Purpose of Review
The population over age 60 is growing more rapidly than the general population. Given the projected increase and need for data that can inform treatment, this review provides a ...brief description of newer publications focused on mania in older-age bipolar disorder (OABD), including epidemiology, diagnosis, and treatments.
Recent Findings
Age cutoffs to define OABD range from 50 to 65 years. OABD clinical presentation and course of illness is highly variable, often characterized by mood episode recurrence, medical comorbidity, cognitive deficits, and impaired functioning. There is little pharmacotherapy data on mania in OABD. Lithium and valproate have been tested in a single randomized controlled trial and there is data of more limited quality with other compounds.
Summary
Treating OABD is challenging due to medical complexity, comorbidity, diminished tolerance to treatment, and a limited evidence base. More data is needed to keep pace with clinical demand.
Older Age Bipolar Disorder Dols, Annemiek; Beekman, Aartjan
The Psychiatric clinics of North America,
03/2018, Letnik:
41, Številka:
1
Journal Article
Recenzirano
Further understanding of older age bipolar disorder (OABD) may lead to more specific recommendations for treatment adjusted to the specific characteristics and needs caused by age-related somatic and ...cognitive changes. Late-onset mania has a broad differential diagnosis and requires full psychiatric and somatic work-up, including brain imaging. Research on pharmacotherapy in OABD is limited. First-line treatment of OABD is similar to that for adult bipolar disorder (BD), with specific attention to vulnerability to side effects and somatic comorbidity. Because findings in younger adults with BD cannot be extrapolated to OABD, more research in OABD is warranted.
Although deficits in social cognition are established as core features in behavioral variant frontotemporal dementia (bvFTD), it remains unresolved if impaired social cognition distinguishes bvFTD ...from the broad differential diagnoses in clinical practice. Our aim was to study whether social cognition discriminates bvFTD from other neurodegenerative diseases and psychiatric disorders in patients presenting with late-onset frontal symptoms. Next, we studied the association of social cognition with frontal symptoms and cognitive functioning.
In this longitudinal multicenter study, besides clinical rating scales for frontal symptoms, social cognition was determined by Ekman 60 Faces test and Faux Pas in addition to neuropsychological tests for other cognitive domains in patients with probable and definite bvFTD (N = 22), other neurodegenerative diseases (N = 24), and psychiatric disorders (N = 33). Median symptom duration was 2.8 years, and patients were prospectively followed over 2 years.
Total scores from Ekman 60 Faces test were significantly lower in bvFTD than in other neurodegenerative diseases and psychiatric disorders. Ekman 60 Faces test explained 91.2% of the variance of psychiatric disorders and other neurodegenerative diseases versus bvFTD (χ
= 11.02, df = 1, p = 0.001) and was associated with all other cognitive domains. Faux Pas and the other cognitive domains did not differ between these diagnostic groups.
In this clinical sample Ekman 60 Faces test distinguished bvFTD successfully from other neurodegenerative diseases and psychiatric disorders. Although associated with social cognition, other cognitive domains were not discriminative. This study provides arguments to add the Ekman 60 Faces test to the neuropsychological examination in the diagnostic procedure of bvFTD.
The clinical profile of late-life depression (LLD) is frequently associated with cognitive impairment, aging-related brain changes, and somatic comorbidity. This two-site naturalistic longitudinal ...study aimed to explore differences in clinical and brain characteristics and response to electroconvulsive therapy (ECT) in early- (EOD) versus late-onset (LOD) late-life depression (respectively onset <55 and ≥55 years).
Between January 2011 and December 2013, 110 patients aged 55 years and older with ECT-treated unipolar depression were included in The Mood Disorders in Elderly treated with ECT study. Clinical profile and somatic health were assessed. Magnetic resonance imaging (MRI) scans were performed before the first ECT and visually rated.
Response rate was 78.2% and similar between the two sites but significantly higher in LOD compared with EOD (86.9 versus 67.3%). Clinical, somatic, and brain characteristics were not different between EOD and LOD. Response to ECT was associated with late age at onset and presence of psychotic symptoms and not with structural MRI characteristics. In EOD only, the odds for a higher response were associated with a shorter index episode.
The clinical profile, somatic comorbidities, and brain characteristics in LLD were similar in EOD and LOD. Nevertheless, patients with LOD showed a superior response to ECT compared with patients with EOD. Our results indicate that ECT is very effective in LLD, even in vascular burdened patients.
Objectives
In the coming generation, older adults with bipolar disorder (BD) will increase in absolute numbers as well as proportion of the general population. This is the first report of the ...International Society for Bipolar Disorder (ISBD) Task Force on Older‐Age Bipolar Disorder (OABD).
Methods
This task force report addresses the unique aspects of OABD including epidemiology and clinical features, neuropathology and biomarkers, physical health, cognition, and care approaches.
Results
The report describes an expert consensus summary on OABD that is intended to advance the care of patients, and shed light on issues of relevance to BD research across the lifespan. Although there is still a dearth of research and health efforts focused on older adults with BD, emerging data have brought some answers, innovative questions, and novel perspectives related to the notion of late onset, medical comorbidity, and the vexing issue of cognitive impairment and decline.
Conclusions
Improving our understanding of the biological, clinical, and social underpinnings relevant to OABD is an indispensable step in building a complete map of BD across the lifespan.
Objective
The pathology of frontotemporal dementia, termed frontotemporal lobar degeneration (FTLD), is characterized by distinct molecular classes of aggregated proteins, the most common being TAR ...DNA‐binding protein‐43 (TDP‐43), tau, and fused in sarcoma (FUS). With a few exceptions, it is currently not possible to predict the underlying pathology based on the clinical syndrome. In this study, we set out to investigate the relationship between pathological and clinical presentation at single symptom level, including neuropsychiatric features.
Methods
The presence or absence of symptoms from the current clinical guidelines, together with neuropsychiatric features, such as hallucinations and delusions, were scored and compared across pathological groups in a cohort of 150 brain donors.
Results
Our cohort consisted of 68.6% FTLD donors (35.3% TDP‐43, 28% tau, and 5.3% FUS) and 31.3% non‐FTLD donors with a clinical diagnosis of frontotemporal dementia and a different pathological substrate, such as Alzheimer's disease (23%). The presence of hyperorality points to FTLD rather than non‐FTLD pathology (p < 0.001). Within the FTLD group, hallucinations in the initial years of the disease were related to TDP‐43 pathology (p = 0.02), including but not limited to chromosome 9 open reading frame 72 (C9orf72) repeat expansion carriers. The presence of perseverative or compulsive behavior was more common in the TDP‐B and TDP‐C histotypes (p = 0.002).
Interpretation
Our findings indicate that neuropsychiatric features are common in FTLD and form an important indicator of underlying pathology. In order to allow better inclusion of patients in targeted molecular trials, the routine evaluation of patients with frontotemporal dementia should include the presence and nature of neuropsychiatric symptoms. ANN NEUROL 2020;87:950–961
Objects
Studies of older age bipolar disorder (OABD) have mostly focused on “younger old” individuals. Little is known about the oldest OABD (OOABD) individuals aged ≥70 years old. The Global Aging ...and Geriatric Experiments in Bipolar Disorder (GAGE‐BD) project provides an opportunity to evaluate the OOABD group to understand their characteristics compared to younger groups.
Methods
We conducted cross‐sectional analyses of the GAGE‐BD database, an integrated, harmonized dataset from 19 international studies. We compared the sociodemographic and clinical characteristics of those aged <50 (YABD, n = 184), 50–69 (OABD, n = 881), and ≥70 (OOABD, n = 304). To standardize the comparisons between age categories and all characteristics, we used multinomial logistic regression models with age category as the dependent variable, with each characteristic as the independent variable, and clustering of standard errors to account for the correlation between observations from each of the studies.
Results
OOABD and OABD had lower severity of manic symptoms (Mean YMRS = 3.3, 3.8 respectively) than YABD (YMRS = 7.6), and lower depressive symptoms (% of absent = 65.4%, and 59.5% respectively) than YABD (18.3%). OOABD and OABD had higher physical burden than YABD, especially in the cardiovascular domain (prevalence = 65% in OOABD, 41% in OABD and 17% in YABD); OOABD had the highest prevalence (56%) in the musculoskeletal domain (significantly differed from 39% in OABD and 31% in YABD which didn't differ from each other). Overall, OOABD had significant cumulative physical burden in numbers of domains (mean = 4) compared to both OABD (mean = 2) and YABD (mean = 1). OOABD had the lowest rates of suicidal thoughts (10%), which significantly differed from YABD (26%) though didn't differ from OABD (21%). Functional status was higher in both OOABD (GAF = 63) and OABD (GAF = 64), though only OABD had significantly higher function than YABD (GAF = 59).
Conclusions
OOABD have unique features, suggesting that (1) OOABD individuals may be easier to manage psychiatrically, but require more attention to comorbid physical conditions; (2) OOABD is a survivor cohort associated with resilience despite high medical burden, warranting both qualitative and quantitative methods to better understand how to advance clinical care and ways to age successfully with BD.
Key points
Limited knowledge of older and oldest older age bipolar disorder derived from limited sample sizes.
The Global Aging and Geriatric Experiments in Bipolar Disorder consortium provided international data to compare younger age, older age, and oldest older age people with BD
International sites (n = 14) provided data on patients aged <50 (n = 184 YABD), 50–69 (n = 881 OABD), and ≥70 (n = 304 OOABD) to assess differences among three groups
OABD and OOABD represent distinct cohorts within BD and differ in sociodemographic and clinical characteristics from YABD in general. OOABD individuals may be easier to manage psychiatrically but require more attention to their comorbid physical conditions. OOABD likely is a survivor cohort associated with resilience despite high medical burden, warranting future study using both qualitative and quantitative methods to better understand what makes OOABD resilient, how to advance clinical care and age successfully with BD.
Recent longitudinal neuroimaging studies in patients with electroconvulsive therapy (ECT) suggest local effects of electric stimulation (lateralized) occur in tandem with global seizure activity ...(generalized). We used electric field (EF) modeling in 151 ECT treated patients with depression to determine the regional relationships between EF, unbiased longitudinal volume change, and antidepressant response across 85 brain regions. The majority of regional volumes increased significantly, and volumetric changes correlated with regional electric field (t = 3.77, df = 83, r = 0.38, p=0.0003). After controlling for nuisance variables (age, treatment number, and study site), we identified two regions (left amygdala and left hippocampus) with a strong relationship between EF and volume change (FDR corrected p<0.01). However, neither structural volume changes nor electric field was associated with antidepressant response. In summary, we showed that high electrical fields are strongly associated with robust volume changes in a dose-dependent fashion.
Bipolar disorder is associated with concurrent mental and physical disorders. Although well studied among younger adults, less is known about concurrent morbidity among older patients. This is ...important because comorbidity may increase with age and optimal treatment requires awareness of medical and psychiatric comorbidities. This study analyzed psychiatric and medical comorbidity in a Dutch bipolar elderly cohort.
This cross-sectional descriptive study included demographic and clinical data on 101 bipolar patients aged 60 and over (mean age: 68.9 ± 7.8 years); 53.4% were women. Psychiatric diagnoses were confirmed by semistructured diagnostic interviews. Somatic history, including current somatic complaints, was obtained by interview. Medication and indicators of metabolic syndrome were obtained via record review.
Most patients received outpatient care. Bipolar I disorder was diagnosed in 56.4% of patients, and 75.6% had an onset of first affective symptoms before age 50. The prevalence rates of psychiatric comorbidities were low, except for lifetime alcohol dependence (24.8%) and abuse (13.9%). On average, there were 1.7 (SD: 1.6) medical comorbid conditions, predominantly hypertension (27.8%), arthrosis (29.1%), and allergies (25.6%). Polypharmacy was found in 31.7% of patients and metabolic syndrome in 28.7%.
Psychiatric comorbidity (especially anxiety disorders) was relatively uncommon, except for substance use disorder. Geriatric bipolar patients had on average two comorbid medical conditions and relatively high medication use. Findings underline the need to assess for comorbid conditions in bipolar elders, thereby enabling tailored treatment to optimize the general condition of these patients.
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