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OBM Geriatrics

(ISSN 2638-1311)

OBM Geriatrics is an international peer-reviewed Open Access journal published quarterly online by LIDSEN Publishing Inc. The journal takes the premise that innovative approaches – including gene therapy, cell therapy, and epigenetic modulation – will result in clinical interventions that alter the fundamental pathology and the clinical course of age-related human diseases. We will give strong preference to papers that emphasize an alteration (or a potential alteration) in the fundamental disease course of Alzheimer’s disease, vascular aging diseases, osteoarthritis, osteoporosis, skin aging, immune senescence, and other age-related diseases.

Geriatric medicine is now entering a unique point in history, where the focus will no longer be on palliative, ameliorative, or social aspects of care for age-related disease, but will be capable of stopping, preventing, and reversing major disease constellations that have heretofore been entirely resistant to interventions based on “small molecular” pharmacological approaches. With the changing emphasis from genetic to epigenetic understandings of pathology (including telomere biology), with the use of gene delivery systems (including viral delivery systems), and with the use of cell-based therapies (including stem cell therapies), a fatalistic view of age-related disease is no longer a reasonable clinical default nor an appropriate clinical research paradigm.

Precedence will be given to papers describing fundamental interventions, including interventions that affect cell senescence, patterns of gene expression, telomere biology, stem cell biology, and other innovative, 21st century interventions, especially if the focus is on clinical applications, ongoing clinical trials, or animal trials preparatory to phase 1 human clinical trials.

Papers must be clear and concise, but detailed data is strongly encouraged. The journal publishes a variety of article types (Original Research, Review, Communication, Opinion, Comment, Conference Report, Technical Note, Book Review, etc.). There is no restriction on the length of the papers and we encourage scientists to publish their results in as much detail as possible.

 
 

Publication Speed (median values for papers published in 2024): Submission to First Decision: 6.3 weeks; Submission to Acceptance: 11.4 weeks; Acceptance to Publication: 7 days (1-2 days of FREE language polishing included)

 
 
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Open Access Original Research

End-of-Life Care Disparities in Older Adults with Schizophrenia Spectrum Disorders

Joshua M. Baruth 1,*, Jennifer Geske 2, Elizabeth Sokolowski 3, Maria I. Lapid 4

  1. Department of Psychiatry and Psychology, Mayo Clinic Health System, Austin MN, USA

  2. Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA

  3. Division of Community Internal Medicine, Geriatrics and Palliative Care, Department of Medicine, Mayo Clinic, Rochester, MN, USA

  4. Department of Psychiatry and Psychology Mayo Clinic, Rochester, MN, USA

* Correspondence: Joshua M. Baruth

Academic Editor: Giuseppe Ferdinando Colloca

Received: October 14, 2025 | Accepted: March 03, 2026 | Published: March 10, 2026

OBM Geriatrics 2026, Volume 10, Issue 1, doi:10.21926/obm.geriatr.2601336

Recommended citation: Baruth JM, Geske J, Sokolowski E, Lapid MI. End-of-Life Care Disparities in Older Adults with Schizophrenia Spectrum Disorders. OBM Geriatrics 2026; 10(1): 336; doi:10.21926/obm.geriatr.2601336.

© 2026 by the authors. This is an open access article distributed under the conditions of the Creative Commons by Attribution License, which permits unrestricted use, distribution, and reproduction in any medium or format, provided the original work is correctly cited.

Abstract

Schizophrenia spectrum disorders (SSDs) are complex conditions with chronic symptoms and impairments associated with greater risk for physical comorbidity and early mortality. Understanding end-of-life care in older adults with SSDs is crucial for improving geriatric psychiatric care and identifying healthcare disparities. A cohort of 254 older adult decedents with a history of schizophrenia or schizoaffective disorder was identified using the Rochester Epidemiology Project. A control group of 254 older adult decedents without psychiatric history, matched by age and sex, was also identified. Data on diagnostic codes, demographics, cause, and manner of death were extracted and analyzed. Statistical comparisons were made using conditional logistic regression, McNemar’s tests and prevalence ratio analyses. Older adults with SSD had a mean age of death of 64.5 years. The SSD group was significantly more likely to have dementia listed as their primary cause of death. There was also a higher prevalence of death due to congestive heart failure in the SSD group compared to controls and a lower prevalence of death due to cancer compared to controls. Individuals with SSDs were more likely to die in a skilled nursing facility and less likely to die in a hospice facility compared to controls. The study identified significant end-of-life care disparities for older adults with SSDs including differences in primary causes of death and in locations of death. These findings highlight the need for targeted interventions and improved care models in geriatric psychiatry to address these disparities.

Keywords

Schizophrenia; schizoaffective disorder; end-of-life; disparity; mortality

1. Introduction

Schizophrenia spectrum disorders (SSDs) are complex conditions with chronic symptoms and impairments which significantly impact individuals, families, and communities at-large [1,2]. Individuals with SSDs are more likely to have physical comorbidities like cancer, cardiovascular disease, and diabetes [3,4,5,6], and are at risk of early mortality with estimates between 10-20 years earlier than the general population [7,8].

The interplay between managing co-occurring psychiatric and physical disease processes can be bidirectional with one process negatively impacting other processes. For example, untreated psychiatric symptoms may make it more difficult to organize and manage the care of diabetes or cardiovascular disease; at the same time, neuroleptic medications may increase risk for developing these conditions [9,10]. Combinations of disease processes can share risk factors which in turn can compound the risk of developing other diseases. For example, SSDs, diabetes, and cardiovascular disease, are all individually associated with greater risk of developing neurocognitive disorders [11,12,13].

Older adults with SSDs face unique vulnerabilities as they age, including increased risk of medical comorbidities and also experiencing cognitive decline. To increase vulnerability further, individuals with SSDs are at greater risk of receiving substandard care like reduced access to preventative healthcare, routine screenings, diagnostic procedures, and specialty care [9,14,15]. At the end of life, individuals with SSDs have been shown to have reduced access to palliative and hospice care [16,17]. As the number of older adults is expected to double over the next three decades, there is a critical need for research dedicated to older adults with SSDs who are at risk of end-of-life healthcare disparities [18]. The aim of this study is to investigate end-of-life circumstances in older adults with SSDs to inform future investigations and improve end-of-life care for this population.

2. Materials and Methods

The Rochester Epidemiology Project (REP) and SAS statistical software (Cary, NC; version 9.4) with REP macros were used to identify cases and controls. The REP has maintained medical records and death certificates since 1966 for over 90% of Olmsted County Minnesota, including Mayo Clinic Rochester, Olmsted Medical Center, and affiliated hospitals [19]. Clinical Classification Software (CCS) was used to extract diagnostic codes, demographic characteristics, manner of death, location of death and primary cause of death from death certificates.

A cohort of 254 older adult decedents was randomly identified between 01/01/2000 and 12/31/2017 with a history of schizophrenia or schizoaffective disorder. The SSD group met criteria for either schizophrenia or schizoaffective disorder based on the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV TR, DSM-V) and International Classification of Diseases diagnosis codes (ICD-9, 295. *; ICD-10, F20. *). A control group of 254 older adults was also identified and matched exactly by sex and age in years on the date of death. Control subjects with a history of psychiatric diagnosis were excluded using the following ICD parameters: ICD-9: 290-319 and ICD-10: F01-F99. Subjects who had no record of research authorization, less than 12 months of record history, or subjects with missing data were excluded.

Primary causes of death were categorized using the Charlson Comorbidity Index (CCI) which is a widely accepted tool used for categorizing common medical comorbidities associated with mortality risk [20]. The CCI includes the following categories: myocardial infarction, congestive heart failure, peripheral vascular disease, cerebrovascular disease, dementia, arrhythmia, non-metastatic malignancy, metastatic tumor, leukemia, lymphoma, aspiration, acute lung disease, chronic pulmonary disease, liver disease, renal disease, connective tissue disease, peptic ulcer disease, hemiplegia or paraplegia, diabetes with chronic complication, diabetes without chronic complication, asphyxiation, sepsis, gastrointestinal, and other [20].

The manner of death as listed on the death certificate and as determined by the certifier or coroner was also compared between groups. The manner of death included the following categories: natural, accident, suicide, homicide, or could not determined/Not classifiable. Drug-related deaths (e.g., ingestion, toxicity, overdose, substance abuse) were categorized as accidents, suicides, or homicides as determined by the certifier or coroner. Among natural causes of death CCI categories were combined into the following subgroups for comparison: cardiovascular disease, cancer, pulmonary disease, end-stage liver or renal disease, dementia, sepsis or other. For a cross-sectional study categorical variables were summarized using N (percent), and groups were compared using McNemar’s tests of agreement and conditional logistic regression with odds ratios using SAS. The null hypothesis was rejected if p < 0.05 with an α = 0.05 to define statistical significance.

2.1 Ethics Statement

All participants were 18 years of age or older with a record of research authorization. The REP complies with Minnesota Research Authorization (Minnesota State privacy law – Statute 144.335, 1997) which requires that persons provide permission for their medical records to be used for research studies. For decedents permission was obtained prior to death. The REP Research Review Committee (REP-RRC) and the Mayo Clinic Institutional Review Board (IRB) approved the study to ensure that the rights and safety of study participants are protected.

3. Results

3.1 Demographic Characteristics

The cohort of older adults with SSDs had a mean age of 64.5 years at the time of death, with 51.6% being female, which was identical to matched controls. There were significant group differences in marital status; individuals with SSDs had a higher prevalence of being divorced or never married, while controls were more likely to be married or widowed (p < 0.001). The groups also differed significantly in educational background with the SSD group being more likely to be limited to elementary or middle school education (p = 0.020) (Table 1).

Table 1 Demographic Characteristics in Schizophrenia Spectrum Disorders (SSD) and Controls.

3.2 Cause and Manner of Death

There were a greater number of unnatural deaths specifically due to accidents and suicides in the SSD group; however, this did not reach statistical significance (Table 2). There were highly significant group differences in primary cause of death among older adults with SSDs compared to controls (p < 0.0001). The SSD group was more likely to have dementia listed as their primary cause of death (OR:18.13, 95% CI [2.40, 137.21], p < 0.0001). Conversely, the SSD group was less likely to have a primary cause of death due to cancer compared to controls (OR: 0.21, 95% CI [0.12, 0.37], p < 0.001) (Table 3). Sub-analyses in those dying from cardiovascular diseases revealed a significantly higher prevalence of death due to congestive heart failure in the SSD group compared to controls (63.9% vs. 34.3%; p = 0.023). The control group had more deaths due to peripheral vascular disease, but this did not reach statistical significance (29.9% vs. 8.8%; p = 0.055) (Table 4). Among those dying from cancer, sub-analysis did not reveal any statistically significant group differences in CCI categories (Table 5).

Table 2 Manner of Death Prevalence in Schizophrenia Spectrum Disorders (SSD) and Controls.

Table 3 Primary Cause of Death Prevalence and Relative Risk in Schizophrenia Spectrum Disorders (SSD) and Controls.

Table 4 Prevalence of Mortality Due to Cardiovascular-Disease in Schizophrenia Spectrum Disorders (SSD) and Controls.

Table 5 Prevalence of Cancer-Related Mortality in Schizophrenia Spectrum Disorders (SSD) and Controls.

3.3 Location of Death

There were highly significant group differences in location of death among older adults with SSD compared to controls (p < 0.0001). Individuals with SSDs were more likely to die in skilled nursing facilities compared to controls (OR: 4.70, 95% CI [2.35, 9.41], p < 0.0001). Additionally, those with SSDs were less likely to die in a hospice facility (OR: 0.63, 95% CI [0.27, 1.48], p = 0.044) compared to controls (Table 6).

Table 6 Location of Death Prevalence and Relative Risk in Schizophrenia Spectrum Disorders (SSD) and Controls.

4. Discussion

The study aimed to investigate end-of-life care disparities in older adults with SSDs. Our findings highlight significant sociodemographic disparities, a higher prevalence of dementia-related deaths, lower cancer-related mortality, and notable differences in end-of-life care settings for individuals with SSDs compared to controls.

4.1 Sociodemographic Disparities

The demographic differences observed in this study reveal significant sociodemographic disparities between older adults with SSDs and those without psychiatric history. The average age of death in the SSD group was 64.5 years which is consistent with previous studies pointing to early mortality with estimates ranging from 10-20 years earlier than the general population [7,8,21]. The higher prevalence of being divorced or unmarried among individuals with SSDs underscores the lack of psychosocial support. Previous studies have reported lower marriage rates, limited social supports, and lower socioeconomic status in SSDs [22,23,24]. Factors like low socioeconomic status and social isolation have been shown to also be associated with poor health outcomes, greater morbidity, and increased mortality [25,26]. Addressing these disparities is essential to improve overall well-being and end-of-life care for this population. Psychosocial factors play an influential role in determining outcomes and are critical interventional targets capable of improving end-of-life care for those with SSDs.

4.2 Higher Prevalence of Unnatural Death

Previous studies have demonstrated a significantly higher risk of dying from unnatural causes such as suicides and accidents in adults with SSDs [27,28]. In schizophrenia for example the rate of suicide has been estimated to be up to 7 times more likely compared to individuals without a history of mental illness [29,30]. While not statistically significant, the results did show a higher percentage of deaths in older adults with SSDs from unnatural causes (13.0% compared to 10.2% in controls). Rates of death from suicide and accidents in older adults with SSDs were 3.9% and 9.1% respectively compared with 2.4% and 7.1% in controls. In this study drug-related deaths were categorized as accidents or suicides in those with SSDs which is consistent with other studies indicating greater rates of premature mortality due to substance use in this population [25]. Increasing access to primary care with routine preventative health screenings that incorporate assessments for substance abuse and suicide risk are potential interventional targets.

4.3 Greater Mortality Risk Due to Dementia

The higher prevalence of dementia as a cause of death in individuals with SSDs is consistent with prior studies. Neurocognitive disorders in general have been shown to be more common in those with a history of psychiatric illness [12,31,32,33,34,35,36]. Conditions manifesting symptoms of psychosis appear to have the greatest risk with some studies pointing to a 2-3-fold greater risk of developing a neurocognitive disorder [37,38]. While shared genetic associations have been reported between psychosis symptoms and neurocognitive disorders, like Alzheimer’s disease [39], lifestyle factors and common neuropathological processes are also likely contributors. Neuroinflammation, mitochondrial damage, oxygen distress, and dysregulation of the hypothalamic-pituitary-adrenal axis are also mechanisms of interest mediating neurotoxicity in psychosis and neurocognitive disorders [40,41,42,43,44]. Dysregulation of dopaminergic, serotonergic, and glutamatergic neurotransmission have also been linked to neurotoxicity.

There is also significant overlap between vascular dementia and other neurocognitive disorders with some estimates being up to 70% [45]. Individuals with psychiatric disease have higher rates of diabetes, hypertension, and metabolic syndrome which are shared risk factors for developing neurocognitive disorders [46]. The higher prevalence of death due to congestive heart failure and ‘dementia’ in this study underscores this relationship. Furthermore, polypharmacy and specifically anticholinergic burden (ACB) is another contributing factor to cognitive decline. Psychotropic medications commonly have anticholinergic properties, and a dose dependent relationship has been shown between ACB and risk of developing dementia [47,48,49,50].

Furthermore, with several possible etiologies of cognitive decline in SSDs, the term ‘dementia’ as a primary cause of death likely is not the most accurate and may not fully account for the influence of psychiatric disease. With overlapping risk factors multiple candidate interventional targets exist which support the need for comprehensive clinical models like Integrated Behavioral Health. Earlier onset of neurocognitive disorders in individuals with SSDs necessitates focused geriatric psychiatric care that comprehensively addresses mental, physical, and cognitive health.

4.4 Lower Mortality Risk due to Cancer

Conversely, cancer-related mortality was significantly less prevalent in individuals with SSDs which contrasts with previous studies [51,52]. It has been thought that cancer-related mortality in SSDs has been mainly a result of relatively reduced access to cancer screening, less access to specialty oncology care, as well as reduced access to advanced diagnostics which has been widely reported [14,51,53,54,55].

Less prevalent cancer-related mortality in this study might be as a result of prior studies including more common psychiatric illnesses like mood and anxiety disorders or not limiting the population specifically to older adults. The incidence of several cancer types has been shown to decrease with increasing age in schizophrenia which is thought to be related to early mortality; shared risk factors between cancer and cardiovascular disease would decrease at a higher rate in individuals with schizophrenia due to early mortality [56,57]. Additionally, there has been increasing interest in antineoplastic properties of antipsychotic medications [58]. Modulation of tumor growth by dopamine and its receptors may play a role, but preliminary findings need to be translated beyond preclinical trials in large-scale, prospective studies [59,60]. Geographical location could also be a factor as Minnesota is consistently ranked in the top 10% of states for the highest rates of health insurance coverage [61].

Nonetheless, the factors involved in cancer-related mortality for individuals with SSDs need to be better understood throughout the life span. Improving access to cancer screening and prompt oncological care for older adults with SSDs could help address disparities.

4.5 Mortality Due to Cardiovascular Disease

The study reveals a higher prevalence of death due to congestive heart failure in the SSD group. This is consistent with existing studies which have reported a greater risk of death due to congestive heart failure in adults with SSDs compared to the general population. Overlapping risk factors like genetics and psychosocial factors have been thought to play a determinantal role [3]. However, cardiovascular diseases are less likely to be diagnosed in individuals with SSDs [62] which points to possible disparities in screening or interventional treatment among other factors. Future research prioritizing preventive care and disease management strategies for older adults with SSDs could significantly reduce mortality and improve quality of life in this population.

4.6 End-of-Life Care Settings

The study findings showed that individuals with SSDs were more likely to die in skilled nursing facilities (or nursing homes). This is most likely a direct result of individuals with severe mental illness being more likely to be placed in skilled nursing facilities [63]. It has been reported that 1 in 5 nursing home residents has a severe mental illness [64]. Skilled nursing facility admissions should be screened through the Preadmission Screening and Resident Review process (PASRR) which assesses for appropriateness of admission, need for specialized services, or alternative placement [65]. However, if the admission is anticipated to be less than 30 days which is often the case for those with SSDs, patients are exempt from this process [66]. In the absence of adequate community resources and housing support those with SSDs often end up requiring longer stays [67]. These facilities are often not equipped to meet the specialized care needs of these patients [68], and within this environment are also at greater risk of neglect or abuse [69].

The study finding of a lower prevalence of death in hospice facilities is consistent with other studies pointing to disparities in end-of-life care for this population. There is increased risk of continued procedures, lack of appropriate pain management, and reduced access to palliative and hospice care [14,15,70,71]. Individuals with schizophrenia are less likely to receive end-of-life treatments like endoscopies, blood transfusions, intensive care unit admissions, imaging, chemotherapy or surgery compared to controls without mental illness [72].

Individuals with SSDs are at risk of stigma negatively impacting their care. Some providers may lack psychiatric training or experience managing severe mental illness with co-occurring physical conditions [73,74]. Qualifying diagnoses for hospice care can be ambiguous especially in cases of comorbid psychiatric illness and neurocognitive disorders [75]. Diagnostic overshadowing can also play a role whereby physical symptoms are attributed to psychiatric disease [73,74].

In conclusion, this study identifies specific vulnerabilities and associated healthcare disparities for older adults with SSDs at the end-of-life. A ‘one-size-fits-all’ approach to end-of-life care is often inadequate, and a specialized area of psychiatry incorporating palliative principles with an emphasis on quality of life and patient autonomy is needed [16]. Individuals with SSDs may follow the frailty model of functional decline with decreased functioning during the last year of life, and more severe impairment during the last month of life [76]. Improved definitions and guidelines are needed to address barriers preventing those with SSDs from receiving palliative and hospice services [17,77].

There is an urgent need to improve access to comprehensive healthcare services and develop specialized psychiatric and palliative care models for those with SSDs. Such targeted interventions are crucial steps needed to enhance health outcomes and mitigate disparities for this vulnerable population at the end of life. Future research should focus on implementing and evaluating these interventions to ensure that older adults with SSDs receive the compassionate and effective end-of-life care that they deserve.

5. Limitations

This study has several limitations. The study participants were residents of Olmsted County, Minnesota, and findings may not be generalizable to other geographical regions. However, the use of the Rochester Epidemiology Project, with its comprehensive and long-term data collection, provides a robust basis for identifying and analyzing these trends. The cross-sectional study design restricts the ability to determine associations between factors as opposed to making any inferences about causation, but the associations observed provide valuable insights into potential areas for further investigation and intervention. Additionally, the study was limited to the categories established by the Charlson Comorbidity Index (CCI), which may have excluded specific conditions of interest. On death certificates nonspecific terminology was used when dementia was listed as a primary cause of death. Several examples include: “Dementia”, “Progressive Dementia”, “Complications of Advanced Dementia”, “End-Stage Dementia”, “Dementia Presume Alzheimer’s”. Given cognitive decline is often multifactorial (e.g., polypharmacy, cerebrovascular disease, psychiatric comorbidity) such nonspecific terminology would be subject to classification bias. Despite this, the CCI is a well-established tool that allows for meaningful comparisons across a wide range of health conditions. The narrow age range (50 or older) focuses the study on older adults and provides targeted insights relevant to the geriatric population. Including individuals with schizophrenia and schizoaffective disorder may have increased subject variability, but it also reflects the real-world clinical range of SSDs, enhancing the applicability of the findings.

Acknowledgments

The authors would like to thank Ann Marie Rydberg, M.D., for assistance with editing the manuscript, and the Mayo Clinic Center for Clinical and Translational Science, National Center for Advancing Translational Sciences, National Institutes of Health, Rochester Epidemiology Project, National Institute on Aging, and the Mayo Clinic Research Committee. For specific funding information see section below.

Author Contributions

Joshua M. Baruth, M.D., Ph.D.: Conceptualization, design, data acquisition, data analysis, and data interpretation, writing – original draft, review, and editing. Maria I. Lapid, M.D.: Conceptualization, design, data interpretation, writing – review and editing. Elizabeth Sokolowski, M.D.: Data interpretation, writing – review and editing. Jennifer Geske, M.S.: Data acquisition, data analysis, and data interpretation, writing – original draft, review, and editing.

Funding

This publication was made possible by the Mayo Clinic CTSA through grant number UL1TR002377 from the National Center for Advancing Translational Sciences (NCATS), a component of the National Institutes of Health (NIH). This study used the resources of the Rochester Epidemiology Project (REP) medical records-linkage system, which is supported by the National Institute on Aging (NIA; AG 058738), by the Mayo Clinic Research Committee, and by fees paid annually by REP users. The content of this article is solely the responsibility of the authors and does not represent the official views of the National Institutes of Health (NIH) or the Mayo Clinic.

Competing Interests

The authors have declared that no competing interests exist.

Data Availability Statement

Data is available on request. Please contact the corresponding author for further information.

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