Two-year course of cognitive function and instrumental activities of daily living in older adults with bipolar disorder: evidence for neuroprogression?

Psychiatric Disease as a Potential Risk Factor for Dementia: A Narrative Review

Neurodegenerative disease is a major global health problem with 150 million people predicted to have dementia by 2050. Genetic factors, environmental factors, demographics, and some diseases have been associated with dementia. In addition to associations between diseases such as hypertension and cerebrovascular disease and dementia, emerging findings associate some psychiatric disorders with incident dementia. Because of the high and increasing global prevalence of dementia and the high worldwide prevalence of psychiatric disorders, the primary objective of this narrative review was to evaluate published findings that evaluate the association between bipolar disorder, depression, anxiety, post-traumatic stress disorder, obsessive-compulsive disorder, attention-deficit/hyperactivity disorder, autism spectrum disorder, schizophrenia and other psychosis syndromes, and personality disorders and personality traits and incident dementia. Here, we highlight findings indicating possible associations between these psychiatric disorders and subsequent dementia and suggest that some psychiatric disorders may be risk factors for incident dementia. Further research, including more large longitudinal studies and additional meta-analyses, however, is needed to better characterize the associations between psychiatric disorders and incident dementia, to identify possible mechanisms for these putative associations, and to identify risk factors within psychiatric disorders that predispose some people with a psychiatric disorder but not others to subsequent dementia. Additional important questions concern how the treatment of psychiatric disorders might affect the risk of incident dementia.

A longitudinal study of cognition, functional outcome and quality of life in bipolar disorder and major depression

OBJECTIVE

Cognitive impairments are known to be a frequent cause of disability in bipolar disorder (BD) and major depression (MDD). Yet there is no consensus regarding the particular cognitive functions whose impairments can lead to disability in each domain of functioning. The aim of this study was to perform a longitudinal evaluation of working memory, inhibition, cognitive flexibility and attention in BD and MDD, investigate the relationship of these cognitive functions to disability and quality of life, and evaluate the impact of variables related to cognitive reserve (education and daily cognitive stimulation) on cognitive performance.

METHOD

31 participants (MDD = 12; BD = 19) were evaluated at baseline and after an average time of 2 years.

RESULTS

the BD group showed improvements in attention while patients with MDD improved on measures of attention and working memory. In BD working memory performance was associated with the cognition and mobility domains of functioning, and with physical and environmental quality of life. In MDD, cognitive flexibility was related to social relationships and environmental quality of life.

CONCLUSION

working memory and cognitive flexibility may be an interesting target for interventions aiming to improve everyday functioning and quality of life in BD and MDD.

Direct and Indirect Predictors of Medication Adherence With Bipolar Disorder: Path Analysis

BACKGROUND

Despite the efficacy of treatment and severity of symptoms, medication adherence by many with bipolar disorder (BD) is variable at best. This poses a significant challenge for BD care management.

OBJECTIVE

For this study, we set out to identify psychosocial and psychiatric predictors of medication adherence with BD.

METHODS

Using microtargeted social media advertising, we recruited an international sample of young and older adults with BD living in North America (Canada and the United States), Western Europe (eg, United Kingdom and Ireland), Australia and New Zealand (N=92). On average, participants were 55.35 (SD 9.65; range 22-73) years of age, had been diagnosed with BD 14.25 (SD 11.14; range 1-46) years ago, and were currently prescribed 2.40 (SD 1.28; range 0-6) psychotropic medications. Participants completed questionnaires online including the Morisky Medication Adherence Scale.

RESULTS

Medication adherence did not significantly differ across BD subtypes, country of residence, or prescription of lithium versus other mood stabilizers (eg, anticonvulsants). Path analyses indicate that alcohol misuse and subjective or perceived cognitive failures are direct predictors of medication adherence. BD symptoms, psychological well-being, and the number of comorbid psychiatric conditions emerged as indirect predictors of medication adherence via perceived cognitive failures.

CONCLUSIONS

Alcohol misuse did not predict perceived cognitive failures. Nor did age predict medication adherence or cognitive failures. This is noteworthy given the 51-year age range of participants. That is, persons in their 20s with BD reported similar levels of medication adherence and perceived cognitive failures as those in their 60s. This suggests that perceived cognitive loss is a facet of adult life with BD, in contrast to the assumption that accelerated cognitive aging with BD begins in midlife.

Illness progression in older-age bipolar disorder: Exploring the applicability, dispersion, concordance, and associated clinical markers of two staging models for bipolar disorder in an older population

OBJECTIVES

The validity and applicability of two existing staging models reflecting illness progression have been studied in bipolar disorder (BD) in adults, but not in older adult populations. Staging model A is primarily defined by the number and recurrence of mood episodes, model B is defined by the level of inter-episodic functioning. This study aimed to explore the applicability, dispersion, and concordance of, and associations with clinical markers in these two staging models in older-age bipolar disorder (OABD).

METHODS

Using cross-sectional data from the Dutch Older Bipolars study, OABD outpatients (N = 126, ≥50 years) were staged using models A and B. Dispersion over the stages and concordance between the models were assessed. Associations were explored between model stages and clinical markers (familial loading, childhood abuse, illness duration, episode density, treatment resistance, Mini-Mental State Examination, and composite cognitive score).

RESULTS

Ninety subjects could be assigned to model A, 111 to model B, 80 cases to both. The majority (61%) had multiple relapses (model A, stage 3C) but were living independently (model B, stage I-III). Concordance between models was low. For model A, the markers childhood abuse, illness duration, and episode density significantly increased over subsequent stages. Model B was not associated with a significant change in any marker.

CONCLUSIONS

Assigning stages to OABD subjects was possible for both models, with age-related adjustments for model B. Model B as currently operationalized may be less suitable for OABD or may measure different aspects of illness progression, reflected by its low correspondence with model A and lack of associated clinical markers.

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.

Systematic evaluation of the associations between mental disorders and dementia: An umbrella review of systematic reviews and meta-analyses

BACKGROUND

Increasing evidence support the correlation between mental disorders and the likelihood of developing dementia. We aim to conduct an umbrella review to assess the risk of dementia in patients with eight mental disorders.

METHODS

We searched PubMed, Embase, Web of science, CNKI, VIP, and Wanfang databases from inception to October 29, 2021. For each included meta-analysis, the effect size with a 95% confidence interval was estimated using either a random effect model or a fixed effect model, and between-study heterogeneity was expressed by I² and Cochran's Q test. The ROBIS tool was used to assess the risk of bias.

RESULTS

A total of ten systematic reviews were included. Among these studies, we identified seven risk factors, including anxiety disorder, bipolar disorder, depression, late-life depression, post-traumatic stress disorder, schizophrenia, and sleep disorder. Light to moderate alcohol drinking was identified as a protective factor. The evaluation results of the ROBIS tool showed that nine systematic reviews had high risk of bias and one had low risk of bias. The strength of evidence supporting the associations between late-life depression and all-cause dementia, Alzheimer's disease, and vascular dementia was high; the strength of evidence supporting the association between depression and all-cause dementia was moderate.

LIMITATIONS

Most associations had low strength of evidence and high risk of bias.

CONCLUSIONS

This umbrella review shows that high and moderate evidence supports the associations between some mental disorders and dementia. More cohort studies are needed to support the associations between mental disorders and dementia.

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.

Evaluating a Low-Cost Technology to Enable People with Intellectual Disability or Psychiatric Disorders to Initiate and Perform Functional Daily Activities

People with intellectual disability or psychiatric disorders and cognitive dysfunctions may need assistive technology to maintain and improve their levels of functioning and independence. This study assessed a smartphone-based system to remind the user to initiate functional daily activities (e.g., setting a table for lunch) and perform them without the support of a caregiver. The system was evaluated through a non-concurrent multiple baseline design across two groups of participants. During the intervention sessions, the participants were provided with a system involving a Samsung Galaxy A3 smartphone fitted with the Easy Alarm YouTube application and audio files. The alarm served to remind the participant to carry out a planned activity. Following the reminder, the smartphone presented each of the step instructions preset for the activity. The data showed a statistically significant increase in the number of activities initiated independently from baseline to intervention for all participants. All participants also showed a significant increase in the number of activity steps correctly performed when supported by the smartphone. These results suggest that a low-cost system (i.e., smartphone) can be used to improve independence of people with intellectual disability or psychiatric disorders with cognitive dysfunctions.

The Heterogeneity of Longitudinal Cognitive Decline in Euthymic Bipolar I Disorder With Clinical Characteristics and Functional Outcomes

We characterized the heterogeneity and risk factors of cognitive decline in euthymic bipolar disorder (BD), and their magnitude of associations with subjective daily functions. In this retrospective cohort, BD type I patients (N = 128) were followed for an average of 6.5 years. Intelligence quotient (IQ) at index date was recorded, and premorbid IQ was estimated. We used Brief Assessment of Cognition in Affective Disorders (BAC-A) to assess cognition at follow-up. We evaluated current functions with World Health Organization Disability Assessment Schedule 2.0. Clinical and sociodemographic factors were examined for their independent effects on longitudinal cognitive decline. In addition, we employed multivariate adaptive regression spline to detect inflection points for the nature of slope changes in cognitive decline among BD patients. During follow-up years, 21 BD patients (16.4%) showed longitudinal cognitive decline. In cognitive decline group, all cognitive domains of BAC-A were significantly worsened. We found that density of episodes with psychotic features was an independent risk factor for cognitive decline after adjusted for age, gender and dose of mood stabilizer. After the age of 42 years, a steeper cognitive change was observed in the cognitive decline group. The correlation pattern between cognitive domains and functional outcomes differed between patients with and without cognitive decline. The present study characterized cognitive heterogeneity longitudinally in BD patients. As density of episodes play roles for cognitive decline, our results emphasize the importance of relapse prevention. Our findings provide hints for future personalized interventions and facilitating genetic and biological studies for dissecting the heterogeneity of bipolar illness.

Long-term trajectory of cognitive performance in people with bipolar disorder and controls: 6-year longitudinal study

BACKGROUND

Cross-sectional studies have found impaired cognitive functioning in patients with bipolar disorder, but long-term longitudinal studies are scarce.

AIMS

The aims of this study were to examine the 6-year longitudinal course of cognitive functioning in patients with bipolar disorder and healthy controls. Subsets of patients were examined to investigate possible differences in cognitive trajectories.

METHOD

Patients with bipolar I disorder (n = 44) or bipolar II disorder (n = 28) and healthy controls (n = 59) were tested with a comprehensive cognitive test battery at baseline and retested after 6 years. We conducted repeated measures ANCOVAs with group as a between-subject factor and tested the significance of group and time interaction.

RESULTS

By and large, the change in cognitive functioning between baseline and follow-up did not differ significantly between participants with bipolar disorder and healthy controls. Comparing subsets of patients, for example those with bipolar I and II disorder and those with and without manic episodes during follow-up, did not reveal subgroups more vulnerable to cognitive decline.

CONCLUSIONS

Cognitive performance remained stable in patients with bipolar disorder over a 6-year period and evolved similarly to healthy controls. These findings argue against the notion of a general progressive decline in cognitive functioning in bipolar disorder.

Older Age Bipolar Disorder

Further understanding of older age bipolar disorder (OABD) may lead to more specific recommendations for treatment adjusted to the specific characteristics and needs caused by age-related somatic and cognitive changes. Late-onset mania has a broad differential diagnosis and requires full psychiatric and somatic work-up, including brain imaging. Research on pharmacotherapy in OABD is limited. First-line treatment of OABD is similar to that for adult bipolar disorder (BD), with specific attention to vulnerability to side effects and somatic comorbidity. Because findings in younger adults with BD cannot be extrapolated to OABD, more research in OABD is warranted.

Cognitive Trajectories in Comorbid Dementia With Schizophrenia or Bipolar Disorder: The South London and Maudsley NHS Foundation Trust Biomedical Research Centre (SLaM BRC) Case Register

OBJECTIVES

We aimed to compare trajectories of cognitive performance in individuals diagnosed with dementia with and without severe mental illness (SMI).

DESIGN

Retrospective cohort study.

SETTING

We used data from a large longitudinal mental healthcare case register, the Clinical Record Interactive Search (CRIS), at the South London and Maudsley NHS Foundation Trust (SLaM) which provides mental health services to four south London boroughs.

PARTICIPANTS

Our sample (N = 4718) consisted of any individual who had a primary or secondary diagnosis of dementia from 2007 to 2018, was 50 years old or over at first diagnosis of dementia and had at least 3 recorded Mini-Mental State Examination (MMSE) scores.

MEASUREMENTS

Cognitive performance was measured using MMSE. Linear mixed models were fitted to explore whether MMSE trajectories differed between individuals with or without prior/current SMI diagnoses. Models were adjusted by socio-demographics, cardiovascular risk, smoking, and medication.

RESULTS AND CONCLUSIONS

Our results showed differences in the rate of change, where individuals with comorbid SMI had a faster decline when compared with those that have dementia without comorbid SMI. However, this association was partially attenuated when adjusted by socio-demographics, smoking and cardiovascular risk factors; and more substantially attenuated when medication was included in models. Additional analyses showed that this accelerated decline might be more evident in individuals with bipolar disorders. Future research to detangle the potential biological underlying mechanisms of these associations is needed.

Neuroprogression as an Illness Trajectory in Bipolar Disorder: A Selective Review of the Current Literature

Bipolar disorder (BD) is a chronic and disabling psychiatric condition that is linked to significant disability and psychosocial impairment. Although current neuropsychological, molecular, and neuroimaging evidence support the existence of neuroprogression and its effects on the course and outcome of this condition, whether and to what extent neuroprogressive changes may impact the illness trajectory is still poorly understood. Thus, this selective review was aimed toward comprehensively and critically investigating the link between BD and neurodegeneration based on the currently available evidence. According to the most relevant findings of the present review, most of the existing neuropsychological, neuroimaging, and molecular evidence demonstrates the existence of neuroprogression, at least in a subgroup of BD patients. These studies mainly focused on the most relevant effects of neuroprogression on the course and outcome of BD. The main implications of this assumption are discussed in light of specific shortcomings/limitations, such as the inability to carry out a meta-analysis, the inclusion of studies with small sample sizes, retrospective study designs, and different longitudinal investigations at various time points.

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.

Increased Risk of Dementia Among Veterans With Bipolar Disorder or Schizophrenia Receiving Care in the VA Health System

OBJECTIVE

The Veterans Health Administration (VHA) provides a continuum of care over the life course. Among U.S. adults, bipolar disorder and schizophrenia are associated with increased risk of dementia. To inform service planning, this study assessed the incidence of dementia among veteran VHA patients with bipolar disorder or schizophrenia, with adjustment for comorbid medical conditions.

METHODS

Using data from the VHA Corporate Data Warehouse, the authors identified all veterans who received VHA care in 2004 and 2005 without a dementia diagnosis and who were alive and between ages 18 and 100 as of January 1, 2006. Individuals were categorized as having bipolar disorder, schizophrenia, or neither condition on the basis of diagnoses in 2004-2005. Among ongoing VHA users, incidence of dementia was assessed for up to 10 years (2006-2015).

RESULTS

The cohort included 3,648,852 individuals. After analyses controlled for baseline comorbid general medical conditions and substance use disorders, the incidence rate ratios (IRRs) for dementia were 2.92 for those with schizophrenia and 2.26 for those with bipolar disorder, compared with VHA patients with neither condition.

CONCLUSIONS

Among veterans receiving VHA care, diagnoses of bipolar disorder and schizophrenia were each associated with increased risk of receiving a new diagnosis of dementia, even when analyses controlled for baseline medical comorbidities. IRRs were elevated for patients with either condition, compared with those with neither condition, and highest for those with schizophrenia. VHA clinicians should evaluate patients for dementia when signs or symptoms of cognitive impairment are present.

Risk of dementia in bipolar disorder and the interplay of lithium: a systematic review and meta-analyses

OBJECTIVES

To assess whether bipolar disorder (BD) increases the rate of dementia and whether lithium is related to a lower risk of dementia in BD.

METHODS

A total of 10 studies (6859 BD; 487 966 controls) were included in the meta-analysis to test whether BD is a risk factor for dementia. In addition, five studies (6483 lithium; 43 496 non-lithium) were included in the meta-analysis about the potential protective effect of lithium in BD.

RESULTS

BD increases the risk of dementia (odds ratio (OR): 2.96 [95% CI: 2.09-4.18], P < 0.001), and treatment with lithium decreases the risk of dementia in BD (OR: 0.51 [95% CI: 0.36-0.72], P < 0.0001). In addition, secondary findings from our systematic review showed that the risk of progression to dementia is higher in BD than in major depressive disorder (MDD). Moreover, the number of mood episodes predicted the development of dementia in BD.

CONCLUSION

Individuals with BD are at higher risk of dementia than both the general population or those with MDD. Lithium appears to reduce the risk of developing dementia in BD.

Clozapine in bipolar disorder: A systematic review and meta-analysis

OBJECTIVES

To assess the clinical efficacy of clozapine in bipolar disorder and its adverse effect profile.

METHODS

A literature search with no year and no language restriction was conducted. The search yielded 3858 articles, with 2453 remaining after duplicate removal; 9 were suitable for the systematic review. From the 9 included studies, 3 (100 patients treated with clozapine and 102 patients treated with other antipsychotics) could be included in a meta-analysis to test clozapine efficacy in the treatment of manic episodes.

RESULTS

Clozapine's efficacy was similar to other antipsychotics (Mean difference (MD): 0.03 [95%CI: 0.86-0.92], p = 0.59) in manic episodes. The systematic review also suggested that clozapine is faster at improving symptoms in manic episodes. In addition, two studies included patients with treatment resistant bipolar disorder (TRBD) and showed that clozapine is superior to other treatments for this specific population. Sedation was the most frequent side effect (49.6%), followed by constipation (31.8%) and tachycardia (23.2%).

CONCLUSION

Clozapine's efficacy was similar to other antipsychotics in manic episodes and is superior to other antipsychotics among TRBD patients.

Longitudinal analysis of cognitive performances in recent-onset and late-life Bipolar Disorder: A systematic review and meta-analysis

OBJECTIVES

Neurocognitive deficits have been widely reported in euthymic Bipolar Disorder (BD) patients and contribute to functional disability. However, the longitudinal trajectory of these deficits remains a subject of debate. Although most research to this date shows that neurocognitive deficits tend to be stable among middle-age BD patients, it remains plausible that deterioration occurs at either early or late stages of this condition.

METHODS

We conducted a comprehensive meta-analysis of studies that reported longitudinal neurocognitive performance among individuals with BD either within the year of their diagnosis or among late-life BD patients. Pooled effects of standardized mean differences (SMDs) for changes in neuropsychological scores over follow-up were estimated using random effects model. We also examined effect moderators, such as length of follow-up, mood state, or pharmacological load.

RESULTS

Eight studies met inclusion criteria for recent-onset and four studies for late-life BD analysis. No evidence for a deterioration in neurocognitive functioning was observed among recent-onset BD patients (8 studies, 284 patients, SMD: 0.12, 95% CI -0.06 to 0.30, mean follow-up: 17 months) nor for late-life BD patients (4 studies, 153 patients, SMD: -0.35, 95% CI -0.84 to 0.15, mean follow-up: 33 months). None of the moderators were shown to be significant.

CONCLUSIONS

These results, when appraised together with the findings in middle-life BD patients and individuals at genetic risk for BD, suggest that neurodevelopmental factors might play a significant role in cognitive deficits in BD and do not support the notion of progressive cognitive decline in most patients with BD.

Cognitive impairment in late life bipolar disorder: Risk factors and clinical outcomes

BACKGROUND

Late Life Bipolar Disorder (LLBD) is associated with a high prevalence of cognitive impairments, but few studies have examined their risk factors and clinical correlates METHODS: Participants with bipolar disorder older than 60 (n = 86) were recruited from psychiatric outpatient and inpatients units. Patients were assessed with various instruments, including the Clinical Dementia Rating scale, the Montreal Cognitive Assessment and the Cumulative Illness Rating Scale. The distribution of disorder-specific and general risk factors was compared between patients with LLBD plus cognitive impairments (mild cognitive impairment or dementia) and those with LLBD but no cognitive impairment. Analyses were first conducted at the bivariate level, then using multiple regression. The association with disability, aggressive behavior and suicidal ideation was also explored.

RESULTS

Cognitive impairments in LLBD were associated with a diagnosis of type 1 bipolar disorder (OR = 6.40, 95%CI: 1.84 - 22.31, p = 0.004), fewer years of education (OR = 0.79, 95%CI: 0.69 - 0.91, p = 0.001) and higher severity of physical diseases (OR 26.54, 95%CI: 2.07 - 340.37, p = 0.01). Moreover, cognitive impairments were associated with an increased likelihood of disability and recent aggressive behavior, but not suicidal ideation.

LIMITATIONS

retrospective design, conflation of MCI and dementia, not all subjects were in euthymia CONCLUSIONS: In LLBD, the presence of cognitive impairments was associated with a diagnosis of type I bipolar disorder, lower education and more severe physical comorbidities. In turn, MCI or dementia were associated with increased disability and aggressive behavior. These findings may aid the identification of patients at risk for cognitive deterioration in everyday clinical practice.

Impact of number of episodes on neurocognitive trajectory in bipolar disorder patients: a 5-year follow-up study

BACKGROUND

The neurocognitive trajectory in bipolar disorder (BD) is variable, with controversial findings, and most evidence come from cross-sectional studies. We aimed to examine the course of neurocognitive functioning in a sample of euthymic BD patients in comparison with a control group during a 5-year follow-up.

METHODS

Ninety-nine euthymic bipolar patients and 40 healthy controls were assessed using a comprehensive neurocognitive battery (six neurocognitive domains) at baseline (T1) and then at 5-year follow-up (T2) in a longitudinal study.

RESULTS

No evidence of a progression in neurocognitive dysfunction was found either in cognitive composite index or in any of the neurocognitive domains for the whole cohort. However, there was a negative correlation between number of manic episodes and hospitalisations due to manic episodes and change in neurocognitive composite index (NCI) during the follow-up. Moreover, patients with higher number of manic and hypomanic episodes have a greater decrease in NCI, working memory and visual memory. History of psychotic symptoms was not related to the trajectory of neurocognitive impairment.

CONCLUSIONS

Our results suggest that, although the progression of cognitive decline is not a general rule in BD, BD patients who have a greater number of manic or hypomanic episodes may constitute a subgroup characterised by the progression of neurocognitive impairment. Prevention of manic and hypomanic episodes could have a positive impact on the trajectory of cognitive function.

Steeper aging-related declines in cognitive control processes among adults with bipolar disorders

BACKGROUND

Little is known about the specificity of executive functioning (EF) decline in older adults with bipolar disorders (OABD), or the impact of bipolar disorders (BD) on the timing and slope of age-related declines in EF processes implicated in both BD etiology and normative aging-cognitive control (CC). This cross-sectional study investigated age-related CC decline in BD.

METHODS

Participants were 43 adults with BD (M age = 61.5, SD = 15.8; 86% male) and 45 Controls (M age = 65.2, SD = 12.2; 98% male). Two-way ANOVAs examined the effects of median-age-split and diagnostic groups on cognitive processes with established BD deficits-CC processes (mental flexibility and response inhibition), verbal learning, and verbal fluency.

RESULTS

The median-split-age-by-diagnostic-group interaction was significant for mental flexibility; OABD performed significantly worse than younger adults with BD and younger and older Controls. Exploratory multivariate adaptive regression spline characterized non-linear nature of aging-slope changes in mental flexibility for each diagnostic group, yielding an inflection point at older age and steeper subsequent decline in OABD versus Controls.

LIMITATIONS

This study is limited by a small sample (particularly for select neuropsychological measures) of mostly Caucasian men and BD diagnoses based on clinical interview and medical records review.

CONCLUSIONS

Compared to healthy older adults, OABD showed steeper age-related decline in mental flexibility-select EF processes that depend on the integrity of the CC system. Preliminary evidence links CC integrity to daily functioning in OABD; accelerated aging decline in CC may pose a mechanism for high risk of functional impairment and dementia in OABD.

Statins and cognition in late-life bipolar disorder

OBJECTIVES

Recent data suggests that statins have positive effects on cognition in older adults. Studies in patients with mood disorders have found contradicting positive and negative effects of statins on mood and cognition, with limited data in bipolar disorder (BD). The objective of this study was to assess the association between statin use and cognition in older adults with BD.

METHODS

In a cross-sectional sample of 143 euthymic older adults with BD (age ≥ 50), statin users (n = 48) and nonusers (n = 95) were compared for cognitive outcomes: Global and cognitive domain z-scores were calculated from detailed neuropsychological batteries using normative data from healthy comparators (n = 87).

RESULTS

The sample had a mean age of 64.3 (±8.9) years, 65.0% were female, with an average of 15.1 (±2.79) years of education. Statin users did not differ from nonusers on global (-0.60 [±0.69] vs -0.49 [±0.68], t[127] = 0.80, P = .42) or individual cognitive domains z-score.

CONCLUSIONS

In older patients with BD, statin use is not independently associated with cognitive impairment. This suggests that in older BD patients, the cognitive dysfunction associated with BD trumps the potential cognitive benefit that is associated with statins in older adults without a psychiatric disorder. Further, statins do not seem to exacerbate this cognitive dysfunction. Future longitudinal studies are needed to confirm these findings.

Measurement tools for assessment of older age bipolar disorder: A systematic review of the recent global literature

OBJECTIVES

More than 50% of people with bipolar disorder will be age 60 years or older by 2030. There is a need for more data to guide assessment and treatment in older age bipolar disorder (OABD); however, interpretation of findings from small, single-site studies may not be generalizable and there are few large trials. As a step in the direction of coordinated large-scale OABD data collection, it is critical to identify which measurements are currently used and identify potential gaps in domains typically assessed.

METHODS

An international group of OABD experts performed a systematic literature review to identify studies examining OABD in the past 6 years. Relevant articles were assessed to categorize the types of clinical, cognitive, biomarker, and neuroimaging OABD tools routinely used in OABD studies.

RESULTS

A total of 53 papers were identified, with a broad range of assessments. Most studies evaluated demographic and clinical domains, with fewer studies assessing cognition. There are relatively few biomarker and neuroimaging data, and data collection methods were less comprehensively covered.

CONCLUSION

Assessment tools used in the recent OABD literature may help to identify both a minimum and a comprehensive dataset that should be evaluated in OABD. Our review also highlights gaps where key clinical outcomes have not been routinely assessed. Biomarker and neuroimaging assessment could be further developed and standardized. Clinical data could be combined with neuroimaging, genetic, and other biomarkers in large-scale coordinated data collection to further improve our understanding of OABD phenomenology and biology, thereby contributing to research that advances care.

Psychometric validation of the Geriatric Suicide Ideation Scale (GSIS) among older adults with bipolar disorder

OBJECTIVES

Across age groups, bipolar disorder (BD) carries the greatest risk of death by suicide of all psychiatric conditions; 25%-50% of those with BD will make one or more suicide attempt. Psychometrically sound instruments are required to reliably measure suicide ideation and risk of self-harm for older adults with BD. For this study, we validate the geriatric suicide ideation scale (GSIS) with adults 50+ years with BD.

METHODS

We recruited a global sample of 220 older adults with BD (M = 58.50 years of age) over 19 days using socio-demographically targeted, social media advertising and online data collection. To demonstrate the construct validation of GSIS responses by older adults with BD, we computed correlations and performed regression analyses to identify predictors of suicide ideation.

RESULTS

Our analyses support a four-factor model of responses to the GSIS (ideation, death ideation, loss of personal and social worth, and perceived meaning in life) measuring a higher order latent construct. Older adults with BD reporting low satisfaction with life and current depressive symptoms, and who misuse alcohol, report significantly higher levels of suicide ideation. Sleep quality and cognitive failures are also correlated with GSIS responses.

CONCLUSIONS

Results support the factorial validity of the GSIS with older adults with BD. Similar to other populations, the GSIS measures a four-factor structure of suicide ideation. Across BD subtypes, the GSIS appears to reliably measure suicide ideation among older adults with BD.

Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) 2018 guidelines for the management of patients with bipolar disorder

The Canadian Network for Mood and Anxiety Treatments (CANMAT) previously published treatment guidelines for bipolar disorder in 2005, along with international commentaries and subsequent updates in 2007, 2009, and 2013. The last two updates were published in collaboration with the International Society for Bipolar Disorders (ISBD). These 2018 CANMAT and ISBD Bipolar Treatment Guidelines represent the significant advances in the field since the last full edition was published in 2005, including updates to diagnosis and management as well as new research into pharmacological and psychological treatments. These advances have been translated into clear and easy to use recommendations for first, second, and third- line treatments, with consideration given to levels of evidence for efficacy, clinical support based on experience, and consensus ratings of safety, tolerability, and treatment-emergent switch risk. New to these guidelines, hierarchical rankings were created for first and second- line treatments recommended for acute mania, acute depression, and maintenance treatment in bipolar I disorder. Created by considering the impact of each treatment across all phases of illness, this hierarchy will further assist clinicians in making evidence-based treatment decisions. Lithium, quetiapine, divalproex, asenapine, aripiprazole, paliperidone, risperidone, and cariprazine alone or in combination are recommended as first-line treatments for acute mania. First-line options for bipolar I depression include quetiapine, lurasidone plus lithium or divalproex, lithium, lamotrigine, lurasidone, or adjunctive lamotrigine. While medications that have been shown to be effective for the acute phase should generally be continued for the maintenance phase in bipolar I disorder, there are some exceptions (such as with antidepressants); and available data suggest that lithium, quetiapine, divalproex, lamotrigine, asenapine, and aripiprazole monotherapy or combination treatments should be considered first-line for those initiating or switching treatment during the maintenance phase. In addition to addressing issues in bipolar I disorder, these guidelines also provide an overview of, and recommendations for, clinical management of bipolar II disorder, as well as advice on specific populations, such as women at various stages of the reproductive cycle, children and adolescents, and older adults. There are also discussions on the impact of specific psychiatric and medical comorbidities such as substance use, anxiety, and metabolic disorders. Finally, an overview of issues related to safety and monitoring is provided. The CANMAT and ISBD groups hope that these guidelines become a valuable tool for practitioners across the globe.

Allostatic load but not medical burden predicts memory performance in late-life bipolar disorder

OBJECTIVE

Older patients with bipolar disorder (BD) present with variable degrees of cognitive impairment. Over time, stress, mood episodes, and comorbidities increase the body's allostatic load. We assessed the extent to which allostatic load vs more traditional measures of medical burden account for the heterogeneity in cognition in this population.

METHODS

Thirty-five older euthymic patients with BD and 30 age-equated, gender-equated, and education-equated comparison participants were administered a comprehensive assessment including a neuropsychological battery, and 9 physiological measures to determine allostatic load. The relationship among allostatic load, medical burden, and cognition was assessed.

RESULTS

Compared with the mentally healthy comparators, patients were impaired globally, and in 4 cognitive domains-information-processing speed / executive functioning, delayed memory, language, and visuomotor ability, and presented with greater medical burden but not a different allostatic load. Allostatic load, but not medical burden, was associated with delayed memory performance both in a correlational analysis and in a multivariate regression analysis.

CONCLUSION

Euthymic older patients with BD are impaired on several cognitive domains and have high medical burden. Their memory performance is more strongly associated with allostatic load than with traditional measures of medical burden. These findings need to be replicated and extended longitudinally.

Older Age Bipolar Disorder

Further understanding of older age bipolar disorder (OABD) may lead to more specific recommendations for treatment adjusted to the specific characteristics and needs caused by age-related somatic and cognitive changes. Late-onset mania has a broad differential diagnosis and requires full psychiatric and somatic work-up, including brain imaging. Research on pharmacotherapy in OABD is limited. First-line treatment of OABD is similar to that for adult bipolar disorder (BD), with specific attention to vulnerability to side effects and somatic comorbidity. Because findings in younger adults with BD cannot be extrapolated to OABD, more research in OABD is warranted.

Assessing bipolar disorder in the older adult: the GERI-BD toolbox

INTRODUCTION

The evidence base regarding characteristics of older adults with bipolar disorder (BD) remains limited. The NIH-funded multicenter study Acute Pharmacotherapy of Late-Life Mania (GERI-BD) assessed various clinical domains before and during mood stabilizer treatment in older adults participating in a 9-week, double-blind randomized controlled trial. We describe the rationale for selecting these instruments.

METHODS

Domains and instruments were selected on the basis of the study design and the participants. The investigators' experience in clinical trials involving young adults with BD or older adults with major depressive disorder, along with open studies of older adults with BD, contributed to the selection process.

RESULTS

We identified domains and selected instruments that could be used to assess the participants given their diagnostic, treatment history, and medical and mood state characteristics. They were also intended to measure tolerability and efficacy and permit examination of potential moderating and mediating factors.

CONCLUSIONS

Decisions regarding the assessment domains to be included in the clinical trial highlight the challenges facing researchers studying drug treatments for older adults with BD, or more generally, mood disorders. We suggest that the domains and instruments selected by GERI-BD investigators constitute a "toolbox" that can be customized for other investigators. Copyright © 2017 John Wiley & Sons, Ltd.

Meta-analysis of longitudinal studies of cognition in bipolar disorder: comparison with healthy controls and schizophrenia

BACKGROUND

Bipolar disorder (BP) is associated with significant cognitive impairment. Recent evidence suggests that cognitive deficits are already evident after first-episode mania. However, it is not clear whether BP is associated with further decline in cognitive functions in individuals with established illness. Aim of this meta-analytic review was to examine longitudinal neurocognitive changes in BP and to compare trajectory of cognitive deficits in BP with schizophrenia and healthy controls.

METHODS

Electronic databases were searched for the studies published between January 1987 and November 2016. In total 22 reports were included in the current meta-analysis. The main analysis assessed the longitudinal change in cognition in 643 patients with BP. Further analyses were conducted in studies investigating cognitive changes in BP along with healthy controls (459 BP and 367 healthy controls) and schizophrenia (172 BP and 168 schizophrenia).

RESULTS

There was no cognitive decline overtime neither in short-term (mean duration = 1.5 years) nor in long-term (mean duration = 5.5 years) follow-up studies in BP. In contrast, there was evidence for modest improvements in task performance in memory and working memory at follow-up. The trajectory of cognitive functioning in BP was not significantly different from changes in schizophrenia and healthy controls.

CONCLUSIONS

Together with the findings in early BP and individuals at genetic risk for BP, current findings suggest that neurodevelopmental factors might play a significant role in cognitive deficits in BP and do not support the notion of progressive cognitive decline in most patients with BP.

Predictors of suicide ideation among older adults with bipolar disorder

OBJECTIVES

Bipolar disorder (BD) carries the greatest risk of death by suicide of all psychiatric conditions as 25%-50% of those with BD will make one or more suicide attempt, and about 15% will intentionally end their lives. Among young adults with BD, substance misuse, medication non-adherence, age at onset, and comorbid psychiatric conditions each predict self-harm. It is currently unclear if these same factors or others predict suicide ideation among older adults with BD.

METHODS

We recruited a global sample of 220 older adults with BD over 19 days using socio-demographically targeted, social media advertising and online data collection (Mean = 58.50, SD = 5.42; range 50 to 81 years). Path analyses allowed us to identify direct and indirect predictors of suicide ideation among older adults with BD.

RESULTS

Cognitive failures (perception, memory, and motor function), depressive symptoms, alcohol misuse, and dissatisfaction with life as direct predictors of suicide ideation; duration of BD symptoms and medication non-adherence emerged as indirect predictors. Of note, the significant impact of sleep on suicide ideation is indirect via depressive symptoms, cognitive failures, medication non-adherence and life dissatisfaction.

CONCLUSIONS

As with young adults with BD, alcohol misuse and medication non-adherence emerged as significant predictors of suicide ideation. In addition, cognitive failures directly and indirectly predict suicide ideation in this sample of older adults with BD. Population aging and treatment efficacy are leading to ever growing numbers of older adults with BD. Both direct and indirect predictors of suicide ideation need to be considered in future BD research and treatment planning.

Caregiver burden in older adults with bipolar disorder: relationship to functionality and neuropsychiatric symptoms

BACKGROUND

There are few studies addressing caregivers of bipolar disorder (BD) patients, especially patients who are older adults with an increased need for care, often given by a relative. The aim of this study was to describe which factors increase caregiver burden among caregivers of elderly BD outpatients.

METHODS

Patients were older than 60 years and met the Diagnostic and Statistical Manual of Mental Disorders, fifth edition, criteria for BD. They were evaluated for current mood, cognitive and other neuropsychiatric symptoms, functionality, medical comorbidities, quality of life, years since BD diagnosis, and number of psychiatric admissions. The caregiver who spent the greatest time with each patient was evaluated with the Zarit Caregiver Burden Interview. The caregivers' global health, mood symptoms, quality of life, and tasks performed for the patient were also assessed.

RESULTS

Thirty-six BD patients and their caregivers were assessed. The Zarit Caregiver Burden Interview was positively correlated with patients' neuropsychiatric symptoms (r = 0.508, P = 0.002) and functional impairment (r = 0.466, P = 0.004). The Zarit Caregiver Burden Interview was also correlated with caregivers' own depression (r = 0.576, P < 0.001), anxiety (r = 0.360, P = 0.031), quality of life (r = -0.406, P = 0.014), medical comorbidities (r = 0.387, P = 0.020), and number of tasks that they completed for the patient (r = 0.480, P = 0.003).

CONCLUSIONS

In this group of elderly BD patients, caregiver burden was more associated with symptoms frequently seen in others diseases as in dementia than with depressive, manic, or anxiety symptoms, which are often used as treatment outcomes measures goals in BD. Potential treatable and modifiable factors associated with caregiver burden could be caregivers' depression, anxiety, and medical comorbidities, as well as support for caregivers in terms of services and social relationships.

Accuracy statistics in predicting Independent Activities of Daily Living (IADL) capacity with comprehensive and brief neuropsychological test batteries

This investigation was designed to determine the predictive accuracy of a comprehensive neuropsychological and brief neuropsychological test battery with regard to the capacity to perform instrumental activities of daily living (IADLs). Accuracy statistics that included measures of sensitivity, specificity, positive and negative predicted power and positive likelihood ratio were calculated for both types of batteries. The sample was drawn from a general neurological group of adults (n = 117) that included a number of older participants (age >55; n = 38). Standardized neuropsychological assessments were administered to all participants and were comprised of the Halstead Reitan Battery and portions of the Wechsler Adult Intelligence Scale-III. A comprehensive test battery yielded a moderate increase over base-rate in predictive accuracy that generalized to older individuals. There was only limited support for using a brief battery, for although sensitivity was high, specificity was low. We found that a comprehensive neuropsychological test battery provided good classification accuracy for predicting IADL capacity.

History of Bipolar Disorder and the Risk of Dementia: A Systematic Review and Meta-Analysis

OBJECTIVE

We carried out a systematic review and meta-analysis to evaluate whether history of bipolar disorder (BD) increases the risk of dementia.

METHODS

We searched PubMed and Scopus to identify studies that evaluated the risk of dementia in individuals with a history of BD. A total of 6 studies including 3,026 individuals with history of BD and 191,029 non-BD individuals were included in the meta-analysis.

RESULTS

History of BD significantly increased the risk of diagnosis of dementia (pooled odds ratio: 2.36; 95% confidence interval: 1.36-4.09; z = 3.07, p < 0.001). Evidence of heterogeneity and of publication bias in the analysis was found.

CONCLUSION

History of BD is associated with significantly higher risk of dementia in older adults. Future studies are necessary to evaluate the potential mediators of this association and to evaluate interventions that may reduce the risk of dementia in this population.

Executive Function Is Selectively Impaired in Old Age Bipolar Depression

Background: Little is known about the cognitive signature of bipolar disorder (BD) in elderly brains. The neuropsychological features of depressive elderly with early-onset BD are largely unknown. This issue is relevant because cognitive impairment can produce an additional impact on the already compromised functionality of elderly with BD. The aim of this study is to assess executive functions (EFs) in the depressive phase of elderly outpatients with early-onset BD. Methods: Forty-nine elderly outpatients with early-onset BD were assessed with several neuropsychological tests for EF in the depressive phase of the disorder. Results: Executive dysfunction is very common in old age bipolar depression. Thirteen patients (26.5%) had a pseudodementia presentation. The worst performances were observed in the following tests: Trail Making B, Stroop Test 3, Backward Digit Span and Wisconsin Card Sorting Test. Conclusion: Executive dysfunction profile in elderly BD is complex and heterogeneous, but most cases display difficulties in working memory, inhibitory control, mental flexibility, and information processing speed. The performance of elderly with bipolar depression in executive assessment can be divided into two main categories: (1) Single EF domain impairment; and (2) Multiple EF domain impairment with or without a pseudodementia syndrome. Executive dysfunction in old age bipolar depression may be explained by lack of sufficient mental energy to run those cognitive processes that require larger amounts of effort to be performed.

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.

Areas of controversy in neuroprogression in bipolar disorder

OBJECTIVE

We aimed to review clinical features and biological underpinnings related to neuroprogression in bipolar disorder (BD). Also, we discussed areas of controversy and future research in the field.

METHOD

We systematically reviewed the extant literature pertaining to neuroprogression and BD by searching PubMed and EMBASE for articles published up to March 2016.

RESULTS

A total of 114 studies were included. Neuroimaging and clinical evidence from cross-sectional and longitudinal studies show that a subset of patients with BD presents a neuroprogressive course with brain changes and unfavorable outcomes. Risk factors associated with these unfavorable outcomes are number of mood episodes, early trauma, and psychiatric and clinical comorbidity.

CONCLUSION

Illness trajectories are largely variable, and illness progression is not a general rule in BD. The number of manic episodes seems to be the clinical marker more robustly associated with neuroprogression in BD. However, the majority of the evidence came from cross-sectional studies that are prone to bias. Longitudinal studies may help to identify signatures of neuroprogression and integrate findings from the field of neuroimaging, neurocognition, and biomarkers.

Similar Trajectory of Executive Functioning Performance over 5 years among individuals with Bipolar Disorder and Unaffected Controls using Latent Growth Modeling

OBJECTIVE

Executive Functioning (EF) deficits in bipolar disorder (BD) are commonly present regardless of mood state and therefore are considered core features of the illness. However, very little is known about the temporal stability of these deficits. We examined the natural course of EF over a five year period in BD and healthy control (HC) samples.

METHOD

Using a 5-year longitudinal cohort, 91 individuals with BD and 17 HC were administered a battery of neuropsychological tests that captured four main areas of EF: Processing Speed with Interference Resolution, Verbal Fluency with Processing Speed, Inhibitory Control, and Conceptual Reasoning and Set Shifting. Evaluations occurred at study entry, one, and five years later.

RESULTS

Latent Growth Curve Modeling demonstrated that the BD group performed significantly worse in all EF areas than the HC group. Changes in EF from baseline to 5-year follow-up were similar across both diagnostic groups. Older age at baseline, above and beyond education and diagnosis, was associated with worse initial performance in EF. Being of older age was associated with greater decline in Processing Speed with Interference Resolution, and Verbal Fluency with Processing Speed. Higher education was marginally associated with a smaller declining slope for Processing Speed with Interference Resolution.

CONCLUSIONS

Executive functioning deficits in BD persist over time, and in the context of normative age-related decline, may place individuals at greater risk for cognitive disability as the disease progresses. Age and having a BD diagnosis together, however, do not accelerate executive functioning decline over time.

Five-year follow-up of cognitive impairment in older adults with bipolar disorder

OBJECTIVE

To date, cognitive impairment has been thought to be an integral part of bipolar disorder. In clinical staging models, cognitive impairment is one of the hallmarks to define the clinical stage and it plays an important role in identifying the risk factors for progression to later stages of the illness. It is important to examine neurocognitive performance over longer periods to test the hypothesis of neuroprogression of bipolar disorder.

METHODS

A comprehensive neuropsychological test battery was applied at baseline and five years later to 56 euthymic older outpatients with bipolar disorder (mean age = 68.35 years, range: 60-90 years) and to a demographically matched sample of 44 healthy subjects. A group-by-time repeated measures multivariate analysis of variance was performed to measure changes over time for the two groups. The impact of baseline illness characteristics on the intra-individual change in neurocognitive performance within the bipolar disorder group was studied by using logistic regression analysis.

RESULTS

At baseline and at follow-up, patients with bipolar disorder performed worse on all neurocognitive measures compared to the matched healthy subjects. However, there was no significant group-by-time interaction between the patients with bipolar disorder and the comparison group.

CONCLUSIONS

Although older patients with bipolar disorder had worse cognitive function than healthy subjects, they did not have greater cognitive decline over a five-year period. The change in acquired cognitive impairment of patients with bipolar disorder might parallel the cognitive development as seen in normal aging.

Late life bipolar disorder evolving into frontotemporal dementia mimic

OBJECTIVES

Although bipolar disorder has been understood classically as a cyclic disease with full recovery between mood episodes, in the last decade, evidence has accumulated supporting progressive features. The clinical picture of advanced or end-stage bipolar disorder is heterogeneous with possible deficits in cognition and behavior, as illustrated by our case series.

CASES

From our neuropsychiatric outpatient clinic, we describe four cases with bipolar disorder gradually developing a clinical syndrome, including apathy, disinhibition, loss of empathy, stereotypical behavior, and compulsiveness, fulfilling the criteria for possible behavioral variant frontotemporal dementia. All cases were diagnosed with bipolar 1 disorder at least 10 years before the onset of the current symptoms, which were not due to recent mood episodes or switches of medication. In all cases, 3-7 years of follow-up yielded no progression. Repeated neuroimaging was within normal limits. Cerebrospinal fluid biomarker studies were not supportive of underlying neurodegenerative pathology. C9orf72 mutation status was negative in all cases.

CONCLUSION

Symptoms fitting the criteria for possible behavioral variant frontotemporal dementia may be present in end-stage of bipolar disorder. An alternative neurodegenerative nature seems unlikely based on repeated normal neuroimaging and the absence of clinical progression. Functional involvement of the frontal-subcortical networks might play a role.

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.

Predictors of psychiatric re-hospitalization in older adults with severe mental illness

OBJECTIVE

Many patients with severe recurrent mental illness are approaching late life; however, little is known about psychiatric re-hospitalization in this population. Our objective was to identify predictors of psychiatric re-hospitalization.

METHODS

This was a retrospective cohort study of all 226 geriatric patients (age ≥65 years) admitted to a tertiary care Canadian inpatient psychiatric unit between 2003 and 2008. The main outcome was psychiatric re-hospitalization in 5-year follow-up post-discharge (e.g. 2008-2013 if a patient had been first admitted in 2008). Multivariate Cox regression analyses were used to identify potential predictors of re-hospitalization.

RESULTS

Over 5-year follow-up, 32.3% (73/226) required psychiatric re-hospitalization. Prior lifetime history of psychiatric admission, currently living in a supervised setting and bipolar disorder diagnosis all independently predicted a lower time to psychiatric re-hospitalization (HRs > 2.0, p < 0.05).

CONCLUSIONS

The rate of psychiatric re-hospitalization is high in older adults admitted for severe mental illness. Clinicians should be aware of the especially high rates of re-hospitalization in geriatric psychiatric inpatients with bipolar disorder, previous psychiatric admissions, or those living in a supervised setting. Future research could investigate approaches to prevent psychiatric re-hospitalization in these vulnerable sub-populations.

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.

Psychiatric disorders and leukocyte telomere length: Underlying mechanisms linking mental illness with cellular aging

Many psychiatric illnesses are associated with early mortality and with an increased risk of developing physical diseases that are more typically seen in the elderly. Moreover, certain psychiatric illnesses may be associated with accelerated cellular aging, evidenced by shortened leukocyte telomere length (LTL), which could underlie this association. Shortened LTL reflects a cell's mitotic history and cumulative exposure to inflammation and oxidation as well as the availability of telomerase, a telomere-lengthening enzyme. Critically short telomeres can cause cells to undergo senescence, apoptosis or genomic instability, and shorter LTL correlates with poorer health and predicts mortality. Emerging data suggest that LTL may be reduced in certain psychiatric illnesses, perhaps in proportion to exposure to the psychiatric illnesses, although conflicting data exist. Telomerase has been less well characterized in psychiatric illnesses, but a role in depression and in antidepressant and neurotrophic effects has been suggested by preclinical and clinical studies. In this article, studies on LTL and telomerase activity in psychiatric illnesses are critically reviewed, potential mediators are discussed, and future directions are suggested. A deeper understanding of cellular aging in psychiatric illnesses could lead to re-conceptualizing them as systemic illnesses with manifestations inside and outside the brain and could identify new treatment targets.

Instrumental activities of daily living performance and role satisfaction in people with and without mild cognitive impairment: a pilot project

OBJECTIVE

We investigated differences in observed performance of instrumental activities of daily living (IADLs) and self-reported satisfaction with social role performance between people with amnestic mild cognitive impairment (a-MCI) and age- and gender-matched control participants.

METHOD

We measured observed performance of 14 IADLs using the Independence, Safety, and Adequacy domains of the Performance Assessment of Self-Care Skills (PASS) and the Patient-Reported Outcomes Measurement Information Systems (PROMIS) to examine satisfaction with social role performance.

RESULTS

Total PASS scores were significantly lower in participants with a-MCI (median=40.6) than in control participants (median=44.2; p=.006). Adequacy scores were also significantly lower. No significant differences were found between groups on the PROMIS measures.

CONCLUSION

IADL differences between groups were related more to errors in adequacy than to safety and independence. Occupational therapy practitioners can play a key role in the diagnosis and treatment of subtle IADL deficits in people with MCI.

Longer lithium exposure is associated with better white matter integrity in older adults with bipolar disorder

OBJECTIVES

Bipolar disorder (BD) is associated with cognitive dysfunction and structural brain abnormalities. In human and non-human studies, lithium has been related to neuroprotective and neurotrophic effects. We explored whether lithium treatment is related to better brain integrity and cognitive function in older adults with BD.

METHODS

We examined cognitive and neuroimaging data in 58 individuals with BD [mean (standard deviation) age = 64.5 (9.8) years] and 21 mentally healthy comparators (controls) of similar age and education. Subjects received comprehensive neurocognitive assessment and structural brain imaging, examining total gray matter volume, overall white matter integrity (fractional anisotropy), and total white matter hyperintensity burden.

RESULTS

In comparison to controls, subjects with BD had worse overall cognitive performance, lower total gray matter volume, and lower white matter integrity. Among subjects with BD, longer duration of lithium treatment was related to higher white matter integrity after controlling for age and vascular disease burden, but not with better cognitive performance.

CONCLUSIONS

Lithium treatment appears to be related to better brain integrity in older individuals with BD, in particular, in those who take lithium long-term. While intriguing, these findings need to be confirmed in a larger sample.

Age as a predictor of cognitive decline in bipolar disorder

OBJECTIVE

Cognitive dysfunction is a core feature of bipolar disorder (BD) in both adult and geriatric patients. However, little is known about whether cognitive functioning declines at a faster rate in patients with BD, and there are conflicting reports regarding the relationship between age and cognitive functioning in this population. This cross-sectional study examined the relationship between age and cognitive functioning in patients with BD.

METHODS

Patients with BD I (N = 113) and healthy adults (N = 64) ages 18-87 completed measures of processing speed, attention, executive functioning, verbal fluency, and clinical symptomatology. Groupwise comparisons were used to examine differences between patients and the comparison group and adult and geriatric BD cohorts. A series of linear regressions was conducted to examine the relationship of age and cognitive functioning and clinical variables and cognition.

RESULTS

Patients performed significantly worse than the comparison group on all neuropsychological measures. Age was a significant predictor of Trails A scores with older age associated with worse performance.

CONCLUSIONS

Older age was associated with poorer performance on Trails A in patients with BD but not healthy adults. These results are suggestive of greater dysfunction in processing speed with older age in patients with BD compared with a healthy comparison group. Because cognitive functioning is associated with community outcomes, these findings suggest a need for treatments targeting cognitive symptoms across the life span. Future research exploring neurobiologic evidence for neurodegenerative processes in BD will pave the way for potential therapeutic interventions.

A five-year follow-up study of neurocognitive functioning in bipolar disorder

OBJECTIVES

Cognitive dysfunction in bipolar disorder has been well-established in cross-sectional studies; however, there are few data regarding the longitudinal course of cognitive performance in bipolar disorder. The aim of this study was to examine the course of cognitive function in a sample of euthymic patients with bipolar disorder during a five-year follow-up period.

METHODS

Eighty euthymic outpatients with a DSM-IV diagnosis of bipolar disorder and 40 healthy control comparison subjects were neuropsychologically assessed at baseline (T1) and then at follow-up of five years (T2). A neurocognitive battery including the main cognitive domains of speed of processing, working memory, attention, verbal memory, visual memory, and executive function was used to evaluate cognitive performance.

RESULTS

Repeated-measures multivariate analyses showed that progression of cognitive dysfunction in patients was not different to that of control subjects in any of the six cognitive domains examined. Only a measure from the verbal memory domain, delayed free recall, worsened more in patients with bipolar disorder. Additionally, it was found that clinical course during the follow-up period did not influence the course of cognitive dysfunction.

CONCLUSIONS

Cognitive dysfunction that is characteristic of bipolar disorder is persistent and stable over time. Only dysfunction in verbal recall was found to show a progressive course that cannot be explained by clinical or treatment variables.

Openness predicts cognitive functioning in bipolar disorder

OBJECTIVES

Openness to experience (O) is a well-established personality factor and is associated with cognitive performance. Little is known about the personality-cognitive relationship in bipolar disorder, an illness with significant variability in mood. Cognitive evaluation is essential in psychopathology assessment as it may reflect underlying disease processes and psychosocial functional capacity. Screening using a proxy personality variable may identify those in need of comprehensive cognitive testing. We hypothesized that O and measures of cognition would associate in both the Bipolar Disorder (BD) and healthy control (HC) samples, whereas neuroticism and extraversion would correlate with cognition only in the BD sample.

METHODS

Data from a longitudinal study of BD were used to study the association between personality factors and cognitive measures of attention, executive functioning, memory and fine motor skills. Regression analyses were used to determine the variables that account for the association between personality and cognition.

RESULTS

Aspects of O explained significant cognitive variance (~5%) in both groups; this persisted when demographic variables (including BD versus HC status) were considered. Neuroticism and extraversion did not consistently correlate with cognitive performance in either group.

LIMITATIONS

There were more females in the HC group who were slightly younger compared to the BD group. We lack direct measures of positive affect, and there is a reliance on a single measure of personality.

CONCLUSIONS

BD Individuals scoring low on self-reported Openness are potential candidates for more comprehensive cognitive assessments (which represent a limited resource).