28 Original article
Cognitive and functional impairment in Egyptian patients
with late-onset schizophrenia versus elderly healthy controls
Doaa N. Radwana, Dalia H. Alia, Ahmed A. Elmissirya
and Mohamed M. Elbanoubyb
a
Department of Neuropsychiatry, Institute of
Psychiatry, Faculty of Medicine and bDepartment of
Geriatric Medicine, Faculty of Medicine, Ain Shams
University, Cairo, Egypt
Correspondence to Dalia H. Ali, MD, PhD in Psychiatry,
Department of Psychiatry, Institute of Psychiatry,
Ain Shams University, Cairo, 64399 RIYADH, Egypt
Tel: + 20 966 050 392 8802/ + 20 966 562 000
02837; fax: + 20 96615620000(2837);
e-mail: daliahegazy74@yahoo.com
Received 1 October 2012
Accepted 20 October 2013
Middle East Current Psychiatry
2014, 21:28–37
Introduction
The Arab world will have a rapidly aging population in
the next few decades [1]. The anticipated increase in
Egyptian individuals older than 60 years of age is from 6
to 11.5% by the year 2025 [2] and this increase will exert
a profound impact on the mental healthcare system [3].
Although older patients with late-onset schizophrenia
(LOS) represent a minority (2–4%) among the elderly
2090-5408 & 2014 Institute of Psychiatry, Ain Shams University
Copyright © Middle East Current Psychiatry. Unauthorized reproduction of this article is prohibited.
Background
Although patients with late-onset schizophrenia (LOS) represent a minority among the
elderly population, they account for a disproportional amount of services and costs.
Unfortunately, there have been very few attempts to identify this problem in Egypt.
Objectives
To compare the sociodemographic, daily living, functioning, and cognitive impairment
between patients with LOS and matched mentally healthy elderly controls.
Participants and methods
A cross-sectional comparative study was carried out; we selected 50 patients with
schizophrenia with onset after the age of 50 years (group 1) and 50 matched healthy
controls (group 2). All patients were interviewed using the Structured Clinical Interview
for DSM Axis-I diagnosis for diagnosis, Functional assessment of daily living, section B
(CAMCOG) of the Cambridge Mental Disorders of the Elderly Examination, the Wechsler
Adult Intelligence Scale, and Fahmy and El-Sherbini’s Social Classification Scale.
The control group was chosen on the basis of assessment using the General Health
Questionnaire and these participants were assessed for cognitive and functional abilities.
Results
There were no significant differences between patients and controls in age, sex, social
class, and educational level; however, significantly more patients were never married
(54%) or divorced (62%), and living alone (62%) compared with participants in the
control group who were married (56%) or widowed (34%), and living with sponsors
(52%) or children (28%). Patients had significantly more chest diseases, auditory
impairment, musculoskeletal problems, and gastrointestinal diseases than their healthy
counterparts. LOS patients were insignificantly worse in daily living functioning
compared with controls. Cognitive assessment showed that patients scored
significantly worse in cognitive functions as estimated by CAMGOG on the following
items: global cognition, language, memory, praxis, abstract, and perception items;
moreover, they scored significantly lower in most of the Wechsler Adult Intelligence
Scale items compared with the matched healthy controls, who scored within the
average norms on all cognitive items.
Conclusion
Patients with late-onset schizophrenia, compared with mentally healthy elderly
controls, differ in a number of psychosocial, daily functioning, and cognitive abilities.
The results of this study provide a better understanding of an elderly patient population
with late-onset schizophrenia. This research is an essential step toward direct future
provision of services to this neglected group.
Keywords:
activities of daily living, cognitive functions, late-onset schizophrenia,
mentally healthy elderly
Middle East Curr Psychiatry 21:28–37
& 2014 Institute of Psychiatry, Ain Shams University
2090-5408
population [4,5], they account for a disproportional
amount of services and costs [6].
‘Late-onset schizophrenia’ was first described and
defined by Manfred Bleuler in 1943 as a form of
schizophrenia with manifested onset of symptoms after
the age of 40 years [7]. Systematic studies in this field
continued in Germany and other European coun-
tries [8,9].
DOI: 10.1097/01.XME.0000438434.30383.69
 Cognitive and functional impairment in LOS patients Radwan et al.
In the UK, psychiatrists often used the term ‘Late-onset
paraphrenia’ interchangeably with ‘Late-onset schizo-
phrenia’ to designate this disorder. However, late-onset
paraphrenia is a British concept that includes all
delusional disorders starting after the age of 60
years [8,10]. American psychiatrists paid little attention
to this patient group; thus, it is only within the Diagnostic
and Statistical Manual of Mental Disorders, 3rd ed., Revised
(DSM-III-R) that a separate category was created for
patients who developed schizophrenia after the age of 44
years [11]. Currently, there is no longer a ‘late-onset’
category for either schizophrenia or an age criterion for
the diagnosis of schizophrenia in the DSM-IV [12], nor
International Statistical Classification of Diseases and
Related Health Problems, tenth revision (ICD 10) [13].
In the French nosography, schizophrenia is excluded
when a nonaffective, nonorganic psychosis begins after
the age of 40 years. These chronic delusion syndromes fall
into a specific French category: ‘Psychose Hallucinatoire
Chronique’ (chronic hallucinatory psychosis) [14].
In their review, Vahia et al. [11] reported that there is still
opportune time to consider available empirical data to
place LOS in the development of ICD11 or DSM-V as a
subtype of schizophrenia.
In the year 2000, an international consensus was
established with respect to a specific definition and
research questions; the consensus assigned LOS to
schizophrenia or to a related disorder, for example
schizoaffective, schizophreniform, or delusional disorder
after the age of 50 years [15] and with women
predominance.
Paranoid subtype of LOS is the most common subtype,
with less severe negative symptoms, less cognitive
impairment, and a better prognosis compared with those
who are diagnosed at a younger age [15–17].
There are still conflicting reports on the epidemiology of
LOS [15]. The proportion of schizophrenic patients
whose illness first emerges after the age of 40 years in the
absence of dementia or primary affective disorder has
been estimated to be about 23% [16] to 25% [18,19]. The
possible risk factors contributing toward LOS have been
reviewed extensively by different workers. who pointed
to female sex, being isolated, and having sensory
deficits [15,19–22].
Although there is a general agreement on the presence of
neuropsychological impairment accompanying LOS,
there have not been many attempts to identify and
characterize the profile of cognitive and functional
impairments of these patients [6,23,24].
Hopkins and Roth [25] were the first investigators to
study cognitive deficits in LOS; however, their attempts
were limited because of the absence of a control group.
Knowledge is still sparse and controversial on the
cognitive profile and functioning of these pa-
tients [17,26,27].
Little is known about this problem in Egypt, where
increasing longevity [2] may be associated with the risk
Copyright © Middle East Current Psychiatry. Unauthorized reproduction of this article is prohibited.
29
of increased medical, psychiatric, and behavioral pro-
blems in the elderly population [3,28].Thus, there is a
great need to implement mental health plans for elderly
Egyptian patients with LOS.
We consider this study as an essential step for the
guidance of mental health professionals in order to
streamline comprehensive recommendations, aiming
to minimize the costs of this devastating disorder.
Aim and ethical considerations
This study focuses on the cognitive deficits and
impairment in daily functioning that results from the
illness rather than those that occur as a result of normal
aging. This will help to achieve a better understanding of
the illness and to better respond to the needs of this
largely neglected group.
The research protocol was approved by the Ethical and
Research Committee of Ain Shams University. Written
informed consent from patients or their legal substitute
was obtained by the appointed researchers, who dis-
cussed the study protocol with the patients, ensured the
confidentiality of the information provided, and assured
the patients that they were free to participate in or
withdraw from the study at any time.
Patients and methods
The study design was a cross-sectional comparative study
and the sample was selective. A total of 100 candidates
were recruited over a 1-year period from March 2008 to
February 2009; they were selected as follows:
(1) Group 1 included 50 patients with LOS. We used also
the operational definition according to the consensus
statement by the International Late-Onset Schizo-
phrenia Group, which stated that the term could be
applied to those patients with onset of prodromal
symptoms after the age of 50 years and refers to
schizophrenia or a related disorder (schizoaffective,
schizophreniform, or delusional disorder) [6,15,20].
All patients, both men and women, fulfilled the
diagnostic criteria of schizophrenia and other psycho-
tic disorders according to the DSM-IV classification.
They were recruited from among the inpatients and
outpatients attending the Geriatric Hospital and
Institute of Psychiatry, Ain Shams University Hospi-
tals. Some patients were also recruited from the
Abbasseya state mental Hospital because of the rarity
of patients. All patients enrolled in the study had to
have developed schizophrenia after the age of 50
years; patients should neither have a lifetime history
of schizophrenia, other psychoses including (schi-
zoaffective disorder, paranoid disorder), nor psychotic
symptoms secondary to other mental or general
medical disorders or dementia. All patients were
under psychotropic medication to enable them to
engage in the process of interview.
30 Middle East Current Psychiatry
(2) Group 2 included 50 apparently mentally healthy
control male and female participants (older than 50
years of age) who were matched for age and sex with
(group 1) and were recruited from among the
relatives of patients attending the inpatient and
outpatient clinics of the Geriatric Ain Shams
University Hospital. Before inclusion in the study,
the apparently healthy individuals recruited were
asked to fill out the Arabic version of the General
Health Questionnaire [29] translated by Okasha [30].
The General Health Questionnaire is a self-adminis-
tered screening questionnaire designed by Gold-
berg [29] for use in consulting settings aimed at
detecting those with a diagnosable psychiatric
disorder. Any participant with a score of 7 or more
(cut-off points in Egyptian population) might have
had minor psychiatric morbidity, and was thus
excluded from the study.
(3) All consenting individuals in each study group who
fulfilled the research criteria were subjected to a
preliminary evaluation of history of illness, obtained
from the patient and his/her companions. A specialist
gerontologist performed the physical and neurological
examination of all enrolled individuals. Before inclu-
sion in the study proper, all patients were interviewed
by the researchers using the Structured Clinical
Interview for DSM Axis-I Disorders [31], which is a
semistructured, clinician-administered interview that
was developed to provide broad coverage of psychia-
tric diagnosis according to DSM-IV [12]. Most
diagnoses are made on a lifetime (ever present) and
current (fulfilled diagnostic criteria in the past
month) basis and are recorded on the summary score
sheet at the beginning of the Structured Clinical
Interview for DSM Axis-I Disorders. Diagnoses are
made by the interviewer during the course of the
interview.
(4) Reviewing medical files: medical data were collected
from the patient’s hospital files and reviewed by the
research team.
Both the patient (group 1) and the control group (group 2)
were assessed comprehensively as follows.
Sociodemographic data were assessed using the social
classification scale in an Egyptian community [32].
Assessment of daily functioning
Activities of daily living [33]
This assesses certain basic abilities that an individual
must possess to remain at home independently. These
abilities allow an individual to perform basic self-care
tasks. Accordingly, patients were classified as follows:
needs no support (10), needs partial support (6–9), or
needs full support (0–5). The Arabic standardized version
was used [34].
Instrumental activities of daily living [33]
This scale measures two broad categories: (a) basic self-
maintenance behaviors such as feeding, dressing, bathing
and mobility and (b) more complex behaviors such as
Copyright © Middle East Current Psychiatry. Unauthorized reproduction of this article is prohibited.
managing finances, traveling, and taking medications.
These abilities are higher level abilities that allow an
individual to function independently at home or in the
community. Accordingly, patients were classified as
follows: needs no support (10), needs partial support
(6–9), or needs full support (0–5). We used the Arabic
standardized version [34].
Cognitive assessments using the Cambridge Mental
Disorders Of The Elderly Examination scale [35]
We used section B of the scale (CAMCOG), which was
developed to assess the diagnosis and measurement of
dementia in the elderly. This scale assessed orientation,
language (expression, comprehension), memory (recent
and remote), learning, praxis, attention, abstract thinking,
perception, and calculation. It was translated into Arabic
and validated by Mahmoud [36].
All measures were administered by the researchers, who
had completed training for several months on the tools
and showed a high inter-rater reliability before perform-
ing the evaluations.
Neuropsychological assessment using the Wechsler
Adult Intelligence Scale [37]
The Wechsler Adult Intelligence Scale (WAIS) is viewed
as a tool for the broad assessment of cognitive functions
that provides information about the important aspects of
an individual’s intellectual functioning such as compre-
hension, arithmetic, similarities, vocabulary, digit span,
picture completion, block design, and digit symbol. We
used the standardized Arabic version [38].
The WAIS was administered to all candidates by a
consultant psychologist who had proper working experi-
ence with the use of WAIS.
Data processing and statistical analysis
Statistical analysis was carried out using the statistical
package for social sciences software, version 17.0 (SPSS
v. 17, Inc., Chicago, Illinois, USA). Descriptive statistics
were calculated as means and SD for numerical
parametric data, whereas number and percentage were
calculated for categorical data. Inferential analyses were
carried out for quantitative variables using the Student t-
test for two independent groups. Qualitative data were
analyzed using the Pearson w2-test. The level of
significance was considered at P value less than 0.05;
otherwise, it was nonsignificant.
Results
We compared the two groups with each other in terms of
their sociodemographic characteristics, activities of daily
living (ADL), and cognitive functioning.
The mean age of the patients in group 1 was
(69.5 ± 3.39) years; they developed their first onset of
schizophrenia symptoms at the mean age of (57.24 ± 6.6)
years and they had schizophrenia for (12 ± 3.4) years;
however, they did not consult mental health professionals
 Cognitive and functional impairment in LOS patients Radwan et al.
at the onset of the illness. The majority (70%) were
diagnosed with paranoid schizophrenia, whereas 14% had
schizoaffective disorder and 12% had delusional disorder
and only 4% had undifferentiated schizophrenia; details
of the clinical characteristics have been described in the
study by Mahmoud et al. [22].
Data shown in Table 1 indicated no statistically
significant differences between group 1 and group 2 in
age, sex, education, previous occupation, or social class
because the control group was matched with the study
group as much as possible. It is clear from Table 1 that
there is a preponderance of women (72%) compared with
only 28% of male patients.
Despite insignificant differences between the levels of
education in both groups (P = 0.59), the participants in
group 2 tended to be more illiterate and they could only
read and write compared with the participants in group 1,
who had received mainly secondary school education.
Significantly more patients with LOS (group 1) were never
married or divorced, and living alone compared with the
elderly healthy controls (group 2), who were married or
widowed and living with their spouses and children
(Table 1). The patients in group 1 showed insignificantly
higher prevalence of a positive family history of psychiatric
disorders than the participants in group 2 (Table 1).
The patients of group 1 had significantly (P = 0.000)
more chest diseases (72%), auditory impairment (30%),
musculoskeletal problems (66%), and gastrointestinal
(GIT) diseases (50%) compared with the controls. No
statistically significant difference was found between the
two groups in diabetes mellitus, hypertension, cardiac
diseases, neurological disease, renal diseases, and visual
impairment (Table 1).
Functional assessment of daily living
Data showed nonsignificant differences between both
groups (groups 1 and 2) in the scores obtained in the
ADL and instrumental activities of daily living (IADL)
assessments (Table 2).
Yet, 4% of patients with (LOS) needed complete support
in ADL and 8% needed partial support compared with 0
and 6%, respectively, of the participants in the control
group (P = 0.98).
Also, in IADL, 4% of the patients needed complete
support and 16% needed partial support compared with 0
and 12%, respectively, of the controls (P40.05).
Cognitive assessment
Using section B in CAMGOG of the Cambridge Mental
Disorders Of The Elderly Examination scale, it was found
that the patients in group 1 scored significantly worse in
the total CAMGOG scores and in the following subitems:
perception, abstract, apraxia, memory, and language than
did the healthy controls. However, there were no
statistically significant differences between the two
groups in attention and orientation scores (Table 3).
Copyright © Middle East Current Psychiatry. Unauthorized reproduction of this article is prohibited.
31
Data of the WAIS showed that the patients of group 1
scored lower on the total scores and most of the subitems
of WAIS, except digit symbol code, than did participants
in group 2 (Table 4).
Discussion
Psychotic symptoms arising in the elderly are of increas-
ing clinical interest [15] and may be more common than
was considered previously [17,39]; there is clearly an
enormous need to clarify this issue among our elderly
Egyptian patients as this topic remains poorly understood
and investigated.
The current study was designed to assess demographic
data, cognitive, and daily functions of patients with LOS
compared with age-matched and sex-matched healthy
controls, with the intention that the data obtained would
be useful to the mental healthcare authority.
Demographic data
Our results showed that the ratio of women to men was
almost 3 : 1, which replicates previous studies that showed a
female preponderance among patients with LOS [6,21].
This sex disparity can be attributed to several factors,
including neuroendocrine changes (estrogen hypothesis),
which relates the risk of late-onset psychosis in women to
the decrease in estradiol levels during the menopausal
period along with associated excess of dopaminergic
functions [23,40]. Estrogen has been postulated to confer
some protection from psychosis before menopause;
however, definite evidence for this hypothesis is lack-
ing [12,41]. Other factors that contribute toward sex
differences in LOS include psychosocial stressors and
different role expectations [21].
Social isolation
Social isolation has been cited as a factor that may
predispose to psychosis in later life [6,11,42].
Our results showed that 54% of patients were never
married and 62% were living alone compared with 56 and
4%, respectively, of the controls. In a different culture,
Almeida et al. [19] reported that 79% of the participants
were socially isolated. The differences in the results
could be attributed to cultural differences, as in Egypt,
the elderly often live with their extended families,
especially in rural areas.
Sensory impairment
Sensory impairments as well as visual and hearing loss
have been proposed in a number of studies as possible
etiological factors in the emergence of auditory and visual
hallucinations and psychosis [14,23,43]. The current
study estimated that the risk of auditory impairment is
five times greater than that in the matched controls.
However, our results are in agreement with those of some
previous investigations, that is, the mechanisms explain-
ing how sensory impairment could produce psychiatric
illness are unclear [19,44].
32 Middle East Current Psychiatry

Table 1 Demographic and clinical data: a comparison between patients with late-onset schizophrenia and elderly healthy controls
Group 1 Group 2

Patients with late-onset schizophrenia Elderly healthy controls

(n = 50) [N (%)] (n = 50) [N (%)] Test

Age
Mean ± SD 69.5 ± 3.39 71.99 ± 2.2 –
Sex
Female 36 (72) 31 (62) P = 0.4, d.f. = 1 (insignificant)
Male 14 (28) 19 (38)
Marital status
Married 14 (28) 28 (56) w2 = 32.44, d.f. = 3, P = 0.000, VHS
Never married 27 (54) 4 (8)
Divorced 5 (10) 1 (2)
Widow 4 (8) 17 (34)
Living status
Spouse 5 (10) 26 (52) w2 = 55.7, d.f. = 4, P = 0.000, VHS
Children 3 (6) 14 (28)
Others 1 (2) 6 (12)
Family 10 (20) 6 (8)
Alone 31 (62) 2 (4)
Education
Illiterate 7 (14) 10 (20) w2 = 10.62, d.f. = 5, P = 0.59 (insignificant)
Read and write 8 (16) 12 (24)
Primary school 3 (6) 7 (14)
Preparatory school 5 (10) 8 (16)
Secondary school 21 (42) 7 (14)
University 6 (12) 6 (12)
Previous occupation
None 27 (54) 21 (42) w2 = 2.57, d.f. = 3, P = 0.46 (insignificant)
Professional 8 (16) 14 (28)
Semiprofessional 4 (8) 3 (6)
Skilled and others 11 (22) 12 (24)
Social class
High 9 (18) 10 (20) w2 = 0.071, d.f. = 3, P = 0.9 (insignificant)
High middle 6 (12) 6 (12)
Low middle 8 (16) 8 (16)
Low 27 (54) 26 (52)
Family history
Positive 4 (8) 3 (6) P40.05 (insignificant)
Negative 46 (92) 47 (94)
Medical history
Diabetes
Positive 19 (38) 12 (24) w2 = 2.29, P = 0.13 (insignificant)
Negative 31 (62) 38 (76)
Cardiovascular diseases
Positive 21 (42) 14 (28) w2 = 2.15, P = 0.14 (insignificant)
Negative 29 (58) 36 (72)
Chest diseases
Positive 36 (72) 9 (18) w2 = 29.4, P = 0.00, VHS
Negative 14 (28) 41 (82)
GIT diseases
Positive 25 (50) 5 (10) w2 = 19.05, P = 0.000, VHS
Negative 25 (50) 45 (90)
Renal diseases
Positive 6 (2) 4 (8) w2 = 0.44, P = 0.50 (insignificant)
Negative 44 (88) 46 (92)
CNS diseases
Positive 8 (16) 5 (10) w2 = 0.79, P = 0.37, (insignificant)
Negative 42 (84) 45 (90)
Visual impairment
Positive 18 (36) 19 (38) w2 = 0.43, P = 0.83 (insignificant)
Negative 32 (64) 31 (62)
Auditory impairment
Positive 15 (30) 3 (6) w2 = 9.7, P = 0.002 (significant)
Negative 35 (70) 47 (94)
Musculoskeletal problems
Positive 33 (66) 5 (10) w2 = 32.27, P = 0.000, VHS
Negative 17 (34) 45 (90)
CNS, central nervous system; GIT, gastrointestinal; VHS, very highly significant.

Medical comorbidity could be attributed to the excessive smoking usually

As both the studied groups were matched in age and sex, reported in patients with schizophrenia [45,46]. LOS
they had very similar medical profiles, except that LOS patients are less physically fit than their healthy counter-
patients had higher rates of respiratory morbidity; this parts. The higher rates of musculoskeletal and GIT

Copyright © Middle East Current Psychiatry. Unauthorized reproduction of this article is prohibited.
 Cognitive and functional impairment in LOS patients Radwan et al. 33

Table 2 Functional assessment: comparison between patients with late-onset schizophrenia and elderly healthy controls
Group 1 Group 2

Patients with late-onset schizophrenia Elderly healthy controls

Test (n = 50) [N (%)] (n = 50) [N (%)] Test

ADL
ADL (mean ± SD) 10.8 ± 9.8 11.56 ± 1.1 t = 1.08, P = 0.98 (insignificant)
Need complete support (0–5) 2 (4) 0 (0) P40.05 (insignificant)
Need partial support (6–9) 4 (8) 3 (6)
No need support (10–12) 44 (88) 47 (94)
IADL
IADL (mean ± SD) 12.31 ± 2.81 13.66 ± 3.4 P40.05 (insignificant)
Need complete support (0–5) 2 (4) 0 (0)
Need partial support (6–9) 8 (16) 6 (12)
No need support (10–12) 42 (84) 44 (88)
ADL, activities of daily living; IADL, instrumental activities of daily living.

Table 3 Cognitive assessment: a comparison between patients with late-onset schizophrenia and elderly healthy controls using
(CAMCOG)
Group 1 Group 2

Patients with late-onset schizophrenia Elderly healthy controls (n = 50)

(n = 50) (mean ± SD) (mean ± SD) Test

Orientation 9.08 ± 1.00 9.2 ± 0.84 t = 0.75, P = 0.45

(insignificant)
Language 18.61 ± 2.18 20.02 ± 2.18 Po0.001, VHS
Memory 17.20 ± 2.64 19.12 ± 2.9 t = 3.4, P = 0.001,
VHS
Attention 5.74 ± 2.38 6.4 ± 2.22 t = 0.63, P = 0.52
(insignificant)
Apraxia 9.45 ± 2.15 12.68 ± 2.9 t = 6.38, P = 0.000,
VHS
Abstract 4.46 ± 2.0 6.8 ± 1.7 t = 5.98, P = 0.000,
VHS
Perception 5.96 ± 1.3 8.9 ± 1.5 t = 10.76, P = 0.000,
VHS
Total 70.5 ± 13.65 83.12 ± 14.24 t = 5.98, P = 0.00,
VHS
Norms (mean ± SD)
Orientation Language Memory Attention Apraxia Abstract Perception
9.2 ± 1.0 21.9 ± 2.6 20.7 ± 3.6 5.1 ± 1.9 10.1 ± 2.0 5.3 ± 3.2 7.8 ± 1.8
VHS, very highly significant.

problems in our patients may contribute toward their
difficult mobility, and hence their social isolation; also,
the frequency of GIT complaints may probably be related
to the use of NSAIDs.
Hereditary factors
In our study, we found a lower prevalence of family
loading of schizophrenia among family members of
patients with LOS compared with matched controls.
In contrast to our finding, some investigators found that
more family members of LOS patients had schizo-
phrenia [23,47,48].
Our results are in agreement with those of many previous
researches reporting that hereditary factors are less
influential in the development of LOS [49].
In a previous a Egyptian study carried out by Fawzi [50],
it was found that patients with LOS had less familial
aggregation than patients with early-onset schizophrenia.
Recently, Köhler et al. [26] reported that LOS constitutes
a separate phenotype within the schizophrenia spectrum.
Assessment of daily living functioning
Inability to function in everyday settings is responsible
for the huge indirect costs of early-onset schizophre-
nia [46]. In contrast, patients with LOS were more likely
to have little association with impaired everyday func-
tioning [11,51]. This is the case in the current study, in
which assessment of daily functioning showed that our
patients with LOS had insignificantly higher ADL and
IADL scores compared with the healthy matched
controls. Thus, these patients can maintain indepen-
dence in residential functioning.
Cognitive functions
Cognitive deficits in schizophrenia are core features of
the illness and are believed to be a manifestation
of a process affecting different brain functions [27,52].

Copyright © Middle East Current Psychiatry. Unauthorized reproduction of this article is prohibited.
34 Middle East Current Psychiatry

Table 4 Cognitive assessment: a comparison between patients with late-onset schizophrenia and elderly healthy controls
using WAIS
Group 1 Group 2

Patients with late-onset schizophrenia Elderly healthy controls

Subtest Abilities assessed (n = 50) (mean ± SD) (n = 50) (mean ± SD) Test

Comprehension Social common sense 7.52 ± 3.54 11.92 ± 4.30 t = – 5.57, P = 0.000, VHS
Organization of information
Digit span Immediate memory 4.2 ± 2.55 6.1 ± 2.38 t = – 4.008, P = 0.000, VHS
Auditory imagination
Arithmetic Mathematical processes 2.48 ± 1.18 4.7 ± 2.69 t = – 5.43, P = 0.000, VHS
Similarities Abstract thinking 6.74 ± 1.18 9.84 ± 3.38 t = – 5.60, P = 0.000, VHS
Vocabulary Concept formation 5.57 ± 1.30 7.26 ± 2.03 t = – 4.89, P = 0.000, VHS
General verbal development
Picture Visual perception 6.06 ± 1.40 8.24 ± 2.39 t = – 5.55, P = 0.000, VHS
completion Visual imagination
Block design Visual perception 4.54 ± 0.99 6.4 ± 1.9 t = – 6.111, P = 0.000, VHS
Visiomotor abilities
Digit symbols Immediate memory 5.4 ± 12.00 5.84 ± 3.43 t = – 0.24, P = 0.08 (insignificant)
Visiomotor coordination
Verbal IQ Global verbal function 80.56 ± 14.21 96.26 ± 12.65 t = – 5.83, P = 0.000, VHS
Performance IQ Global performance function 84 ± 7.1 106.62 ± 11.49 t = – 6.5, P = 0.000, VHS
Total IQ Total score 82.16 ± 13.7 99.6 ± 12.68 t = – 6.22, P = 0.000, VHS
IQ, intelligence quotient; VHS, very highly significant; WAIS, Wechsler Adult Intelligence Scale.

In the current study, patients with LOS performed Visiomotor coordination

significantly worse than healthy controls on measures of
global cognitive functions; our results are in agreement
with those reported by previous investigators [6,15,27,46].
Language and verbal functions
Regarding our LOS patient’s vocabulary and language
abilities are inconsistent with the work carried out by
Paulsen et al. [53], and Rajji et al. [27], who assessed the
semantic organization in patients with LOS and reported
that these functions were preserved. However, our results
are in agreement with those of Mueser et al. [54], who
concluded that vocabulary and language functions were
significantly worse in LOS patients than their healthy
counterparts. Verbal functions, pragmatic errors, and a
dysfunctional semantic system have been suggested as
possible origins of formal thought disorder and impaired
communication in LOS patients [55,56].
Memory functions
Our patients with LOS scored significantly lower than
controls on the memory subscale of CAMCOG and the
digit span test of Wechsler, which reflect visual and
auditory memory functioning.
In agreement with our results, Rajji and Mulsant [57]
reported that memory functions were consistently
impaired in LOS.
Attention
Results on attention were more conflicting; no deficit in
attention could be elicited in our LOS patients compared
with matched healthy controls. The present findings are
in contrast to those of Rajji et al. [27], who concluded that
patients with LOS have more impaired auditory, visual
attention, and visuospatial construction. The inconsis-
tency between these findings in cognitive dysfunctions in
LOS may be because of the different methodology and
inclusion criteria.
In this study, LOS patients and controls had preserved
digit symbol code, which reflects immediate memory and
visuomotor coordination. Similar findings have also been
reported by previous studies [6,27].
The slight deficit in the digit symbol code is of particular
interest as performance on this task is considered to
depend on a nonspecific neurological process and corre-
lated with prefrontal and temporal gray matter volume.
Thus, the preservation of this task suggests a specific
rather than a generalized cognitive deficit in LOS [58].
Arithmetic, praxis, and perceptual functions
LOS patients showed poor arithmetic and praxis abilities
and worse perceptual functions (as measured by block
design and CAMCOG), in addition to poor abstraction (as
estimated by similarities). Our results are in partial
agreement with the findings reported by Gold et al. [59]
and Heinrichs and Zakzanis [60].
Conclusion
The current study found that patients with LOS had
little impairment in daily living functioning; however,
they showed significant global cognitive impairments
compared with the general population of the same age
group that is not accounted for by the simple aging
process. The insights gained from the current research
may lead to a broader understanding for this disorder in
this neglected group and may direct efforts for future
provision of services aiming to decrease the emotional
and financial burden of caring for these patients.
Strength, limitations, and recommendations
The study provides useful information on this poorly
understood and underinvestigated area of research in
Egypt. However, the data obtained should be considered
preliminary data because of the limitations of the small size

Copyright © Middle East Current Psychiatry. Unauthorized reproduction of this article is prohibited.
 Cognitive and functional impairment in LOS patients Radwan et al.
taking into consideration the difficulty in recruiting LOS
patients; the second limitation is the type of sample, which
was a selective rather than a stratified random sample. The
third limitation is that the majority of LOS patients
enrolled were being treated with antipsychotics, which
could impair their cognitive functions. Furthermore, long-
itudinal studies are needed to improve our knowledge of
the cause–effect relationship. Future studies should
encompass different geographical regions in Egypt.
Acknowledgements
The authors are grateful to Professor Afaf Hamed Khalil, Professor of
Psychiatry, for her guidance and advise and Dr Mahmoud Tamara,
Geriatric Medicine Department, for his efforts in the recruitment of
cases. The authors are also grateful to Dr Hisham Sadek, Dr Abeer
Mahmoud, Dr Hanan Hussien, Dr Ahmed El Shafeiy, Dr Marwa Abdel
Meguid, and Dr Marwa Elmissiry for their efforts in training on tools and
reviewing of the medical files.
The authors thank Dr Olfat Kahla, senior psychologist in Geriatric
Hospital, for her efforts and the psychometric assessment; we also
thank Dr Mohamed Hassan Taha from TIT solution for the statistical
analysis. Last but not least, the authors thank every participant enrolled
in this study and their families for their participation, time, and effort.
Conflicts of interest
There are no conflicts of interest.
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 Cognitive and functional impairment in LOS patients Radwan et al. 37

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