Bipolar Disorder in Later Life

Edited by Martha Sajatovic and Frederic C. Blow
Baltimore: Johns Hopkins University Press; 2007
280 pages • $50.00 (hardcover)

Among clinicians and researchers in geriatric psychiatry, interest in late-life bipolar disorder is growing, fueled not only by the increasing size of this clinical population but also by the recent discovery that mood stabilizers such as lithium (Eskalith, Lithobid) may influence the pathogenesis of Alzheimer disease. Until now, the literature on bipolar disorder in the elderly has been fairly scant. Old myths persist, such as the idea that bipolar disorder "burns out" in old age. Moreover, even today, it is not uncommon to see older persons with bipolar disorder treated with antidepressant monotherapy who are simply resigned to chronic symptoms and rapid cycling. Clearly, there is room for improvement in clinical care for this population.

Bipolar Disorder in Later Life provides a welcome starting point for review of what is known about late-life bipolar disorder. The editors-Martha Sajatovic and Frederic Blow-are well known for their work in the field of major psychiatric disorders in the elderly, and particularly bipolar disorder and its comorbid conditions. Twenty-three contributing authors lend their expertise to 1 of 4 sections of the book: Epidemiology and Assessment; Treatment; Complexity and Comorbidity; and Specialized Care Delivery and Research.

The chapters are well-researched and well-referenced and cover all the important issues of late-life bipolar disorder. The first section includes a discussion of the differences between early- and late-onset bipolar disorder in terms of etiology and symptom presentation, it examines mood rating scales and their application in geriatrics, and it makes a case for the use of data from the current Resident Assessment Instrument to address a number of research questions on bipolar disorder in the long-term care setting.

In the Treatment section, the first chapter includes a discussion of secondary mania and its causes and outlines a diagnostic workup to distinguish secondary mania from idiopathic disease. Subsequent chapters review the use of mood stabilizers, antipsychotics, antidepressants, and electroconvulsive therapy. The chapter covering psychosocial interventions gives an overview of the Life Goals Program, a structured, manual-based, group intervention to improve illness management skills. The last chapter of this section deals with treatment adherence in the elderly with bipolar disorder and suggests several strategies to improve adherence.

The Complexity and Comorbidity section includes chapters that are devoted to substance abuse and medical comorbidity-issues that are known to complicate diagnosis and treatment of late-life bipolar disorder. A chapter on cultural issues provides some thought-provoking examples of how the clinical presentation of bipolar disorder differs between cultures (eg, predom-inance of manic episodes among Israelis and depressive episodes among Europeans). The role of the Internet as a source of information (and misinformation) about bipolar disorder is discussed briefly.

In the last section, a convincing case is made that the quality of care for elderly patients with bipolar disorder is generally suboptimal. Performance-based quality measures are encouraged, as are guideline-based treatment models. The book concludes with chapters that cover evidence-based medicine and legal and ethical issues in bipolar disorder research involving older patients.

Bipolar Disorder in Later Life represents a solid contribution to the knowledge base in geriatric psychiatry. It is well indexed and includes numerous illustrative cases. Careful reading of the text yields many useful clinical pearls and will likely stimulate new areas of research inquiry.