Thought, language, and communication deficits and association with everyday functional outcomes among community-dwelling middle-aged and older adults with schizophrenia
Introduction
Community-dwelling older adults with schizophrenia experience poorer community integration and social functioning when compared to their same-age peers, including elevated rates of unemployment, underperformance in everyday activities, and social isolation (Abdallah et al., 2009, Madiedo et al., 2012, Meesters et al., 2010). Moreover, older adults with schizophrenia are vastly overrepresented in nursing homes (Miller and Rosenheck, 2006, Miller and Rosenheck, 2007) and are at increased risk for nursing home placement as early as their forties (Andrews et al., 2009). This indicates that, although there is great heterogeneity in outcomes as individuals with schizophrenia age (Jeste et al., 2011), for some, aging may be accompanied by faster and more severe functional decline than that experienced by their same-age peers without psychiatric disorders. Further elucidation of the factors which contribute to poor functional outcomes in community-dwelling older adults with schizophrenia is necessary to inform targeted interventions for this group.
While cognitive decline accounts for worsening of functional outcomes in older adults with schizophrenia in some cases (Reichenberg et al., 2014), research indicates that only a subset of these individuals exhibit substantial cognitive decline with age (Harvey et al., 2010, Thompson et al., 2013). Additionally, while considerable research has examined the relationships among neurocognition, symptom severity, and functional outcomes in adults with schizophrenia (e.g., Bowie et al., 2006), much less attention has focused on one of the cardinal features of the illness: impairments in thought, language, and communication.
Thought, language, and communication (TLC) deficits, also referred to as formal thought disorder and alogia, are common in schizophrenia, and are associated with impairments in everyday functioning (Racenstein et al., 1999, Bowie et al., 2011). TLC deficits are thought to fall into two categories: “positive” thought disorder, characterized by the presence of disorganized, circumstantial, or tangential speech, and “negative” thought disorder (i.e., alogia), characterized by an absence of speech production (Andreasen, 1986). Previous research with chronically institutionalized older patients with schizophrenia, both “positive” TLC deficits (hereafter referred to as disconnected speech) and “negative” TLC deficits (hereafter referred to as verbal underproductivity) were associated with deficits in social outcomes, but not with deficits in other functional domains (e.g., activities of daily living, recreation; Bowie and Harvey, 2008). Additionally, verbal underproductivity worsened with age, especially among the older-old and oldest-old patients (ages 74 and up; Bowie et al., 2005). Importantly, the relationships among age, TLC deficits, and functional outcomes have not been examined in community-dwelling older adults with schizophrenia, for whom adaptive functioning may be much more dependent on the ability to skillfully communicate.
Previous studies on TLC deficits and functional outcomes in schizophrenia have generally relied on consumer or informant reports of everyday functioning (Racenstein et al., 1999, Bowie and Harvey, 2008). One limitation of this approach is that real-world functional performance may be influenced by factors beyond a consumer's communication abilities, such as socioenvironmental constraints. Therefore, it is unknown whether TLC deficits are associated with poorer functional outcomes because they directly influence a consumer's ability to successfully communicate (i.e., a consumer cannot communicate his/her thoughts or needs when given the opportunity) or because that consumer has fewer opportunities to communicate (i.e., TLC deficits lead to increased social isolation and fewer opportunities for interaction). To address this, performance-based measures of functioning, which prompt participants to demonstrate social and occupational skills through in-vivo tasks, may be used. These measures capture functional capacity, or their ability to accomplish activities of daily living under optimal conditions (Bowie et al., 2006). The only study to examine the association of TLC deficits with functional capacity in adults with schizophrenia, found that both verbal underproductivity and disconnected speech were associated with performance on in-vivo, social skills based role plays (Bowie et al., 2011). These associations have not been examined in an older adult sample of individuals with schizophrenia.
The present study aimed to further elucidate the association of TLC deficits and functional outcomes among community-dwelling middle-aged and older adults with schizophrenia. We aimed to examine, adjusting for demographic factors, cognitive impairment, and symptom severity, whether verbal underproductivity and disconnected speech would be associated with poorer clinician-rated community functioning across occupational, everyday living, and interpersonal domains. Secondly, we aimed to examine, again adjusting for demographic factors, cognitive impairment, and symptom severity, whether verbal underproductivity and disconnected speech would be associated with poorer performance on laboratory social skills tasks and functional tasks of communication. Exploratory analyses tested whether TLC deficits mediated relationships between age and functional outcomes, to explain the greater functional deficits seen in older people with schizophrenia.
Section snippets
Participants
This study presents analyses of baseline data from a large longitudinal study, which assessed the course of cognition and functioning in a sample of community-dwelling adults with schizophrenia (see Bowie et al., 2006 for more details on methodology). The present analyses utilized data from all participants with a schizophrenia diagnosis, ages 40 and up, who completed baseline assessments for the study (N = 245; see Table 1). Participants were recruited through academic, state, and VA
Results
Demographics and descriptive statistics are presented in Table 1. Age ranged from 40 to 85 years. All participants were receiving antipsychotic and/or other psychotropic medication(s). Among participants for whom chart data was available (~ 70%), the majority of participants were overweight or obese (mean BMI = 30.34 ± 7.05), 14.2% had Type I or II diabetes, and 5.9% had heart disease. Missing data was < 10% for all variables in the analyses except the SLOF scale, which was missing for
Discussion
Older adults with schizophrenia were previously reported to exhibit age-related changes in cognition, communication, and everyday functioning. In this sample of community-dwelling middle-aged and older adults with schizophrenia, TLC deficits were associated with poorer functioning across occupational, interpersonal, and everyday living domains, accounting for between 3.4% and 4.8% of the variance in community functioning. This is in contrast to previous work with chronically institutionalized
Role of the funding source
This research was funded by NIMH grant MH 63116 to Dr. Harvey and by funds from the U.S. Department of Veterans Affairs VISN 3 MIRECC. The funding sources had no role in the study design, in the collection, analysis and interpretation of data, in the writing of the report, or in the decision to submit the article for publication.
Contributors
Dr. Harvey obtained the research funding and designed the overall study with Dr. Bowie. Dr. Bowie supervised data collection. Dr. Muralidharan conceptualized the research question, conducted data analyses, and oversaw the writing of the manuscript. All four authors contributed to the writing of this manuscript. All authors contributed to and have approved the final manuscript.
Conflict of interest
Dr. Muralidharan and Dr. Finch have no conflicts of interest to report with regard to this work.
Dr. Harvey has received consulting fees or travel reimbursements from Allergan, Boehringer Ingelheim, Lundbeck Pharma, Minerva Pharma, Otsuka Digital Health, Sanofi Pharma, Sunovion Pharma, and Takeda Pharma during the past year. He has a research grant from Takeda and from the Stanley Medical Research Foundation.
Dr. Bowie has received consulting fees from Boehringer Ingelheim, Lundbeck Pharma,
Acknowledgements
This research was funded by NIMH grant MH 63116 to Dr. Harvey and by funds from the U.S. Department of Veterans Affairs VISN 3 MIRECC. This manuscript is result of work supported with resources and the use of facilities at the U.S. Department of Veterans Affairs VISN 5 MIRECC. All authors who contributed to this paper are listed as authors. No professional medical writer was involved in any portion of the preparation of the manuscript. This work reflects the authors' personal views and in no
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