Cognitive and motor features in elderly people with bipolar disorder

Neuropsychological aspects of bipolar disorder

Bipolar disorder (BD) is a chronic condition with serious consequences on the health and functionality of patients who suffer from it, with a high heritability and segregation, and aprevalence of between 1% and 2%. Neuropsychological deficits have been implicated as a very important issue related to BD prognosis, so a review was conducted of these deficits, the related factors and their functional consequences. It has been determined that the presence of neuropsychological deficits can vary in patients with BD according to their mood state, with a great influence of depressive symptoms on the cognitive variability of patients with respect to the general population and differences with respect to patients in the manic phase. In euthymic patients, the most affected cognitive domains are those of memory, attention, and executive function, associated with a more severe disease, sociodemographic vulnerability factors, and stable over time. A relationship has been found between poor cognitive performance, especially executive dysfunction, and objective functional deficit. Furthermore, cognitive differences have been outlined between BD and other serious mental illnesses that are described in this review.

Cognition in older adults with bipolar disorder: An ISBD task force systematic review and meta-analysis based on a comprehensive neuropsychological assessment

OBJECTIVES

We aim to characterize the cognitive performance in euthymic older adults with bipolar disorder (OABD) through a comprehensive neuropsychological assessment to obtain a detailed neuropsychological profile.

METHODS

We conducted a systematic search in MEDLINE/Pubmed, Cochrane, and PsycInfo databases. Original studies assessing cognitive function in OABD (age ≥50 years ) containing, at a minimum, the domains of attention/processing speed, memory, and executive functions were included. A random-effects meta-analysis was conducted to summarize differences between patients and matched controls in each cognitive domain. We also conducted meta-regressions to estimate the impact of clinical and socio-demographic variables on these differences.

RESULTS

Eight articles, providing data for 328 euthymic OABD patients and 302 healthy controls, were included in the meta-analysis. OABD showed worse performance in comparison with healthy controls, with large significant effect sizes (Hedge's g from -0.77 to -0.89; p < 0.001) in verbal learning and verbal and visual delayed memory. They also displayed statistically significant deficits, with moderate effect size, in processing speed, working memory, immediate memory, cognitive flexibility, verbal fluency, psychomotor function, executive functions, attention, inhibition, and recognition (Hedge's g from -0.52 to -0.76; p < 0.001), but not in language and visuoconstruction domains. None of the examined variables were associated with these deficits.

CONCLUSIONS

Cognitive dysfunction is present in OABD, with important deficits in almost all cognitive domains, especially in the memory domain. Our results highlight the importance of including a routine complete neuropsychological assessment in OABD and also considering therapeutic strategies in OABD.

Neuropsychological Aspects of Bipolar Disorder

Bipolar disorder (BD) is a chronic condition with serious consequences on the health and functionality of patients who suffer from it, with a high heritability and segregation, and a prevalence of between 1% and 2%. Neuropsychological deficits have been implicated as a very important issue related to BD prognosis, so a review was conducted of these deficits, the related factors and their functional consequences. It has been determined that the presence of neuropsychological deficits can vary in patients with BD according to their mood state, with a great influence of depressive symptoms on the cognitive variability of patients with respect to the general population and differences with respect to patients in the manic phase. In euthymic patients, the most affected cognitive domains are those of memory, attention, and executive function, associated with a more severe disease, sociodemographic vulnerability factors, and stable over time. A relationship has been found between poor cognitive performance, especially executive dysfunction, and objective functional deficit. Furthermore, cognitive differences have been outlined between BD and other serious mental illnesses that are described in the review.

Cognitive impairment in bipolar disorder Neuroprogression or behavioral variant frontotemporal dementia?

Patients with Bipolar Disorder (BD) usually display cognitive deficits with aging. However, the correlation between BD and dementia syndromes is inconclusive, despite the similarity with behavioral variant frontotemporal dementia. We report a 78-year-old female patient who had bipolar type 1 disorder since adolescence. Her symptoms ranged from apathy to psychotic mania. She had had three hospitalizations, and since her last stay 10 years ago, her symptoms had remained stable. However, in the past 2 years, she displayed different symptoms, such as irritability manifested as verbal and physical aggression, cognitive impairment, repetitive pattern of behavior, perambulation, persecutory delusions, disorientation, and hyporexia. Treatment with anticholinesterases or mood stabilizers promoted no improvement. She scored 17/30 points on the Mini-Mental State Examination. Neuropsychological assessment suggested deficits in executive function, attention, and memory. Neuroimaging tests revealed frontotemporal degeneration and hypoperfusion. Diagnostic and therapeutic approaches for this type of patient represent a significant challenge for clinicians.

Handwriting movements for assessment of motor symptoms in schizophrenia spectrum disorders and bipolar disorder

The main aim of the present study was to explore the value of several measures of handwriting in the study of motor abnormalities in patients with bipolar or psychotic disorders. 54 adult participants with a schizophrenia spectrum disorder or bipolar disorder and 44 matched healthy controls, participated in the study. Participants were asked to copy a handwriting pattern consisting of four loops, with an inking pen on a digitizing tablet. We collected a number of classical, non-linear and geometrical measures of handwriting. The handwriting of patients was characterized by a significant decrease in velocity and acceleration and an increase in the length, disfluency and pressure with respect to controls. Concerning non-linear measures, we found significant differences between patients and controls in the Sample Entropy of velocity and pressure, Lempel-Ziv of velocity and pressure, and Higuchi Fractal Dimension of pressure. Finally, Lacunarity, a measure of geometrical heterogeneity, was significantly greater in handwriting patterns from patients than from controls. We did not find differences in any handwriting measure on function of the specific diagnosis or the antipsychotic dose. Results indicate that participants with a schizophrenia spectrum disorder or bipolar disorder exhibit significant motor impairments and that these impairments can be readily quantified using measures of handwriting movements. Besides, they suggest that motor abnormalities are a core feature of several mental disorders and they seem to be unrelated to the pharmacological treatment.

Functional Impairment in Older Adults With Bipolar Disorder

Data describing bipolar disorder in older adults people are scarce, particularly with regard to functional status. This observational, comparative study assessed psychosocial functioning in 33 euthymic older adults with bipolar disorder compared with 30 healthy controls. In addition, we evaluated the association between clinical variables and poor functioning in the patient group. The mean age of the group was 68.70 years. Patients with bipolar disorder experienced poorer psychosocial functioning (19.15 ± 11.36) than healthy controls (5.17 ± 3.72; p = 0.0001), as assessed using the Functioning Assessment Short Test. Significant differences between the groups were found for specific domains of functioning: autonomy, occupational functioning, cognitive functioning, financial issues, and interpersonal relationships (p = 0.0001, respectively). The largest variation was observed in overall functioning (Cohen's d = 0.63). The number of previous hospitalizations was strongly associated with poor overall functioning (F = 7.217, p = 0.002). Older patients with bipolar disorder had a greater functional impairment than the healthy control group. Implementation of novel rehabilitation models is critical to help patients manage their illness.

Influence of cognitive reserve on neuropsychological functioning in bipolar disorder: Findings from a 5-year longitudinal study

OBJECTIVES

The present study examined the 5-year longitudinal course of cognitive functioning in a large sample of well-characterized patients with bipolar disorder (BP), compared to healthy controls (HCs), and the influence of cognitive reserve factors (e.g., education and IQ) on cognitive change over time.

METHODS

Participants included 159 individuals diagnosed with BP and 54 HCs recruited as part of a longitudinal naturalistic study of BP who had completed neuropsychological testing at the time of their enrollment and again 5 years later.

RESULTS

The overall relative rate of change did not differ between the BP and HC groups. In total, 46.5% of the BP group and 37% of the HC group showed evidence of decline on at least one measure over time. T-test analyses did not find differences between BP 'decliners' and 'non-decliners' in cognitive reserve variables. However, we found that higher baseline intellectual ability was associated with more stability in cognitive test scores over time for the BP group. Results of linear regression modeling revealed that lower verbal IQ and education were related to increased cognitive decline in specific domains in the BP group.

CONCLUSIONS

This study has explored the influence of cognitive reserve on preservation of specific cognitive abilities over time in BP. The BP group did not demonstrate accelerated cognitive decline over 5 years compared to the HC group. Although the trajectory of cognitive change over time was similar between BP patients and HCs, higher overall intellectual ability may be a protective factor against cognitive decline, particularly for BP patients.

A report on older-age bipolar disorder from the International Society for Bipolar Disorders Task Force

OBJECTIVES

In the coming generation, older adults with bipolar disorder (BD) will increase in absolute numbers as well as proportion of the general population. This is the first report of the International Society for Bipolar Disorder (ISBD) Task Force on Older-Age Bipolar Disorder (OABD).

METHODS

This task force report addresses the unique aspects of OABD including epidemiology and clinical features, neuropathology and biomarkers, physical health, cognition, and care approaches.

RESULTS

The report describes an expert consensus summary on OABD that is intended to advance the care of patients, and shed light on issues of relevance to BD research across the lifespan. Although there is still a dearth of research and health efforts focused on older adults with BD, emerging data have brought some answers, innovative questions, and novel perspectives related to the notion of late onset, medical comorbidity, and the vexing issue of cognitive impairment and decline.

CONCLUSIONS

Improving our understanding of the biological, clinical, and social underpinnings relevant to OABD is an indispensable step in building a complete map of BD across the lifespan.

Neuroprogression and Cognitive Functioning in Bipolar Disorder: A Systematic Review

Bipolar disorder (BD) has been associated with impairments in a range of cognitive domains including attention, verbal learning, and mental flexibility. These deficits are increased during the acute phases of the illness and worsen over the course of BD. This review will examine the literature in relation to potential mechanisms associated with cognitive decline in BD. Scopus (all databases), Pubmed, and Ovid Medline were systematically searched with no language or year restrictions, up to January 2015, for human studies that collected cross-sectional and longitudinal cognitive data in adults with BD and matched healthy controls (HC). Selected search terms were "bipolar," "cognitive," "aging," "illness duration," "onset," and "progression." Thirty-nine studies satisfied the criteria for consideration. There is evidence that cognitive function in BD is negatively associated with features of illness progression such as number of mood episodes, illness duration, and hospitalizations. Aging does not appear to affect cognitive functioning to a greater extent than in HC. Furthermore, the small number of longitudinal studies in this field does not allow to reaching firm conclusion in terms of which sub-populations would be more prone to cognitive decline in BD. The decline in cognitive abilities over the course of the BD seems to be associated with the number of episodes and number of hospitalizations. No meaningful interaction of age and bipolar disorder has been found in terms of cognitive decline. Future large-scale longitudinal studies are necessary to confirm these findings and assist in the development of preventive interventions in vulnerable individuals.

Sensorimotor performance in euthymic bipolar disorder: the MPraxis (PennCNP) analysis

BACKGROUND

Sensorimotor deficits are an important phenomenological facet observed in patients with bipolar disorder (BD). However, there is little research on this topic. We hypothesize that the MPraxis test can be used to screen for motor impairments in BD aiming movements.

METHOD

The MPraxis, which is a quick and easy-to-apply computerized test, measures sensorimotor control. During the test, the participant must move the computer mouse cursor over an ever-shrinking green box and click on it once. We predict that the MPraxis test is capable of detecting differences in sensorimotor performance between patients with BD and controls. We assessed 21 euthymic type I BD patients, without DSM-IV-TR Axis I comorbidity, and 21 healthy controls.

RESULTS AND CONCLUSIONS

Compared to the controls, the patients with BD presented a lower response time in their movements in all conditions. Our results showed sensorimotor deficits in BD and suggested that the MPraxis test can be used to screen for motor impairments in patients with euthymic BD.

Impulsivity: present during euthymia in bipolar disorder? - a systematic review

Because impulsivity is part of the presentation of bipolar disorder (BD) and is associated with its course, this systematic review presents the evidence whether increased impulsivity is present in a stable, euthymic mood and therefore potentially a vulnerability marker for BD. A multi-faceted model of impulsivity was adopted to explore how different facets may relate differently to BD. The evidence was explored in relation to studies employing measures of trait impulsivity (in self-report format) and studies exploring impulsivity with behavioural paradigms. Behavioural paradigms were separated into studies measuring response inhibition and those measuring the ability to delay gratification. Twenty-three papers met the inclusion criteria. Most studies using self-report measures found significant differences between euthymic BD patients and healthy controls. There was little evidence of increased impulsivity as measured by behavioural paradigms. Most studies found no significant difference in response inhibition between groups, though it is possible that much of the literature in this area was underpowered to detect an effect. Only five studies explored delay of gratification, of which the two methodologically strongest studies found no group differences. In conclusion, there is evidence that euthymic patients with BD report increased impulsivity when using self-ratings. However, there is currently limited evidence of impulsivity on behavioural measures assessing response inhibition, and this might be restricted to more severe cases. More research is needed on the ability to delay gratification before drawing any conclusions. However, to establish facets of impulsivity as vulnerability markers, future studies should include at-risk individuals to evaluate whether self-rated or behavioural impulsivity precedes the onset of BD.

Cognitive function in adulthood and elderly euthymic bipolar patients: a comparison to test models of cognitive evolution

OBJECTIVE

Neurocognitive dysfunction is considered as the main predictor of overall outcome of BD. The issue of whether neurocognitive dysfunction in BD is progressive-or not-has become critical in the effort to define staging models for these disorders. Data about cognitive dysfunction evolution are scarce and contradictory. While some studies showed a progressive pattern others have found a stable form of evolution.

METHODS

Twenty four patients with BD aged 60 years or older (E-BD), 24 patients with BD aged 40 years or younger (Y-BD) and 20 healthy controls matched by the E-BD group were evaluated with traditional clinical instruments and an extensive neuropsychological battery was completed. We used ANOVA and Chi-squared for comparisons. Raw score of neurocognitive tasks was transformed to standardized Z-score from the normative data of each test to avoid the effect of age. In order to decrease the risk of type I errors, one-way multivariate analysis of variance was conducted.

RESULTS

Despite having an illness duration that was 4 times longer, E-BD did not differ in terms of key cognitive domains compared to Y-BD. These data do not support the hypothesis of a progression of cognitive dysfunction due to illness chronicity.

A quantitative review of neurocognition in euthymic late-life bipolar disorder

OBJECTIVES

A sizeable body of work has consistently documented that a number of euthymic mixed-age bipolar disorder subjects exhibit prominent impairments in a variety of cognitive domains. By contrast, knowledge about neuropsychological functioning in elderly patients is scant, despite being necessary for the adequate treatment of this population and the understanding of illness evolution. The aim of this study was to combine findings from the available literature in order to examine the pattern and extent of cognitive deficits in euthymic late-life bipolar disorder subjects.

METHODS

A literature search was conducted through the online databases PubMed, ScienceDirect, EBSCO, and Wiley-Blackwell, covering the period between January 1990 and April 2012. Effect sizes reflecting patient-control differences for 10 cognitive variables were extracted from selected investigations and combined by means of meta-analytical procedures.

RESULTS

No significant patient-control differences were found for global cognitive status as assessed with the Mini-Mental State Examination and the Clock Drawing Test. Significant overall effect sizes (Hedges' g) of between 0.61 and 0.88 were noted for sustained attention, digit span (forwards and backwards), delayed recall, serial learning, cognitive flexibility, and verbal fluency (phonemic and categorical).

CONCLUSIONS

The extent of cognitive dysfunction in euthymic late-life bipolar disorder subjects may be, on average, similar to that reported for remitted young adult patients. Larger effect sizes of impairment may be associated with late illness onset. Implications and future directions for research are proposed.

A kinematic analysis of manual aiming control on euthymic bipolar disorder

Motor deficits in tasks that require force steadiness or scaling of movement velocity have been found in bipolar disorder (BD). A potential explanation for these results is the abnormal functioning of the frontostriatal circuitry. We designed this study to investigate the possible impairments in a manual aiming task. Participants comprised 15 euthymic BD patients and 15 healthy controls, who performed 100 trials of a goal-directed manual movement with a non-inking pen on a digitizing tablet. Four different conditions of execution were required. The control condition appeared on the computer screen in 70% of the trials, and the other three conditions, (a) distractor, (b) inhibition of response and (c) higher index of difficulty, each appeared in 10% of the trials. Compared to the controls, the BD patients were less fluent in their movements, relied more heavily on visual feedback to control their manual movements and presented a lower spatial accuracy. We found that motor deficits in euthymic BD were observed in the kinematic analysis of manual aiming. Our findings are consistent with the hypothesis of abnormal functioning of the frontostriatal circuitry in euthymic BD.

Relationship between neurocognitive functioning and episode recurrences in bipolar disorder

BACKGROUND

The relationship between neurocognitive impairment and clinical course in bipolar disorder (BD) is inconclusive. The aim of this study was to compare time to recurrence between patients with and without clinically significant cognitive impairment.

METHODS

Seventy euthymic patients with BD were included. Based on baseline neurocognitive performance, patients were divided into those with (n=49) and those without (n=21) clinically significant cognitive impairment. Both groups of patients were prospectivelly assessed by a modified life chart method during a mean of 16.3 months.

RESULTS

Patients with some cognitive domain compromised had an increased risk of suffering any recurrence (HR: 3.13; CI 95%: 1.64-5.96), hypo/manic episodes (HR: 2.42; CI 95%: 1.13-5.19), or depressive episodes (HR: 3.84, CI 95%: 1.66-8.84) compared with those patients without clinically significant cognitive impairment. These associations remained significant after adjusting for several potential counfounders such as number of previous episodes, time since last episode, clinical subtype of BD, exposure to antipsychotics, and subclinical symptoms.

LIMITATIONS

We classified patients as with or without clinically significant cognitive impairment, although deficits in different cognitive domains may not be equivalent in terms of risk of recurrence.

CONCLUSIONS

The results did not support the hypothesis that the experience of successive episodes is related to a progressive neurocognitive decline. On the contrary, cognitive impairment could be the cause more than the consequence of poorer clinical course. Alternatively, a specific subgroup of patients with clinically significant cognitive impairment and a progressive illness in terms of counts of recurrence and shortening of wellness intervals might explain the association showed in this study.

The overlap of symptomatic dimensions between frontotemporal dementia and several psychiatric disorders that appear in late adulthood

Several factors make diagnosis of a possible behavioural variant of frontotemporal dementia (bvFTD) particularly challenging, especially the overlap of certain symptomatic dimensions such as apathy, disinhibition, depression, anhedonia, stereotyped behaviour, and psychosis between bvFTD and several psychiatric disorders that appear in late adulthood. We discuss the most frequent psychiatric conditions that can simulate early bvFTD symptoms, including late onset bipolar disorder, late onset schizophrenia-like psychosis, late onset depression, and attention deficit hyperactivity disorder in middle and older age.

Contextual social cognition impairments in schizophrenia and bipolar disorder

Background

The ability to integrate contextual information with social cues to generate social meaning is a key aspect of social cognition. It is widely accepted that patients with schizophrenia and bipolar disorders have deficits in social cognition; however, previous studies on these disorders did not use tasks that replicate everyday situations.

Methodology/Principal Findings

This study evaluates the performance of patients with schizophrenia and bipolar disorders on social cognition tasks (emotional processing, empathy, and social norms knowledge) that incorporate different levels of contextual dependence and involvement of real-life scenarios. Furthermore, we explored the association between social cognition measures, clinical symptoms and executive functions. Using a logistic regression analysis, we explored whether the involvement of more basic skills in emotional processing predicted performance on empathy tasks. The results showed that both patient groups exhibited deficits in social cognition tasks with greater context sensitivity and involvement of real-life scenarios. These deficits were more severe in schizophrenic than in bipolar patients. Patients did not differ from controls in tasks involving explicit knowledge. Moreover, schizophrenic patients’ depression levels were negatively correlated with performance on empathy tasks.

Conclusions/Significance

Overall performance on emotion recognition predicted performance on intentionality attribution during the more ambiguous situations of the empathy task. These results suggest that social cognition deficits could be related to a general impairment in the capacity to implicitly integrate contextual cues. Important implications for the assessment and treatment of individuals with schizophrenia and bipolar disorders, as well as for neurocognitive models of these pathologies are discussed.

Neurocognitive functioning in early-onset and late-onset older patients with euthymic bipolar disorder

OBJECTIVE

Most neurocognitive studies have not taken into account the fact that older patients with bipolar disorder (BD) are a heterogeneous population. The main goal of this study was to compare neurocognitive performance and extrapyramidal symptoms in older patients with early-onset BD (EO-BD) and late-onset BD (LO-BD).

METHODS

Euthymic older patients with EO-BD (n = 20), LO-BD (n = 20), and healthy controls (n = 20) were evaluated with traditional clinical instruments and measures of exposure to psychotropic drugs, as well as extrapyramidal symptoms. All subjects completed an extensive neuropsychological battery.

RESULTS

Patients with EO-BD showed poorer performance than healthy controls in two measures of verbal memory and two measures of executive functions, whereas patients with LO-BD exhibited lower performance scores than healthy controls in almost all of the measures assessed. Impairments in the LO-BD group included even neurocognitive domains typically spared in mixed-age patients. Additionally, there was a trend toward displaying higher extrapyramidal symptoms in the LO-BD group compared with both EO-BD and healthy control groups. In both patient groups, psychosocial functioning was related with executive dysfunction and extrapyramidal symptoms.

CONCLUSIONS

Patients with LO-BD may have more extensive and severe cognitive impairments, as well as higher vulnerability to extrapyramidal symptoms, compared with patients with EO-BD. Cognitive-motor disturbances may help to explain impairments in daily functioning among older patients with EO-BD and LO-BD during remission.

Deficit status in bipolar disorder: investigation on prevalence rate and description of seven cases

OBJECTIVE

While the Kraepelinian dichotomy explicitly distinguishes between schizophrenia and bipolar disorder, it remains unclear as to whether a deficit form of bipolar disorder exists.

METHOD

We conducted a study to investigate the prevalence rate of the deficit form of bipolar disorder; the criteria of which were basically adopted by the original proposal for schizophrenia that described the predominance of negative symptoms for over a year. Moreover, we presented a series of cases with "deficit" bipolar disorder to characterize its clinical pictures in detail.

RESULTS

Consecutive outpatients who visited one psychiatric hospital in Tokyo, Japan in March 2007 were evaluated cross-sectionally. Additionally, medical charts of inpatients who were hospitalized in the same hospital between April 2006 and March 2007 were also thoroughly reviewed. Of 494 patients, 7 patients (1.4%; 10.9% of 64 bipolar cases) fulfilled the criteria for bipolar disorder with deficit syndrome. Seven "deficit" cases had a mean±SD age of 61±5 year-old with the age at onset being 25±8 year-old. In addition to pervasive negative symptoms, they exhibited evidence of cognitive impairments close to the magnitude of what is usually noted in schizophrenia (i.e. a mean±SD total IQ score of 80±9 in the Wechsler Adult Intelligence Scale and 0.4±0.5 in the Wisconsin Card Sorting Test, categories achieved).

CONCLUSION

Although preliminary, the evidence on deficit status in patients with bipolar disorder that we found in this study appears more consistent with recent evidence and challenges the Kraepelinian dichotomy that reserves deficit status solely to schizophrenia patients.

Clinical implications of cognitive function in bipolar disorder

In recent years there has been increased interest in cognitive function in bipolar disorder (BD) as a means of understanding and exploring biological mechanisms relating to predisposition, disease expression and outcome. Despite significant methodological differences between studies we can begin to discern meaningful patterns from existing data. The evidence reviewed suggests that: (a) premorbid cognitive dysfunction is not a dominant feature of BD; in contrast to other severe psychiatric conditions, enhanced cognitive function may be a risk marker for BD; (b) in BD patients with established syndromal disease, trait-related cognitive impairment is reliably seen in the speed of information processing, verbal Learning and memory and response inhibition; (c) cognitive function appears to remain stable post-disease onset in the majority of patients although the risk of dementia in old age is increased; (d) cognitive impairment is a key predictor of functional outcome in BD. These findings underscore the importance of cognition in BD as a marker of neural integrity across all phases of the illness and as a therapeutic target in disability reduction.

Longitudinal analysis of cognitive performances and structural brain changes in late-life bipolar disorder

OBJECTIVES

Cross-sectional studies in bipolar disorder (BD) suggested the presence of cognitive deficits and subtle magnetic resonance imaging (MRI) changes in limbic areas that may persist at euthymic stages. Whether or not cognitive and MRI changes represent stable attributes of BD or evolve with time is still matter of debate. To address this issue, we performed a 2-year longitudinal study including detailed neuropsychological and magnetic resonance imaging (MRI) analyses of 15 euthymic older BD patients and 15 controls.

METHODS

Neuropsychological evaluation concerned working memory, episodic memory, processing speed, and executive functions. MRI analyses included voxel-based morphometry (VBM) analysis of gray matter including region of interest (ROI) analysis and tract-based spatial statistics (TBSS) analysis of white matter of diffusion tensor imaging derived fractional anisotropy (FA).

RESULTS

BD patients displayed significantly lower performances in processing speed and episodic memory but not in working memory and executive functions compared to controls. However, BD patients did not differ from controls in the mean trajectory of cognitive changes during the 2 years follow-up. In the same line, longitudinal gray matter (VBM, ROI) and white matter (TBSS FA) changes did not differ between BD patients and controls.

CONCLUSION

The lack of distinction between BD patients and controls in respect to the 2-year changes in cognition and MRI findings supports the notion that this disorder does not have a significant adverse impact on cognitive and brain aging. From this point of view, the present results convey a message of hope for patients suffering from BD.

Combined analysis of grey matter voxel-based morphometry and white matter tract-based spatial statistics in late-life bipolar disorder

BACKGROUND

Previous magnetic resonance imaging (MRI) studies in young patients with bipolar disorder indicated the presence of grey matter concentration changes as well as microstructural alterations in white matter in various neocortical areas and the corpus callosum. Whether these structural changes are also present in elderly patients with bipolar disorder with long-lasting clinical evolution remains unclear.

METHODS

We performed a prospective MRI study of consecutive elderly, euthymic patients with bipolar disorder and healthy, elderly controls. We conducted a voxel-based morphometry (VBM) analysis and a tract-based spatial statistics (TBSS) analysis to assess fractional anisotropy and longitudinal, radial and mean diffusivity derived by diffusion tensor imaging (DTI).

RESULTS

We included 19 patients with bipolar disorder and 47 controls in our study. Fractional anisotropy was the most sensitive DTI marker and decreased significantly in the ventral part of the corpus callosum in patients with bipolar disorder. Longitudinal, radial and mean diffusivity showed no significant between-group differences. Grey matter concentration was reduced in patients with bipolar disorder in the right anterior insula, head of the caudate nucleus, nucleus accumbens, ventral putamen and frontal orbital cortex. Conversely, there was no grey matter concentration or fractional anisotropy increase in any brain region in patients with bipolar disorder compared with controls.

LIMITATIONS

The major limitation of our study is the small number of patients with bipolar disorder.

CONCLUSION

Our data document the concomitant presence of grey matter concentration decreases in the anterior limbic areas and the reduced fibre tract coherence in the corpus callosum of elderly patients with long-lasting bipolar disorder.

Dopamine sudden depletion as a model for mixed depression

Up to date research on Bipolar Disorders' phenomenology is in keeping with early descriptions made by E. Kraëpelin regarding the overlap in clinical presentation of both manic and depressive symptoms, namely, mixed states. The latter constitute a highly prevalent and characteristic clinical presentation of Bipolar Disorders' and entail therapeutic difficulties, prognostic implications and increased suicidal risk. Notwithstanding, mixed states', more specifically mixed depression, have been underestimated and bypassed to the point where currently neither diagnostic criteria nor specific therapeutic recommendations are provided. In addition to the lack of agreement on nosography and diagnostic criteria, mixed depression is usually excluded from Bipolar Disorders' neurobiological models. Furthermore, renewed interest in the role of dopamine in Bipolar Disorders' physiopathology has left aside hypothesis that may account for the aforementioned clinical presentation. Interestingly enough, other syndromes arising from sudden dopamine depletion such as neuroleptic dysphoria or withdrawal syndromes from dopaminergic drugs, bear remarkable clinical similarities with mixed depression. These syndromes have been subject of further research and may thus provide a model for mixed states' physiopathology. Indeed, this article accounts for clinical similarities between mixed depression, neuroleptic induced dysphoria, and other behavioural syndromes arising from sudden dopamine depletion. After reviewing neurochemical basis of such syndromes we present, to the best of our knowledge, the first neurobiological hypothesis for mixed depression. Specifically, such hypothesis regards over activation symptoms as auto regulatory attempts to compensate for sudden dopaminergic depletion. This hypothesis provides with a beginning step for the neglected problem of mixed depression, a non-antithetic link between the dopaminergic hypothesis for both manic and depressive symptoms, a plausible explanation regarding inter individual variability to mixed depression susceptibility, and suggests new approaches for the development of novel treatments in which dopamine dysregulation should be targeted.

Late-onset bipolar illness: the geriatric bipolar type VI

In parallel to considerable progress in understanding and treatment of bipolarity and despite growing interest in old age psychiatry, late-onset bipolar illness (LOBI) has remained relatively understudied so far, probably in reason of its complexity. To update available data, a systematic review was conducted, focusing on the main issues addressed in literature in regard to this topic. In addition to data on epidemiology, clinical features and treatment, five main issues could be identified: LOBI as secondary disorder, LOBI as expression of a lower vulnerability to the disease, LOBI as subform of pseudodementia, LOBI as risk factor for developing dementia, and LOBI as bipolar type VI (bipolarity in the context of dementia like processes). Levels of available evidence were found to vary according to the addressed issue. Although the concept of bipolar type VI could be criticized for subsuming under one single heading all the four other issues, this concept may be of pragmatic value in helping clinicians to orientate both diagnosis process and treatment decisions. Among others, the question as to whether some forms of bipolar type VI could constitute a special risk factor for developing dementia deserves further investigation. More studies are also needed to better disentangle the effects of age at onset from those of age itself.

Neuroanatomical and neuropsychological features of euthymic patients with bipolar disorder

OBJECTIVE

Previous studies reported that the severity of cognitive deficits in euthymic patients with bipolar disorder (BD) increases with the duration of illness and postulated that progressive neuronal loss or shrinkage and white matter changes may be at the origin of this phenomenon. To explore this issue, the authors performed a case-control study including detailed neuropsychological and magnetic resonance imaging analyses in 17 euthymic elderly patients with BD and 17 healthy individuals.

METHODS

Neuropsychological evaluation concerned working memory, episodic memory, processing speed, and executive functions. Volumetric estimates of the amygdala, hippocampus, entorhinal cortex, and anterior cingulate cortex were obtained using both voxel-based and region of interest morphometric methods. Periventricular and deep white matter were assessed semiquantitatively. Differences in cognitive performances and structural data between BD and comparison groups were analyzed using paired t-test or analysis of variance. Wilcoxon test was used in the absence of normal distribution.

RESULTS

Compared with healthy individuals, patients with BD obtained significantly lower performances in processing speed, working memory, and episodic memory but not in executive functions. Morphometric analyses did not show significant volumetric or white matter differences between the two groups.

CONCLUSIONS

Our results revealed impairment in verbal memory, working memory, and processing speed in euthymic older adults with BD. These cognitive deficits are comparable both in terms of affected functions and size effects to those previously reported in younger cohorts with BD. Both this observation and the absence of structural brain abnormalities in our cohort do not support a progressively evolving neurotoxic effect in BD.

Cognitive features in euthymic bipolar patients in old age

OBJECTIVES

Studies of cognition in bipolar disorder (BD) have reported impairments in processing speed, working memory, episodic memory, and executive function, but they have primarily focused on young and middle-aged adults. In such studies, the severity of cognitive deficits increases with the duration of illness. Therefore, one would expect more pronounced deficits in patients with longstanding BD. The first aim of the present study was to determine the pattern and the magnitude of cognitive impairment in older euthymic BD patients. The second aim was to explore the interrelationship between these cognitive deficits and determine whether they reflect a single core impairment or the co-occurrence of independent cognitive deficits.

METHODS

Twenty-two euthymic elderly BD patients and 22 controls, matched for gender, age, and education, underwent a comprehensive neuropsychological assessment.

RESULTS

Compared to controls, BD patients had significantly reduced performance in processing speed, working memory, verbal fluency, and episodic memory, but not in executive function. Hierarchical regression analyses showed that verbal fluency and working memory impairments were fully mediated by changes in processing speed. This was not the case for the episodic memory dysfunction.

CONCLUSION

The cognitive profile in older euthymic BD cases is similar to the one described in younger BD cohorts. Our results further suggest that impaired processing speed plays a major role in the cognitive changes observed in BD patients except for deficits in episodic memory, thus providing strong evidence that processing speed and episodic memory are two core deficits in elderly BD patients.

Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) collaborative update of CANMAT guidelines for the management of patients with bipolar disorder: update 2009

The Canadian Network for Mood and Anxiety Treatments (CANMAT) published guidelines for the management of bipolar disorder in 2005, with a 2007 update. This second update, in conjunction with the International Society for Bipolar Disorders (ISBD), reviews new evidence and is designed to be used in conjunction with the previous publications. The recommendations for the management of acute mania remain mostly unchanged. Lithium, valproate, and several atypical antipsychotics continue to be first-line treatments for acute mania. Tamoxifen is now suggested as a third-line augmentation option. The combination of olanzapine and carbamazepine is not recommended. For the management of bipolar depression, lithium, lamotrigine, and quetiapine monotherapy, olanzapine plus selective serotonin reuptake inhibitor (SSRI), and lithium or divalproex plus SSRI/bupropion remain first-line options. New data support the use of adjunctive modafinil as a second-line option, but also indicate that aripiprazole should not be used as monotherapy for bipolar depression. Lithium, lamotrigine, valproate, and olanzapine continue to be first-line options for maintenance treatment of bipolar disorder. New data support the use of quetiapine monotherapy and adjunctive therapy for the prevention of manic and depressive events, aripiprazole monotherapy for the prevention of manic events, and risperidone long-acting injection monotherapy and adjunctive therapy, and adjunctive ziprasidone for the prevention of mood events. Bipolar II disorder is frequently overlooked in treatment guidelines, but has an important clinical impact on patients' lives. This update provides an expanded look at bipolar II disorder.