Cognitive performance in older-age bipolar disorder: Investigating psychiatric characteristics, cardiovascular burden and psychotropic medication

Cognition in older age bipolar disorder: An analysis of archival data across the globe

BACKGROUND

Cognitive deficits in bipolar disorder (BD) impact functioning and are main contributors to disability in older age BD (OABD). We investigated the difference between OABD and age-comparable healthy comparison (HC) participants and, among those with BD, the associations between age, global cognitive performance, symptom severity and functioning using a large, cross-sectional, archival dataset harmonized from 7 international OABD studies.

METHODS

Data from the Global Aging and Geriatric Experiments in Bipolar Disorder (GAGE-BD) database, spanning various standardized measures of cognition, functioning and clinical characteristics, were analyzed. The sample included 662 euthymic to mildly symptomatic participants aged minimum 50years (509 BD, 153 HC), able to undergo extensive cognitive testing. Linear mixed models estimated associations between diagnosis and global cognitive performance (g-score, harmonized across studies), and within OABD between g-score and severity of mania and depressive symptoms, duration of illness and lithium use and of global functioning.

RESULTS

After adjustment for study cohort, age, gender and employment status, there was no significant difference in g-score between OABD and HC, while a significant interaction emerged between employment status and diagnostic group (better global cognition associated with working) in BD. Within OABD, better g-scores were associated with fewer manic symptoms, higher education and better functioning.

LIMITATIONS

Cross-sectional design and loss of granularity due to harmonization.

CONCLUSION

More research is needed to understand heterogenous longitudinal patterns of cognitive change in BD and understand whether particular cognitive domains might be affected in OABD in order to develop new therapeutic efforts for cognitive dysfunction OABD.

Neurocognitive correlates of metabolic dysregulation in individuals with mood disorders: a systematic review and meta-analysis

Individuals with mood disorders are predisposed to metabolic dysfunction, while those with metabolic dysregulation such as diabetes and obesity experience more severe depressive symptoms. Both metabolic dysfunction and mood disorders are independently associated with cognitive deficits. Therefore, given their close association, this study aimed to explore the association between metabolic dysfunction in individuals with mood disorders in relation to cognitive outcomes. A comprehensive search comprised of these three domains was carried out; a random-effects meta-analysis pooling mean cognitive outcomes was conducted (PROSPERO ID: CRD42022295765). Sixty-three studies were included in this review; 26 were synthesized in a quantitative meta-analysis. Comorbid metabolic dysregulation was associated with significantly lower global cognition among individuals with mood disorders. These trends were significant within each mood disorder subgroup, including major depressive disorder, bipolar disorder, and self-report depression/depressive symptoms. Type 2 diabetes was associated with the lowest cognitive performance in individuals with mood disorders, followed by peripheral insulin resistance, body mass index ⩾25 kg/m2, and metabolic syndrome. Significant reduction in scores was also observed among individual cognitive domains (in descending order) of working memory, attention, executive function, processing speed, verbal memory, and visual memory. These findings demonstrate the detrimental effects of comorbid metabolic dysfunction in individuals with mood disorders. Further research is required to understand the underlying mechanisms connecting mood disorders, metabolism, and cognition.

Bipolarity in Older individuals Living without Drugs (BOLD): Protocol and preliminary findings

INTRODUCTION

Although clinical guidelines regard prophylactic medication as the cornerstone of treatment, it is estimated almost half of patients with bipolar disorder (BD) live without medication. This group is underrepresented in research but can provide indispensable knowledge on natural course, resilience and self-management strategies. We aim to describe the clinical phenotype of patients diagnosed with BD who have discontinued maintenance treatment.

METHODS

The mixed-methods BOLD study included 58 individuals aged 50 years and over with BD that did not use maintenance medication in the past 5 years. A preliminary, quantitative comparison of clinical characteristics between BOLD and our pre-existing cohort of >220 older BD outpatients with medication (Dutch Older Bipolars, DOBi) was performed.

RESULTS

BD-I, psychiatric comorbidities, number of mood episodes and lifetime psychotic features were more prevalent in BOLD compared to DOBi. BOLD participants had a younger age at onset and reported more childhood trauma. BOLD participants reported fewer current mood symptoms and higher cognitive, social, and global functioning.

LIMITATIONS

Our findings may not be generalizable to all individuals diagnosed with BD living without maintenance medication due to selection-bias.

CONCLUSION

A group of individuals exists that meets diagnostic criteria of BD and is living without maintenance medication. They appear to be relatively successful in terms of psychosocial functioning, although they do not have a milder clinical course than those on maintenance medication. The high prevalence of childhood trauma warrants further investigation. Future analyses will examine differences between BOLD and DOBi per domain (e.g. cognition, physical health, psychosocial functioning, coping).

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.

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.

Cognitive functioning in late life affective disorders: Comparing older adults with bipolar disorder, late life depression and healthy controls

INTRODUCTION

Both older age bipolar disorder (OABD) and late life depression (LLD) have been associated with cognitive dysfunction. It is unclear how cognitive functioning differs between these disorders and what the influence of current depressive symptoms is.

METHODS

We compared OABD (n = 148), LLD (n = 378) and healthy controls (HC) (n = 132) on cognitive functioning. Cognitive functioning was measured by an extensive neuropsychological assessment, and divided into four domains: episodic memory, processing speed, interference inhibition and working memory. Separate linear regression analyses were conducted with OABD as reference category, controlling for age, gender, level of education and severity of depressive symptoms.

RESULTS

Our findings show that OABD and LLD patients exhibit more cognitive dysfunction than HC, with OABD showing worst cognitive functioning on all cognitive domains, except for interference inhibition. These differences remained significant, even after controlling for the effect of depressive symptoms at the time of testing.

DISCUSSION

Our findings suggest that cognitive dysfunction in OABD is more severe in magnitude albeit in the same domains as in LLD. This difference cannot be fully explained by the severity of depressive symptoms. Future research should focus on other disease characteristics and how these characteristics are associated with the complex concept of cognitive functioning in both OABD and LLD.

Disrupted network switching in euthymic bipolar disorder: Working memory and self-referential paradigms

BACKGROUND

Patients with bipolar disorder (BD) frequently suffer from neurocognitive deficits that can persist during periods of clinical stability. Specifically, impairments in executive functioning such as working memory and in self-processing have been identified as the main components of the neurocognitive profile observed in euthymic BD patients. The study of the neurobiological correlates of these state-independent alterations may be a prerequisite to develop reliable biomarkers in BD.

METHODS

A sample of 27 euthymic BD patients and 25 healthy participants (HC) completed working memory and self-referential functional Magnetic Resonance Imaging (fMRI) tasks. Activation maps obtained for each group and contrast images (i.e., 2-back > 1-back/self > control) were used for comparisons between patients and HC.

RESULTS

Euthymic BD patients, in comparison to HC, showed a higher ventromedial prefrontal cortex activation during working memory, a result driven by the lack of deactivation in BD patients. In addition, euthymic BD patients displayed a greater dorsomedial and dorsolateral prefrontal cortex activation during self-reference processing.

LIMITATIONS

Pharmacotherapy was described but not included as a confounder in our models. Sample size was modest.

CONCLUSION

Our findings revealed a lack of deactivation in the anterior default mode network (aDMN) during a working memory task, a finding consistent with prior research in BD patients, but also a higher activation in frontal regions within the central executive network (CEN) during self-processing. These results suggest that an imbalance of neural network dynamics underlying external/internal oriented cognition (the CEN and the aDMN, respectively) may be one of the first reliable biomarkers in euthymic bipolar patients.

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.

Aging in bipolar disorder: Cognitive performance and clinical factors based on an adulthood-lifespan perspective

BACKGROUND

The evolution of cognitive performance throughout the lifespan in bipolar disorder (BD) is understudied. This cross-sectional study aims to describe the cognitive performance across age groups.

METHODS

A sample of 654 participants was recruited for this study (BD = 432 and healthy controls -HC- =222). Three subgroups, divided according to age range (18 to 35, 36 to 49, and ≥50 years old) were analyzed after administering a comprehensive neuropsychological battery including six cognitive domains. Demographic, clinical, and psychosocial functioning data were also analyzed. Generalized linear models (GLM) with age, diagnostic group, and age × group as main effects were carried out to examine their potential association on cognitive domains. Subsequently, a GLM in the BD sample was conducted to analyze interactions of several clinical variables by age on each cognitive domain.

RESULTS

Main effects of diagnostic group and age were found in all cognitive domains. Significant group × age effect interaction was found for attention domain (p = 0.02) demonstrating a worse cognitive evolution across age in BD, driven by older age, but not in HC. Significant interaction effects of higher number of manic episodes and older age were also found in attention and verbal memory. Older age was also associated with a longer duration of illness, higher number of episodes, more somatic comorbidities, and poorer psychosocial functioning.

CONCLUSIONS

These results suggest that older age was associated with a selective cognitive decline in BD in the attentional domain. These findings highlight the importance of developing interventions targeting cognitive dysfunction throughout the BD adulthood lifespan.

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.

Identifying neurocognitive heterogeneity in Older Adults with Bipolar Disorder: a cluster analysis

BACKGROUND

Cognitive profiles of BD patients show a demonstrated heterogeneity among young and middle-aged patients, but this issue has not yet deeply explored in Older Adults with bipolar disorder (OABD). The aim of the present study was to analyze cognitive variability in a sample of OABD.

METHODS

A total of 138 OABD patients and 73 healthy controls were included in this study. A comprehensive neuropsychological assessment was administered. We performed a k-means cluster analysis method based on the neurocognitive performance to detect heterogeneous subgroups. Demographic, clinical, cognitive and functional variables were compared. Finally, univariate logistic regressions were conducted to detect variables associated with the severity of the cognitive impairment.

RESULTS

We identified three distinct clusters based on the severity of cognitive impairment: (1) a preserved group (n = 58; 42%) with similar cognitive performance to HC, (2) a group showing mild cognitive deficits in all cognitive domains (n = 64; 46%) and, finally, (3) a group exhibiting severe cognitive impairment (n = 16; 12%). Older age, late onset, higher number of psychiatric admissions and lower psychosocial functioning were associated with the greatest cognitive impairment. Lower age, more years of education and higher estimated IQ were associated with a preserve cognitive functioning.

LIMITATIONS

The small sample size of the severely impaired group.

CONCLUSIONS

Cognitive heterogeneity remains at late-life bipolar disorder. Demographic and specific illness factors are related to cognitive dysfunction. Detecting distinct cognitive subgroups may have significant clinical implications for tailoring specific intervention strategies adapted to the level of the impairment and also to prevent cognitive decline.