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Assessment of Bi-polar Spectrum Disorder in Older Adults

Assessment of Bi-polar Spectrum Disorder in Older Adults. Cynthia Zubritsky, PhD & Karen Fortuna, MSW Center for Mental Health Policy and Services Research, University of Pennsylvania Pennsylvania 3rd Annual Suicide Prevention Conference, State College September 2009. Overview.

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Assessment of Bi-polar Spectrum Disorder in Older Adults

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  1. Assessment of Bi-polar Spectrum Disorder in Older Adults Cynthia Zubritsky, PhD & Karen Fortuna, MSW Center for Mental Health Policy and Services Research, University of Pennsylvania Pennsylvania 3rd Annual Suicide Prevention Conference, State College September 2009

  2. Overview • What are the issues? • Which older adults are at the highest risks for suicide? • Does untreated Bi-polar Spectrum Disorder (BSD) increase suicide risk for older adults? • Has BSD in older adults been studied? • What are the barriers to reducing suicide among older adults with BSD? • What can be done?

  3. What are the issues? Older Adults and Suicide

  4. Older Adult Demographics • People 65 years and older are the fastest growing age group in the United States. • 44.5 million people are over the age of 75 and by 2050 they will number almost 50 million. (NCHS, 2005)

  5. Percentage of the U.S. Population Age 65 and Older, 1900 to 2050 Changes in the age distribution of people 65 and older in the U.S. population over the last century and projected through 2050. Source: U.S. Census Bureau, Decennial Census, Population Estimates and projections.

  6. Older Adult Suicide • Although older adults comprised only 12% of the U.S. population in 2004, people aged 65 and older accounted for 16% of suicide deaths(Centers for Disease Control and Prevention, 2005). • There are approximately 15 older adult suicides per day or 1 older adult suicide every 95 minutes(American Association of Suicidology, 2004).

  7. Suicide Rates by Gender & Age • Suicide rates among individuals 75 years and older are about three times higher than those under 25 years of age. (World Health Organization, 2005)

  8. Which older adults are at the highest risk for suicide? Suicide Determinants in Older Adults

  9. Suicide Determinants in Older Adults: Physical Illness • Physical illness contributes to suicide in almost 70% of victims over 60 years of age. • Illnesses that often contribute to a higher suicide risk • HIV/AIDS • Huntington’s Disease • Multiple Sclerosis • Peptic ulcer • Renal disease • Spinal cord injury • Lupus (Conwell, Duberstein & Caine, 2002)

  10. Suicide Determinants in Older Adults: Loss/Social Support • Negative life events/loss • Lack of social support • Unmarried status • Bereavement • Family discord (Conwell et al., 2002)

  11. Suicide Determinants in Older Adults: Personality Traits • Personality traits linked to older adult suicide include shyness, seclusiveness, hypocondriasis, hostility, and independence(Conwell et al.,2002). • A history of suicide attempts places older adults at a higher risk for suicide completion (Alexopoulos, Bruce, Hull et al., 1999). • Substance use disorders increase suicide risk for older adults(Conwell et al., 2002).

  12. Suicide Determinants in Older Adults: Mental Illness • Untreated, severe mental illnesses substantially increases the risk of suicide(Rihmer & Kiss, 2002). • Mood disorders are the most common mental illness that result in older adult suicide(Conwell et al., 2002).

  13. Bi-polar Spectrum Disorder • BSD causes shifts in an individual’s mood, perception, energy level, and ability to function effectively. • BSD includes both Bi-polar Disorder I and II. (American Psychiatric Association, 2000)

  14. Bi-polar Spectrum Disorder • Bi-polar I Disorder is characterized by episodes of mania that alternate between episodes of depression or mixed states. • Bi-polar II Disorder is presented as frequent episodes of depression and mild symptoms of mania or hypomania. (American Psychiatric Association, 2000)

  15. Criteria for BSD • The criteria for a manic BSD episode includes elevated mood and three of the following symptoms: • Exaggerated self-esteem; • Less need for sleep; • Highly talkative; • Racing thoughts; • Distractibility; • Goal-orientated activity; and • Distorted judgment. (American Psychiatric Association, 2000)

  16. Criteria for BSD • Criteria for a depressive BSD episode include five or more of the following symptoms present during a 2-week period: • Weight gain or weight loss; • Depressed mood; • Loss of interests in activities that were once enjoyable; • Insomnia or hypersomnia; • Loss of energy; • Loss of concentration skills; • Thoughts of suicide; and • Negative feelings of guilt and worthlessness. (American Psychiatric Association, 2000)

  17. Does untreated Bi-polar Spectrum Disorder increase suicide risk for older adults? • Suicide and Bi-polar Spectrum Disorder (BSD)

  18. Suicide and Bi-polar Spectrum Disorder (BSD) • Most research on older adult suicide has targeted depression, not BSD(Aizenberg, Olmer, & Barak, 2006). • There is an increased risk of suicide among patients with BSD, estimated at 17-19%, or 15-20 times more than that of the general population(McElroy et al., 2006).

  19. Suicide and BSD • BSD in older adults is most commonly misdiagnosed as depression(Angst & Cassano, 2005; Ghaemi et al., 2000). • Misdiagnosis + lack of treatment in individuals with BSD is considered a major risk factor for suicide. • The majority of deaths by suicide are among older adults with BSD(Charney et al., 2003).

  20. Has BSD in older adults been studied? BSD Prevalence in Older Adults

  21. Research on the Prevalence of BSD in Older Adults The diagnosis of late-life Bi-polar Disorder is an especially neglected and understudied of research. Research that does exist has reported conflicting findings 1). Age of Onset • It was reported that the mean age for the onset of BSD ranges from 24.8 to 34.8 years (N=38,000) (Weissman et al., 1996). • It was later reported that the mean age of onset is between 35 and 45 years (N = 25,460) (Shi et al., McCombs, 2004). • In a geropsychiatric inpatient unit, the average age of onset was 43.9 years (N=48)(Sajatovic et al., 2005).

  22. Research on the Prevalence of BSD in Older Adults 2).Prevalence Rates of BSD in Older Adults • .08% of adults over age 65 screened positive for BSD (Klap et al., 2003). • 5-12% of geriatric psychiatry admissions were individuals with BSD (N = 217) (Van Gerpen, Johnson & Winstead, 1999). • Bi-polar Disorder accounts for an estimated 5-19% of mood disorders in older adults(Cassano, et al., 2000).

  23. Has BSD in older adults been studied? • BSD Assessment in Older Adults

  24. Assessment of Bi-polar Spectrum Disorder in Older Adults • The presentation of the BSD in older adults is different than in younger adults (Cassano et al., 2000; Kessing, 2006). • BSD diagnostic screening instruments designed to identify BSD symptoms in older adults may provide a more accurate diagnosis.

  25. Assessment of Bi-polar Spectrum Disorder in Older Adults • Most suicides occur when individuals are actively experiencing symptoms. • Accurate diagnosis using a BSD diagnostic screening instruments designed for older adults can increase the likelihood that proper treatment can begin and target BSD symptoms (Thase, 2005).

  26. Research Questions • Do diagnostic screening tools designed to identify BSD in older adults exist? • Are characteristics of older adults with BSD explored in screening instruments that are commonly used in the general adult population?

  27. Research Study • A literature review was conducted to identify validated BSD diagnostic screening instruments (1978 to 2008). • 17 commonly used BSD screening tools (1985-2008) • 21 national studies (53.8% of 39 studies) • 18 international studies (46.2% of 39 studies)

  28. 1) Altman Self Rating Scale 2) Bi-polar Depression Rating Scale 3) Chronorecord 4) Diagnostic Assessment for the Severely Handicapped 5) Hypomania Checklist 6) Hypomanic Personality Scale 7) Mood Disorder Questionnaire 8) Bi-polar Spectrum Diagnostic Scale 9) Million Clinical Multiaxial Inventory 10) Oxford Happiness Scale 11) Internal State Scale 12) Self-Report Manic Inventory; 13) Structured Clinical Interview for Mood Spectrum 14) DSM-IV Structured Clinical Interview 15) The MINI-International Nueropsychiatric Interview 16) The Mania Rating Scale 17) World Health Organization Composite International Diagnostic Interview BSD Screening Instruments Reviewed

  29. U.S. Studies • Fifteen U.S. studies included individuals under the age of 65 (93.7%). • 1 study included older adults 65 years or older (6.2%). * Based on age range reported

  30. Mean Age of Sample in U.S. Studies

  31. International Studies 12 (92%) studies included individuals under the age of 65. 1 (8%) study included individuals over the age of 65. * Based on age range reported

  32. Mean Age of Sample in International Studies

  33. Mean Age of Sample in all Studies

  34. Findings • Screening instruments designed to identify BSD in older adults have not been developed. • There were re-occurring barriers in the screening instruments reviewed that may prevent a correct diagnosis of BSD in older adults: • Average age of sample population; • Presentation of illness; • Stigmatization and stereotyping; • Memory; and • Language and formatting.

  35. What are the barriers to reducing suicide among older adults with BSD? Barriers

  36. Barrier: Average Age of Sample Population • The validation studies rarely included older adults. • Not including older adults in the validation studies may decrease the likelihood of the diagnostic accuracy of the instrument for older adults.

  37. Barrier: BSD Presentation 1) Individuals who only partially fulfill the criteria for having BSD, are commonly unrecognized, particularly in special populations (Cassano et al., 2000). 2) Persons with late onset BSD tend to experience only mild elation of mood and delusions resulting in a misdiagnosis of depression or dementia (Cassano et al., 2000). 3) Older adults with BSD show fewer psychotic symptoms(Kessing, 2006).

  38. Barrier: BSD Presentation 4) Older adults may present symptoms of anxiety(Turnbull, 1989) and depressiondifferently than other age groups (Gallo, Robins & Anthony, 1999). 5) Co-occurring physical disorders are common among this population (Charney et al., 2003). Clinicians who do not have knowledge of working with older adults may view mental health symptoms as physical health symptoms. 6) Older adults experience higher levels of mixed states(Bauer et al., 2002).

  39. Barrier: Stigmatization and Stereotyping • An individual’s feelings of stigmatization related to mental illness may alter the older adults’ self-report of their symptoms (Sirey et al., 2001). • Clinicians who do not have knowledge of working with older adults may view mental health symptoms as physical health symptoms or as a normal part of aging. (Surgeon General’s Report on Mental Health, 1999).

  40. Barrier: Memory • Older adults may have a problem remembering their symptoms since some symptoms of mental illnesses that are common among the aging population affect memory, such as Alzheimer’s Disease and Depression. • Memory loss may make reporting symptoms difficult and/or inaccurate. (American Psychiatric Association, 2000)

  41. Barrier: Language and Formatting Barriers • All screening tools were in 12-point font, which may be difficult for older adults with vision problems to read. • Most screening instruments were in English, and individuals who speak and/or read other languages may not be able to complete a self-report screening tool. • 52% of adults older than 50 years old speak English “less than well” (US Census Bureau, 2000).

  42. What can be done? BSD Assessment in Older Adults: Prospective Review

  43. BSA Assessment in Older Adults • A prospective review was conducted to identify unrecognized characteristics of older adults who have BSD. • A prospective review is a small study that enables researchers to explore research questions without conducting a large scale study. • The Bi-polar Spectrum Disorder Scale, developed by Ghaemi, was modified and designed specifically for older adults based on an extensive literature review and the clinical expertise of the researchers.

  44. Eleven older adults with mood disorders participated in a focus group to complete and discuss the modified Bi-polar Spectrum Disorder Scale. 1 - African-American 9 - Caucasian 1 - Other Average age - 63 years Range - 50-80 years old 6 - Male 5 - Female 4 - screened positive for BSD Focus Group

  45. Findings • Average age at diagnosis was 49 years • First BSD symptoms – 42 years • Gap may be a result of: • Under and misdiagnosis of BSD • Low rates of mental health service utilization

  46. Vivid dreams, emotions, and realistic nightmares Feelings of unhappiness and helplessness Physical pains Increased levels of hostility, aggressiveness, and irritability Impaired ability to function in a community or social setting Racing thoughts Less frequently associated features of BSD included the following. Reports of a family history of mental illness Increased sexual activity Increased sociability with friends, family, relatives, or strangers Results: Clinical Characteristics Symptoms identified by older adults with a moderate to high probability of a BSD diagnosis included the following.

  47. Focus Group Discussion Results: Consumer Response • 9 participants reported that the screening tool was confusing. • 9 participants repeatedly stated that they needed extra clarification on directions. • Directions to complete the screening tool should be clearly marked in large font.

  48. Consumer Input into Design • General consensus that the participants were not clear if they should report their thoughts and behaviors at the moment or in their entire lifetime. • The participants stated that they have great difficulty remembering lifetime symptoms.

  49. Consumer Input into Design • Participants suggested that their history of moods could be reported in two time periods. • Participants did not believe that the question related to increased sexual activity was relevant because they are older and because side effects of their medications (reduced interest in sexuality).

  50. Recommendations • Development of an age-specific screening tool and/or • Validation of existing screening tools with older adult populations. • The development of effective screening instruments will reduce misdiagnosis and/or under-diagnosis of BSD in older adults; the resultant appropriate and effective treatment should reduce suicide-related deaths of older adults with BSD.

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