Functional Impairment in Older Adults With Bipolar Disorder

Psychosocial Impairment in Older Patients With Bipolar I Disorder

BACKGROUND

The goal of this study was to assess psychosocial functioning in older patients with bipolar I disorder compared with healthy subjects and to identify the psychopathological factors associated with poor functioning in patients.

METHODS

We recruited 68 euthymic patients with bipolar I disorder from the outpatient unit and 89 healthy controls who were older than 50 years of age. In addition to clinical variables, we used other standardized measures, including the Young Mania Rating Scale, the Hamilton Depression Rating Scale, the Hamilton Anxiety Rating Scale, the Functional Assessment Short Test, and the Montreal Cognitive Assessment.

RESULTS

Older patients with bipolar I disorder had poorer psychosocial functioning in general and in the domains of occupation, autonomy, and cognition than the healthy controls on the basis of previously defined Functional Assessment Short Test cutoff scores. We found that 35.3% (95% CI: 23%-47%) of the patients did not have clinically significant functional impairment, 38.2% (95% CI: 26%-50%) had mild impairment, and 26.5% (95% CI: 16%-37%) had moderate impairment. Depressive symptoms and impaired cognition were associated with poor overall functioning.

CONCLUSIONS

The level of psychosocial functioning was heterogeneous among the patients. Subsyndromal depressive symptoms, even at low levels, and impaired cognition predicted poor functioning in euthymic middle-aged and older patients with bipolar I disorder.

Older age bipolar disorder

PURPOSE OF REVIEW

Older age bipolar disorder (OABD) refers to patients with bipolar disorder aged 50 years and over. There is a paucity of evidence-based guidelines specific to OABD, but in recent years, several studies have been published on OABD. The current review synthesizes previous literature (up to January 1, 2021) as well as most recent literature on OABD (since January 1, 2021).

RECENT FINDINGS

This review covers the following themes: diagnosis and specifiers, clinical course, psychosocial functioning, cognition, physical comorbidities, and pharmacotherapy. On the basis of the latest data, specific clinical recommendations are proposed for each theme.

SUMMARY

OABD forms a more complex subgroup of bipolar disorder, with an increased risk of cognitive deficits, physical comorbidities, impaired psychosocial functioning, and premature death. The distinctions between BD-I and BD-II and between EOBD and LOBD do not clinically represent relevant subtypes for OABD patients. Mental healthcare professionals should treat all OABD patients with an integrative care model that takes into account cognitive and physical comorbidities and that contains elements aimed at improvement of psychosocial functioning and quality of life. Older age itself should not be a reason to withhold lithium treatment. Future research should collect data on essential data domains using validated measurement scales.

Functioning in older adults with bipolar disorder: A report on recommendations by the International Society of bipolar disorder (ISBD) older adults with bipolar disorder (OABD) task force

OBJECTIVES

Despite the importance of psychosocial functioning impairment in Bipolar Disorder (BD), its role among Older Adults with BD (OABD) is not well known. The development of guidelines for the assessment of psychosocial functioning helps to facilitate a better understanding of OABD and can lead to better tailored interventions to improve the clinical outcomes of this population.

METHODS

Through a series of virtual meetings, experts from eight countries in the International Society of Bipolar Disorder (ISBD) on OABD task force developed recommendations for the assessment of psychosocial functioning.

RESULTS

We present (1) a conceptualization of functioning in OABD and differences compared with younger patients; (2) factors related to functioning in OABD; (3) current measures of functioning in OABD and their strengths and limitations; and, (4) other potential sources of information to assess functioning.

CONCLUSIONS

The task force created recommendations for assessing functioning in OABD. Current instruments are limited, so measures specifically designed for OABD, such as the validated FAST-O scale, should be more widely adopted. Following the proposed recommendations for assessment can improve research and clinical care in OABD and potentially lead to better treatment outcomes.

Developing a profile of activities of daily living for bipolar disorder: a systematic review protocol and meta-analysis

INTRODUCTION

Bipolar disorder (BD) is a severe mental health disorder that affects 2% of the adult population. Individuals with this disorder are at a higher risk for morbidity and functional difficulties. They may also experience significant challenges in their activities of daily living (ADLs). This systematic review will identify all available studies that examine subsets of ADLs that impact individuals with BD.

METHODS AND ANALYSIS

MEDLINE, Embase, CINAHL and APA PsycINFO will be searched to identify observational studies that examined functioning, independence or performance across a variety of ADLs. Title and abstract, full-text screening and a risk of bias assessment will be conducted in duplicate. An overarching table that summarises the level of functioning across different ADLs or an 'ADL profile' will be developed, and if there are sufficient data, these will be separated based on the phases of BD, such as manic/hypomanic, depressed and euthymic.

ETHICS AND DISSEMINATION

As this systematic review uses information from previous literature, this review does not require ethics approval. This review will help identify the trends in daily activities that individuals struggle with and can help healthcare practitioners identify specific areas of need for support. We plan to disseminate the results in a peer-reviewed journal and conferences targeting occupational therapists and mental health clinicians.

PROSPERO REGISTRATION NUMBER

CRD42021255089.

A systematic review of psychosocial functioning and quality of life in older people with bipolar disorder

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The Global Assessment of Functioning (GAF; Endicott et al., 1976) is the most widely used functioning measure used with older adults with bipolar disorder.

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Older adults with bipolar disorder demonstrate a wide range of functioning.

•

No existing validated measure assessing the psychosocial functioning or quality of life of older people with BD could be identified.

•

There is a significant lack of research in the area of older people with bipolar disorder compared to the younger population.

Background

There is evidence to suggest that older people with Bipolar Disorder (BD) are more likely to demonstrate poor levels of functioning and score lower on well-being scales compared to non-clinical controls, even when in remission (Depp et al., 2006). To our knowledge, this is the first review paper to identify how quality of life and functioning has been measured in an older adult BD population.

Methods

We conducted a systematic review of studies including a quantitative measure of psychosocial functioning or quality of life and older people over the age of 50 with a formal diagnosis of BD I or II.

Results

Eleven studies (N = 726, mean age range 59.8 to 71.1) were included in the review, demonstrating a significant lack of research in the area compered to younger people with BD. The most commonly used measure of functioning was the Global Assessment of Functioning Scale (GAF) and results indicated that older adults with BD demonstrate a wide range of functioning.

Limitations

The review used a comprehensive and systematic search strategy, however, very few eligible studies were available for review. The pooled analyses and reported means must be interpreted with caution due to the relatively small sample sizes.

Conclusions

Older people with BD present with a wide range of functioning, ranging ‘major impairment’ to ‘superior’ scores. No existing validated measure assessing the psychosocial functioning or quality of life of older people with BD could be identified. Such a tool should be developed for use in future research.

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.

Psychoeducation in bipolar disorder: A systematic review

BACKGROUND

Bipolar disorder (BD) is a severe psychiatric disorder characterized by mood swings. Psychosocial interventions, such as psychoeducation, play an essential role in promoting social rehabilitation and improving pharmacological treatment.

AIM

To investigate the role of psychoeducation in BD.

METHODS

A systematic review of original studies regarding psychoeducation interventions in patients with BD and their relatives was developed. A systematic literature search was performed using the Medline, Scopus, and Lilacs databases. No review articles or qualitative studies were included in the analysis. There were no date restriction criteria, and studies published up to April 2021 were included.

RESULTS

A total of forty-seven studies were selected for this review. Thirty-eight studies included patients, and nine included family members. Psychoeducation of patients and family members was associated with a lower number of new mood episodes and a reduction in number and length of stay of hospitalizations. Psychoeducational interventions with patients are associated with improved adherence to drug treatment. The strategies studied in patients and family members do not interfere with the severity of symptoms of mania or depression or with the patient's quality of life or functionality. Psychoeducational interventions with family members do not alter patients' adherence to pharmacotherapy.

CONCLUSION

Psychoeducation as an adjunct strategy to pharmacotherapy in the treatment of BD leads to a reduction in the frequency of new mood episodes, length of hospital stay and adherence to drug therapy.

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.

End-of-Life Care Among Patients With Bipolar Disorder and Cancer: A Nationwide Cohort Study

OBJECTIVE

This study aimed to describe end-of-life (EOL) care in individuals with bipolar disorder (BD) who died of cancer compared with mentally healthy individuals.

METHODS

This was a nationwide cohort study of all adult individuals who died of cancer in hospitals in France between 2013 and 2016. Outcomes were compared between individuals with BD and mentally healthy individuals in the last month of life including palliative care and high-intensity EOL care (chemotherapy, artificial nutrition, and other interventions). A subanalysis explored differences between patients with BD and patients with schizophrenia.

RESULTS

The study included 2015 individuals with BD and 222,477 mentally healthy controls. Compared with the controls, individuals with BD died 5 years earlier, more often had comorbidities and thoracic cancer, and had fewer metastases, but did not have shorter delays from cancer diagnosis to death. After matching and adjustment for covariates, individuals with BD more often received palliative care in the last 3 days of life (25% versus 13%, p < .001) and less high-intensity care (e.g., chemotherapy 12% versus 15%, p = .004), but more artificial nutrition (6% versus 4.6%, p = .003). Compared with the schizophrenia comparison group, chemotherapy was received more by individuals with BD in the last 14 days of life (12.5% for BD versus 9.4%, p < .001).

CONCLUSIONS

Individuals with BD were more likely to receive palliative care and less likely to receive high-intensity EOL care, except for artificial nutrition. These results may not be specific to BD, as no difference was found between patients with BD and schizophrenia except for chemotherapy.

Predictive factors of functional outcome in patients with bipolar I disorder: a five-year follow-up

BACKGROUND

Functional impairment is commonly encountered among patients with bipolar disorder (BD) during periods of remission. The distribution of the impairment of the functional outcome is heterogeneous. The objective of this current investigation was to identify neurocognitive and clinical predictors of psychosocial functioning in a sample of patients with BD.

METHODS

Seventy-six patients (59.2% females) and 40 healthy controls (50% females), aged 18 to 55 years, were assessed using a comprehensive neurocognitive battery (six neurocognitive domains), and the Functioning Assessment Short Test (FAST), at baseline and after a 5-year follow-up. Stepwise regression models were used to identify predictor variables related to psychosocial functioning.

RESULTS

The number of hospitalizations during the follow-up, the change occurred in the neurocognitive composite index (NCI change), and NCI at baseline explained 30.8% of the variance of functioning. The number of hospitalizations during the follow-up was the variable that explained a greater percentage of the variance (16.9%). Verbal memory at baseline and the change in sustained attention during the follow-up explained 10% and 5.9% of the variance of the psychosocial functioning, respectively.

LIMITATIONS

The interval of 5 years between the two assessments could be too short to detect a possible progression in functional outcome for the overall sample.

CONCLUSIONS

The clinical course during the follow-up is the factor that has a greater impact on psychosocial functioning in patients with BD. Thus, the interventions aimed to promote prevention of relapses should be considered as essential for avoiding functional impairment in these patients.

Further Exploration of Personal and Social Functioning: The Role of Interpersonal Violence, Service Engagement, and Social Network

Social functioning (SF) has mainly been studied in major psychoses in relation to symptom severity, but other factors may interfere with the achievement of a functional remission. The aim of this study is to explore interpersonal violence (IV), service engagement (SE), and social network (SN), together with demographics, as predictors of SF in a sample of subjects with severe mental illness (SMI). Consecutive adult inpatients were evaluated using self-report and clinician-rated questionnaires. Findings suggest that IV, SE, SN, male sex, and illness duration explained 39.1% of SF variance in people affected by SMI. IV was the strongest predictor, followed by sex and duration of illness. Lifetime expression of violence is a stronger predictor than lifetime exposure to violence. Positive SE and SN were found to predict SF, whereas age was not associated. This study underlines the need of other non-symptom-related variables for the comprehension of SF in mental disorders.

Assessment of the Functioning Levels and Related Factors in Patients with Bipolar Disorder during Remission

Introduction

The course of bipolar disorder (BD) is characterized by relapse and remission periods. Although the symptoms show a significant and sometimes almost complete improvement during remission, the patients' functioning levels may be lower compared to the premorbid period. This study aimed to compare the functional levels between patients with BD during remission period and healthy controls and to evaluate the factors related to the functional status of the patients.

Methods

In this cross-sectional study, functioning levels of the BD-I patients, who were in remission for three months or longer, were compared with those of the healthy controls. Young Mania Rating Scale and Hamilton Depression Rating Scale were used to determine remission status, and Bipolar Disorder Functioning Questionnaire (BDFQ) was used to determine the level of functioning.

Results

The study included 165 BD-I patients during remission and 63 healthy controls. The BDFQ scores of the patients including intellectual functioning, sexual functioning, feeling of stigmatization, introversion, relationships with friends, participation in social activities, daily activities and hobbies, and taking initiative were found to be statistically significantly lower than those of the controls. When the functioning comparisons were carried out within the patients considering the drugs they were using, the functioning levels including domestic functioning and introversion domains were found to be significantly impaired in those who use at least one antipsychotic in addition to the mood stabilizers than in those who use only mood stabilizers.

Conclusion

In BD, the impairments within multiple functioning domains are observed even during remission periods. Besides targeting remission through pharmacological treatment, psychosocial interventions for functioning are also important in the treatment of these patients.

Physical activity as prognostic factor for bipolar disorder: An 18-month prospective study

INTRODUCTION

Exercise is an adjuvant therapy indicated for various psychiatric disorders. However, prospective studies in patients with bipolar disorder (BD) are scarce and with uncertain conclusions. This study aims to evaluate physical activity as a prognostic factor for BD, analyzing relationship with levels of anxiety, functionality, sleep, mood episodes and hospitalizations.

METHODS

Three psychiatrists interviewed 80 BD outpatients in euthymia, referred from four different institutions in Brazil. In this moment, they evaluated the intensity of physical activities using the International Physical Activity Questionnaire (IPAQ) - short form. They reevaluated patients and reviewed medical records monthly for 18 months to identify mood episodes and psychiatric hospitalizations.

RESULTS

Thirty-eight patients (47.5%) were physically inactive (or sedentary) and 42 (52.5%) active. Physically active patients had lower Body Mass Index (p = 0.006), waist circumference (p = 0.002), lower levels of anxiety (p = 0.032) and less insomnia (p = 0.001). Sedentary individuals revealed poorer global functioning (p < 0.001) and in all domains: autonomy (p < 0.001), occupational functioning (p = 0.008), cognitive functioning (p = 0.013), capacity of managing the finances (p = 0.012), interpersonal relationships (p = 0.011) and leisure time (p = 0.001). Less activity was associated with more mood episodes (p = 0.042) and psychiatric hospitalizations (p = 0.043) over 18 months.

CONCLUSION

This study suggested physical activity as a good prognostic factor for BD during euthymia. This reinforces the need to encourage this practice in clinical settings. Future prospective surveys with longer duration using objective instruments are proposed.

Psychometric properties of the Chinese version of the Functioning Assessment Short Test (FAST) in bipolar disorder

OBJECTIVES

Bipolar disorder (BD) is often associated with significant functional impairment. However, there is currently no valid and reliable instrument for this variable that is both brief and easy to administer in China. We thus aimed to evaluate the psychometric properties of the Chinese version of the Functioning Assessment Short Test (FAST) in Chinese adults with BD.

METHODS

In this sample of adult subjects, 176 with BD and 53 healthy controls were included. The Chinese version of the FAST, the Young Mania Rating Scale (YMRS), the 17-item Hamilton Depression Rating Scale (HDRS-17) and the Global Assessment Functioning (GAF) were administered, and the psychometric analysis of the FAST was conducted.

RESULTS

The internal consistency (Cronbach's alpha) was 0.89 and 0.88 for the FAST at the baseline and week 1, respectively. Four domains (occupational functioning, cognitive functioning, interpersonal relationship and financial issues) at baseline had high item-total correlations. The FAST assessments at baseline and week 1 were highly correlated, indicating high test-retest reliability. The FAST total score was strongly associated with GAF total scores at week 0 (r  = -0.952, p < 0.001), HDRS (r = 0.575, p < 0.001) and YRMS (r = 0.394, p < 0.001) and at week 1 (r  = -0.945, p < 0.001; r  = 0.582, p < 0.001; r  = 0.363, p < 0.001), respectively, suggesting high concurrent validity. The FAST showed four dimensional measurement properties in exploratory factor analysis at baseline.

CONCLUSIONS

The Chinese version of the FAST has satisfactory psychometric properties in terms of validity and reliability in Chinese adults with BD.

Psychosocial functioning in patients with psychotic and non-psychotic bipolar I disorder. A comparative study with individuals with schizophrenia

BACKGROUND

More than 50% of individuals with bipolar disorder (BD) do not reach full psychosocial functioning, even during periods of euthymia. It has been suggested that history of psychotic symptoms is one of the factors which are associated with a worse functional outcome. The objective was to compare psychosocial functioning between patients with BD, with (BD-P), and without (BD-NP) a history of psychotic symptoms, and to examine whether the history of psychotic symptoms, or other clinical or neurocognitive variables predict psychosocial functioning.

METHODS

Psychosocial functioning and neurocognition were examined in 100 euthymic patients with bipolar I disorder (50 BD-P, and 50 BD-NP), compared to 50 stabilised patients with schizophrenia (SZ), and 51 healthy controls (HC).

RESULTS

1) There were no differences between BD-P and BD-NP in the GAF-F score or in the FAST total score. 2) The two groups of patients with BD had better scores than SZ both in the GAF-F, and in all measures of the FAST, except for the subscale leisure time. 3) The neurocognitive composite index, verbal memory and subclinical depressive symptoms were the variables which explained a higher percentage of the variance of functional outcome.

LIMITATIONS

The cross-sectional design, and the relatively small sample size are the main limitations.

CONCLUSIONS

A history of psychotic symptoms has no relevant impact on the level of psychosocial functioning in BD. Neurocognitive dysfunction and subclinical depressive symptoms are the variables that best explain the functional impairment. These findings have important clinical implications.