Caring for the Whole Person: Integrated Health Care for Older Adults with Severe Mental Illness and Medical Comorbidity

Schizophrenia is associated with a 20% shorter life span than for the general population1 and high rates of chronic medical illnesses, including diabetes mellitus (DM), hypertension, heart disease, and emphysema.2 Recent research suggests that premature mortality and excess physical disability in schizophrenia is associated with a variety of extrinsic risk factors that are potentially preventable, including unhealthy lifestyles, metabolic and neurological side effects of psychiatric medications, and poor health care. The aging of the population of persons with severe mental illness (SMI) further contributes to growing rates of medical comorbidity. The number of older adults with major psychiatric illness is predicted to more than double by 2030.3 This paper provides an overview of selected research findings on the prevalence and causes of medical comorbidity in schizophrenia and other SMIs, current challenges to providing quality health care, and suggested directions for integrated models of care for the older person with a SMI. Approximately 3% of American adults have SMI, including 1% with schizophrenia and 2% with depression or bipolar disorder that is refractory to treatment.4 In older adults, the prevalence of schizophrenia and bipolar disorder decreases to approximately 0.5% and 0.2%, respectively, whereas the prevalence of major depression ranges from less than 1% to 5%.5,6 The lower prevalence of schizophrenia in older persons is most likely due to remission of psychotic symptoms7,8 for some individuals and premature mortality. Schizophrenia is associated with a 20% shorter life expectancy than for the general population.1 The lives of men with schizophrenia are 10 years shorter than those of men without schizophrenia, whereas the lives of women with schizophrenia are about 9 years shorter than those of women without schizophrenia.9–12 Factors that contribute to premature death and poor outcomes for persons with schizophrenia and other SMIs include high prevalence of comorbid medical disorders, poor health behaviors, and inadequate health care.10–17 The research literature on medical comorbidity and health care for persons with SMI consists of studies specific to schizophrenia and studies that also include individuals with other psychotic-spectrum disorders, bipolar disorder, and treatment-refractory severe depression, collectively referred to as SMI. Throughout the following overview of medical comorbidity and health care, studies on the subgroup of persons with the diagnosis of schizophrenia and on the larger group of persons with SMI are included. Much of what is known about medical comorbidity and health care in persons with SMI has been derived from samples of young and middle-aged mentally ill persons. Hence, in the following overview of this topic, data on comorbidity and health care for the larger population, which includes younger and middle-aged persons, are included, in addition to the few studies specific to the older adult population (≥65), where available. A substantial research literature documents the high prevalence of medical comorbidity in young and middle-aged adults (18–64) who have SMI. Approximately half (48%) of adults with schizophrenia in this age group have at least one current medical condition, and one-fifth (20%) have multiple current medical conditions.18 SMIs are associated with higher rates of comorbid medical conditions, such as DM, cardiovascular disease, gastrointestinal disorders, skin infections, hepatic disorders, asthma, and acute respiratory ailments than in non-mentally ill adults.19,20 High rates of comorbid medical illnesses are found in adults with psychotic disorders (schizophrenia and schizoaffective) and adults with affective disorders (depression and bipolar disorder).20Table 1 compares the prevalence of common medical disorders in adults aged 18 to 65 receiving community-based psychiatric services with the prevalence of medical disorders in the general population. Higher rates are found for almost all medical disorders in individuals with schizophrenia and mood disorders, with the most pronounced differences found for DM; cardiovascular disease; and respiratory, renal, and liver disorders. Consistent with other reports,22,23 rates of medical comorbidity are highest for depression, most likely due to the bidirectional relationship of medical illness as a cause of depressive symptoms and depression as a cause of poor outcomes and lower rates of recovery in medical disorders.24 Medicaid claims provide a similar perspective on high rates of medical comorbidity in schizophrenia for adults aged 18 to 64. In a study of Massachusetts Medicaid beneficiaries, those treated for schizophrenia had a greater prevalence of asthma (8.5% vs 5.5%) and acute respiratory disorders (pneumonia and influenza) (32.8% vs 26.3%) than those without schizophrenia. Similarly, those with schizophrenia had greater rates of hypertension (10% vs 9.3%) and heart disease (8.8% vs 5.6%).19 Finally, Medicaid beneficiaries with schizophrenia had co-occurring DM at a rate more than 2.5 times greater than persons without schizophrenia.19 Increased rates of DM in persons with schizophrenia have been documented in a substantial research literature ranging from 7% to 16%.19,25–28 A limited research literature on older adults with SMI (aged ≥65) confirms the high prevalence of co-occurring major medical disorders.17 For example, in older veteran outpatients with SMI (aged≥60, n=90), significant medical comorbidity (defined as at least one concurrent major medical illness) was found in 92% of depressed patients, 75% of persons with bipolar disorder, and 67% of persons with schizophrenia. Across diagnostic categories, rates for cancer were higher in persons with depression, and dermatological conditions were significantly higher in persons with schizophrenia.29 High rates of medical comorbidity are also found in older inpatients hospitalized for psychiatric illness. In a chart review study of 95 psychiatric inpatients aged 60 and older (including 47% with mood disorders, 20% with organic disorders, and 28% with schizophrenia or other psychotic disorders), almost all (91.5%) had one or more significant medical problems, with an average of 1.9 medical conditions. Nearly one-third of the sample had one medical illness (30.6%), 32.6% had two medical illnesses, and 26.3% had three to four medical illnesses. The most prevalent medical disorders included cardiovascular (34%), neurological (22%), genitourinary (17%), respiratory (17%), gastrointestinal (17%), endocrine (16%), and hematological or oncological (16%).30 Finally, in a larger study of older psychiatric inpatients (aged ≥50, n=868) persons with psychotic disorders (n=90) had an average of 4.7 medical disorders, and persons with mood disorders (n=329) had 5.6 medical disorders. Medical illnesses were slightly more prevalent in persons with mood disorders relative to schizophrenia, including circulatory disorders (83.5% vs 60.0%), endocrine disorders (52.0% vs 45.5%), musculoskeletal disorders (47.4% vs 40.0%), and digestive disorders (62.9% vs 37.8%).31 Older age is associated with greater rates of medical illness in persons with SMI. Table 2 compares the prevalence of common medical disorders in younger and older Medicaid beneficiaries with schizophrenia and depression in an analysis conducted for this review. New Hampshire Medicaid claims for DM, chronic obstructive pulmonary disease/asthma, and cardiovascular disease for 2001 were tabulated for persons with schizophrenia and mood disorders (major depression and bipolar disorder), stratified by younger and older age. The highest rates of comorbidity were found for mood disorders, consistent with comparisons for young adults (Table 1). Higher rates of medical illness were found in older than younger persons with schizophrenia and mood disorders. For instance, the prevalence of cardiovascular disease was greater in older adults with schizophrenia or mood disorders. Respiratory disease and multiple comorbid illnesses were more prevalent in older adults with schizophrenia than in younger persons with schizophrenia. The aging of the population of individuals with schizophrenia compounds the effect of medical illness on the course and outcome of schizophrenia.17 Overlapping, but different, age-associated factors contribute to growing rates of co-occurring medical disorders in younger than in older persons with SMI. For example, younger persons with SMI are at especially high risk of infectious diseases such as hepatitis and human immunodeficiency virus (HIV) associated with high rates of substance abuse and unsafe sexual practices in this age group.32,33 Both younger and older persons with SMI have increased risk for medical illness due to poor health behaviors, including smoking, alcoholism, poor diet, and lack of exercise.34–37 A convergence of lifestyle and health behaviors associated with SMI38 and health-related side effects of antipsychotic medication39 most likely cause compromised health and increased rates of chronic medical illness in older persons with SMI. In addition to poor diet and sedentary behaviors, exposure to second-generation (atypical) antipsychotic medications is associated with hyperlipidemia, weight gain, glucose intolerance, and greater rates of DM.28,34 Medical comorbidity in individuals with schizophrenia has also been linked to complications of the disorder itself (e.g., catatonia, polydipsia).14 The older person with SMI is subject to the double jeopardy of an increased risk of medical illness associated with advancing age in conjunction with the increased risks of medical illness associated with having a SMI. The cumulative long-term effect of poor health behaviors and long-term exposure to psychiatric medications with substantial metabolic and neurological side effects places the older person with SMI at a greater risk of respiratory, cardiovascular, and endocrine disorders. Older age also complicates mental and physical functioning in persons with SMI because of the neurocognitive deficits that can increase in late life.40,41 Finally, older persons with SMI have a greater likelihood of poorer quality of healthcare relative to non-mentally ill older adults.42,43 A fragmented healthcare system presenting barriers to adequate medical care may worsen medical conditions.14,44 Lifestyles associated with poor health are observed early in the course of SMI, and these behaviors (or their effects) generally continue throughout the life cycle. For example, in younger adults with SMI, rates of alcohol- and drug-use disorders range between 15% and 60% and are associated with serious medical problems, including HIV and hepatitis.14,32,45 Substance abuse in schizophrenia is also associated with poor outcomes that include an increase in psychotic symptoms, poorer treatment compliance, housing instability, and homelessness.15 Although the incidence of alcohol- and substance-use disorders in SMI decreases with age, the alarming rate of hepatitis C and long-term (and potentially fatal) effects on hepatic functioning place the current cohort of middle-aged persons at long-term risk.32,33 Although the incidence of dual-diagnosis (co-occurring substance abuse and mental illness) is significantly lower in older adults (6.9%) than in younger adults (26.7%),45 dually diagnosed older adults have more psychiatric outpatient visits than dually diagnosed younger adults and older adults with psychiatric or substance-use disorders alone.45 In addition, they have longer inpatient substance abuse stays and more outpatient substance abuse stays than older adults with psychiatric or substance-use disorders alone.45 Tobacco use is the most common form of substance abuse in individuals with SMI. Between 60% and 80% of individuals with schizophrenia are nicotine dependent, compared with one-third of individuals in the general population.46 High rates of smoking are likely to contribute to increased rates of asthma, emphysema, and other chronic and acute respiratory disease found in schizophrenia.20 In addition, high rates of smoking directly contribute to the increased risk of hypertension and heart disease, which is further compounded by lack of exercise. Sedentary lifestyle has been documented as a common risk factor for many individuals with SMI. Fewer than one-fifth of individuals with schizophrenia engage in one or more periods of moderate exercise weekly.47 Poor diet has also been documented in schizophrenia, including significantly lower consumption of fruits and vegetables than in age- and sex-matched controls.48 Individuals with schizophrenia have diets that are higher in fat and lower in fiber than persons of similar socioeconomic status without psychiatric illness.47 These behaviors may combine with the metabolic side effects of antipsychotic medications to produce the high rates of obesity, DM, and heart disease found in persons with SMI. Finally, the added effect of age-associated changes in metabolism, physiology, and physical activity combined with increased rates of related chronic diseases places the older person with SMI at especially high risk for poor health outcomes. Reports of an increased risk of obesity, DM, and other medical conditions associated with second-generation (atypical/novel) antipsychotics have stimulated recent expert consensus recommendations on physical health monitoring.2,39 These recommendations add to earlier literature supporting screening for extrapyramidal side effects and tardive dyskinesia associated with first-generation (typical/conventional) antipsychotics, especially in older persons who are at increased risk for these side effects.49–52 Forty-two percent of individuals with schizophrenia meet criteria for obesity (body mass index (BMI)>27 kg/m2), compared with 27% of the general population.53 First- and second-generation antipsychotics are associated with weight gain,54,55 with selected agents accounting for the greatest increases in weight. For example, a meta-analysis of studies evaluating mean weight gain over 10 weeks of treatment with atypical antipsychotics found the highest weight gain for clozapine (4.45 kg) and olanzapine (4.15 kg), with lower (but significant) weight gain with sertindole (2.92 kg) and risperidone (2.10 kg) and the lowest weight gain for ziprasidone (0.04 kg).56 Because of the strong association between obesity and medical conditions such as heart disease, hypertension, osteoarthritis, and DM, it is now recommended that weight and BMI be monitored before initiating or changing antipsychotic medication, and that weight then be monitored at all treatment visits over the first 6 months and quarterly thereafter.2 The high prevalence of DM in schizophrenia is strongly associated with high rates of obesity, although it is possible that atypical antipsychotics also contribute to increased risk of DM by altering metabolic variables. A recent expert consensus panel convened by the American Diabetes Association and the American Psychiatric Association confirmed a strong association between several atypical antipsychotic agents and hyperlipidemia and decreased glucose tolerance.39 For example, clozapine and olanzapine can increase insulin resistance,57,58 and increased rates of DM have been found in patients taking clozapine, olanzapine, and quetiapine. The association between second-generation antipsychotics and DM is strongest in patients younger than 40, suggesting that the added risk may decrease (rather than increase) with older age.59 Based on the overall association of atypical antipsychotics with metabolic alterations, clinicians prescribing atypical antipsychotics are now encouraged to incorporate metabolic and weight monitoring in routine psychiatric practice. Consensus guidelines recommending metabolic screening and physical health measures as a part of routine clinical practice are shown in Table 3. These guidelines include recommendations for a fasting plasma glucose test, although a hemoglobin A1c test can also be considered when a fasting glucose test is not feasible.2 In addition, lipid profile recommendations reflect the association between some second-generation antipsychotics and hyperlipidemia and the relationship between elevated cholesterol and triglyceride levels to hypertension, cardiovascular disease, and myocardial infarction (MI). Other side effects of antipsychotic medications of particular relevance to older persons include QTc-interval prolongation on electrocardiogram, hyperprolactinemia, and cataracts.2 For example, the first-generation antipsychotics thioridazine, mesoridazine, and pimozide are contraindicated in persons with heart disease, history of syncope, or prolonged QTc interval. Similarly, the second-generation antipsychotic ziprasidone is contraindicated in persons with QTc-interval prolongation, underscoring the need for baseline and follow-up electrocardiograms before prescribing these agents.2 Hyperprolactinemia is a potential side effect of first-generation antipsychotics and risperidone.2 Although sexual side effects are most considered as a possible of hyperprolactinemia, the potential increased risk of associated with prolonged treatment with antipsychotics is of particular for the older person with SMI. For example, in a study of persons with schizophrenia receiving antipsychotic medications for more than 10 of the men and of the women association between risperidone and in women with schizophrenia has also been Although a relationship between antipsychotic agents and screening in women and older men be considered as an of health care for older persons with a history of prolonged antipsychotic Finally, the of for older persons with SMI is especially for those treated with agents potentially associated with and such as and the between physical health and mental health psychiatric clinicians and mental health of care have to incorporate medical health care the of clinical practice. The recent on of mental health and medical health care the life span as a especially for the older person with psychiatric illnesses are or treated in individuals with psychiatric older adults with mental disorders are less likely to health care, to increased rates of with SMI a variety of barriers to medical care. For example, adult outpatients with schizophrenia and affective disorder most that they have health care because of a lack of of of poor of lack of and or to percent of persons with SMI at least one to medical care, compared with without a psychiatric SMI is associated with high general health in part due to treatment and care where the of care is more For instance, healthcare of individuals with schizophrenia who are dually for and Medicaid are higher than for those with depression or medical These with Older adults with SMI are at greater risk of receiving inadequate or care, including lower quality of health care, and to outpatient services for older adults with SMI of visits for psychiatric mental health care and services on of psychiatric the added of medical illness in the older person with SMI, they are likely to a lower of health For example, a study of older patients with psychiatric disorders found that older persons healthcare services than younger adults Older persons with DM are less likely to more than one medical they have schizophrenia, bipolar disorder, or disorder than individuals without with hypertension and psychiatric disorder are less likely to more than one medical than persons without a mental Older adults with SMI have a increased rate of mortality acute medical most likely due to a lower likelihood of receiving and adequate acute health care. In an analysis of older adults with mental illness were found to poorer medical care than older adults without a mental The of psychiatric illness was associated with a increase in mortality. In the subgroup of patients who were for (but considered not to be because of one or more psychiatric illness was associated with poorer quality of health care the For example, patients with psychiatric illness had a lower likelihood of receiving (10% and Older patients with schizophrenia were as likely as patients without a psychiatric illness to for these quality measures of care, the association between mental disorders and greater mortality was longer These findings to the that deficits in quality of health care may a substantial part of the mortality by older adults with SMI. 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