The nature and management of mania in old age

Treatment of bipolar disorders in older adults: a review

BACKGROUND

Old age bipolar disorder has been an orphan of psychiatric research for a long time despite the fact that bipolar disorder (BD)-I and II together may affect 0.5-1.0% of the elderly. It is also unclear whether aetiology, course of illness and treatment should differ in patients with a first manifestation in older age and patients suffering from a recurrence of a BD known for decades. This narrative review will summarize the current state of knowledge about the epidemiology, clinical features, and treatment of BD in the elderly.

METHODS

We conducted a Medline literature search from 1970 to 2021 using MeSH terms "Bipolar Disorder" × "Aged" or "Geriatric" or "Elderly". Search results were complemented by additional literature retrieved from examining cross references and by hand search in text books. Varying cut-off ages have been applied to differentiate old age from adult age BD. Within old age BD, there is a reasonable agreement of distinct entities, early and late-onset BD. They differ to some extent in clinical symptoms, course of illness, and some co-morbidities. Point prevalence of BD in older adults appears slightly lower than in working-age adults, with polarity of episodes shifting towards depression. Psychopharmacological treatment needs to take into account the special aspects of somatic gerontology and the age-related change of pharmacokinetic and pharmacodynamic characteristics. The evidence for commonly used treatments such as lithium, mood-stabilizing antiepileptics, antipsychotics, and antidepressants remains sparse. Preliminary results support a role of ECT as well as psychotherapy and psychosocial interventions in old age BD.

CONCLUSIONS

There is an obvious need of further research for all treatment modalities of BD in old age. The focus should be pharmacological and psychosocial approaches, as well as their combination, and the role of physical treatment modalities such as ECT.

Old Age Bipolar Disorder-Epidemiology, Aetiology and Treatment

Data regarding older age bipolar disorder (OABD) are sparse. Two major groups are classified as patients with first occurrence of mania in old age, the so called “late onset” patients (LOBD), and the elder patients with a long-standing clinical history, the so called “early onset” patients (EOBD). The aim of the present literature review is to provide more information on specific issues concerning OABD, such as epidemiology, aetiology and treatments outcomes. We conducted a Medline literature search from 1970–2021 using the MeSH terms “bipolar disorder” and “aged” or “geriatric” or “elderly”. The additional literature was retrieved by examining cross references and by a hand search in textbooks. With sparse data on the treatment of OABD, current guidelines concluded that first-line treatment of OABD should be similar to that for working-age bipolar disorder, with specific attention to side effects, somatic comorbidities and specific risks of OABD. With constant monitoring and awareness of the possible toxic drug interactions, lithium is a safe drug for OABD patients, both in mania and maintenance. Lamotrigine and lurasidone could be considered in bipolar depression. Mood stabilizers, rather than second generation antipsychotics, are the treatment of choice for maintenance. If medication fails, electroconvulsive therapy is recommended for mania, mixed states and depression, and can also be offered for continuation and maintenance treatment. Preliminary results also support a role of psychotherapy and psychosocial interventions in old age BD. The recommended treatments for OABD include lithium and antiepileptics such as valproic acid and lamotrigine, and lurasidone for bipolar depression, although the evidence is still weak. Combined psychosocial and pharmacological treatments also appear to be a treatment of choice for OABD. More research is needed on the optimal pharmacological and psychosocial approaches to OABD, as well as their combination and ranking in an evidence-based therapy algorithm.

How to treat mania

OBJECTIVE

In this paper, we aimed at reviewing evidence-based treatment options for bipolar mania and proposed tentative evidence-based clinical suggestions regarding the management of a manic episode, especially regarding the choice of the proper mood stabilizer and antipsychotic medication.

METHOD

A narrative review was undertaken addressing 'treatment of bipolar mania'. Findings have been synthesized and incorporated with clinical experience into a model to support different treatment choices.

RESULTS

To date, there is solid evidence supporting the use of several medications, such as lithium, divalproex, and carbamazepine, and antipsychotics, such as chlorpromazine, haloperidol, risperidone, olanzapine, quetiapine, ziprasidone, aripiprazole, inhaled loxapine, asenapine, and cariprazine in acute mania, and some evidence supporting the use of clozapine or electroconvulsive therapy in treatment-refractory cases. However, in clinical practice, when making decisions about treatment, personalized treatment is needed, according to the different clinical presentations and more complex clinical situations within the manic episode and considering a long-term view and with the objective of not only a symptomatic but also functional recovery. After remission from acute mania, psychoeducation strategies are useful to ensure adherence.

DISCUSSION

Despite the evidence forefficacy of many currently available treatments for mania, the majority of RCTs provide little direction for the clinician as to what steps might be optimal in different presentations of mania as well as in the presence of specific patient characteristics. Manic episodes should be managed on a personalized basis considering the clinical course and patient criteria and with the expectation of maintaining that treatment in the long-term.

Association between bipolar disorder and subsequent traumatic brain injury in patients who received inpatient treatment

Mental disorders may confer a high risk of traumatic brain injury, but only rare studies have investigated mood disorders. This nationwide cohort study compared the risk of traumatic brain injury in patients with and without bipolar disorder. We compared 1017 patients with bipolar disorder who received inpatient treatment and 9080 compared patients. The annual incidence rate of traumatic brain injury was calculated as the number of new cases divided by the total number of person-years in the available records. The incidence of subsequent traumatic brain injury was significantly higher in the bipolar group than in control group. The adjusted hazard ratio for those with multiple hospitalizations was higher than the counterpart. Except for patients in the 50-59-year age group, those in all other age groups had higher risks of traumatic brain injury. Our findings reveal a higher risk of traumatic brain injury in patients with bipolar disorder. Patients with recurrent hospitalization and multiple psychotropic use had an increased risk of traumatic brain injury. Age may modify the risk of traumatic brain injury, with a higher risk in middle-aged patients.

A patient with bipolar disorder and antiphospholipid syndrome

Antiphospholipidsyndrome (APS) is an autoimmune disorder which causes a hyper-coagulable state characterized by recurrent thrombosis. It has a diverse range of central nervous system manifestations. We describe a case of a 61 year old man with bipolar disorder and APS, and we compare this to a previously reported case. Additionally, we reviewed literature regarding APS-related markers and the relationship of APS to other psychiatric and neurologic illnesses. We discuss possible mechanisms for an association between APS and bipolar disorder. We encourage clinicians to be aware of this possible relationship and have proposed research strategies.

Mania and stroke: a systematic review

BACKGROUND

Mania is a rare consequence of stroke and according to the sparse published information it is difficult to describe its demographic, clinical and prognostic characteristics.

METHODS

We performed a systematic review of all cases of mania and stroke to describe those characteristics. Studies were identified from comprehensive searches of electronic databases, reference lists of the studies collected and handbooks. Two authors independently assessed abstracts, and collected and extracted data.

RESULTS

From 265 abstracts, 139 were potentially relevant. For the first analysis, which tries to answer the clinical question of the relationship between mania and stroke, 49 studies met the inclusion criteria and described 74 cases. For the second analysis, we looked for an explicit temporal and causal relationship between manic symptoms and stroke, and selected 32 studies describing 49 cases. In both analyses, the typical patient was male, without a personal or family history of psychiatric disorder, with at least one vascular risk factor, but without subcortical atrophy and had suffered a right cerebral infarct. The majority of patients (92%) presented elevated mood as the first symptom. The other frequent symptoms were an increased rate or amount of speech (71%), insomnia (69%) and agitation (63%).

CONCLUSIONS

Post-stroke mania should be considered in any manic patient who presents concomitant neurological focal deficits and is older than expected for the onset of primary mania. The results of a systematic study of mania in acute stroke with subsequent follow-up and data from diffusion MR or perfusion CT in a multicenter study with a central database would be relevant.

State-dependent microstructural white matter changes in bipolar I depression

Abnormalities in fronto-limbic-striatal white matter (WM) have been reported in bipolar disorder (BD), but results have been inconsistent across studies. Furthermore, there have been no detailed investigations as to whether acute mood states contribute to microstructural changes in WM tracts. In order to compare fiber density and structural integrity within WM tracts between BD depression and remission, whole-brain fractional anisotropy (FA) and mean diffusivity (MD) were assessed in 37 bipolar I disorder (BD-I) patients (16 depressed and 21 remitted), and 26 healthy individuals with diffusion tensor imaging. Significantly decreased FA and increased MD in bilateral prefronto-limbic-striatal white matter and right inferior fronto-occipital, superior and inferior longitudinal fasciculi were shown in all BD-I patients versus controls, as well as in depressed BD-I patients compared to both controls and remitted BD-I patients. Depressed BD-I patients also exhibited increased FA in the ventromedial prefrontal cortex. Remitted BD-I patients did not differ from controls in FA or MD. These findings suggest that BD-I depression may be associated with acute microstructural WM changes.

Comorbidity of cardiovascular diseases with mood and anxiety disorder: a population based 4-year study

AIMS

Accumulating evidence from Caucasian patients has shown that depression, bipolar and anxiety disorders are associated with an increased risk of cardiovascular diseases (CVD), but reports in the Asian population are limited, and age effect is rarely investigated. This population-based study was carried out to examine and compare the CVD comorbidities among patients with mood and anxiety disorders in different age groups.

METHOD

A 4-year cross-sectional survey was carried out using the Taiwan National Health Insurance Research Database from 2000 to 2003.

RESULTS

An average total of 1,031,557 patients with mood and anxiety disorders were enrolled as study participants, including 76,430 cases of major depressive disorder, 41,557 cases of bipolar disorder, and 913,570 cases of anxiety disorder. When compared with the insured population without mood or anxiety disorders (average 21,356,304 people), the average relative risk (RR) of developing ischemic heart disease and hypertensive disorders in 1,031,557 study participants was 2.0 and 2.05, respectively. The highest RR was found in the age group under 20 years (RR = 4.74 and 4.08, respectively), and the lowest RR in the age group equal to or older than 65 years (RR = 0.47 and 0.58, respectively).

CONCLUSIONS

Taiwanese patients with mood and anxiety disorders experience high cardiovascular morbidity, especially patients with anxiety disorders. Age acted as an important modifier variable that influenced the relationship between mood, anxiety disorder and CVD. This study highlights the need for future research in different age groups, in order to elucidate the causality and the trajectory of developing CVD among patients with mental disorders.

Bipolar disorder in late life: clinical characteristics in a sample of older adults admitted for manic episode

BACKGROUND

Although manic episodes in older adults are not rare, little published data exist on late-life manic episodes. Resistance to treatment and concomitant neurological lesions are frequent correlates of elderly mania. The aim of this study was to investigate the prevalence of hospitalizations due to mania in patients older than 64 years through a period of 5 years in an Italian public psychiatric ward. Moreover, we aimed at describing clinical presentation of elderly manic episodes.

METHODS

A retrospective chart review was conducted in order to describe clinical presentation of 20 elderly patients hospitalized for manic episode; moreover, we compared age at onset, the presence of family history for mood disorders, psychosis and irritability between the elderly group and a matched group of 20 younger manic inpatients.

RESULTS

Seven percent of the whole inpatient elderly people suffered from mania. Half of those patients had a mood disorder age at onset after 50 years and 5 patients were at their first manic episode. Geriatric- and adulthood mania showed similar clinical presentation but younger people had more frequently a mood disorders family history.

CONCLUSION

Half of our older manic inpatients consisted of "classic" bipolar patients with an extension of clinical manifestations into later life; the other half of our sample was heterogeneous, even though it was not possible to identify clearly which patients may have had vascular lesions related to the onset of mania.

Late onset bipolar disorder associated with white matter hyperintensities: a pathophysiological hypothesis

Vascular depression is, nowadays, a well-established concept in the literature. However, the possible emergence of late onset bipolar disorder in subjects with no antecedents of mood disorder or after a chronic or recurrent course of unipolar depression constitutes a poorly studied issue, despite its importance in clinical practice. Here, we present the case of a 72-year-old female patient who began to present recurrent major depressive symptoms, resistant to pharmacological treatment, from the age of 58. Three years later, she started to present phases of mania with rapid cycling features. A brain MRI scan showed prominent white matter hyperintensities (WMH). WMH are frequently found in the elderly population, but with greater burden in individuals with hypertension and cerebrovascular disease. WMH impair cortical function and damage the cerebral tissue. WMH have been associated with adult-onset bipolar disorder and late onset depression, and are linked to a worse prognosis of both conditions. The present case report highlights the possibility that vascular-related WMH may provoke late onset bipolar disorder by damaging frontolimbic circuits implicated in the pathophysiology of mania.

Secondary mania of vascular origin in elderly patients: A report of two clinical cases

The concept of secondary mania continues to be debated together with unresolved or partially resolved issues such as lateralization, localization, age of onset, disinhibition syndromes, and others. We have described two patients with secondary mania following a stroke. One had a large left hemisphere cerebral infarction and the symptoms arose about 2.5 years later, possibly triggered by a transient ischemic attack involving the right hemisphere. The other had an infarction in the right posterior artery territory extending to the thalamus and internal capsule together with infarctions in the deep border zones of both hemispheres at the level of the centrum semiovale with the manic symptoms concomitant with the onset of the event. The clinical and neuro-anatomic mechanisms that underlie the diverse locations of secondary mania are discussed. The cerebral components of secondary mania and disinhibition syndromes are very similar and it is proposed that disinhibition syndromes, secondary hypomania and secondary mania with and without psychotic symptoms are simply a continuum of severity of mood disorder and secondary mania with psychotic symptoms may be an extreme form. The concept of secondary mania in the elderly is not likely to disappear although several unresolved issues remain. For the neurophysician, geriatrician, and the psychiatrist there is much to be attained by simplifying the issues and accepting the view that secondary mania is a discrete entity.

Effect of antidepressant use on admissions to hospital among elderly bipolar patients

OBJECTIVE

The goal of this study was to examine the association between antidepressant use and hospitalization rate for mania or bipolar depression in a large, community-based sample of elderly bipolar patients.

METHOD

Population-based retrospective cohort design. Administrative healthcare databases were linked for all individuals aged 66 years or older in the Province of Ontario, Canada. Bipolar subjects who received a prescription for an antidepressant medication (n = 1,072) between 1 April 1997 and 31 March 2001 comprised the antidepressant cohort. The control group (n = 3,000) consisted of randomly selected subjects from the eligible bipolar population who did not receive a prescription for an antidepressant medication during the same surveillance period. Primary outcomes were admission to hospital for a manic/mixed or depressive episode.

RESULTS

During a total of 5135 person-years of follow up, 113 admissions for a manic/mixed episode and 28 admissions for a depressive episode were identified. Model based estimates adjusted for a number of covariates revealed that, as compared with the control group, the antidepressant cohort had significantly lower likelihood of admissions for manic/mixed (adjusted rate ratio [aRR] = 0.5, 95% CI = 0.3-0.8) but not depressive episodes (aRR = 0.7, 95% CI = 0.2-2.2).

CONCLUSION

Antidepressant use among elderly bipolar patients was associated with decreased rates of hospitalization for manic/mixed episodes. This finding requires confirmation with further data of antidepressant use among elderly bipolars.

Medical comorbidity and health-related quality of life in bipolar disorder across the adult age span

BACKGROUND

Little is known about medical comorbidity or health-related quality of life (HRQOL) in bipolar disorder across the adult age span, especially in public sector patients.

METHODS

We obtained cross-sectional demographic, clinical, and functional ratings for 330 veterans hospitalized for bipolar disorder with Mini-Mental State score > or = 27 and without active alcohol/substance intoxication or withdrawal, who had had at least 2 prior psychiatric admissions in the last 5 years. Structured medical record review identified current/lifetime comorbid medical conditions. SF-36 Physical (PCS) and Mental (MCS) Component Scores, measured physical and mental HRQOL. Univariate and multivariate analyses addressed main hypotheses that physical and mental function decrease with age with decrements due to increasing medical comorbidity.

RESULTS

PCS decreased (worsened) with age; number of current comorbid medical diagnoses, but not age, explained the decline. Older individuals had higher (better) MCS, even without controlling for medical comorbidity. Multivariate analysis indicated association of MCS with age, current depressed/mixed episode, number of past-year depressive episodes, and current anxiety disorder, but not with medical comorbidity, number of past-year manic episodes, current substance disorder or lifetime comorbidities.

LIMITATIONS

This cross-sectional design studied a predominantly male hospitalized sample who qualified for and consented to subsequent randomized treatment.

CONCLUSIONS

Medical comorbidity is associated with lower (worse) physical HRQOL, independent of age. Surprisingly, younger rather than older subjects reported lower mental HRQOL. This appears due in part to more complex psychiatric presentations, and several mechanisms are discussed. Both results suggest that age-specific assessment and treatment may enhance HRQOL outcome.

Anticonvulsivantes e antipsicóticos no tratamento do transtorno bipolar

O transtorno bipolar é uma condição médica complexa e até o momento não há um tratamento único comprovadamente eficaz no controle de todos aspectos da doença. Foram revisadas a literatura disponível sobre o uso de anticonvulsivantes (valproato, carbamazepina, oxcarbazepina, lamotrigina, gabapentina, topiramato, clonazepam) e antipsicóticos atípicos (clozapina, risperidona, olanzapina, quetiapina, ziprasidona e aripiprazole) no tratamento agudo e profilático do transtorno bipolar. Existe um acúmulo de evidências acerca da eficácia do lítio na profilaxia e de ser melhor no tratamento da mania aguda do que nos episódios depressivos. Outros dados indicam que a carbamazepina e o valproato são eficazes na mania aguda. A lamotrigina parece reduzir ciclagem e ser eficaz em episódios depressivos. Baseado nas informações disponíveis, as evidências apontam a olanzapina como o antipsicótico atípico mais apropriado no tratamento de pacientes bipolares em mania, embora existam estudos sugerindo a eficácia da risperidona, aripiprazol e da clozapina. Resultados preliminares avaliando a eficácia de ziprasidona e quetiapina no transtorno bipolar ainda são bastante limitadas. Não há dados consistentes apoiando o uso profilático dos novos antipsicóticos.

Bipolar disorder in older adults: a critical review

OBJECTIVES

The goal of this article is to provide a comprehensive critical review of studies reporting the prevalence, features, age of onset, course, comorbidity, and neuropsychology of, as well as service utilization, in bipolar disorder in older age.

METHODS

We searched the Medline, Pubmed, and PsycINFO databases using combinations of the keywords 'Bipolar', 'Manic/a', 'Manic Depression', 'Elderly', and 'Older'. We included English-language reports presenting quantitative data on the prevalence and/or any descriptive information about adults with bipolar disorder over age 50. Findings from similar studies were pooled when possible. A total of 61 studies met our broad criteria.

RESULTS

Common methodological problems in the published studies included small sample sizes, retrospective chart review, lack of standardized measures, overemphasis on inpatients, and dearth of longitudinal data. Strong evidence indicates that bipolar disorder becomes less common with age, accounts for 8-10% of late life psychiatric admissions, is associated with neurologic factors in late-onset groups, and is a heterogeneous life-long illness. Weak or inconsistent evidence was found for a higher prevalence of mixed episodes in older adults, a lower treatment response, and the association with lower family history in late-onset groups. Minimal information is available on bipolar depression in late life.

CONCLUSIONS

Bipolar disorder in old age is a growing public health problem. Greater research on bipolar disorder in older people will assist in enhancing services to this group as well as inform research on bipolar disorder across the life span.

Depressive mixed state frequency: age/gender effects

Depressive mixed state (DMX), a major depressive episode (MDE) combined with few manic/hypomanic symptoms, is understudied. Age and gender are important variables in mood disorders. The aim of the present study was to determine whether age and gender had any effect on the frequency of DMX. Consecutive unipolar (n = 144) and bipolar II (n = 218) drug-free MDE out-patients were interviewed with the Structured Clinical Interview for DSM-IV when presenting for MDE treatment. The presence of hypomanic symptoms during the index MDE was assessed systematically. Depressive mixed state was defined as a MDE with three or more concurrent hypomanic symptoms (DMX3), following previous reports. Associations were tested by logistic regression. The results showed that the DMX3 frequency was 43.9% and that it affected more females than males. Frequency decreased with age. The lower frequency with age was related to the lower frequency of bipolar II disorder with age. Bipolar disorder family history of DMX3 patients did not change with age. In conclusion, the frequency of DMX3 was high and related to age. The high frequency of DMX3 supports the clinical usefulness of the definition, as well as observations that antidepressants may worsen its hypomanic symptoms, whereas antipsychotics and mood stabilisers may treat them. A bipolar vulnerability seems to be required for the appearance of DMX3 also in later life.

Lithium in bipolar disorder: can drug concentrations predict therapeutic effect?

The evidence is reviewed for effective serum lithium concentrations for the acute and prophylactic treatment of mania and depression in patients with bipolar disorder. The efficacy of lithium in the treatment of acute manic episodes has been recognised for several decades, primarily using concentrations in the range of 0.8 to 2 mmol/L. The number of patients responding increases as the serum lithium concentration increases, although individual patients may respond at lower concentrations (<0.8 mmol/L). Lithium doses and serum concentrations similar to those used to treat acute mania have been studied in bipolar depression, with no evaluation of a relationship between concentration and clinical response. Several prospective controlled trials have evaluated this relationship in the prophylactic treatment of bipolar disorder. Maintaining higher serum lithium concentrations (0.8 to 1 mmol/L) improves the likelihood of good effect in prophylactic treatment, although individual patients may do well on lower concentrations. Despite the paucity of evidence to specifically support the efficacy of lithium at lower serum lithium concentrations in the elderly, lower target ranges (0.5 to 0.8 mmol/L) are commonly recommended due to an increased sensitivity to adverse effects, particularly neurotoxicity. The serum lithium concentrations recommended in adults have been applied to children; however, this has not been studied. Overall, the evidence suggests a relationship between serum lithium concentration and therapeutic effect, although the exact nature of this relationship is not clear. For example, it is not known why some people respond to lower concentrations and others do not. There are many factors that influence studies trying to elucidate this relationship. Many of these factors are related to the interpretation of the serum lithium concentration. In summary, patients have an increased chance of responding to lithium if 12-hour serum lithium concentrations at steady state are above 0.8 mmol/L. Many patients will respond to lower concentrations (0.4 to 0.7 mmol/L), but we are unable to identify these patients a priori. The relationship between serum lithium concentrations and adverse effects is also very important in determining appropriate target lithium concentrations. The current best advice is to individualise the target serum lithium concentrations based on efficacy and tolerability and to optimise the interpretation of these concentrations by ensuring within-patient consistency with respect to dosage schedule, lithium preparation and the timing of blood sampling.

Assessment of late life depression

This article focuses on diagnostic and nosologic challenges intrinsic to geriatric depression, including characteristics interfering with symptom and syndrome ascertainment, the impact of medical and cognitive disorders, the usefulness of screening instruments, and barriers imposed by treatment settings. The article also identifies gaps in existing knowledge and outlines a research agenda. Nosologic characterization of depressives syndromes contributed by specific medical disorders may lead to effective strategies for prevention and treatment of depression. Studies need to examine whether treatment of depression can improve the outcome of medical illnesses requiring active patient involvement in treatment. Considering disability a distinct aspect of health status may add an important dimension to the assessment of depression and result in complementary interventions aimed at depression and disability concurrently. The provisional criteria for depression of Alzheimer's disease, if validated, may facilitate treatment research. Studies need to characterize cognitive dysfunctions associated with later development of dementia or poor treatment response in patients with depression. Care managers working together with primary care physicians can improve the recognition and treatment of depressed elderly patients by obtaining the training in using validated instruments and treatment algorithms.

Mania in neurologic disorders

Neurologic disorders can produce "secondary" mania. Clinicians must distinguish secondary mania from primary, idiopathic manic-depressive illness (MBI). In addition to medical and drug-induced causes of secondary mania, neurologic causes usually develop in older patients who may lack a strong family history of MDI. Neurologic causes of mania include focal strokes in the right basotemporal or inferofrontal region, strokes or tumors in the perihypothalamic region, Huntington's disease and other movement disorders, multiple sclerosis and other white matter diseases, head trauma, infections such as neurosyphilis and Creutzfeldt-Jakob disease, and frontotemporal dementia. Patients with new-onset mania require an evaluation that includes a thorough history, a neurologic examination, neuroimaging, and other selected tests. The management of patients with neurologic mania involving correcting the underlying disorder when possible and the judicious use of drugs such as the anticonvulsant medications.