CASE REPORT

Semiological Differences between Late-life Schizophrenia andSenile Dementia
Min-Ho Song,1 Hidemichi Hamada1 and Masaru Mimura2
1Department of Psychiatry, Gunma Hospital, Gunma, Japan

2Department of Neuropsychiatry, Keio University, Tokyo, Japan(Received for publication on July 9, 2012)(Revised for publication on January 21, 2014)(Accepted for publication on February 20, 2014)(Published online in advance on June 10, 2014)

It is sometimes difficult to distinguish late-life schizophrenia from senile dementia because elderly patients with schizophrenia can present in chronic remission and show gradual cognitive decline withaging. We aimed to elucidate the semiological characteristics of late-life chronic schizophrenia. Threepatients aged between 60 and 66 years who were admitted to our hospital were included in this study.
Detailed history taking and psychiatric interviews were performed and reviewed in the light of psychopathological semiology. Although the three patients with late-life schizophrenia showed significant
cognitive decline on the Hasegawa dementia rating scale and their negative symptoms mimicked dementia, the following psychopathological characteristics clearly differentiated them from patients with
senile dementia: (1) a shift of temporal organization toward the future with intact memory, (2) hypersensitivity, (3) ambivalent personal relationships, (4) systematic bodily delusions, and (5) an ante
festum mindset. Identifying such clinical features of patients with late-life schizophrenia could be important for developing more effective pharmacotherapy and for providing appropriate psychotherapy.
(doi: 10.2302/kjm.2012-0009-OA; Keio J Med 63 (2) : 34–38, June 2014)

Keywords: chizophrenia, dementia, aging, geriatric psychiatry

Introduction

Cases

Elderly patients with schizophrenia may be misdiagnosed as having dementia. Cognitive functional decline
related to aging accelerates with schizophrenia and it becomes hard to determine the contribution of the original
disease. In the clinical setting of a psychiatric hospital,
it is often difficult to appropriately differentiate late-life
schizophrenic patients from those with dementia, such asthat resulting from Alzheimer’s disease. We examined
the psychopathological features of late-life schizophrenia
and performed a semiological comparison with dementia
in the present study.

We selected three patients who were aged between 60
and 66 years and who had been hospitalized for morethan 30 years since the onset of schizophrenia fromamong the patients admitted to our hospital. The positive
and negative syndrome scale (PANSS),1 the mini mental
state examination (MMSE),2 and the revised Hasegawa
dementia scale (HDSR) were used to evaluate the patients. The daily doses of antipsychotic medications were
calculated on a chlorpromazine equivalent basis. All
patients underwent a brain computed tomography scanand magnetic resonance imaging, which revealed no abnormal findings except for age-appropriate mild cerebral
atrophy. All patients underwent single-photon emission
computed tomography, which revealed no significant re-

Reprint requests to:Min-Ho Song, MD, Department of Psychiatry, Gunma Hospital, 136 Tokadai-machi, Takasaki, Gunma 370-3516, Japan,
E-mail: songmhmd@yahoo.co.jp
Copyright © 2014 by The Keio Journal of Medicine
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Keio J Med 2014; 63 (2): 34–38

duction of blood flow in the parietal or temporal lobes.
We did not perform cerebrospinal fluid tau measurement.
All patients were evaluated using the clock drawing test,
Raven’s colored progressive matrices test, the revised,
the Alzheimer’s disease assessment scale, the Stroop test,
and the trail making test, the results of which were within
normal limits. This retrospective and observational study
was approved by the Gunma Hospital Institutional Review Board. Informed consent and permission for releaseof information were obtained from each patient. We took
special precautions to protect the privacy of the patients.
Case 1This 60-year-old woman was the fourth of four siblings. Her family history was unremarkable. She graduated from high school and began to work as a clerk. She
married at 25 years old. Delusions of persecution such as“Somebody is speaking ill of me and harming me” began
when she was 29 years old, after which she was hospitalized with the diagnosis of paranoid schizophrenia. She
had repeated episodes of psychomotor excitement which
required protective isolation and episodes of catatonia
that required electroconvulsive therapy. Her problems
included excessive telephone calls, irritability, demand
repetition, stereotypic postural abnormality, and pouring water on the floor. Regarding the latter activity, shesaid that she must put out a fire because there had been afire that affected four neighbors when she was a primaryschool child. She put her finger in a glass filled with water
to “dissolve the spirit of her finger” and poured the wateron the floor. She would call her deceased husband on thetelephone and when she was unable to talk to him, shewould shout into the phone, hang up, or even break thetelephone. On one occasion, she wrapped clothing aroundher head and said with a smile that it was a new fashion,
after which she shouted sullenly that she wanted to be left
alone. She said the reason for wrapping a towel aroundher head was to protect her hair from being shaved bya deaf man. She demanded that we change her meals to“normal” meals (even though she was eating a normal
diet), that she be allowed to do her own make-up, andthat she be allowed to take fewer medications because thedrugs caused wrinkles. She would not admit that she hadno teeth and said that she was dying because of suffocation at meal times. When her demands were not met, shebegan to make wild statements such as “Sputum, whatcurse with judgment, a fool doc, the bean jam of this junior high school graduate pop.” After her nails were cut,
she would not go back to her room and would remain
standing still in the corridor with her neck bent. After being unresponsive, she would suddenly come back to thisworld. When asked what she was doing, she replied that itwas not possible for her to move, which suggested blocking of thought.

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The patient’s PANSS positive score was 33 points, her
PANSS negative score was 37 points, and her general
psychopathologic score was 46 points. Her MMSE score
was 14 points and her HDSR was 18. Her medications
were equivalent to 1100 mg/day of chlorpromazine.
Case 2This 62-year-old woman was the fifth of six siblings.
Her family history was unremarkable. When she moved
to an international school at 15 years old, she developed
inappropriate laughter, monologues, and poriomania. She
was diagnosed as having hebephrenia and was admitted
to a locked protective ward when she was 19 years old.
Auditory hallucinations and delusions were usually notprominent, but she actualized her situation and sometimes became threatening. She spent the daytime lying
in bed with a towel over her face. In the evenings she
was relatively active, but her movements were slow without Parkinsonism. She complained that her mouth went
upward, her tongue did not work, her eyes melted when
she overslept, she was sleepy in the daytime, her fingers
had shrunk, her fingers were variously shorter or longer,
she developed a runny nose when she drank water, andher nose was blocked. She often walked the corridor afterplugging her nasal cavities with paper. Autism, abulia,
and flattened affect were observed.
Her PANSS positive score was 27 points, her negativescore was 31 points, and her general psychopathologic
score was 36 points. Her MMSE score was 13 points andher HDSR was 16. Her medications were equivalent to1750 mg/day of chlorpromazine.
Case 3This 66-year-old woman was the second of three siblings. There was a history of mental illness in her father’sfamily. After graduating from high school, she began towork and she got married when she was 23 years old.
Bizarre thoughts and statements like “There is somethingburied in the garden” were first noted when she was 20
years old. She was divorced when she was 30 years old.
At the age of 32, she began complaining of electricity
being transmitted to her, that correspondence was annoying, and that there were lots of spirits around. She
became violent towards her mother and then was hospitalized with a diagnosis of delusional schizophrenia. She
has remained in hospital since then. At the time of thestudy, she was not talking about hallucinations or delusions, but she showed abulia. She walked back and forthalong the corridor. She constantly remained aloof and did
not talk with others even if they come close to her. Sometimes she complained about delusions of persecution. She
said “Somebody made fun of me. Somebody made myhair solid at midnight. Is it fun? It is murder. I am gettingSong M, et al: Semiology of Late-life Schizophrenia

36sicker because I am cursed.” Communication with others
was poor because she mainly spoke to herself. A flattened
affect and abulic state were apparent.
Her PANSS positive score was 27 points, her negative score was 32 points, and her general psychopathologic PANSS score was 44 points. Her MMSE score was
18 points and her HDSR was 22. Her medications wereequivalent to 600 mg/day of chlorpromazine.
Discussion
Late-life schizophrenia and dementia
To distinguish late-life schizophrenia from dementia
secondary to Alzheimer’s disease, the clinical picture oflate-life schizophrenia showing hebetude and indifference has historically been called Verblödung. Kraepelinclassified it into six types: hallucinatory, confused, blunt,
foolish, manneristic, and refusal.3 The three cases presented in this article could be classified using these six
types. Although the semiology of late-life schizophrenia
superficially mimics that of dementia, in late-life schizophrenia intelligence is preserved, and this was termeddémence vesanique by Baillarger,4 démence incoherent
by Leuret,5 affective Verblödung by Bleuler (who put
the emphasis on affect),6 and démence pragmatique by
Minkowski (who reported that patients were unable toutilize knowledge even though it was not lost).7 Some patients with late-life schizophrenia may also have dementia, so Claude et al. used the term schizomanie and applied
the name of dementia praecox to advanced schizophrenia
patients mainly with hebephrenia.8
Dementia generally differs from late-life schizophrenia with respect to the nature of the delusions. It is wellknown that the delusions of demented patients are basedon memory impairment and cognitive deficit and frequently include delusions of theft or phantom boarders.9
In Case 1, delusions of persecution were present froma young age and gradually changed into absurd delusions
later. Case 2 had paranoid delusions related to the mouth,
eyes, nose, and fingers. In Case 3, a prominent part ofthe clinical picture was persecutory delusions related toher hair and body. Physical hypersensitivity and systematized delusions were common among the three patients.
These delusions seem to be different from the delusionsof patients with dementia, which tend to focus on theft,injury, and outside noise and are closely related to dailylife.
The MMSE scores of our three patients were 18 or less,which meet the criterion for dementia. However, the patients correctly answered questions involving memorizing, retention, retrieval, orientation, and calculation, butthey were unable to answer questions about semantic
verbal fluency using vegetables as the category. Thus, it
is evident that the MMSE results are different between

these three chronic schizophrenic patients and patientswith Alzheimer’s disease who present with significant
cognitive decline centered in amnesia and visuospatial
deficit.10 Also, as observed in our three cases, institutionalized schizophrenic patients demonstrated an age-related pattern of MMSE score different from that observedfor Alzheimer’s patients, and the cognitive and functional
status of these schizophrenic patients was fairly stable
until late life, reinforcing the finding that cognitive decline may not occur in younger patients over an interval
as long as 6 years.11
It is not uncommon for late-life schizophrenics to havefewer hallucinations and delusions and to reach a stablestate with late remission. They tend to maintain the negative symptoms reported by Crow,12 such as a blunted affect, slow thoughts and activities, mutism, abulia, poverty of conversation, and social withdrawal. Patients cannot
control themselves well, explode with anger for trivial
reasons, and employ stereotypy to avoid changes.
Impairment of personal interaction, such as the poorinterpersonal contact and misanthropy documented by
Strauss,13 was observed in our three patients. They often
spoke to themselves and did not show meaningful empathy to others.
Personality structure of late-life schizophrenia
Elderly schizophrenics are characterized by resilience,
toughness, and poverty of communication skills and by
the sensitive capability of comprehending subtle signs.14
They have suffered from exceptional experiences because
their acute psychosis was a time of physical disturbanceand a period of hypersensitivity. Therefore, their cognitive function has become vulnerable.15 On the other hand,their unique personality structure arises because thesepatients have survived long-term and difficult pathological experiences. This type of structure may involve personality reactions and result from self-help efforts overa very long time, even though it is poorly personality.16
Late-life schizophrenia often features abulia and autism. Sufferers are not much interested in others, they
become autistic to protect themselves because they care
extraordinarily about the views of others, and they show
stereotypy. Binswanger considered that perverseness
represented a lack of decency and consideration of mutuality and commonness with others. He also stated thatthe mannerisms associated with late-life schizophrenia
involve self-deception, in which the patient cannot live
their own lifestyle and overcome this issue by putting onan act. Thus, Binswanger identified failure of existentiality in schizophrenia.17 Personal relationships between theelderly schizophrenic and others are always ambivalent,with repetition of over-approach and over-withdrawal.
Schizophrenic patients often begin to experience hypoesthesia, i.e., decreased sensitivity and perception, deaf-

Keio J Med 2014; 63 (2): 34–38

ness, and depersonalization because of disturbance of theego. As the disease progresses, patients feel vague uncertainty and do not comprehend their surroundings well,with the sensory threshold being set low by inner hyperarousal, so that rather than hypoesthesia, hyperesthesia,
i.e., increased sensitivity and heightened perception, andhypochondriasis become features of late-life schizophrenia.18
Patients with schizophrenia have often lived without aplace of safety, while their position has been ambiguous
and they have failed to find a purpose. Because they cannot project themselves into the future and cannot pursue
a career, they are continually anxious about their future.
This psychopathology is the basis of their unique ante
festum mindset, in which they cannot achieve self-realization in the present and they always try to anticipate thenext event and forestall it.19 For example, Case 1 maderepeated telephone calls to her deceased husband, not because she had forgotten his death but to block the desire
to see him again; she seemed to try hard to avoid factors
tying her to the real world. The term antegrade dementia
has been used for cognitive impairment of schizophrenics
in the opposite time direction to that of general dementia,
meaning that the past memory is maintained and the future cannot be foreseen.20
Therapeutic approach
The need to treat schizophrenia is self-evident. The disease affects the whole human being, and so both psychotherapy and psychopharmacology are used. Psychiatrists
often encounter schizophrenic patients with medical or
surgical complications who tend to show stabilization of
their psychiatric symptoms. Matsumoto contended fromthe standpoint of psychopathology that the role of pharmacotherapy is to regain the physical body of a disorganized psychosomatic patient.21 The first task is to control
physical illness and to adjust the body and mind.
Although we do not yet have effective pharmacology
for schizophrenics with advanced disease and negative
symptoms, we are anticipating new therapeutic approaches from regenerative medicine and neuroneogenesis. Also
warranted are effective drugs that block or modulate the
N-methyl-d-aspartate receptor, which plays a significant
role in the semiology of schizophrenia.
We also need continuing development of psychotherapy and cognitive behavioral therapy to address the social isolation, stress, and affective reactions of late-life
schizophrenia.22 Kobayashi et al. pointed out that senile
hallucinations and delusions are often derived from factors in the everyday lives of the patients, such as solitude,
independence, and loss of a sense of place, and stated that
it is a psychosocial imperative to restore a dependable
sense of place when we considered the therapeutic strategy for elderly schizophrenics.23

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In summary, there are similarities and differences between elderly patients with schizophrenia and those withdementia. By removing and integrating the modifying
factors that accumulate with aging, it is possible to clarify each patient’s semiology and personality structure.
Describing the clinical characteristics of late-life schizophrenia as distinct from those of Alzheimer’s disease
may eventually contribute to the creation of an effective
therapeutic strategy for the psychopathology and pharmacologic abnormalities of schizophrenia.
Acknowledgment
We are sincerely grateful for the dedicated assistance of
Ms. Sakiko Hirabayashi during preparation of this manuscript.
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