A retrospective case-note study of bipolar disorder in old age

COMplex mental health PAThways (COMPAT) Study: A mixed methods study to inform an evidence-based service delivery model for people with complex needs: Study protocol

Background

Mental health services for adults, as they are currently configured, have been designed to provide predominantly community-based interventions. It has long been recognised that some patients have such significant clinical and/or risk needs that those needs cannot be adequately met within standard service delivery models, resulting in a pressing need to consider the best models for this group of people. This paper shares a protocol for a mixed methods study that aims to understand: the profile and history of service users described as having complex needs; the decision-making processes by clinicians that lead to complex needs categorisation; service users and carers experience of service use; and, associated economic impact. This protocol describes a comprehensive evaluation that aims to inform an evidence-based service delivery model for people with complex needs.

Methods

We will use a mixed methods design, combining quantitative and qualitative methods using in-depth descriptive and inferential analysis of patient records, written medical notes and in-depth interviews with service users, carers, and clinicians. The study will include five components: (1) a quantitative description and analysis of the demographic clinical characteristics of the patient group; (2) an economic evaluation of alternative patient pathways; (3) semi-structured interviews about service user and carer experiences; (4) using data from components 1–3 to co-produce vignettes jointly with relevant stakeholders involved in the care of service users with complex mental health needs; and, (5) semi-structured interviews about clinical decision-making by clinicians in relation to this patient group, using the vignettes as example case studies.

Discussion

The study’s key outcomes will be to: examine the resource use and cost-impact associated with alternative care pathways to the NHS and other sectors of the economy (including social care); explore patient health and non-health outcomes associated with alternative care pathways; and, gain an understanding of a complex service user group and how treatment decisions are made to inform consistent and person-centred future service delivery.

Geriatric bipolar disorder

Because the elderly are the fastest growing segment of the population, the number of older adults with bipolar disorder is increasing. Geriatric bipolar disorder is relatively rare, with an estimated lifetime prevalence of 0.5% to 1%, although approximately 4% to 17% of older patients in clinical psychiatric settings have bipolar disorder. Bipolar elders are disproportionately affected by medical burden. Given the complex nature of this disorder, comorbidity, and behavioral disturbances, various interventions may be indicated, including pharmacotherapies, electroconvulsive therapy, psychotherapies, and integrated care models. Additional research is needed to better understand the epidemiology, phenomenology, and treatment of geriatric bipolar disorder.

Mania and stroke: a systematic review

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Medical and substance-related comorbidity in bipolar disorder: translational research and treatment opportunities

It is well established that individuals with bipolar disorder are differentially affected by substance-related as well as medical disorders (ie, cardiometabolic disorders, respiratory disorders, neurological disorders, and infectious diseases). Emerging evidence indicates that some comorbid conditions (eg, diabetes mellitus) in bipolar individuals may be subserved by overlapping neurobiological networks. Disturbances in glucocorticoid/insulin signaling and immunoinflammatory effector systems are points of pathophysiological commonality between bipolar disorder and “stress-sensitive” medical disorders. Subphenotyping bipolar disorder as a function of comorbidity and temporality of onset may provide an opportunity for refining disease pathophysiological models and developing innovative disease-modifying therapies.

[Recurrences of bipolar disorders - comparative study of bipolar disorders, recurring depressions and single depressions in a cohort of patients aged over 65 years]

BACKGROUND

Bipolar mood disorders, after starting at adulthood, may remain active throughout life, but bipolar disorders may only be revealed in later life. Indeed, Yet few data on bipolar disorders in the elderly have been reported in the litterature. The influence of normal aging on the outcome of the disease as well as the specific prognosis of bipolar disorders in the elderly has occasionally been studied. Eventually Finally, and contrasting with adults, few studies comparing the various subtypes of mood disorders were have been performed in the elderly.

OBJECTIVES

We therefore developed a study in patients aged 65 or above, in order to evaluate the course (recurrences) of bipolar disorders, compared to recurring depressions and single depressions, and to determine the influence of recurrences on the outcome of bipolar disorders.

METHOD

Patients aged over 65 years were inpatients admitted to the department of psychiatry in 2000 for one of the three previously mentioned diagnoses according to DSM IV. Retrospective data were collected from medical reports. Prospectively, data were collected from the general practitioner of each patient (relying on telephone calls), before statistical analysis was performed.

RESULTS

Our study demonstrates a more severe outcome for bipolar disorders compared to recurring depressions and single depressions. Patients with bipolar disorders have a higher prevalence of psychiatric recurrences. Furthermore, the greater the number of previous relapses (or the longer the duration and intensity of the disease), the higher the risk of future new future recurrences both in bipolar disorders and recurring depressions. An age of onset of bipolar disorders before 60 years and more than 5 in-hospital admissions increase the risk of recurrences.

CONCLUSION

We originally compare the outcome of bipolar disorders in the elderly, to recurring depressions and single depressions. We confirm the fatal outcome of recurrences in bipolar disorders in old age. Bipolar disorders in the elderly should be considered as a real public health care problem: strategies to minimize the number of episodes experienced by patients with bipolar illness must be pursued aggressively throughout life.

Vascular mania: an old concept in danger of sclerosing? A clinical overview

OBJECTIVE

To review the evidence for an association between vascular disease and mania, and in this context, to assess the suitability of previously proposed diagnostic criteria.

METHOD

Relevant articles were retrieved and reviewed with the aid of search engines [MEDLINE, PsychInfo and EMBASE from 1996 to 2006] using pertinent search terms. Because of the paucity of data, systematic criteria for levels of evidence could not be applied.

RESULTS

The literature is limited by the preponderance of case reports or case series, the use of overlapping terms, such as secondary mania, disinhibition syndrome and poststroke mania, and variable definitions of mania per se. There is general support for a tentative association between mania and vascular risk factors, and also between mania and cerebrovascular disease. Such associations seem best described by the term vascular mania for the sake of clinical utility, although it erroneously conveys causality. Proposed diagnostic criteria have defined a late-age at onset (50 years +) sub-type of mania, with associated neuroimaging and neuropsychological changes which are not specific to this age group.

CONCLUSION

Further studies are needed to determine whether mania associated with vascular disease is a specific and separate sub-type with a late-age at onset. An alternative framework for considering vascular mania is proposed.

Medical comorbidity in bipolar disorder: re-prioritizing unmet needs

PURPOSE OF REVIEW

The aim of this review is to synthesize results from extant investigations which report on the co-occurrence of bipolar disorder and medical comorbidity.

RECENT FINDINGS

We conducted a MEDLINE search of all English-language articles published between January 2004 and November 2006. Most studies report on medical comorbidity in bipolar samples; relatively fewer studies report the reciprocal association. Individuals with bipolar disorder are differentially affected by several 'stress-sensitive' medical disorders notably circulatory disorders, obesity and diabetes mellitus. Neurological disorders (e.g. migraine), respiratory disorders and infectious diseases are also prevalent. Although relatively few studies have scrutinized the co-occurrence of bipolar disorder in medical settings, individuals with epilepsy, multiple sclerosis, migraine and circulatory disorders may have a higher prevalence of bipolar disorder. A clustering of traditional and emerging (e.g. immuno-inflammatory activation) risk factors presage somatic health issues in the bipolar disorder population. Iatrogenic factors and insufficient access to primary, preventive and integrated healthcare systems are also contributory.

SUMMARY

Somatic health issues in individuals with bipolar disorder are ubiquitous, under-recognized and suboptimally treated. Facile screening for risk factors and laboratory abnormalities along with behavioral modification for reducing medical comorbidity are warranted.

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

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

Cognitive impairment in bipolar disorder in old age: literature review and findings in manic patients

BACKGROUND

Descriptions of aged patients with bipolar (BP) disorder have commented on cognitive impairments. However, the literature regarding cognitive test performance in this population has apparently been scant.

METHOD

1. We reviewed studies reporting cognitive performance in aged BP patients. 2. We compared the performance of elderly BP manic patients and aged community comparison subjects on the Mini-Mental State Examination (MMSE) and the Mattis Dementia Rating Scale (DRS).

RESULTS

1. Seven published studies of cognitive measures in aged BP patients were identified. They utilized different assessment methods and addressed different illness states, but they indicate impairments in these patients. 2. In our sample, the manic patients (n=70) had lower MMSE scores and DRS scores than did the comparison subjects (n=37). In these patients, cognitive scores were not significantly associated with Mania Rating Scale scores.

LIMITATIONS

The patients in our study were assessed cross-sectionally, and they were treated naturalistically.

CONCLUSIONS

Manic or depressed BP elders have impaired cognitive function; in some patients these impairments may persist. Research characterizing these impairments and their clinical implications is warranted.

Bipolar disorder in older adults: a critical review

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Late-life mood disorders

Mental disorders are not uncommon in late life. Although most psychiatric disorders occur less frequently in older populations compared with populations of younger adults, more than 10% of older adults have one or more psychiatric disorders. In addition, many older adults present with symptoms that do not meet the criteria for a specific disorder but nevertheless are clinically significant and affect quality of life. In this article the authors summarize the epidemiologic data for five psychiatric disorders and their subclinical forms: depression, anxiety, dementia, schizophrenia, and alcoholism. Also included is a discussion of risk factors and outcomes of these disorders.

Age-at-first-registration and heterogeneity in affective psychoses

BACKGROUND

Previous research into age of onset in affective disorders has produced conflicting results. This paper examines the influence of heterogeneity on the age-at-first-registration distribution for the ICD-9 diagnostic group 'affective psychosis'.

METHOD

For 1979-1991, data for age-at-first-registration for 4985 individuals diagnosed with affective psychosis (ICD-9 296.x) were extracted from a name-linked mental health register. These data were divided into (i) '296.1 only', a category used to code unipolar depression (males = 700; females = 1321); and (ii) '296 other', all 296 cases other than 296.1 (males = 1280; females = 1684). Inception rates for each 5-year age division were adjusted for the background population age-structure as a rate per 100,000 population.

RESULTS

The age-at-first-registration distribution for affective psychosis has a wide age range, with women outnumbering men. There is a near-linear increase in inception rates for both men and women with 296.1 only, while the bulk of those with affective psychoses (296 other) have an inverted U-shaped age distribution. Males have an earlier modal age-at-first-registration for 296 other compared to females.

CONCLUSION

The heterogeneity in terms of subtypes and sex in affective psychosis clouds the interpretation of age-at-first-registration. Separating those with unipolar psychotic depression from other subclassifications and differentiating by sex may provide clues to factors that precipitate the onset of affective psychosis.

Biological risk factors in late life depression

A number of biological risk factors have been tentatively identified for unipolar and bipolar disorder in the elderly. The list includes genetic factors as well as medical illness in general and vascular disease in particular. Most of these risk factors have been identified on the basis of cross sectional studies rather than longitudinal studies. There is a need for long term epidemiologic and prevention studies (in the case of modifiable risk factors). The modifiable risk factors include medical illness in general and vascular disease in particular. An example is the use of antidepressants following stroke to prevent the onset of depression. Of particular interest is the role of vascular risk factors and MRI changes suggesting subtle cerebrovascular disease in the development of depression and bipolar disorder in late life. The changes have been established using both clinical samples and in the case of depression in cross sectional epidemiologic samples. The location of these cerebrovascular changes has contributed to our understanding of the regions of the brain implicated in the pathophysiology of depression. Further longitudinal and preventive studies are needed to conclusively demonstrate these as biological risk factors.

Pharmacologic treatment of geriatric mania

The prevalence of geriatric mania is uncertain. Although there are high rates of mania in clinical and residential facilities, community based epidemiologic studies are limited. Given the difficulty in making an accurate diagnosis, geriatric mania appears to be underreported. Although the commonly held opinion is that onset and prevalence of mania decreases with age, there is contradictory evidence that, particularly in men, the incidence of new onset mania increases with age. Clinically, the diagnosis and treatment of geriatric mania is challenging, because these patients present with comorbid medical, neurologic, and dementing illnesses. This paper reviews presentations of mania in the elderly and updates the pharmacologic treatment of mania in the elderly. Although few of the studies target the elderly, the published data in younger patients on the use of the atypical antipsychotics, as well as the advent of newer anticonvulsants, have demonstrated promise in the treatment of older patients.

Mania in neurologic disorders

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

Differential pharmacokinetics of lithium in elderly patients

The pharmacotherapeutic use of lithium in the elderly as acute and maintenance therapy in bipolar disorder and augmentation therapy for major depression is well documented. Differences in the response to lithium are explained, in part, by the effect of age-related physiological changes, comorbid conditions, and concurrent medications on the pharmacokinetics of lithium in the elderly. The pharmacokinetic profile of lithium has been studied for many years, primarily in younger adult populations. Lithium pharmacokinetics may be influenced by a number of factors including age. It was first noted several years ago that elderly individuals required lower doses of lithium to achieve serum concentrations similar to those observed in younger adults. This is due to the combination of a reduced volume of distribution and reduced renal clearance. The composition of the human body changes with aging producing an increase in body fat, a decrease in fat-free mass and a decrease in total body water. Lithium clearance decreases as the glomerular filtration rate decreases with increasing age. The effects of other medical conditions in the elderly on the pharmacokinetics of lithium are less well delineated. Reduced lithium clearance is expected in patients with hypertension, congestive heart failure or renal dysfunction. Larger lithium maintenance doses are required in obese compared with non-obese patients. The most clinically significant pharmacokinetic drug interactions associated with lithium involve drugs which are commonly used in the elderly. Thiazide diuretics, ACE inhibitors, and nonsteroidal anti-inflammatory drugs can increase serum lithium concentrations. The tolerability of lithium is lower in the elderly. Neurotoxicity clearly occurs in the elderly at concentrations considered 'therapeutic' in general adult populations. There are no placebo-controlled randomised trials of lithium in old age and recommendations for clinical use are based on extrapolations from pharmacokinetic studies, anecdotal reports from mixed age populations and clinical experience in old age psychiatry. Serum concentrations of lithium need to be markedly reduced in the elderly population and particularly so in the very old and frail elderly.

The nature and management of mania in old age

Mania in old age represents a syndrome involving affective vulnerability in association with neurologic lesions that affect specific areas of the brain. Most patients suffering from mania in late life have converted to bipolarity later in life after many years and often repeated episodes of depression or else have developed mania in association with specific neurologic insults, particularly cerebrovascular disease (vascular mania). The outcome is generally worse in mania than in depression with higher prevalence of cognitive dysfunction, persistent symptoms, and greater mortality. The management of elderly bipolar patients with mood stabilizers reflects the experience with a mixed age population primarily involving the use of lithium carbonate and valproate in appropriately adjusted dosages and serum levels, with valproate having an edge on better tolerability. The use of neuroleptics is often unavoidable in initial stabilization, and electroconvulsive therapy can be life-saving in severely overactive or refractory patients.

Mania in the geriatric patient population: a review of the literature

The diagnosis of mania in the geriatric population is uncommon. However, it comprises significant healthcare utilization and cost requirements, which are expected to increase in the near future with the projected increase in the geriatric population. The authors review literature pertaining to geriatric mania and discuss epidemiology, psychopathology, neuropathology, differential diagnosis, evaluation, treatment, and outcomes. Literature searches were performed by GratefulMed for the years 1960-1997, with secondary- and tertiary-source follow-up. It is clear from this review that geriatric mania is a complex illness with many possible etiologies and treatments. Much more research needs to be conducted in all of the areas reviewed.

Post-stroke mania late in life involving the left hemisphere

OBJECTIVE

Although post-stroke depression is well recognised, post-stroke mania has rarely been reported and researched. Most reported cases have involved lesions of the non-dominant hemisphere. We report a case of late-onset mania following stroke with a lesion in the dominant hemisphere.

CLINICAL PICTURE

A 78-year-old, right-handed man developed sudden cognitive deficits and manic symptoms. Investigations revealed lesions in the dominant hemisphere.

TREATMENT

Pharmacological intervention was complicated by side effects.

OUTCOME

His symptoms resolved gradually over 2 months and he was back to normal in 4 months.

CONCLUSIONS

We would encourage further study in the area of post-stroke mania and especially in relation to the site of the lesion in the brain.

Bipolar disorder in the latter half of life: symptom presentation, global functioning and age of onset

BACKGROUND

Little is known about bipolar disorder in late life. Recent research has been in acute, in-patient, settings, and has focused on late-onset mania, or has produced samples with surprisingly late mean ages of onset. No recent study has used a larger out-patient sample to address late-life outcomes of bipolar disorder.

METHODS

86 community-residing, middle-aged and older adults who met RDC for bipolar I or II were interviewed using the Schedule for Affective Disorders and Schizophrenia, three times over 8 months.

RESULTS

Participants were primarily unmarried and impoverished. Most were living alone or with immediate family members. The majority were in depressive episodes. Depressive symptoms were more common and more predictive of functioning than manic symptoms. Age of onset was related to global functioning. The effect of age of onset was mediated by number of depressive episodes.

CONCLUSION

Most adults in this sample had supports to maintain them in the community in spite of chronic or intermittently cycling manifestations of affective disorder and limited medication. Consistent with prior research, early age of onset was related to poorer functioning, apparently by increasing the number and severity of depressive episodes.

LIMITATIONS

Limitations stem from possible exclusion of those people with the worst and best outcomes. It also is a relatively young sample for a gerontological study.

CLINICAL RELEVANCE

The study suggests that more attention needs to be paid to diagnosing and treating depressive episodes in later life.

Bipolar disorder in late life: a review

Although there is a broad base of literature on depression among elderly patients and on mania in younger patients, there is a relative paucity of information on bipolar disorder in the elderly population. While the quantities of data reflect the relative prevalences of these illnesses, there is evidence to suggest that classification of mania in the elderly with respect to age of onset, natural course, family history, and pathophysiology may be useful in understanding the heterogeneous etiologies of this syndrome. This paper presents a review of the literature on the incidence and course of illness in late-life bipolar disorder. Further, dilemmas of diagnostic classification in relation to associated risk factors will be discussed.

Assessment and treatment of bipolar disorder in the elderly

The aetiology of late-onset bipolar disorder is heterogeneous because the disease is more likely to have a secondary (i.e. a medical disorder or medication-induced) cause in older than in younger patients. Elderly patients with bipolar disorder typically require lithium dosages that are 25 to 50% lower than those used in younger individuals. Information on the use of valproic acid (sodium valproate) in elderly patients with bipolar disorder is limited but encouraging. In contrast, there is virtually no information regarding the use of carbamazepine or other drugs in this patient group. Electroconvulsive therapy is well tolerated by older people and can be useful for these patients.

Disinhibition syndromes, secondary mania and bipolar disorder in old age

BACKGROUND

The neurological literature concerning disinhibition syndromes and secondary mania has run in parallel to clinical reports of bipolar disorder in old age.

METHODS

A critical review was conducted of both the neurological and geriatric psychiatry literature in an attempt to integrate the two streams.

RESULTS

Disinhibition syndromes include lateralization to the right hemisphere and localization of lesions to the orbito-frontal and basotemporal cortex involving limbic and frontal connections (orbito-frontal circuit). Mania in old age is associated with late onset, heterogeneous neurological disorders and poor outcome.

CONCLUSION

Bipolar disorders in old age may be understood in the context of affective vulnerability influenced by a specific neurobiologic substrate.

LIMITATIONS

The clinical literature consists predominantly of small case series and anecdotal reports.

CLINICAL RELEVANCE

Improved understanding of these syndromes may elucidate the pathogenesis and etiology of bipolar disorders and the neuropsychiatric syndromes affecting mood, motivation and behavioural disinhibition.