Give elders their due

People with schizophrenia aged 55 years and above are about to become 25% of the total population with the disease. Yet only 1% of the schizophrenia research budget relates to older adults. So it is not surprising that much about the natural history of schizophrenia in this group remains unclear. To what extent is it really a quiescent disease at this stage in life? How does cognitive function change with time?

Data from New York City, presented by Carl Cohen (SUNY Downstate Medical Center, Brooklyn, New York, USA) casts light on what is happening in people with schizophrenia in mid to late life (55 years plus) and living in the community.

The starting point was a group of 250 who had developed schizophrenia before the age of 45. They were outpatients and did not have moderate or severe cognitive deficits or complicating factors such as a history of head trauma at baseline. Those living independently represented 39% of the sample: the others were in some form of supported residence. They were matched at baseline with 113 controls matched for age and income.

The cognition situation in older people is dynamic: some improve, others decline

No mean change does not mean no change

At the start of the study, people with schizophrenia had a mean Dementia Rating Scale (DRS) score of 128, not far below the score of 138 among controls, but perhaps indicative of mild cognitive impairment.

As expected, there was considerable loss to follow-up, not least because of death. But those lost were similar to those who could be re-contacted. After a median follow-up of 4.5 years, the mean score of 127 among 104 people with schizophrenia showed no change. But this did not mean that no px had changed. While 59% showed essentially the same score at follow-up, 21% had experienced a decline in cognition – defined as a fall of 0.5 SD per year – and 19% had shown improvement -- defined as an increase in score of 0.5 SD per year. So the cognition the situation is actually quite dynamic.

On multivariate analysis, those whose cognition scores improved had had poorer scores at baseline. So there may be some regression to the mean. Though pxs living independently had better cognition at baseline, those living in supported housing were less likely to show decline over the period of follow-up, perhaps because of greater access to services.

Does pro-schizophrenia RNA hide deep in the genome?

Although an estimated 8% of the human genome is of retroviral origin, acquired during millions of years of primate evolution, most of it is now junk. It has been inactivated by mutation or epigenetic processes such as methylation. But what if some of it is capable of re-activation, perhaps by infections during embryonic development?

Though he repeatedly acknowledged that the idea is highly speculative, Awais Aftab (Case Western Reserve University, Cleveland, Ohio, USA) presented the argument that Human Endogenous Retroviruses (HERVS), particularly the HERV-W family, may play a malign role in the causation of schizophrenia.

There is evidence that HERV-W nucleotide sequences are more common in those affected with schizophrenia than in controls. The HERV-W envelope protein seems to activate production of inflammatory cytokines, which might contribute to the inflammation story in schizophrenia. And infections linked to schizophrenia can activate HERV-W elements, perhaps through demethylation of relevant genes.

In combination with genetic predisposition and environmental factors, archaeological remnants of millennia-old viral RNA could set the developing brain on the path towards schizophrenia and so provide a missing link in causation, at least in some patients. It is a suggestion worth considering.

Imagine if one working week every month your work performance was limited or compromised. That’s the situation faced by many schizophrenia caregivers who also hold down paid jobs, according to the findings of a large-scale caregiver survey presented by Dr Debra Lerner of the Tufts Medical Center, Boston, at the 2016 APA congress.

Dr Lerner said that over 18% of adults in the US act as unpaid caregivers, and she cited the findings from On Pins and Needles study which showed that three quarters of caregivers looking after someone with mental health issues find the task emotionally stressful.

Holding down a job

Many caregivers to people with schizophrenia and schizoaffective disorder work, and Dr Lerner therefore said it was important to try to understand the impact that their caregiving had on work function and productivity. To this end, Dr Lerner got involved in conducting a survey of caregivers who also worked, asking about their paid work commitments and employment.

She described the anonymous on-line survey, which included a number of validated tools such as the work limitations questionnaire (WLQ), designed to assess time lost from work (absenteeism), presenteeism and impact of caregiving on work productivity.

Results from over 1000 caregiver questionnaires were available for analysis, and showed that the average age of caregivers was 55 years, with the average age of the care-recipient 40 years. Most caregivers were women and most were the parent of the person with schizophrenia or schizoaffective disorder.

Heavy work commitments

Over 60% of caregiver respondents were in current work and of those, 69% reported being in full time work. Dr Lerner said that these statistics showing high rates of full time work among carers, emphasized the need to make things easier for caregivers, particularly as the survey showed that most worked outside of the home and many had lengthy commutes to their place of work.

Work losses common

Over a quarter of caregivers in work said they often had to take time off work but more than half said it was difficult to take time away from work for personal matters. Missing an average of 0.6 days per week from work and associated with work productivity losses of around 8%, Dr Lerner said that caregivers had work losses that are equivalent to those experienced by patients with MDD.

The survey highlights that being a caregiver to a person with schizophrenia spills over into work – with a negative impact on productivity. More research is needed to understand and quantify the burdens on those who care for people with serious mental illness.