Sensory Impairment in Late-life Schizophrenia

Sensory Impairment in Late-Life Schizophrenia by Simeon Prager and Dilip V. Jeste Abstract We reviewed 27 published studies examining a possible association between sensory (visual or hearing) impairment and late-life psychosis with paranoid features. A majority of these investigations supported the postulated association between hearing impairment and late-onset schizophrenia or paranoid disorder. Many of the published studies, however, had important methodological limitations. In a casecontrol study, we assessed visual and hearing impairments in 87 middle-aged and elderly subjects (16 with late-onset schizophrenia, 25 with early-onset schizophrenia, 20 with mood disorder, and 26 normal comparison subjects). Visual and hearing impairments were assessed in a blind manner by means of standardized quantitative assessments. Compared with normal subjects, both of the schizophrenia groups and the mood disorder group had greater impairment in most variables of corrected visual acuity and in self-reported hearing deficit, but not in uncorrected (constitutional) visual acuity or on pure-tone audiometry. Our results suggest that the observed relationship between sensory impairment and late-life psychosis may be due, at least in part, to a suboptimal correction of sensory deficits in older psychiatric patients. When a person becomes deaf through disease .... the result is always the same. Often not knowing what his fellow men are saying he becomes doubtful about them: losing auditory contact with them he has to rely on an inner world of auditory memories and images; he 755 misinterprets auditory sense impressions which have been distorted by disease, and incorporates tinnitus caused by such disease into his world of inner phantasy. He projects his inner feelings of inferiority caused by his deafness on to his environment and develops ideas of reference. Systematization soon follows, with active delusions of persecution. If the personality is sufficiently unstable a psychotic illness results. [Houston and Royce 1954, p. 990] The prevalence of schizophrenia among the elderly is 0.1 to 0.5 percent. Although 90 percent of elderly schizophrenia patients are early-onset schizophrenia patients who have lived into old age (Gurland and Cross 1982), the other patients have experienced lateonset schizophrenia. Harris and Jeste (1988) reported, on the basis of their literature review, that 7 percent of all schizophrenia patients were thought to have had the onset of their symptoms in the sixth decade of life, and 3 percent at some time thereafter. In recent years there has been notable improvement in the diagnostic nomenclature related to late-life psychotic disorders with classification systems such as DSM-IH-R (American Psychiatric Association 1987). Yet, the etiopathology of these conditions continues to be enigmatic. Family history, premorbid personality type, structural brain lesions, and psychosocial stressors are among the postulated risk factors (Miller Reprint requests should be sent to Dr. D.V. Jeste, Geriatric Psychiatry Clinical Research Center (116A), Veterans Affairs Medical Center, 3350 La Jolla Village Dr., San Diego, CA 92161. VOL. 19, NO. 4, 1993 SCHIZOPHRENIA BULLETIN 756 In this article we critically review the available literature on an association between sensory impairment and late-onset psychosis and then present the results of our own case-control study. Literature Review We located English-language articles by means of a MEDLINE computerized search and the Index Medicus. The key words were lateonset, late-life, paranoid disorder, schizophrenia, paraphrenia, delusional disorder, psychosis, aging, sensory (visual or auditory) deficit, impairment, loss, deafness, blindness. Cross-references to articles in published reviews and textbooks were used to obtain additional articles. We selected those studies that assessed visual or hearing impairment or both in relationship to psychotic disorder with paranoid symptoms, primarily in late life. We reviewed the population characteristics, methods, and results in each article. We found 27 studies on sensory (visual or auditory) impairment in psychotic patients published over the past four decades. These 27 studies could be divided into those that evaluated psychopathology in subjects with sensory impairment (Houston and Royce 1954; Singerman et al. 1980; Moore 1981; Zimbardo et al. 1981; Kalayam et al. 1991) and those that assessed sensory loss among patients with late-life psychosis. Of the 22 studies that examined sensory deficits in older psychotic patients, 9 assessed both visual and hearing impairments (Kay and Roth 1961; Sjogren 1964; Herbert and Jacobson 1967; Christenson and Blazer 1984; Holden 1987; Naguib and Levy 1987; Pearlson et al. 1989; Flint et al. 1991; Gurian et al. 1992), 3 assessed visual impairment alone (Cooper and Porter 1976; Berrios and Brook 1984; Burke et al. 1988), and 8 looked at auditory impairment alone (Post 1966; Cooper et al. 1974, 1976; Cooper and Curry 1976; Kay et al. 1976; Eastwood et al. 1981, 1985; Watt 1985). The type of sensory deficit examined was not stated in the two remaining studies (Kay and Roth 1955; Craig and Bregman 1988). A summary of the pertinent data from 25 reviewed articles is provided in table 1. The two studies excluded from table 1 are those by Zimbardo et al. (1981; the only study in the series that included no older psychotic patients) and Eastwood et al. (1981; a single case report of a paraphrenia patient whose psychiatric symptoms resolved after appropriate treatment of her hearing deficit). Methodological Limitations of the Literature Reviewed. A number of the reviewed studies had methodological flaws. Controls were not included in some studies (Herbert and Jacobson 1967; Eastwood et al. 1981, 1985), and vital control group characteristics such as age and gender distribution were not given by some other investigators (Burke et al. 1988; Craig and Bregman 1988). In studies with controls, patients with affective disorder were most frequently used. Most such studies reported an association of hearing impairment with paranoid, rather than affective, psychosis. Moore (1981), however, offered a different interpretation of these results. She suggested that deaf patients were less likely than controls with normal hearing to have affective psychoses, a conclusion indirectly supported by Cooper and Curry (1976), who had difficulty in finding enough deaf affective patients for their study. In contrast, a recent study by Kalayam et al. (1991) found a significantly higher prevalence of sensorineural hearing loss in elderly depressed patients (85%) than in geriatric patients with other psychiatric disorders and those without any psychiatric disorder. It would therefore be useful to have both affectivedisorder patients and normal controls as comparison groups in studies of late-life paranoid psychoses. Some of the studies used unclear or inaccurate methods of p (...truncated)