Bipolar disorder in older adult inpatients

The CANMAT and ISBD Guidelines for the Treatment of Bipolar Disorder: Summary and a 2023 Update of Evidence

Bipolar disorder is a complex and heterogeneous psychiatric condition that affects more than 2% of the population. The assessment and treatment of bipolar disorder can be a challenge for clinicians, given its clinical complexity and the rapidly changing treatment landscape with the growing range of treatment options that are becoming available for various phases of the illness. To help clinicians navigate the complexity involved in the assessment and management of bipolar disorder, the guidelines of the 2018 Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) synthesized the evidence on the efficacy, safety, and tolerability of treatments for bipolar disorder and translated it into first-, second-, and third-line treatment recommendations. The main objective of this contribution is to provide clinicians with a summary of the 2018 CANMAT/ISBD guideline recommendations with the addition of any new evidence for the treatment of bipolar disorder across the lifespan.

Physical health comorbidities in older adults with bipolar disorder: A systematic review

OBJECTIVE

To ascertain the prevalence and predictors of physical health comorbidities in older adults with bipolar disorder.

METHODS

The authors conducted a systematic review and narrative synthesis of peer-reviewed journal articles reporting on physical health comorbidities in older adults (aged ≥50) with a diagnosis of bipolar disorder. The Mixed Methods Appraisal Tool (MMAT) assessed study quality.

RESULTS

23 papers reporting on 19 studies met the inclusion criteria. The literature on diabetes, obesity and renal disease was inconclusive. There was some tentative evidence to higher rates of cardiovascular disease and some forms of cancer in older adults with bipolar disorder in comparison to the general population, but this requires further investigation. We identified no studies looking at oral health.

LIMITATIONS

The quality ratings of the identified research were generally low. Very few studies included a comparison sample from the general population or controlled for key covariates in their analysis.

CONCLUSION

Existing literature provides tentative evidence that some physical health comorbidities are elevated in older adults with bipolar disorder. Clinicians should consider interventions that improve the physical health of this group, alongside the chronic mental health difficulties they experience.

Elderly Bipolar Disorder

PURPOSE OF REVIEW

With more individuals reaching older ages, bipolar disorder is no longer a rare illness in the elderly. Despite the growing number of the older individuals with the illness, there are few studies that focus on bipolar disorder in the geriatric population leading to gaps in clinical knowledge and treatment. The aim of this study is therefore to increase understanding by summarizing the available literature on the epidemiology, symptomatology, comorbidities, and treatment recommendations in this cohort, as well as to suggest areas for future clinical and research focus.

RECENT FINDINGS

The prevalence of bipolar disorder is underestimated in the geriatric population. The illness maintains the main features observed in the other cohorts but it also has some specific characteristics in the older individuals. In this cohort, psychiatric and medical comorbidities tend to be the rule rather than the exception. Higher rates of cognitive impairments than age- and education-matched groups present across all of the illness phases. Treatment is more challenging in the elderly individuals due to higher rates of comorbidities and susceptibility to medication side effects. Two cohorts of older individuals with bipolar disorder can be recognized, those with symptoms that start earlier in life and those with late-life onset. Although the knowledge about elderly bipolar disorder is only slowly growing, it is increasingly recognized as an illness with unique features. More work is needed to improve diagnosis and to establish treatment guidelines.

Readmission Rates and Causes Within The First Six Months After Discharge in Patients with Alcohol Addiction

Introduction

Readmission rate is an important criterion that evaluates the quality of treatment and care. In this study, it was aimed to determine the rates of readmission and variables predicting readmission in patients with alcohol addiction.

Methods

The study sample consisted of 264 alcohol addiction patients with recurrent admissions between 2005-2017 at the Gazi University Hospital Alcohol and Drug Addiction Clinic. In the study, ICD-10 diagnostic classification was used. The differences between the medical comorbidity and psychiatric comorbidity of the patients during the first and second admissions were analyzed.

Results

The average age of the study sample was 51.45±12.04 and 89% (n=235) were male. In the second admission, the comorbid headaches (p=0.001), psychotic symptoms (p=0.013), anxiety disorder (p=0.003) and substance addiction (p=0.027) were significantly higher, and the length of hospital stay was shorter. In the first six months, 24.2% (n=64) of the sample was hospitalized again. While the comorbidity of anxiety disorder increased the risk of readmission within six months 2.2-fold (OR=2.240; p=0.031), the short duration of hospitalization (less than 35 days) increased the risk of readmission 2-fold (OR=0.492; p=0.026).

Discussion

Patients with a short hospital stay have an increased risk of readmission within the first 6 months after discharge. Policies that reduce the length of hospital stay in health services should be reviewed. However, it is noteworthy that in the second admission of patients with alcohol dependence, the diagnosis of drug addiction is added. To prevent this, issues related to substance abuse prevention should be addressed during the treatment stages of alcohol dependence.

Gender influence on the bipolar disorder inpatient length of stay in Sweden, 2005-2014: A register-based study

BACKGROUND

The influence of gender on bipolar disorder is controversial and it is unclear if inpatient care differs between men and women. Here, we investigate for gender differences in the inpatient length of stay for Swedes admitted for bipolar disorder and explore other factors that could explain any observed association.

METHODS

Admission data were extracted from the Swedish National Patient Register and included all patients first admitted to a psychiatric inpatient unit with a bipolar disorder diagnosis, circa 2005-2014. Patients were then retrospectively followed for subsequent hospitalizations. Diagnostic subtypes were categorized by ICD-10 clusters: depressive, depressive with psychotic features, manic, manic with psychotic features, mixed, and other. Psychotropic therapies preceding the corresponding admissions were attained from the Prescribed Drug Register. Mixed-effects zero-truncated negative binomial regressions were employed to model the length of stay per admission.

RESULTS

Analysis included 39,653 admissions by 16,271 inpatients (60.0% women). Overall, when compared to men, women spent 7.5% (95% CI: 4.2-11.0%, p < 0.001) extra days hospitalized per admission. However, upon adjusting for candidate confounders, including the bipolar subtype, and selected comorbidities and psychotropics, the association weakened wherein women then spent 3.7% (95% CI: 0.1-6.9%, p = 0.028) extra days hospitalized per admission.

LIMITATIONS

The integrity of register data can be variable and the adherence to outpatient dispensed psychotropics could not be validated.

CONCLUSION

Although the influence of gender on the bipolar disorder inpatient length of stay is evident, other factors attenuate and better explain this crude observation.

Using Lithium in Older Age Bipolar Disorder: Special Considerations

Lithium is the gold-standard treatment for bipolar disorder, and is effective in the management of manic, depressive, and maintenance phases of bipolar disorder treatment. Despite this, the implications of lithium use in the older population remain less understood. This critical narrative review aims to better understand the impact of lithium in older age bipolar disorder (OABD), including tolerability and efficacy, based on up-to-date evidence. Relevant studies of efficacy, effectiveness, and tolerability published any time prior to May 2018 were identified using the PubMed keyword search "lithium older adult bipolar disorder" and references from recent international bipolar disorder guidelines. One randomized controlled trial was identified, the GERI-BD (Acute Pharmacotherapy in Late-Life Mania) study. This study found lithium to be effective in late-life mania and hypomania. The remaining literature examining lithium in OABD was reviewed, comprising of a number of small open-label and retrospective studies, with special considerations highlighted. In summary, there is a small yet increasing geriatric evidence base that lithium is effective in OABD. Although there can be adverse effects with lithium, it is generally well tolerated, and there are methods to minimize these risks. Further research would strengthen the evidence base for lithium therapy in OABD. In the meantime, lithium remains the gold-standard treatment for OABD.

Lithium interacts with cardiac remodeling: the fundamental value in the pharmacotherapy of bipolar disorder

Patients with bipolar disorder (BD) have an increased risk of cardiovascular morbidity and mortality during the course of their illness. For over half a century, lithium has been the gold-standard medication used to treat the mood burdens of BD. In addition, lithium possesses several biological effects that may modulate cardiovascular risk in patients with BD. In this review, we update the current knowledge of cellular and molecular mechanisms underlying the possible cardiac actions of lithium. The mechanistic insights suggest that lithium at therapeutic levels potentially exerts cardioprotective effects on ischemic hearts by modulating structural and electrical remodeling. The possible cardioprotective actions of lithium may involve an extensive range of signaling pathways, including the Wnt/glycogen synthase kinase-3β, phosphatidylinositol-3-kinase/protein kinase B, phosphoinositide/protein kinase C, and mitogen-activated protein kinase/extracellular signal-regulated kinase cascades. Accordingly, understanding the cardioprotective effects of lithium may lead to the development of a potential strategy for reducing cardiovascular morbidity in patients 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.

Diabetes mellitus and first episode mania associated with cardiovascular diseases in patients with older-age bipolar disorder

Patients with bipolar disorder (BD) are at high risk for developing cardiovascular diseases (CVDs) during aging process. However, investigations are lacking regarding the risk factors for CVDs specific to BD patients. The aim of this study was to examine the relationship between CVDs and traditional risk factors in association with the characteristics of BD in older age. Totally, we recruited 124 patients with BD-I (DSM-IV) who had at least one psychiatric admission and cardiologist-confirmed CVD diagnosis (ICD-9 code 401-414) at mean age of 61.7+4.9 years. Each case subject was matched with one BD-I patient without CVDs based on age, sex, and date of the most recent psychiatric admission (+2 years). Clinical data were obtained by retrospectively reviewing the medical record. A multiple logistic regression model showed that not only traditional risk factor (e.g., diabetes mellitus) but also non-traditional one associated with BD (e.g., first episode mania) significantly increased the risk of CVDs. Given the limitation of this cross-sectional study, longitudinal investigations are needed to elucidate the contributions of both traditional risk factors and the BD characteristics for CVD risk in patients with BD.

Depressive symptoms in early- and late-onset older bipolar patients compared with younger ones

OBJECTIVES

The aim of this study was to determine clinical and outcome differences between older bipolar patients with early onset (EO) and late onset (LO) of the illness and between younger and EO older patients with a bipolar disorder under long-term treatment in an outpatient clinical setting.

METHODS

Three hundred ninety-five bipolar I and II outpatients were followed up for up to 7.7 years. Of these, 213 younger (<50 years) and 88 older (>60 years) patients were included. In the older subsample, 50 EO patients (onset <50 years) versus 38 LO patients (≥50 years) were analyzed. Likewise, younger versus EO older patients were compared.

RESULTS

The likelihood of LO older patients of being bipolar II was higher than for EO older patients. They were also diagnosed earlier than EO older patients. No other clinical differences at baseline and at the prospective follow-up were found. Compared with younger patients, EO older patients had more frequent depressive symptoms at baseline, suffered more major depressive episodes in the previous year and in the prospective follow-up, received more antidepressants at baseline, had higher rates of medical comorbid conditions and were less likely to be tobacco smokers.

CONCLUSIONS

Older patients constitute a meaningful proportion of bipolar patients under treatment. EO older patients suffered significantly from more frequent depressive symptoms than younger ones. LO older patients were predominantly bipolar II. So as bipolar illness progressed, depressive symptomatology became more frequent and manic episodes were less severe. Copyright © 2016 John Wiley & Sons, Ltd.

High serum sodium level in affective episode associated with coronary heart disease in old adults with bipolar disorder

OBJECTIVE

Coronary heart disease (CHD) remains the principal cause of excessive natural deaths in bipolar patients; however, electrocardiogram analyses and clinical features predicting CHDs in elderly bipolar patients remain limited. We sought to examine the relationship between CHDs, as determined by electrocardiogram, and clinical characteristics.

METHODS

We recruited bipolar I outpatients Diagnostic Statistical Manual of Mental Health (DSM-IV) who were more than 60 years old and had at least one psychiatric admission. Subjects were divided into two groups based on the presence or absence of CHD diagnosed by electrocardiogram analysis at entry of study. Clinical data were obtained by a combination of interviewing patients and family members and retrospectively reviewing medical records of the most recent acute psychiatric hospitalization.

RESULTS

Eighty patients with bipolar disorder were enrolled. A total of 20 (25%) in the study had CHDs. The mean age at the time of entry into study was 67.6 ± 5.5 years old in group with CHD and 66.8 ± 6.8 years old in that without CHD. Among the clinical characteristics examined, higher mean levels of serum sodium and thyroxine during the acute affective phase as well as more first-degree family history with bipolar disorder were related to having CHD, particularly the serum sodium level.

CONCLUSIONS

About one fourth of old bipolar patients have CHDs in both Asian and Western populations. Aging patients with bipolar disorder may have unique clinical factors (e.g., hypernatremia or elevated thyroxine) related CHDs that could warrant special attention in their psychiatric and medical care to minimize cardiovascular disease and mortality.

Medical comorbidity, acute medical care use in late-life bipolar disorder: a comparison of lithium, valproate, and other pharmacotherapies

OBJECTIVE

Bipolar disorder is associated with high rates of medical comorbidity, particularly in late life. Little is known about medical health service utilization and potential effects of bipolar pharmacotherapy. We hypothesized that lithium use would not be associated with higher rates of medical hospitalization.

METHODS

Population-based retrospective cohort study of 1388 bipolar disorder patients aged ≥66years discharged from a psychiatric hospitalization in Ontario, Canada, between 2006 and 2012. Patients were divided into lithium users, valproate users, and non-lithium/non-valproate users. The main outcome was acute non-psychiatric, medical/surgical hospitalization during 1-year follow-up.

RESULTS

The rate of medical hospitalizations was 0.22 per patient-year. Time-to-medical hospitalization did not differ among lithium, valproate, and non-lithium/non-valproate users after adjusting for age, sex, past medical hospitalization, and antipsychotic use. Lithium, valproate, and non-lithium/non-valproate users did not differ markedly in terms of reason for medical hospitalization, 1-year acute medical health utilization outcomes, and medical comorbidity rates.

CONCLUSION

There were high rates of health service use for medical conditions among older adults with bipolar disorder, but this did not appear to be associated with lithium use, compared to valproate and other medication use (e.g., antipsychotics). A proactive collaborative care approach may prevent medical service utilization in severe late-life bipolar disorder.

Two years' outcome of acute mania in bipolar disorder: different effects of age and age of onset

BACKGROUND

Information about differences between younger and older patients with bipolar disorder and between older patients with early and late age of onset of illness during long-term treatment is scarce.

OBJECTIVES

This study aimed to investigate the differences in treatment and treatment outcome between older and younger manic bipolar patients and between early-onset bipolar (EOB) and late-onset bipolar (LOB) older patients.

METHOD

The European Mania in Bipolar Longitudinal Evaluation of Medication study was a 2-year prospective, observational study in 3459 bipolar patients on the treatment and outcome of patients with an acute manic or mixed episode. Patients were assessed at 6, 12, 18, and 24 months post-baseline. We calculated the number of patients with a remission, recovery, relapse, and recurrence and the mean time to achieve this.

RESULTS

Older patients did not differ from younger bipolar patients in achieving remission and recovery or suffering a relapse and in the time to achieve this. However, more older patients recurred and in shorter time. Older patients used less atypical antipsychotics and more antidepressants and other concomitant psychiatric medication. Older EOB and LOB patients did not differ in treatment, but more older LOB patients tended to recover than older EOB patients.

CONCLUSION

Older bipolar manic patients did not differ from younger bipolar patients in short-term treatment outcome (remission and recovery), but in the long term, this may be more difficult to maintain. Distinguishing age groups in bipolar study populations may be useful when considering treatment and treatment outcome and warrants further study.

Psychiatric and medical comorbidities: results from a bipolar elderly cohort study

OBJECTIVE

Bipolar disorder is associated with concurrent mental and physical disorders. Although well studied among younger adults, less is known about concurrent morbidity among older patients. This is important because comorbidity may increase with age and optimal treatment requires awareness of medical and psychiatric comorbidities. This study analyzed psychiatric and medical comorbidity in a Dutch bipolar elderly cohort.

METHODS

This cross-sectional descriptive study included demographic and clinical data on 101 bipolar patients aged 60 and over (mean age: 68.9 ± 7.8 years); 53.4% were women. Psychiatric diagnoses were confirmed by semistructured diagnostic interviews. Somatic history, including current somatic complaints, was obtained by interview. Medication and indicators of metabolic syndrome were obtained via record review.

RESULTS

Most patients received outpatient care. Bipolar I disorder was diagnosed in 56.4% of patients, and 75.6% had an onset of first affective symptoms before age 50. The prevalence rates of psychiatric comorbidities were low, except for lifetime alcohol dependence (24.8%) and abuse (13.9%). On average, there were 1.7 (SD: 1.6) medical comorbid conditions, predominantly hypertension (27.8%), arthrosis (29.1%), and allergies (25.6%). Polypharmacy was found in 31.7% of patients and metabolic syndrome in 28.7%.

CONCLUSION

Psychiatric comorbidity (especially anxiety disorders) was relatively uncommon, except for substance use disorder. Geriatric bipolar patients had on average two comorbid medical conditions and relatively high medication use. Findings underline the need to assess for comorbid conditions in bipolar elders, thereby enabling tailored treatment to optimize the general condition of these patients.

The prevalence of late-life mania: a review

OBJECTIVES

Since there is a worldwide steady increase in the number of individuals living longer and an expected increase in the number of older adults who will be diagnosed with bipolar disorder, there is a growing need to better understand late-life mania. We provide in this review a report of published studies focusing on the prevalence of late-life mania in the community and in senior psychiatric care facilities.

METHODS

We conducted a search of PubMed and Psychinfo databases using combinations of the keywords bipolar, manic/a, manic depression, elderly, and older including English-language reports presenting quantitative data on the prevalence of mania in adults over the age of 50 years.

RESULTS

Eighteen out of 188 potentially eligible studies met our inclusion criteria, with most studies focusing on psychiatric inpatient samples. The overall prevalence of late-life mania was estimated to be 6.0% in the reported 1,519 older psychiatric inpatients. In elderly inpatients with bipolar disorder, the mean prevalence of late-onset mania was 44.2%. For other relevant care facilities, no firm conclusions could be drawn.

CONCLUSIONS

Late-life mania is not rare in older psychiatric inpatients and late-onset mania is associated with increased somatic comorbidity in patients aged 50 years and older. Several hypotheses regarding the relationship between somatic illness and late-life mania in the elderly have been proposed and studies on this relationship and the prevalence of late-life mania in different senior psychiatric care facilities deserve specific attention in future research projects.

Medical and psychiatric comorbidities among elderly individuals with bipolar disorder: a literature review

INTRODUCTION

The common comorbid conditions that accompany late-life bipolar disorder (BD) have not been well studied. This is a literature review on psychiatric and medical comorbidities among elderly individuals with BD.

METHODS

A focused literature review searched PubMed. Inclusion criteria were original research reports, in English, until June 2009, specifically focused on medical and psychiatric comorbidities in BD individuals over the age of 50.

RESULTS

A limited number of studies were identified. Most involved small samples (n < 100). Metabolic syndrome, respiratory and cardiovascular conditions, and endocrine abnormalities are common, with patients having an average of 3 to 4 medical comorbid conditions. Approximately 4.5% to 19% of elderly individuals with BD have dementia. Rates of psychiatric comorbidity appear lower than in younger BD populations, with the most common concurrent psychiatric illnesses being anxiety and substance use disorders. Rates of comorbid medical conditions appear similar to rates among geriatric patients without BD.

CONCLUSIONS

Elderly individuals with BD are burdened by multiple concomitant medical disorders. In contrast to the elevated rates of medical comorbidity, rates of psychiatric comorbidity appear lower in elderly individuals with BD than in younger populations with BD. Greater awareness of concurrent medical conditions might help inform coordinated care that considers both mental and physical health among geriatric patients with BD.

Acute bipolar I affective episode presentation across life span

OBJECTIVES

There is a paucity of evidence on bipolar I acute symptoms' presentation in the elderly individuals compared to younger patients. The current literature provides little, and at times conflicting, information on age-related bipolar disorder (BD) symptom presentation. This article aims to compare symptom profile by age group among patients with bipolar I in an acute affective episode as evaluated in outpatient settings.

METHODS

The current analyses include all Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) participants with a lifetime diagnosis of bipolar I disorder. We compared the presence and severity of acute mood elevation (mania and hypomania) and acute depression symptoms between younger (20-59 years old) and older individuals (older than or equal to 60 years).

RESULTS

With the exception of distractibility, all acute depression symptoms presented with comparable frequency and severity between younger and older individuals. No statistical significance was found regarding the presence of psychotic symptoms between the 2 groups, with symptoms reported by 11.2% of younger versus 9.4% older individuals, χ(2) (1, N = 1541) = 0.03, P = .74. No significant effects were found for mood elevation severity between the 2 age groups. Psychotic symptoms were reported in 12.7% versus 15.2%, χ(2) (1, N = 658) = 0.07, P = .65, and irritability in 97.7% versus 97.8%, χ(2) (1, N = 651) = 0.00, P = 1.00, in the younger and older group, respectively.

CONCLUSION

We found no statistically significant association between age and symptoms presentation of acute depression and mood elevation among patients with BD I. Acute BD I affective states present with similar profile and severity in old and young patients.

Bipolar disorder in the elderly; different effects of age and of age of onset

BACKGROUND

Information about differences between younger and elderly patients with bipolar disorder and between elderly patients with early and late age of onset of illness is limited.

METHOD

The European Mania in Bipolar Longitudinal Evaluation of Medication (EMBLEM) study was a 2-year prospective, observational study in 3459 bipolar patients on the treatment and outcome of patients with an acute manic or mixed episode. Within this study, elderly patients (>60 years of age; n=475) were compared with younger patients (<50 years of age; n=2286), and within the elderly group, Late Onset Bipolar (LOB) patients (onset > or =50 years; n=141) were compared with Early Onset Bipolar (EOB) patients (<50 years; n=323).

RESULTS

In the year prior to enrollment, elderly patients, especially those with EOB, more frequently reported a rapid cycling course of illness, but fewer suicide attempts. At baseline, elderly patients more often used one psychotropic medication and demonstrated less severe manic and psychotic symptoms, but no difference in depressive symptomatology. However, prior to enrollment and during the acute phase of treatment, elderly patients more frequently received antidepressants. Atypical antipsychotics were given less frequently. Regarding 12-week outcomes, there was no difference between elderly and younger patients, although LOB elderly recovered faster, and were discharged sooner than EOB elderly patients.

LIMITATIONS

Information about somatic conditions was not systematically collected nor was information about concurrent use of non-psychiatric medication which might have given some indication of somatic comorbidity.

CONCLUSION

Elderly bipolar manic patients differ from younger bipolar manic patients regarding treatment but not treatment outcome. LOB elderly patients demonstrated a more favourable outcome. The use of medication and the occurrence of rapid cycling in EOB elderly patients warrant further study.

Mood disorders in the elderly

Mood disorders in the elderly are a growing source of morbidity and mortality. Unfortunately, mood disorders in later life frequently are not diagnosed and treated. Appropriate, prompt diagnosis and treatment of late-life mood disorders can significantly improve the quality of life of patients and families and may prove life saving. Current treatments can help most older adults with mood disorders. Future treatments are promising, particularly for those with treatment-resistant depression.