Assessment of Individuals With Older Age Bipolar Disorder

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The DSM-5 describes bipolar disorder (BD) as a condition that is characterized by recurrent and/or cyclical episodes of mania or hypomania and depression.¹ In the DSM-5, there are 2 subtypes of BD: bipolar I disorder (BD-I) and bipolar II disorder (BD-II). A diagnosis of BD-I is established if an individual experiences at least 1 manic episode with additional major depressive and/or hypomanic episodes. Individuals are diagnosed with BD-II if they experience at least 1 hypomanic episode and at least 1 major depressive episode without any manic episodes. Although BD is not as common among older adults as it is among younger adults, available evidence indicates that the total number of older adults with BD is expected to increase significantly over the next few decades.^2,3 It has been observed that between 1980 and 1998, the relative frequency of late-onset bipolar disorder increased from 1% to 11%.⁴

According to the International Society for Bipolar Disorders (ISBD) Task Force, “older age bipolar disorder” (OABD) is defined as BD occurring in individuals ≥ 50 years of age.5One quarter of all cases of BD occur among individuals ≥ 60 years of age and > 10% of the cases occurred among individuals ≥ 70 years of age.⁶

OABD has a point prevalence of 0.1% to 0.5% and a lifetime prevalence of 0.5% to 1.0%.⁷ Among older adults who are diagnosed with a mood disorder, 10% to 25% have BD.^8,9 New-onset mania later in life occurs in approximately 10% of individuals with OABD, and it is often associated with neurovascular disease.³ Among older adults who go to the emergency room for a psychiatric evaluation, BD has been noted in 17% of cases.⁸ Approximately 8% to 10% of geriatric inpatient admissions and 6% of geriatric psychiatry outpatient visits include individuals with OABD. Among individuals who live in residential psychiatric program for older adults, the prevalence of bipolar disorder is approximately 17.4%.⁸ A diagnosis of BD is noted in approximately 3% of older nursing home residents and 9.7% of older chronically institutionalized individuals. Approximately 70% of individuals with OABD are women.⁸

Comparison Between OABD and Early-Onset Bipolar Disorder

Individuals with OABD often present with depression rather than hypomania or mania as the presenting symptom.^10-12 They also tend have more frequent recurrences of depressive episodes and present with symptoms that are severe.¹³ In contrast to individuals with early-onset bipolar disorder (EOBD), individuals with OABD present with greater latency periods between the initial and subsequent mood episodes.¹¹ There is also significantly less family history of mood disorders noted among individuals with OABD when compared to individuals with EOBD.^10,14 These individuals also have a history of more stressful life events when compared to age-matched controls.¹⁵

Individuals with OABD also present with more comorbid conditions including cardiovascular, respiratory, endocrine, and metabolic disorders.^16-19 These individuals often present with an average of 3 to 4 comorbid medical conditions.²⁰ These comorbid conditions also worsen outcomes for individuals with OAD, including the risk for suicide.^18,19

When compared to individuals with EOBD, individuals with OABD often present with greater association with cerebrovascular disease and other neurological disorders.⁷ They often present with increased white-matter hyperintensities in frontal, parietal, and putaminal brain areas.^21-23 Individuals with OABD may have greater cortical sulcal widening and lateral ventricle-brain ratio scores when compared to individuals with EOBD.^24,25 On neuroimaging studies, these individuals present with greater morphological abnormalities of the brain when compared to individuals with EOBD.²⁶ It has also been noted that among individuals with OABD, depressive symptoms are often associated with left cerebral hemisphere vascular lesions, whereas manic symptoms are often associated with right cerebral hemisphere vascular changes.^26,27

Available evidence indicates that when compared to age-matched controls, psychiatric comorbidities are more common among individuals with OABD, but the rates of these comorbidities are lower than what is seen among individuals with EOAD.²³ Alcohol use disorder is the most common comorbid psychiatric disorder among individuals with OABD, with a 12-month and a lifetime prevalence of 38.1% and 38.1%, respectively.²⁸ The other common psychiatric comorbidities are (12-month and lifetime prevalence rates): panic disorder (11.9% and 19.0%), generalized anxiety disorder (9.5% and 20.5%), and dysthymia (7.1% and 15.5%). It has been noted that older women with OABD have a greater prevalence of panic disorder when compared to age-matched controls, whereas older men have a greater prevalence of alcoholism.²⁸ Available evidence indicates that the prevalence rates for psychotic symptoms among individuals with OABD are similar to those of individuals with EOBD.⁸ When compared to individuals with EOBD, the risk for suicide among individuals with OABD appears to be lower.⁵

When compared to age-matched controls, varying degrees of cognitive impairment have been identified among a majority of individuals with OABD.²⁹ These include lower Mattis Dementia Rating Scale (DRS) scores (P=0.0003) and Mini-Mental State Examination (MMSE) scores (P=0.0007). When compared to individuals with EOBD, about half of individuals with OABD score ≥ 1 standard deviation (SD) below the mean on the DRS and MMSE total scores.³⁰ However, no correlation has been noted between the Young Mania Rating Scale (YMRS) scores and the cognitive functioning among these individuals.²⁹ Available evidence indicates that individuals with OABD also present with worse psychomotor functioning and mental flexibility when compared to individuals with EOBD.³¹ Greater cognitive impairment has been noted among individuals with OABD who have more vascular risk factors and a greater number of hospitalizations.³²

Table. Differences Between EOBD and OABD

When compared to age-matched individuals with unipolar depression, individuals with OABD have an earlier age at onset of illness.³³ They are also noted to have higher total symptom severity, to have higher positive symptom scores, and to be more impaired in community living skills.³³ When compared to aged-matched controls, these individuals are also 4 times more likely to use mental health services and 4 times more likely to have psychiatric hospitalizations. The Table describes the difference between EOBD and OABD.³⁴

Diagnosis

It is imperative to obtain a detailed history when assessing individuals with OABD.³⁴ This history will also help identify individuals who develop mood symptoms due to secondary medical and/or neurological disorders. Additionally, individuals who develop mood swings due to the effects of prescribed drugs or drugs of abuse can be identified by obtaining a thorough history. Comorbid medical and/or neurological disorders can be identified by a focused physical examination. Laboratory workup can also identify common conditions that cause mood symptoms, including hyperthyroidism.³⁴ Laboratory workup that is commonly ordered as a screening tool among individuals with OABD include a complete blood count, a complete metabolic panel, a thyroid panel, urine-analysis and culture, and drug screen. Additional tests that can be ordered include vitamin B12 and folate levels, rapid plasma regain/Venereal Disease Research Laboratory test, and human immunodeficiency virus (HIV) testing if nutritional deficiency, neurosyphilis, or HIV infections are suspected as possible comorbid conditions. If cerebrovascular disease is suspected as a possible etiology for mood symptoms or there is evidence of cognitive dysfunction among individuals with OABD, computerized tomography or magnetic resonance imaging scans can be obtained.³⁴

Figure. Process for Diagnosing OABD

Although there are no specific screening tools for the diagnosis of OABD, some available instruments can assist with quantifying and qualifying the symptoms of OABD and in monitoring their progress. The Mood Disorder Questionnaire is a common screening tool that has been identified as having good sensitivity and specificity for detecting a lifetime history of mania or hypomania, although the potential for over-diagnosis of BD is a known limitation for this screening instrument.^35,36 Other screening instruments include the Bipolar Spectrum Diagnostic Scale, the Hypomanic Personality Scale, the Bipolar Depression Rating Scale, and the YMRS.^38-40 The most widely used clinical assessment tool for the diagnosis of bipolar disorder is the structured clinical interview from the DSM-IV.³⁷ After the screening process, the DSM-5 criteria can assist with confirming the diagnosis of BD.¹ The Figure describes the process for diagnosing OABD.³⁴

Concluding Thoughts

Available evidence indicates that OABD is not an uncommon condition. Individuals with OABD present with less family history of psychiatric disorders but greater burden of medical comorbidities when compared to individuals with EOBD. When compared to age-matched controls, these individuals have higher rates of health care service utilization and worse outcomes. It is imperative to rule out underlying medical disorders, adverse effects of prescribed medications, and/or the adverse effects of drugs of abuse as possible etiologies for OABD.

Dr Tampi is professor and chairman of the Department of Psychiatry at Creighton University School of Medicine and Catholic Health Initiatives (CHI) Health Behavioral Health Services in Omaha, Nebraska. He is also an adjunct professor of psychiatry at Yale School of Medicine. Ms Tampi is cofounder and managing principal of Behavioral Health Advisory Group in Princeton, New Jersey.

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