The role of vascular risk factors in late onset bipolar disorder

The CANMAT and ISBD Guidelines for the Treatment of Bipolar Disorder: Summary and a 2023 Update of Evidence

Bipolar disorder is a complex and heterogeneous psychiatric condition that affects more than 2% of the population. The assessment and treatment of bipolar disorder can be a challenge for clinicians, given its clinical complexity and the rapidly changing treatment landscape with the growing range of treatment options that are becoming available for various phases of the illness. To help clinicians navigate the complexity involved in the assessment and management of bipolar disorder, the guidelines of the 2018 Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) synthesized the evidence on the efficacy, safety, and tolerability of treatments for bipolar disorder and translated it into first-, second-, and third-line treatment recommendations. The main objective of this contribution is to provide clinicians with a summary of the 2018 CANMAT/ISBD guideline recommendations with the addition of any new evidence for the treatment of bipolar disorder across the lifespan.

Fire and Darkness: On the Assessment and Management of Bipolar Disorder

Bipolar disorder is characterized by recurrent mood episodes, affecting 1% to 2% of the population. Although its defining features are manic and hypomanic episodes, its course is dominated by depressive syndromes. Diagnosis can be challenging owing to symptom overlap with other disorders. Management goals include early and complete remission of acute episodes and the prevention of relapse between episodes. We present an overview of bipolar disorder and its subtypes, including algorithms and suggestions for screening, assessment, and treatment.

Investigating the association between depression and cerebral haemodynamics-A systematic review and meta-analysis

BACKGROUND

Vascular mechanisms may play a role in depression. The aim of this review is to summarise the evidence on alterations in cerebral haemodynamics in depression.

METHODS

MEDLINE (1946- present), Embase (1947-present), Web of Science (1970-present), PsycINFO (1984-present), CINAHL (1976-present) and CENTRAL were searched using a predefined search strategy. A meta-analysis was conducted in four groups: 1) global cerebral blood flow (CBF) in ml/min/100 g, 2) CBF velocity (CBFv) in cm/s (maximum flow of left middle cerebral artery, 3) combined CBF and CBFv, 4) Ratio of uptake of Tc 99 m HMPAO (region of interest compared to whole brain). Data are presented as mean difference or standardised mean difference and 95% confidence interval (95% CI). A narrative synthesis of the remaining studies was performed.

RESULTS

87 studies were included. CBF was significantly reduced in depressed patients compared to HC [15 studies, 538 patients, 416 HC, MD: -2.24 (95% CI -4.12, -0.36), p = 0.02, I² = 64%]. There were no statistically significant differences in other parameters. The narrative synthesis revealed variable changes in CBF in depressed patients, particularly affecting the anterior cingulate and prefrontal cortices.

LIMITATIONS

There were various sources of heterogeneity including the severity of depression, use of antidepressant medication, imaging modality used and reporting of outcomes. All of these factors made direct comparisons between studies difficult.

CONCLUSIONS

The reduction in CBF in depressed patients compared to HCs may indicate a role for assessment and CBF altering interventions in high-risk groups. However, results were inconsistent across studies, warranting further work to investigate specific subgroups.

Depressive and Anxious Temperaments as Predictors of Late Onset Bipolar Disorder? Preliminary Results of a "Real World" Exploratory Study

INTRODUCTION

Bipolar disorder (BD) onset typically occurs between 15 and 30 years, being diagnosed under the age of 50 in 90% of cases, named "non-late onset BD" (non-LOBD). However, clinical observation of late-onset BD (LOBD) raised some concern regarding a differential psychopathological pattern, outcomes and treatment, including a specific affective temperament vulnerability. Therefore, an exploratory study in the "real world" was carried out by investigating psychopathological and temperamental features of a psychogeriatric cohort of LOBD and non-LOBD subjects.

METHODS

A total of 180 patients affected with BD-I, BD-II, and Cyclothymic Disorder were screened in a Mood Disorder Outpatient Service, during the timeframe January 2019-August 2021. Out of 78 enrolled outpatients, 66 (33 non-LOBD, 33 LOBD) were recruited, by the retrospective collection of sociodemographic, cognitive, psychopathological and clinical assessment, including the short-version of the Temperament Evaluation of Memphis, Pisa, and San Diego (TEMPS-M).

RESULTS

LOBD is significantly associated with higher rates of BD-II diagnosis (χ² = 27.692, p < 0.001), depressive episodes (p = 0.025), mixed states (p = 0.009), predominant depressive and anxious affective temperaments (p < 0.001). Non-LOBD is significantly associated with higher endocrinological (χ² = 6.988, p = 0.008) and metabolic comorbidity (χ² = 5.987, p = 0.014), a diagnosis of BD-I, manic episodes, and predominant hyperthymic affective temperaments (p = 0.001). GDS (p < 0.001) and MSRS (p = 0.005) scores were significantly higher in LOBD.

CONCLUSION

Further longitudinal studies with larger sample sizes and a control group are needed to determine whether LOBD may represent a distinct psychopathological entity from non-LOBD and evaluate differences (if any) in terms of prognosis and treatment between non-LOBD and LOBD.

The long-term course of cognition in bipolar disorder: a systematic review and meta-analysis of patient-control differences in test-score changes

Neuropsychological impairment represents a key aspect of bipolar disorder (BD) that is evident even in early-course patients and is a strong predictor of functional outcomes among those affected. Previous meta-analyses of longitudinal studies suggest that BD-related cognitive deficits may not progress along the course of the disorder. However, short test-retest periods were used in most primary studies and comparisons with healthy controls were limited. The aim of this review was to synthesize the findings of research reports comparing long-term neurocognitive trajectories between BD patients and healthy individuals. PubMed, PsycINFO, and Scopus databases were searched from inception through July 2021. Publications were considered for inclusion if they reported cognitive test scores of BD patients and healthy controls at two different time points, with a minimum test-retest interval of 5 years. Fifteen studies compared the long-term course of cognition in BD patients with that of healthy controls. Ten of these were included in the quantitative analysis and involved 540 BD patients and 644 healthy individuals (mean follow-up period: 8.9 years). Patient-control effect sizes (standardized mean differences) were calculated for test-score changes in 24 neuropsychological variables and combined by means of meta-analytic procedures. No significant differences were found between patients and controls regarding long-term cognitive outcomes. These findings are consistent with previous shorter-term longitudinal meta-analyses and do not provide evidence for progressive cognitive deterioration in most bipolar individuals. Future studies should address the longitudinal course of cognition in different subgroups of BD patients and its prognostic and therapeutic value.

Old Age Bipolar Disorder-Epidemiology, Aetiology and Treatment

Data regarding older age bipolar disorder (OABD) are sparse. Two major groups are classified as patients with first occurrence of mania in old age, the so called “late onset” patients (LOBD), and the elder patients with a long-standing clinical history, the so called “early onset” patients (EOBD). The aim of the present literature review is to provide more information on specific issues concerning OABD, such as epidemiology, aetiology and treatments outcomes. We conducted a Medline literature search from 1970–2021 using the MeSH terms “bipolar disorder” and “aged” or “geriatric” or “elderly”. The additional literature was retrieved by examining cross references and by a hand search in textbooks. With sparse data on the treatment of OABD, current guidelines concluded that first-line treatment of OABD should be similar to that for working-age bipolar disorder, with specific attention to side effects, somatic comorbidities and specific risks of OABD. With constant monitoring and awareness of the possible toxic drug interactions, lithium is a safe drug for OABD patients, both in mania and maintenance. Lamotrigine and lurasidone could be considered in bipolar depression. Mood stabilizers, rather than second generation antipsychotics, are the treatment of choice for maintenance. If medication fails, electroconvulsive therapy is recommended for mania, mixed states and depression, and can also be offered for continuation and maintenance treatment. Preliminary results also support a role of psychotherapy and psychosocial interventions in old age BD. The recommended treatments for OABD include lithium and antiepileptics such as valproic acid and lamotrigine, and lurasidone for bipolar depression, although the evidence is still weak. Combined psychosocial and pharmacological treatments also appear to be a treatment of choice for OABD. More research is needed on the optimal pharmacological and psychosocial approaches to OABD, as well as their combination and ranking in an evidence-based therapy algorithm.

Evaluation and treatment of older-age bipolar disorder: a narrative review

Objectives

This narrative review aims to synthesize information from the literature regarding older-age bipolar disorder (OABD) in order to provide up-to-date information on this important illness.

Methods

We searched Ovid (Medline, Embase and PsychInfo) on October 1, 2020, using the keywords “bipolar disorder”, “older adults” and “elderly” to identify relevant articles on OABD. Additionally, the bibliography of identified articles was reviewed for pertinent studies.

Discussions

OABD is a term that is used to describe bipolar disorder (BD) occurring amongst individuals ≥50 years of age. Evidence indicates that OABD accounts for a quarter of all cases of BD. When compared to individuals with early-onset BD, individuals with OABD have a greater association with cerebrovascular disease and other neurological disorders, less family history of mood disorders, and utilize almost four times the total amount of mental health services. In addition, they are four times more likely to have psychiatric hospitalizations when compared to age-matched controls. Despite a dearth of controlled studies on the use of pharmacotherapy amongst individuals with OABD, available evidence from mixed-age studies indicates the efficacy of commonly used medications in individuals with early-onset BD. Additionally, psychosocial treatments have been found to be effective as adjunctive management strategies amongst individuals with OABD. Furthermore, electroconvulsive therapy may be effective in the treatment of refractory cases of OABD.

Conclusions

There is a great need for an improved understanding of the phenomenology and neurobiology of OABD. Additionally, research into effective treatments for this serious psychiatric disorder will mitigate the suffering of individuals with OABD.

A Case of Lung Cancer with Brain Metastasis following Late-Onset Bipolar Disorder

Objective

To describe a case of lung cancer with brain metastasis in a patient who developed new late-onset bipolar disorder 2 years previously.

Background

The typical onset age of bipolar disorder is approximately 20, and the first episode is usually a depressive episode. It is still not clear which age-specific factors contribute to the underlying risk.

Materials and Methods

A 65-year-old male patient presented with a new-onset manic episode characterized by labile mood, impulsivity, decreased need for sleep, and grandiosity. He was diagnosed with late-onset bipolar disorder after excluding other possible physiological conditions. He was hospitalized in the acute psychiatric ward, and a combination of mood stabilizers and antipsychotics was prescribed. His mental condition improved, and he remained stable for 2 years. However, he experienced abrupt cognitive decline for 2 months and was referred to the emergency room for physiological examination.

Results

The patient was diagnosed with lung cancer with brain metastasis by brain magnetic resonance imaging and whole-body positron emission tomography.

Conclusion

In geriatric patients, who are at high risk of multiple medical conditions, excluding secondary causes of bipolar disorder is important.

Homocysteine, rather than age of onset, is a better predictor for cognitive function in older adults with bipolar disorder

OBJECTIVES

The association between older-age bipolar disorder and cognitive impairments may be mediated by vascular burden. The aim of the study was to examine the difference of cognitive function between older people with late-onset bipolar disorder (LOBD) and early-onset bipolar disorder (EOBD) by considering rigorous vascular risk burden evaluation, comprehensive cognitive tests, and relevant biochemistry data.

METHODS

We recruited 95 outpatients aged over 55 with a DSM-IV-TR diagnosis of bipolar I disorder. Fifty had LOBD, defined by age of onset after 40. Cognitive function was evaluated through a battery of tests assessing verbal memory, attention/speed, visuospatial function, verbal fluency, and cognitive flexibility. Vascular risk assessments included individual disorders, 10-year Framingham cardiovascular risk scores, and serum levels of homocysteine, vitamin B12, folate, and triiodothyronine.

RESULTS

No differences were observed between LOBD and EOBD on any cognitive test after adjusting for potential confounders. In addition to age and educational years, multiple linear regression analyses indicated significantly negative associations between serum homocysteine levels and cognitive performances in attention, psychomotor speed, verbal memory, and executive function.

CONCLUSIONS

Among older people with bipolar disorder, LOBD is not associated with more cognitive dysfunction in this study. However, higher serum homocysteine levels were significantly associated with worse cognitive performance in this particular group. Clinicians therefore have to pay attention to the cognitive function in older bipolar patients with higher levels of homocysteine.

A Review of the Pharmacological and Clinical Profile of Newer Atypical Antipsychotics as Treatments for Bipolar Disorder: Considerations for Use in Older Patients

Bipolar disorder prevalence rates vary in the older adult population (defined as age ≥ 65 years), ranging from 1% in community dwellers to as high as 8-10% in hospital inpatients. Although older agents, including lithium and valproic acid, offer significant antimanic efficacy, as supported by a recent randomized controlled trial (RCT), there is growing interest in using atypical antipsychotics to treat bipolar disorder in older adults. Newer atypical antipsychotics are of interest based on their tolerability and efficacy in the general adult bipolar population. The aim of this review was to systematically examine efficacy and tolerability of newer atypical antipsychotics for older adult bipolar disorder (OABD). We conducted a systematic search utilizing the MEDLINE, EMBASE, PsycINFO and Cochrane Library electronic databases, with the aim of identifying all RCTs comparing newer atypical antipsychotics approved by the US FDA since 2002 (including brexpiprazole, cariprazine, lurasidone, iloperidone, asenapine, paliperidone, and aripiprazole) with placebo or another comparator, in the treatment of any phase of bipolar disorder (including mania, depression or mixed episodes while used as an acute or maintenance treatment) in older adults (> 65 years). We found no RCT data on any of the examined agents. Hence, we changed our search criteria to include studies with a lower age cut-off (≥ 55 years), as well as the inclusion of post hoc studies. Two post hoc studies on lurasidone suggest its reasonable safety and efficacy profile in the acute and maintenance treatment of OABD; however, there are no pharmacoeconomic data on the use of lurasidone in the treatment of OABD. Research data from open-label studies on oral asenapine and aripiprazole as add-on therapy suggest that these two agents are adequately tolerated and improved symptoms of depression and mania in OABD; hence, there is an urgent need to conduct RCTs on these two agents. Lastly, we found no studies for the treatment of OABD with brexpiprazole, cariprazine, iloperidone, or paliperidone.

Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) 2018 guidelines for the management of patients with bipolar disorder

The Canadian Network for Mood and Anxiety Treatments (CANMAT) previously published treatment guidelines for bipolar disorder in 2005, along with international commentaries and subsequent updates in 2007, 2009, and 2013. The last two updates were published in collaboration with the International Society for Bipolar Disorders (ISBD). These 2018 CANMAT and ISBD Bipolar Treatment Guidelines represent the significant advances in the field since the last full edition was published in 2005, including updates to diagnosis and management as well as new research into pharmacological and psychological treatments. These advances have been translated into clear and easy to use recommendations for first, second, and third- line treatments, with consideration given to levels of evidence for efficacy, clinical support based on experience, and consensus ratings of safety, tolerability, and treatment-emergent switch risk. New to these guidelines, hierarchical rankings were created for first and second- line treatments recommended for acute mania, acute depression, and maintenance treatment in bipolar I disorder. Created by considering the impact of each treatment across all phases of illness, this hierarchy will further assist clinicians in making evidence-based treatment decisions. Lithium, quetiapine, divalproex, asenapine, aripiprazole, paliperidone, risperidone, and cariprazine alone or in combination are recommended as first-line treatments for acute mania. First-line options for bipolar I depression include quetiapine, lurasidone plus lithium or divalproex, lithium, lamotrigine, lurasidone, or adjunctive lamotrigine. While medications that have been shown to be effective for the acute phase should generally be continued for the maintenance phase in bipolar I disorder, there are some exceptions (such as with antidepressants); and available data suggest that lithium, quetiapine, divalproex, lamotrigine, asenapine, and aripiprazole monotherapy or combination treatments should be considered first-line for those initiating or switching treatment during the maintenance phase. In addition to addressing issues in bipolar I disorder, these guidelines also provide an overview of, and recommendations for, clinical management of bipolar II disorder, as well as advice on specific populations, such as women at various stages of the reproductive cycle, children and adolescents, and older adults. There are also discussions on the impact of specific psychiatric and medical comorbidities such as substance use, anxiety, and metabolic disorders. Finally, an overview of issues related to safety and monitoring is provided. The CANMAT and ISBD groups hope that these guidelines become a valuable tool for practitioners across the globe.

Recommencing lithium in Older Adults with Bipolar I Disorder

OBJECTIVES

This paper addresses considerations in recommencing lithium in elderly patients with Bipolar I Disorder and medical comorbidity. We focus on nephrotoxicity and cognitive impairment.

METHODS

Case reports and review of relevant literature.

RESULTS

Three elderly psychogeriatric inpatients admitted with severe manic relapse following lithium cessation are described. In all cases, lithium was recommenced safely with good response.

CONCLUSIONS

Even with medical comorbidity it may be possible to recommence modified lithium therapy.

Quality of Life in Carotid Atherosclerosis: The Role of Co-morbid Mood Disorders

INTRODUCTION/OBJECTIVE

To study in severe carotid atherosclerosis (CA): the frequency of mood disorders (MD); the impairment of quality of life (QoL); the role of co-morbid MD in such impairment.

METHODS

Case-control study.

CASES

consecutive in-patients with CA (stenosis ≥ 50%).

CONTROLS

subjects with no diagnosis of CA randomized from a database of a community survey. Psychiatric diagnosis according to DSM-IV made by clinicians and semi-structured interview, QoL measured by the Short Form Health Survey (SF-12).

RESULTS

This is the first study on comorbidity on CA disease and MD in which psychiatric diagnoses are conducted by clinicians according to DSM-IV diagnostic criteria. Major Depressive Disorder (MDD) (17.4% vs 2.72%, P <0.0001) but not Bipolar Disorders (BD) (4.3% vs 0.5%, P = 0.99) was higher in cases (N=46) than in controls (N= 184). SF-12 scores in cases were lower than in controls (30.56±8.12 vs 36.81±6:40; p <0.001) with QoL comparable to serious chronic diseases of the central nervous system. The burden of a concomitant MDD or BD amplifies QoL impairment.

CONCLUSION

Comorbid MD aggravates the impairment of QoL in CA. Unlike autoimmune diseases or degenerative diseases of the Central Nervous System, CA shows a strong risk of MDD than BD.

Cognitive impairment in late-life bipolar disorder is not associated with Alzheimer's disease pathological signature in the cerebrospinal fluid

OBJECTIVES

Cognitive impairment is a common feature of late-life bipolar disorder (BD). Yet, there is limited information on the biological mechanisms associated with this process. It is uncertain whether cognitively impaired patients with BD may present the Alzheimer's disease (AD) bio-signature in the cerebrospinal fluid (CSF), defined as a combination of low concentrations of the amyloid-beta peptide (Aβ1-42 ) and high concentrations of total tau (T-tau) and tau phosphorylated at threonine 181 (P-tau). In this study, we sought to determine whether cognitive impairment in elderly patients with BD is associated with the AD CSF bio-signature.

METHODS

Seventy-two participants were enrolled in the study. The test group comprised older adults with BD and mild cognitive impairment (BD-MCI; n = 16) and the comparison groups comprised patients with dementia due to AD (n = 17), patients with amnestic MCI (aMCI; n = 14), and cognitively healthy older adults (control group; n = 25). CSF samples were obtained by lumbar puncture and concentrations of Aβ1-42 , T-tau and P-tau were determined.

RESULTS

CSF concentrations of all biomarkers were significantly different in the AD group compared to all other groups, but did not differentiate BD-MCI subjects from aMCI subjects and controls. BD-MCI patients had a non-significant reduction in CSF Aβ1-42 compared to controls, but this was still higher than in the AD group. Concentrations of T-tau and P-tau in BD-MCI patients were similar to those in controls, and significantly lower than those in AD.

CONCLUSIONS

Cognitively impaired patients with BD do not display the so-called AD bio-signature in the CSF. We therefore hypothesize that cognitive deterioration in BD is not associated with the classical pathophysiological mechanisms observed in AD, i.e., amyloid deposition and hyperphosphorylation of microtubule-associated tau protein.

Late onset mania as an organic syndrome: A review of case reports in the literature

AIMS

Although First Episode Mania presenting over the age of 50 is reported in several cases, there has been little systematic compilation of these case reports. We report a review of case reports on these subjects.

METHODS

We undertook a literature search on MEDLINE, PsychInfo and EMBASE to identify case reports of first episode of mania or hypomania presenting over the age of 50.

RESULTS

35 cases were identified. 29/35 (82%) had a suspected underlying organic cause. Organic causes included vascular causes, iatrogenic drug use, electrolyte imbalance, dementia and thyroid disease. Vascular risk factors were present in 17/35 cases (48%). In 10/35 (28%) of cases organic treatment contributed to successful remission of the manic episode.

LIMITATIONS

As evidently not all cases have been reported the main limitation is that of publication bias for this paper. Any such hypothesis generated from studying these cases would require replication in prospective longitudinal trials of this cohort of patients.

CONCLUSIONS

This review of case reports appears to add to evidence of late onset mania having an organic basis. Whether this is a separate organic syndrome remains to be established. Our provisional findings suggest that such patients should have a thorough medical and psychiatric screening in identifying an underlying cause.

A report on older-age bipolar disorder from the International Society for Bipolar Disorders Task Force

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.

Bipolar disorder after stroke in an elderly patient

The onset of bipolar disorder (BD) secondary to a stroke event is a rare clinical entity. Although it may be related to specific regions of the brain, several other factors have been linked to its expression such as subcortical atrophy or chronic vascular burden. While precise locations and cerebral circuits involved in the bipolarity expression after stroke still need to be determined, their investigation represents an opportunity to study brain function and BD etiopathogenesis. We present a BD secondary to multiple subcortical biparietal lacunar infarctions, a lacunar infarction in left putamen and an ischemic lesion at the cerebral trunk evolving the right median portion, in a 65-year-old male patient who experienced manic, hypomanic, and depressive episodes, after 6, 10, and 16 months, respectively, of the cerebrovascular events.

Using the Brief Assessment of Cognition in Schizophrenia (BACS) to assess cognitive impairment in older patients with schizophrenia and bipolar disorder

OBJECTIVES

A growing body of evidence suggests that impairment in cognitive functioning is an important clinical feature of both schizophrenia and bipolar disorder, and that these cognitive alterations worsen with age. Although cognitive assessments are increasingly becoming a part of research and clinical practice in schizophrenia, a standardized and easily administered test battery for elderly patients with bipolar disorder is still lacking. The Brief Assessment of Cognition in Schizophrenia (BACS) captures those domains of cognition that are the most severely affected in patients with schizophrenia and the most strongly correlated with functional outcome. The primary aim of our study was to investigate the clinical usefulness of the BACS in assessing cognitive functioning in elderly euthymic patients with bipolar disorder, and to compare their cognitive profile to that of elderly patients with schizophrenia.

METHODS

Elderly euthymic patients with bipolar disorder or schizophrenia were assessed using the BACS and a standard cognitive test battery.

RESULTS

Fifty-seven elderly patients (aged 60 years and older) with bipolar disorder (n = 42) or schizophrenia (n = 15) were invited to participate. All of the patients were assessed by the BACS as being cognitively impaired. The patients with bipolar disorder scored significantly higher on the global scale and the verbal memory and attention sub-scores of the BACS than the patients with schizophrenia.

DISCUSSION

The BACS appears to be a feasible and informative cognitive assessment tool for elderly patients with bipolar disorder. We believe that these preliminary results merit further investigation.

A quantitative review of neurocognition in euthymic late-life bipolar disorder

OBJECTIVES

A sizeable body of work has consistently documented that a number of euthymic mixed-age bipolar disorder subjects exhibit prominent impairments in a variety of cognitive domains. By contrast, knowledge about neuropsychological functioning in elderly patients is scant, despite being necessary for the adequate treatment of this population and the understanding of illness evolution. The aim of this study was to combine findings from the available literature in order to examine the pattern and extent of cognitive deficits in euthymic late-life bipolar disorder subjects.

METHODS

A literature search was conducted through the online databases PubMed, ScienceDirect, EBSCO, and Wiley-Blackwell, covering the period between January 1990 and April 2012. Effect sizes reflecting patient-control differences for 10 cognitive variables were extracted from selected investigations and combined by means of meta-analytical procedures.

RESULTS

No significant patient-control differences were found for global cognitive status as assessed with the Mini-Mental State Examination and the Clock Drawing Test. Significant overall effect sizes (Hedges' g) of between 0.61 and 0.88 were noted for sustained attention, digit span (forwards and backwards), delayed recall, serial learning, cognitive flexibility, and verbal fluency (phonemic and categorical).

CONCLUSIONS

The extent of cognitive dysfunction in euthymic late-life bipolar disorder subjects may be, on average, similar to that reported for remitted young adult patients. Larger effect sizes of impairment may be associated with late illness onset. Implications and future directions for research are proposed.

Lithium decreases VEGF mRNA expression in leukocytes of healthy subjects and patients with bipolar disorder

OBJECTIVES

Vascular endothelial growth factor (VEGF) is thought to be involved in the pathophysiology of mood disorders and the target of antidepressants. The aim of this study was to elucidate molecular effects of lithium on VEGF expression by using leukocytes of healthy subjects and patients with bipolar disorder.

METHODS

Eight healthy male subjects participated in the first study. Lithium was prescribed for 2 weeks, enough to reach therapeutic serum concentration. Leukocyte counts and serum lithium concentrations were determined at baseline, at 1- and 2-week medication, and at 2 weeks after stopping medication. VEGF mRNA levels were also examined in nine lithium-treated bipolar patients and healthy controls in the second study.

RESULTS

In the first study, leukocyte counts were significantly increased at 2 weeks compared with those at baseline and were normalized after 2 weeks. VEGF mRNA levels were significantly decreased at 2 weeks and after 2 weeks compared with those at baseline. Consistent with the first study, VEGF mRNA levels were significantly decreased in the lithium-treated bipolar patients compared with healthy controls.

CONCLUSIONS

Our investigation suggests that VEGF mRNA expression may be useful as a peripheral marker of the effects of lithium.

Mania and stroke: a systematic review

BACKGROUND

Mania is a rare consequence of stroke and according to the sparse published information it is difficult to describe its demographic, clinical and prognostic characteristics.

METHODS

We performed a systematic review of all cases of mania and stroke to describe those characteristics. Studies were identified from comprehensive searches of electronic databases, reference lists of the studies collected and handbooks. Two authors independently assessed abstracts, and collected and extracted data.

RESULTS

From 265 abstracts, 139 were potentially relevant. For the first analysis, which tries to answer the clinical question of the relationship between mania and stroke, 49 studies met the inclusion criteria and described 74 cases. For the second analysis, we looked for an explicit temporal and causal relationship between manic symptoms and stroke, and selected 32 studies describing 49 cases. In both analyses, the typical patient was male, without a personal or family history of psychiatric disorder, with at least one vascular risk factor, but without subcortical atrophy and had suffered a right cerebral infarct. The majority of patients (92%) presented elevated mood as the first symptom. The other frequent symptoms were an increased rate or amount of speech (71%), insomnia (69%) and agitation (63%).

CONCLUSIONS

Post-stroke mania should be considered in any manic patient who presents concomitant neurological focal deficits and is older than expected for the onset of primary mania. The results of a systematic study of mania in acute stroke with subsequent follow-up and data from diffusion MR or perfusion CT in a multicenter study with a central database would be relevant.

Post-stroke mania precipitated by withdrawal of antidepressant in an elderly patient with chronic major depression

Post-stroke mania is a rare neuropsychiatric complication that is observed in less than 1% cases of stroke and is less common than depression. Growing evidence suggests that it may be associated with the specific regions of the brain, preexisting subcortical atrophy, a family history of mood disorders, and chronic vascular burden. However, the development of bipolar disorder after stroke is uncommon in a patient with chronic major depression. In this report, we present the case of an elderly woman with depression and chronic vascular burden; she experienced her first episode of mania after a lacunar infarct on the right side and the withdrawal of antidepressant therapy.

Volumetric reduction in various cortical regions of elderly patients with early-onset and late-onset mania

BACKGROUND

Few studies have examined alterations of the brain in elderly bipolar patients. As late-onset mania is associated with increased cerebrovascular morbidity and neurological damage compared with typical/early-onset mania, we investigated differences in the volume of various cortical regions between elderly patients with early-onset versus late-onset mania.

METHODS

We recruited 44 bipolar patients aged over 60 years, who underwent volumetric magnetic resonance imaging at 1.5 T. The analytic method is based on the hidden Markov random field model with an expectation-maximization algorithm. We determined the volume of each cortical region as a percentage of the total intracranial volume. The cutoff age for defining early versus late onset was 45 years.

RESULTS

The study participants consisted of 25 patients with early-onset mania and 19 patients with late-onset mania; their mean ages were 65.7 years and 62.8 years, respectively. The demographic variables of the two groups were comparable. The volumes of the left caudate nucleus (p = 0.022) and left middle frontal gyrus (p = 0.013) were significantly greater and that of the right posterior cingulate gyrus (p = 0.019) was significantly smaller in the late-onset group. More patients with late-onset mania had comorbid cerebrovascular disease (p = 0.072).

CONCLUSIONS

The right posterior cingulate gyrus is smaller and the left caudate nucleus and left middle frontal gyrus are larger in patients with late-onset mania compared with those with early-onset mania. Volumetric change in brain regions may vary in elderly bipolar patients with early and late-onset mania.

Risk factors for cognitive impairment in elderly bipolar patients

OBJECTIVE

Cognitive impairment in elderly bipolar patients persists during euthymic state, yet the aetiology of such impairment is not well understood. The objective of this study is to identify factors contributing to cognitive impairment in elderly patients with bipolar disorder.

METHOD

119 older patients (age >60) with bipolar I or II disorder in a euthymic state were extensively tested on cognitive functioning including attention, memory, visuoconstruction, executive function and verbal fluency with regard to potential risk factors.

RESULTS

Regression analysis shows that health related factors, medication and illness characteristics are associated with cognitive impairment in several cognitive domains: attention, memory, visuoconstruction, executive function and verbal fluency. More vascular burden factors are related to poorer outcome of cognitive functioning. Patients with lithium pharmacotherapy performed worse compared to those with other mood stabilizers, but this was no longer significant in multivariate analysis.

CONCLUSIONS

In elderly bipolar patients, more vascular risk factors and more hospital admissions are associated with more cognitive impairment.

'Bipolar disorder' in the elderly: what's in a name?

Bipolar disorder is a chronic disorder of mood which leads to episodes of either elevated mood or depression in a sizable number of adults in the community (1%). Though the prevalence rates in the elderly are lower in the community (up to 0.1%), there is significantly higher morbidity in protected environments like care homes and hospital settings where prevalence rates may be as high as 10%. Bipolar disorder in the elderly is probably heterogenous and its etiopathogenesis is complex. Bipolar disorder may be divided into two distinct subtypes, the late onset bipolar (LOB) and the early onset bipolar (EOB) groups. LOB patients tend to have a milder illness in terms of manic severity but they have higher medical and neurological burden. They also have lower familial burden of bipolar illness as compared to EOB patients. There is an increased risk of dementia and stroke in patients with late life bipolar disorder (and there may be a protective effect of lithium in preventing dementia). White matter changes, as seen by increased white matter hyperintensities on neuroimaging, are also increased, providing further evidence of cerebrovascular disease. Treatment of late life bipolar is currently based on guidelines drawn up for younger bipolar disorder patients. Good quality intervention studies are needed to estimate the possible protective effect of cognitive enhancers and/or vascular prevention strategies. This review suggests that late life bipolar disorder, particularly late onset bipolar disorder, is probably a distinct diagnostic entity compared to the younger bipolar patients as it has a different presentation, etiology and hence perhaps needs different treatment strategies.

Cognitive impairment in early and late bipolar disorder

BACKGROUND

Late onset disorders are often associated with cerebral disfunctioning and cognitive impairment in elderly patients. It is unknown whether the age of onset affects cognition in patients with bipolar disorder. The authors compare cognition and clinical characteristics of early- and late-onset bipolar patients in a stable and euthymic condition.

METHOD

One hundred and nineteen older patients (age >60) with an early- (<40 years) or late-onset bipolar disorder and a group of 78 comparison subjects were extensively tested for cognitive functioning.

RESULTS

Bipolar subjects scored lower on most cognitive measures. The late-onset patients were more impaired in psychomotor performance and mental flexibility than the early-onset patients. These differences could not be explained by differences in exposure to cerebrovascular risk factors.

CONCLUSIONS

Older patients with bipolar disorder have substantial cognitive impairments. Late onset bipolar disorder is associated with more severe cognitive impairment than early-onset bipolar disorder. For clinical practice, it is important to develop treatment strategies which take this into account.

Increased rates of white matter hyperintensities in late-onset bipolar disorder

OBJECTIVES

Magnetic resonance imaging (MRI) studies have reported an increased frequency of white matter hyperintensities (WMH) in association with late-onset (LO) depression, and this has supported the notion that vascular-related mechanisms may be implicated in the pathophysiology of LO mood disorders. Recent clinical studies have also suggested a link between LO bipolar disorder (LO-BD) and cerebrovascular risk factors, but this has been little investigated with neuroimaging techniques. In order to ascertain whether there could be a specific association between WMH and LO-BD, we directly compared WMH rates between LO-BD subjects (illness onset >or= 60 years), early-onset BD subjects (EO-BD, illness onset <60 years), and elderly healthy volunteers.

METHODS

T2-weighted MRI data were acquired in LO-BD subjects (n = 10, age = 73.60 +/- 4.09), EO-BD patients (n = 49, age = 67.78 +/- 4.44), and healthy subjects (n = 24, age = 69.00 +/- 7.22). WMH rates were assessed using the Scheltens scale.

RESULTS

There was a greater prevalence of WMH in LO-BD patients relative to the two other groups in the deep parietal region (p = 0.018) and basal ganglia (p < 0.045). When between-group comparisons of mean WMH scores were conducted taking account of age differences (ANCOVA), there were more severe scores in LO-BD patients relative to the two other groups in deep frontal and parietal regions, as well as in the putamen (p < 0.05).

CONCLUSIONS

Our results provide empirical support to the proposed link between vascular risk factors and LO-BD. If extended in future studies with larger samples, these findings may help to clarify the pathophysiological distinctions between bipolar disorder emerging at early and late stages of life.