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Management of Bipolar Disease in the Elderly
M. Cornelia Cremens, MDDirector of Inpatient Geriatric Consultation
Division of Medicine and PsychiatryMassachusetts General Hospital
Sunday August 3, 20089:00 - 9:50 am
Concerns of Older Adults
Quality of lifeMental and physical health fundamental to a more meaningful lifeMany more issues in late lifeHow to avoid – early treatment/prevention Increasing numbers struggling with mental health issues
Good news
Most seniors enjoy good mental healthPsychiatric illness is not part of normal agingNIMH 1:5 diagnosed with mental illness
Growing population mentally ill
65+ 20 million in 1970 (7 million)65+ predicted 70 million in 2030 (15 million)
Mental Health Issues in Aging
Most common psychiatric disorders in late-lifeAnxiety (includes phobias and OCD)Cognitive impairment and delirium (Alzheimer’s disease)Mood disorders (depression and bipolar)Range of severity from problematic-severe
• Suicide highest in this age group
Older Adults Avoid Psychiatrists
Mental health services underutilizedStigmaDenialLack of services, access outreachPoor coordination of services and follow-up
Psychiatric Evaluation of Older Adults
Psychiatric assessmentRule out pre-morbid psychiatric illnessRule out co-morbid medical illness
Functional AssessmentADLs
• mobility, dressing, hygiene, feeding and toileting IADLs
• independent living, shopping, cooking, telephone, housekeeping (light), medications, finances, transportation
EvaluationComplete historyPsychiatric, medical, neurological
What is different in evaluation?
EvaluationComplete history,
• Prior clinicians, medical records, medications
• often need family to give historyPsychiatric, medical, neurological
Psychiatric assessmentRule out pre-morbid psychiatric illnessRule out co-morbid medical illness
Evaluation of Function
Functional assessmentActivities of daily living
Feeding, Bathing, Dressing, Transferring, Toileting
Instrumental activities of daily livingFinances, Telephone, Medications, Shopping, CookingHousework, Ambulating, Laundry
Presentation of Illness
Often atypical may present asFalls Behavioral changesBehavioral changesCognitive deficitsFunctional losses
incontinenceNon-specific signs and symptoms
Evaluation of Older Patients
CognitionAssessment Mini-Mental State Exam (Folstein)
Affect Sleep Interest Guilt EnergyConcentration AppetitePsychomotor activitySuicide
Psychosis
Medications, get a listBring the bottles in to appointmentCurrent listNames of prescribersDates on bottlesOver the counterHerbalBorrowed from a friend Old medications, saved
Most commonly prescribedCardiovascular
DiureticAntihypertensiveVasodilatorDigoxin
Psychotropic Analgesic
narcoticantiarthritic
Laxativeantispasmodic
Common culprits
Over the counter sleeping pillsPM combinations
Allergy medications, antihistaminesCough syrup, alcohol or dextromethorphanCold preparations, pseudoephedrineNarcoticsIllicit drugs, cocaine, MJAlcohol, intoxication or withdrawal
More culprits, prescribed
Any medication or substanceDopaminergic medicationsSteroidsStimulantsBenzodiazapinesCardiac medicationsHerbal preparations
Psychosis
Common Types of PsychosisDeliriumDementiaDepression Mania
Psychosis
DSM-IV definition one or more of:HallucinationsDelusionsDisorganized speechDisorganized or catatonic behavior
Psychosis
Dementia Delusional disorderCharles Bonnet Syndrome
confused with psychosispoor response to medications
Rule out alcoholismsubstance abuse
Prescribed drugs Illicit drugs
Demographics of Bipolar Illnessin the elderly population
EpidemiologyUnderreported or not diagnosed
Prevalence1% general population 1.2-1.3% 1-year community based
Bipolar Illness
Bipolar illness - onset often early in life10% of patient with BPI onset >50 yearsFirst onset of mania or hypomania is rare in the elderly Patient often presents with depression firstNot usually hypomania or mania
Bipolar Illness
Associated with or complicated bycognitive impairment substance abuse co-morbid illness history of depression
Secondary mania due to medical conditions or neurological disorders is diagnosed more frequently especially with dementia
Bipolar Illness
Symptoms of mania or hypomania the elderly >anger or irritability - aggressive behavior less grandiosity or euphoria longer episodes of mania cycling may be more rapid pervasive delusions and paranoiainconsistent treatment response
Definitions
Syndrome of 1 or more manic episodes accompanied by 1 or more depressive Seasonal patternsMixed states have significant dysphoria in manic statesSecondary mania, symptoms in the context of delirium, dementia, MCI or toxic
Diagnosis of BPI
Correct diagnosis is key to treatmentHypomania can be easily missedDepressive states more disablingUsually first episode of BPI is depressiveClinical course most salient clinical feature rather than characteristic of individual episode
BPI is difficult to diagnose
Manic symptoms establish diagnosisAbsence of manic symptoms - not ruled outMisdiagnosis of unipolar depressionDiagnosis of manic symptoms, historic
establish diagnosisIrritablity vs euphoria Family or third party informer
Mneumonic useful in diagnosis
DistractabilityImpulsivity, indescretionsGrandioseFlight of IdeasActivity increasedSleep decreasedTalkative, pressured speech
devised by Dr William Falk at MGH
Diagnosis of Bipolar Depression
Subtlety in interview styleInability of patient to recognize symptomsLack of insightDepressive symptoms bring patient in Poor memory of manic symptomsGreater stigma than diagnosis of depression
Predictors of Suicide
agemale sexisolated, divorced or separateddebilitating illnesswidowedalcohol
Other causes to consider
Medical disordersMetabolic, UremiaThyroid disorderInfection or deliriumNeurologic lesions, seizures
MedicationsDeficiencies –
vitamin B12Niacin
Confused with Dementia
Alzheimer’s diseaseVascular dementiaDementia due to traumaLewy body diseaseFrontal lobe dementia, Pick’s diseaseParkinson’s related dementiaPrion disease
Psychosis in Dementia
high prevalence and incidenceepisodic or persistentcan appear early or lateCategories of psychosis in dementia
DelusionsHallucinationsMisconceptions
Behavioral Psychological Symptoms of Dementia (BPSD)
PsychologicalDisorganized or illogical thought processPerceptual disturbances: hallucinations/illusionsDelusions or thought content not reality-based
BehavioralAgitation and anxietyAggression, hostility, uncooperativenessApathyWandering
Involuntary Emotional Expressive Disorder (IEED)
Damage brain areas control emotional outputAlso referred to as:
Pseudobulbar affectEmotional incontinenceAffective or emotional labilityPathologic laughing or crying
Anxiety common comorbidity
Must be addressedBenzodiazapines may cause confusionAntidepressants may precipitate maniaPsychotherapy, individual or CBT
Sleep Disorders in the Elderlyrelated to BPI
Evaluate and treat psychiatric or medical illnessRule out sleep apneaMedications, including OTC medicationsAlcoholOther substances, especially stimulants
Alcoholism
Mimics many medical and psychiatric illnessesTreatment program essential for refractory diseaseMay need medications when sober (antidepressants)Hospitalization required for detoxificationSuicide risk - greatest in this group
AlcoholismLife long pattern of drinking every day
even small amounts every day – problemwithdrawal life threatening
Symptoms includeinsomnia memory loss confusion anxiety and/or depressionsomatic complaints mimic medical illness
Elder Abuse
Subtle presentation Not responding to medicationsFearful or increased startleDelusional
Family/caregivers may be overwhelmedHotlines in every state
Treatments
Psychopharmacologic therapyIndividual psychotherapySupportive psychotherapyCognitive behavioral therapyGroup therapyFamily therapyCaregiver support group therapy
Treatment
Evidence-based research minimal Elderly not usually recruitedIncrease in older participants mostly healthyToo much for frail - not enough for robustTrials should include those who will benefitDifficulty in assessing the health status
Treatment of Mania and Depression
Complete differential diagnosis including medical issuesAssess suicide risk and potential adverse effects of treatmentCareful individualization of treatment choice Education of patient, family, caregivers and support systemAdequate treatment and adherence Attentive monitoring and follow upUse of individual or combined somatic therapies in combination, when appropriate, with psychotherapy
Treatment - medications
Polypharmacy nature of symptomsLithiumAnticonvulsantsAntipsychoticsAntidepressants
FDA approved for mania
LithiumDivalproexCarbamazepineLomatrigine
AripirazoleOlanzapineQuetiapineRisperidoneZiprazodone
Atypical Antipsychotics
Less dopamine blockade and significant 5-HT 2A Less depressionogenic effectFirst generation antipsychotics
Increase antidepressive episodesSecond generation
Reduce both acute and ongoing depressive symptoms and syndromes
Mortality and antipsychotics
Atypical antipsychostics black box warningFirst generation not establishedMortality associated with maniaMortality associated with depression
TreatmentLithium treatment for mania begin low Lithium carbonate 150-900 mg/d
Underlying medical conditions or medications can preclude its use Lithium can be toxic at low levels in elderly
risk of fluid shifts dehydration toxicity
Anticonvulsants more suitablelower side effect profileincreased efficacy
Antipsychotic especially the atypicals good responseMinimal side effects
Antipsychotics Atypical anti-psychoticsclozapine 6.25-100 mg WBC weekly,
excessive drooling, hypotension
risperidone 0.25-3 mg significant EPS olanzapine 1.25-10 mg weight gain, diabetesquetiapine 6.25-300 mg sedation, hypotensionaripiprazole 10-30 mg insomnia, agitationziprazidone 20-160 mg cardiac issues related to
increased QTc
Anticonvulsants
Carbamazepine 50-600 mg/d drug interactions,ataxia
Valproic acid 125-1500 mg/d weight gain, sedation
Gabapentin 100-1800 mg/d ataxia, sedation
Lomotrigine 5-400 mg/d rash, TENS, Stevens-Johnson
Adverse side effects to medications
Lithium • neurological, renal and thyroid problems • polydypsia, polyuria, edema weight gain
and EKG changesDivalproex
• Sedation, tremor, gait disturbanceAtypical antipsychotics
• metabolic syndrome EPS, weight gain, EKG changes, increased mortality
Electroconvulsive Therapy
Resistant to treatment with medicationsIntolerant of side effects from medicationsDue to worsening medical illnessPsychosis associated with depression
Severity of depressionRisk of suicide20-45% older patients are psychotic
Family Education
Discuss with family and if possible patientOutline findings and probable diagnosisSupport services
CompanionsDay programsDriversSupport groups and networks
Caregivers need care
Caregivers are often older and frail Need to care for health of caregiverCare can be sad, depressing and overwhelmingCaregivers may blame themselvesSeek help especially through tough times
Support groups and time for self
“In diseases of the mind…it is an art of no little importance to administer medicines properly; but, it is an art of much greater importance and more difficult acquisition to know when to suspend or altogether omit them.”
Phillipe Pinel, physician 1806
Citizen Pinel Orders Removal of the Chains of the Mad at the SalpêtriéreTony Robert-Fleury (1838–1911). 1876 painting
Resources
American Association of Geriatric Psychiatristwww.aagpgpa.org
Family Caregiver Alliancewww.caregiver.org
National Institute of Agingwww.nih.gov.nia
Resources
Alzheimer’s Associationwww.alz.org
MGH Senior Health www.massgeneral/seniorhealthweb
