two or more of the following symptoms active for a minimum of 1 month’s duration (unless adequately treated) as well as the continuing presence of a symptom for 6 months: delusions, hallucinations, disorganized speech, disorganized behavior, and negative symptoms along with a significant disturbance of the individual’s functioning that results in disturbances in occupation, social interaction, or the management of one’s self-care. These symptoms of schizophrenia can be characterized as either positive or negative.

Positive symptoms

The positive symptoms of schizophrenia consist of abnormalities of sensory experience and cognitive processing. These manifest as hallucinations, delusions, bizarre behavior, or formal thought disorder. Hallucinations are perceptions in the absence of physical stimuli. In schizophrenia, auditory hallucinations usually predominate, but, in patients with late-onset schizophrenia, olfactory, visual, tactile, or gustatory hallucinations may be present. In schizophrenia, the hallucinated voices are described as coming from outside the person’s head and providing a running commentary on the patient’s behavior. At times, these speak directly to the individual or converse with each other. Voices that tell the individual what to do are referred to as command hallucinations.

Delusions are fixed, false, idiosyncratic beliefs and consist of ideas and beliefs that are persecutory, ...

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