Late-Onset Bipolar Disorder: Assessment and Treatment in Elderly Patients

1. 老人躁鬱疾患之評估與治療 2015. 06.05 高雄長庚紀念醫院 復健及社區精神科主治醫師 黃毓琦

2. Bipolar disorder • Chronic mental disorder characterized by alternating episodes of depression, euthymia, (hypo)mania and mixed states • Onset age usually under the age of 30 years • 90% of bipolar patients have become ill by the age of 50 • 15 times higher suicide risk among bipolar patients than in the general population Bauer et al., 2002; Hirschfeld et al., 2003; Harris and Barraclough 1997

3. Bipolar disorder • 10% of the population may develop bipolar disorder for the first time after 50 years of age • 8% and 9% of patients with bipolar disorder were aged 65 years and 60 years or over at the time of first contact with mental health services • Rapid cycling was more prominent in elderly patients Oostervink et al., 2009; Almeida and Fenner, 2002; Kennedy et al., 2005

4. Late onset bipolar disorder (LOB) • Lower familial rate of bipolar disorder than EOB • More medical and neurological comorbidity • LOB mania is generally associated with fewer manic symptoms which are milder • More likely to have irritable behavioral characteristics • Tendency toward treatment resistance, and a higher mortality rate Depp and Jeste, 2004; Cassano, 2000; Sajatovic, 2002a

5. Late onset bipolar disorder (LOB) • Often associated with organic factors • White matter hyperintensities Besga et al., 2011

6. Differences between Younger and Elderly bipolar patients • Mania in the elderly is less severe • Modified Manic State Rating Scale (MMSRS) : elderly group scored lower than a younger group • Young Mania Rating Scale (YMRS) : elderly patients had lower scores on the items • increased activity-energy • language-thought disorder • sexual interest Blackburn et al., 1997; Broadhead and Jacoby, 1990; Young and Falk, 1989

7. Differences between Younger and Elderly bipolar patients • The mean time between the first episode of depression and the onset of mania • 17 years in the elderly group • 3 years in the younger group • More elderly than younger manic patients had suffered three or more depressions before their first mania • Elderly manic patients were more likely to relapse into depression after mania Broadhead and Jacoby, 1990; Calabrese, et l., 2003

8. Differences between Younger and Elderly bipolar patients • Compared to elderly subjects, the younger ones were imprisoned more frequently (11.4% versus 28.2%) • Elderly manic patients were less likely to be treated with antipsychotics after discharge than younger patients Broadhead and Jacoby, 1990

9. Differential diagnosis • Secondary mania resulting from • Physical illness • Neurologic • Endocrine • Metabolic • Antidepressant Krauthammer and Klerman, 1978; Young et al., 2003

10. Pharmacological Treatment in Elderly • Pharmacokinetic and pharmacodynamic changes • Increased risk of drug interactions • 96% of prescriptions had a potential for drug–drug interactions • Average of eight drugs prescribed for each patient Vasudev et al., 2008

11. Pharmacological Treatment • Lithium in older adults is often more complicated by potential adverse effects • Anticonvulsants are increasingly used in the management of bipolar disorder in older adults • High use of antidepressants in the elderly group who were cycling (40%) McDonald, 2000; Aziz et al., 2000; Shulman et al., 2003; Sajatovic, 2005a, Vasude and Thomas, 2010

12. Pharmacological Treatment • Typical antipsychotics is particularly problematic in the elderly because of higher risk of cardiovascular problems and movement disorders • An increased incidence of mortality has been reported in elderly patients with dementia-related psychosis treated with atypical antipsychotics • Atypical antipsychotics in older adults with bipolar disorder although potential benefit must be balanced against the potential risks of treatment Sajatovic2005a, 2002b, 2005b; Young et al., 2004; FDA 2006; Aziz et al, 2006a

13. Psychological intervention • Psychoeducation • Family-Focused Treatment • Cognitive–behavioral therapy • Interpersonal therapy Rouget and Aubry 2007

14. Psychoeducation • Individual or group format by various health professionals (physicians, clinical psychologists, nurses or social workers) • Outpatient settings • During an euthymic phase • ensure a better assimilation of the information dispensed • prophylactic treatment for relapse • Mild depressive episode can usually gain benefit from PE ; (hypo)manic symptoms limits its impact Rouget and Aubry 2007