Innovations in drug treatment and new statutory guidelines are likely to produce a radical change in the way patients with schizophrenia are managed. The specific roles of primary and secondary care physicians are now subject to close definition, leading to new partnership arrangements in treatment. Patients over 65 years will also be subject to this guidance and in this article, Professor Chris McWilliam discusses some of the implications.

Schizophrenia is a complex disorder affecting personal, social and biological functioning and has an impact not only on the lives of patients but also of carers. Many people consider it a disease of younger people, probably because incidence of first episodes peak in the early twenties and younger people with schizophrenia are often more ÔvisibleÕ than their elderly counterparts.

However, for many patients over 65 years, schizophrenia has been a life-long disorder, presenting in early adult life then producing specific problems as they age. These relate to the social problems associated with long term schizophrenia, effects of institutionalization and, in many cases, years of treatment with old neuroleptics with their attendant side effects.

New statutory guidance from the National Institute for Clinical Excellence (NICE)1 is specific about the role of primary care physicians in managing schizophrenia outside of the hospital environment and some of these practice points may become mandatory.

Prevalence and risk factors
Many chronic schizophrenics live relatively uneventful lives in the community with little or no input from hospital services and may only present when they become physically ill or have problems with medication or side effects. However, primary and secondary care services are presented with a complex task of managing ageing patients with schizophrenia along with a significant number of new cases arising over the age of 65 years.

First episode psychoses are relatively common in the elderly, occurring in some 5-10 per cent of the population at some time2. Many of these are associated with dementia, sensory deprivation or other organic states but about a fifth of these will be schizophrenia3.

The risk for females is increased fourfold. There is also a well known association with deafness and visual impairment with patients with cataract and glaucoma being particularly susceptible to visual hallucinations. In addition, there is an association with immigrant status, social isolation and paranoid or schizoid personality. Whether these latter Ôrisk factorsÕ are a cause or effect of the illness is poorly understood.

Statutory framework
Increasing awareness of the clinical, social and economic impact of mental illness, including schizophrenia, on patients, carers and society in general has resulted in the Government releasing several documents detailing guidance for managing mental illness (Table 1). All have implications for service commissioners and providers and are gradually impacting on patient care.

Two of these documents are the National Service Framework (NSF) for Older People4 and NSF for Mental Illness5 Their joint impact on services for the elderly mentally ill is a cause for serious concern as funding has been concentrated on adult mental health provision, leaving old age services poorly resourced. Many patients are now in the invidious position of being able to access fewer support services once they become 65 years old and adult psychiatry disengages from their care. Most elderly schizophrenics belong to this group, often termed Ôgraduate patientsÕ. Many have been lost to follow up after the various changes in service provision during their lifetimes including closure of large mental hospitals, Ôcare in the communityÕ and social drift.

Another document is the NICE/NCCMH Clinical Guideline on Schizophrenia: core interventions in the treatment and management of schizophrenia in primary and secondary care1, which was published in December 2002. This is potentially the most significant document as this defines the expected role of primary care physicians in the management of schizophrenia in conjunction with secondary care, social workers, carers and voluntary support. As indicated earlier this is laid out as guidelines for best practice, which may well become mandatory.

The document was developed in conjunction with the Royal College of Psychiatrists and British Psychological Society and involved consultation with patient and carer support groups. The guideline is accompanied by teaching material including a training website with clinical treatment algorithms. It also details the role of secondary services in providing acute assessment and treatment of new cases and patients in relapse.

Services like Assertive Outreach and Home treatment teams, (which consists of specialized multi-disciplinary teams working in liaison with hospitals and primary care) should also work in conjunction with social services and carers to provide comprehensive tailored care aimed at rapid control of episodes of new cases of psychosis, appropriate intervention in cases of relapse and careful monitoring of patients in remission. These services are common in many areas but tend to be unavailable to people over 65 years. A Care Programme approach and Integrated Care Pathways also provide a basis for care monitoring.

There is very specific advice on the role of the primary care physician in managing the physical health of patients with schizophrenia. This has considerable implications for the way general practitioners (GPs) manage their patients with schizophrenia and may be especially relevant to the elderly. The guidance is very specific that Primary Care Case Registers should be set up for monitoring the physical health of patients with schizophrenia. In addition, consultation with patients is also stressed throughout the guidance, as is the need for such consultations to be recorded in the clinical notes.

In addition, maintenance of physical health is emphasised with the need for checks on diabetes, prolactin (osteoporosis), blood pressure, lipid profiles and side effects. Maintenance of physical health is often more important than monitoring of mental state in many stable elderly patients. Criteria which might trigger a re-referral to the secondary care team should be established, again in conjunction with the patient and formally recorded.

Medical management
This has been clarified in the NICE guidance for schizophrenia, published in June 20026. Key points relevant to the elderly are detailed in Table 2. These came in the wake of the introduction of atypical neuroleptics (with their different side effect profiles and safety concerns) over the older neuroleptics which led to the withdrawal of thioridazine. The guidance stresses the need for shared care between primary and secondary care, involvement of the patient in choice of medication and emphasises the role of atypical neuroleptics in first-line treatment. Any differences in the efficacy of the various atypical drugs (see Table 3) have not been clarified so drug choice is determined by differences in safety and tolerability and will vary from patient to patient. An excellent review comparing side effects and tolerability of the atypicals has been published by UKMi, the UK medicines information pharmacists group7.

The use of atypicals with their generally more benign side effects has certainly improved treatment options for elderly patients with schizophrenia. Patients over 65 years are particularly susceptible to the adverse effects of the older neuroleptics particularly drug induced Parkinsonism8, confusion9, postural hypotension and falls10.

Atypicals significantly reduce or even remove the risk of these side effects and have been of benefit not just in schizophrenia but also in psychoses associated with dementia and sensory deprivation. However, concerns have been raised about their own, less overt but potentially serious side effects. These include diabetes, osteoporosis and cardiovascular problems and these must be considered when initiating drug therapy.

Other interventions
The importance of other methods of treatment in schizophrenia is being increasingly recognised. The management of schizophrenia is being seen more widely as a collaboration between the patient and their carers. Social intervention is often required to improve quality of life and reduce chances of relapse. Psychological treatments such as Cognitive Behavioural Therapy (CBT) have been shown to be of benefit, even in drug resistant patients11 and are becoming more widely available. CBT is a form of psychotherapy aimed at giving patients some insight into how to manage their own illness. Many community nurses are trained in the techniques and it is often available to GPs via their community mental health team.

Conclusion
The treatment of schizophrenia is being seen increasingly as a partnership between the patient, their carers and primary and secondary care teams using multi-disciplinary treatments. Patient involvement in choice of treatment and the nature of their monitoring is emphasised. Statutory guidance has clarified the roles of primary and secondary care physicians in diagnosis and treatment. The importance of maintenance of physical health has now been recognised, taking into account the emerging side-effect profile of the atypical neuroleptics, which are now widely used.

GPs will become responsible for the monitoring and management of physical well-being of their schizophrenic patients with support from secondary care when problems arise. Elderly patients should benefit from this approach, which should reinforce what are often already close links between primary care physicians and their local old age psychiatry services. Whether extra funding will follow these changes is unclear. Elderly psychiatric patients have lost out in the last few years. This may be because some patients fall between the two stools of the NSFs for Old Age and Mental Illness and may often be in receipt of additional funding and enhanced services for their care if they are elderly or mentally ill but not both. Clinicians, patients and carers need to be vigilant that the new monitoring schemes and case registers include patients over 65 years and campaign for equity of service provision across all age groups.

References
1. National Institute for Clinical Excellence Department of Health. London December 2002

2 Howard R. CPD Bulletin. Old Age Psychiatry 1999; 1(3): 65Ð6

3 McWilliam C. Paranoid disorders: easy to overlook in older people. Geriatric Medicine, 1999; 29(4): 43Ð6

4 Department of Health. National service framework for older people. London: Department of Health 2000

5 Department of Health. National service framework for coronary heart disease. London: Department of Health 2000

6 National Institute for Clinical Excellence Department of Health. London June 2002

7 UK medicines information pharmacists group, April 2002

8 Feinberg M. Drugs and Ageing 1993; 3(4):335Ð48

9 Keks NA. Minimizing the non-extrapyramidal side-effects of antipsychotics. Acta Psychiatrica Scand 1996; 389: 18Ð24

10 McShane R, Keene J, Gedling K et al. Do neuroleptic drugs hasten cognitive decline in dementia? Prospective study with necropsy follow up. Br Med J 1997; 314 (7076): 266Ð70

11 Tarrier N, Beckett R, Harwood S et al. A trial of two cognitive-behavioural methods of treating drug-resistant residual psychotic symptoms in schizophrenic patients: I. Outcome. B J Psych 1993; 162: 524Ð32

Professor Chris McWilliam is a Consultant in Psychiatry of Old Age at Department of Health and Social Studies, Bolton Institute

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