Difficulties Diagnosing Geriatric Bipolar Disorder

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In their presentation at the 2021 American Association for Geriatric Psychiatry virtual annual meeting, “Management of Geriatric Bipolar Disorder: A Case Series and Review of Current Evidence Based Treatment Guidelines,” Rana Jawish, MD, and colleague David Atkison, MD, noted the challenges of treating bipolar disorder (BD) in older patients and future possibilities for treatment.

“Compared to younger patients, older patients with bipolar disorder spend less time manic and more time depressed,” said Jawish.

A huge concern is misdiagnosis: 40% to 60% of patients with BD are misdiagnosed, often with major depressive disorder or borderline personality disorder. According to one study Jawish reviewed, 28% of geriatric patients with a neurodegenerative disease received a psychiatric diagnosis, commonly depression.¹ 

It may be difficult to differentiate BD from depression in geriatric patients. Jawish stated these indicators might signify BD in patients with depression: family history of BD; early onset, like in early 20s; seasonality; numerous previous episodes; history of antidepressant-induced episodes, such as mania or hypomania; history of treatment-resistant depression; previous inpatient hospitalizations; and previous suicide attempts.

Also surprising, there is only 1 randomized controlled trial in geriatric BD comparing lithium and divalproex for the treatment of mania and hypomania.² Post-hoc analyses of mixed age trials suggest that medications effective in a younger cohort are effective for geriatric patients as well.

“Only one trial,” Jawish emphasized. “What works for everyone will work for the geriatric population with bipolar too.”

Another issue is late diagnosis. “Due to stigma about seeking mental health treatment, there could be a delay between a patient experiencing significant, distressing symptoms and presenting to care for a diagnosis,” said Atkinson.

With late diagnoses, many patients do not receive a formal diagnosis of BD until their 50s or 60s, an age range where the onset of neurodegenerative diseases is more common. BD might then be mistaken for frontal temporal dementia.

“This is an area that needs more studies,” said Atkinson.

Overall, in their synthesis of existing guidelines, geriatric principles, and case series observations, Jawish and Atkinson agreed that medications intended for general population use were also effective for geriatric populations.

Reference

1. Woolley JD, Khan BK, Murthy NK, et al. The diagnostic challenge of psychiatric symptoms in neurodegenerative disease: rates of and risk factors for prior psychiatric diagnosis in patients with early neurodegenerative disease. J Clin Psychiatry. 2011;72(2):126-133.

2. Young RC, Mulsant BH, Sajatovic M, et al. Geri-BD: A Randomized Double-Blind Controlled Trial of Lithium and Divalproex in the Treatment of Mania in Older Patients with Bipolar Disorder. Am J Psychiatry. 2017;174(11):1086–1093.