Conceptual and methodological issues in designing a randomized, controlled treatment trial for geriatric bipolar disorder: GERI-BD

The Italian Framework of Bipolar Disorders in the Elderly: Old and Current Issues and New Suggestions for the Geriatric Psycho-Oncology Research

BACKGROUND

Older adults with mood disorders constitute a heterogeneous group in a complex spectrum interlinked with physical comorbidities. Worldwide, Bipolar disorders in older people (OABD) remain underestimated and underdiagnosed. OABD is challenging in the clinical setting and is associated with adverse outcomes (increased risk of anti-social behaviour triggered by inappropriate drugs and increased incidence of health deficits, including cancer). This article aims to describe the state of the art of OABD in the Italian framework and provide a new field of research.

METHODS

We performed an overview of the literature, selecting our target population (over 65 years) and synthesising the main challenging issues. By exploiting the Italian database from the Minister of Health in 2021, we analysed epidemiological data in the age range 65-74 years and 75-84 years old.

RESULTS

Females showed the highest prevalence and incidence in both groups, with a regional difference across the country but more evident in the Autonomous Provinces of Bolzano and Trento for the 65-74 years range. Several projects recently focused on this topic, and the urgency to define better the epidemiological framework is mandatory.

CONCLUSIONS

This study represented the first attempt to report the comprehensive Italian framework on OABD aimed at fostering research activities and knowledge.

Assessing bipolar disorder in the older adult: the GERI-BD toolbox

INTRODUCTION

The evidence base regarding characteristics of older adults with bipolar disorder (BD) remains limited. The NIH-funded multicenter study Acute Pharmacotherapy of Late-Life Mania (GERI-BD) assessed various clinical domains before and during mood stabilizer treatment in older adults participating in a 9-week, double-blind randomized controlled trial. We describe the rationale for selecting these instruments.

METHODS

Domains and instruments were selected on the basis of the study design and the participants. The investigators' experience in clinical trials involving young adults with BD or older adults with major depressive disorder, along with open studies of older adults with BD, contributed to the selection process.

RESULTS

We identified domains and selected instruments that could be used to assess the participants given their diagnostic, treatment history, and medical and mood state characteristics. They were also intended to measure tolerability and efficacy and permit examination of potential moderating and mediating factors.

CONCLUSIONS

Decisions regarding the assessment domains to be included in the clinical trial highlight the challenges facing researchers studying drug treatments for older adults with BD, or more generally, mood disorders. We suggest that the domains and instruments selected by GERI-BD investigators constitute a "toolbox" that can be customized for other investigators. Copyright © 2017 John Wiley & Sons, Ltd.

Current psychotropic medication prescribing patterns in late-life bipolar disorder

OBJECTIVE

Many patients with bipolar disorder are reaching old age, but whether they are receiving evidence-based psychotropic treatment remains unclear. Our objective was to describe current psychotropic prescribing patterns in a large Canadian late-life bipolar sample.

METHODS

Population-based cross-sectional study of 1443 bipolar disorder patients aged ≥ 66, discharged from a psychiatric hospitalization in Ontario, Canada from 1 April 2006 to 31 March 2012. We described psychotropic medication prescribing within 30 days post-discharge.

RESULTS

Prescription of ≥2 psychotropic medications was highly prevalent (81.5%). The most common medications were atypical antipsychotics (75.3%), benzodiazepines/zopiclone (42.3%), and antidepressants (38.5%), with less frequent use of valproate (35.4%) and lithium (23.4%). Only 1.4% of patients were on lithium monotherapy, while 4.4% and 15.7% of patients were on antidepressant or atypical antipsychotic monotherapy; 8.9% of all patients were using ≥2 atypical antipsychotics.

CONCLUSIONS

In clinical practice, older adults hospitalized with bipolar disorder are often prescribed multiple psychotropic medications upon discharge. In many instances, practices did not reflect bipolar treatment guidelines and may be putting patients at risk for poor physical health and psychiatric outcomes. One such example is the very infrequent use of lithium monotherapy. Future research should examine whether health system-wide protocolized late-life bipolar treatment may optimize prescribing to improve effectiveness and safety. Copyright © 2016 John Wiley & Sons, Ltd.

An observational study of 110 elderly lithium-treated patients followed up for 6 years with particular reference to renal function

BACKGROUND

Recent observational studies have focused on lithium treatment in the elderly, with particular reference to safety in terms of thyroid and renal functions. The purpose of this study was to compare the clinical characteristics of patients starting lithium treatment before (N = 79) or after (N = 31) the age of 65 years. Patients were followed up for 6 years with focus on renal function and prescription of levothyroxine and methimazole.

RESULTS

At baseline, median lithium serum concentration was 0.55 mmol/l. The estimated glomerular filtration rate was lower than 60 ml/min/1.73 m² in 43 (39%) patients. In a multiple regression analysis controlling for age and gender, we found a significant effect of duration of lithium treatment on estimated glomerular filtration rate (-0.85 ml/min/1.73 m² per year of prior exposure). The annual decline during follow-up was 2.3 ml/min/1.73 m². Two patients were prescribed levothyroxine, and two were prescribed methimazole for the first time during follow-up.

CONCLUSIONS

Median lithium serum concentration in this cohort of elderly patients with mainly bipolar disorders was lower than the therapeutic range indicated for younger adults. The decline in glomerular filtration rate may be accelerated by long-term lithium use. Thyroid and renal functions continue to require close monitoring throughout the course of lithium treatment. Trial registration NP/2013/3836. Registered 24 June 2013.

Lithium in late-life mania: a systematic review

The prevalence of mania among >65-year-olds ranges from 0.1% to 0.4% and its treatment is a particular challenge for clinicians. Although lithium is the treatment of choice for bipolar disorder (BD), its use in elderly population was recently questioned. This study provides a comprehensive review of literature on the efficacy and tolerability of lithium as a pharmacologic treatment for mania in elderly BD patients. We conducted a systematic review, based on PRISMA guidelines, of articles published between 1970 and August 2016 and indexed in the following databases: EMBASE, MEDLINE, Cochrane Library Databases and PsycINFO. The key words "age", "late-life", "geriatric", "elderly", and "older" were combined with words indicating pharmacologic treatments, such as lithium and other mood stabilizers and with the diagnostic terms "bipolar disorder" and "mania". Fifteen out of 196 retrieved studies met our inclusion criteria. Seven studies evaluated both the efficacy and tolerability of lithium treatment in elderly BD patients; a further three evaluated only the efficacy and five assessed tolerability. Only limited data on the treatment of elderly BD patients are available, but evidence suggests that lithium is effective and tolerated in this subgroup of patients and thus should remain a first-line drug. It seems to be more effective at lower doses and close monitoring of plasma concentrations is necessary.

Late-Onset Mania in a Patient with Movement Disorder and Basal Ganglia Calcifications: A Challenge for Diagnosis and Treatment

Age of onset can have a significant impact on clinical course and pathophysiological mechanism of bipolar disorder. Late-onset bipolar episodes are more likely linked to medical illnesses and so are frequently classified as "secondary" forms of mood disorder. We discuss the case of a patient who at the age of 58 presented his first delusional-manic episode. He also had mild frontal and occipital cortical atrophy, white matter posterior ischemic lesions, and small basal ganglia calcifications. Seven years later, he presented a second manic episode with new emergent hyperkinetic choreiform symptoms. Taking into account movement disturbances, the presence of basal ganglia calcification, and worsening of cortical atrophy, we performed a differential diagnosis between Fahr disease, Fahr's syndrome, calcifications due to ageing, supersensitivity psychosis, and dementia. Valproate, quetiapine, and tetrabenazine were sequentially administered and yielded a good therapeutic response as regards manic and movement symptoms. Relationship between medications and course of specific symptoms was observed.

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.

Clinical Characteristics of Patients with Late Life Bipolar Disorder in the Community: Data from the NNDC Registry

OBJECTIVE

To compare clinical characteristics of older and younger patients with bipolar disorder enrolled in the United States' National Network of Depression Centers (NNDC) Clinical Care Registry (CCR).

DESIGN

Multicenter, de-identified naturalistic data from the National NNDC's CCR for all patients with a diagnosis of bipolar disorder who were enrolled in the registry as of April 25, 2013.

PARTICIPANTS

Community-dwelling patients (N = 218), ages 18 years or older, with bipolar disorder diagnosis recruited by NNDC-affiliated medical centers to participate in the NNDC CCR. Subjects aged 55 years or older were compared with subjects younger than age 55 years on clinical measures.

MEASUREMENTS

Patient Health Questionnaire; Quick Inventory of Depressive Symptomatology - Self-Report; Altman Self-Rating Mania Scale; Work and Social Adjustment Scale; Frequency and Intensity of Burden of Side Effects Rating; and the Self-Administered Comorbidity Questionnaire.

RESULTS

A greater percentage of older patients were prescribed antidepressant medications (71.9% versus 50.0%), and the younger cohort had significantly more psychostimulant use (16.7% versus 0%). Younger patients endorsed significantly more depressive symptoms compared with older patients. The mean number of psychotropic medications was not different in both older and younger patients with bipolar disorder. There was no statistically significant difference in frequency, intensity, or burden of psychotropic medication side effects as measured by the Frequency and Intensity of Burden of Side Effects Rating.

CONCLUSION

Findings of higher antidepressant use rates in the older cohort, combined with lower depression symptom severity and a similar degree of manic symptoms, suggests the possibility that older adults with bipolar disorder may have improved antidepressant efficacy and lower switch rates into manic or mixed states compared with younger cohorts. Ongoing data collection by the NNDC CCR will add to current knowledge to inform the care of older patients with bipolar disorder by providing multi-site data regarding phenomenology, treatment response, and longitudinal course of late life bipolar disorder in community settings.

Late-life psychosis: diagnosis and treatment

Psychosis is one of the most common conditions in later life with a lifetime risk of 23 %. Despite its high prevalence, late-onset psychosis remains a diagnostic and treatment dilemma. There are no reliable pathognomonic signs to distinguish primary or secondary psychosis. Primary psychosis is a diagnosis of exclusion and the clinician must rule out secondary causes. Approximately 60 % of older patients with newly incident psychosis have a secondary psychosis. In this article, we review current, evidence-based diagnostic and treatment approaches for this heterogeneous condition, emphasizing a thorough evaluation for the "six d's" of late-life psychosis (delirium, disease, drugs dementia, depression, delusions). Treatment is geared towards the specific cause of psychosis and tailored based on comorbid conditions. Frequently, environmental and psychosocial interventions are first-line treatments with the judicious use of pharmacotherapy as needed. There is an enormous gap between the prevalence of psychotic disorders in older adults and the availability of evidence-based treatment. The dramatic growth in the elderly population over the first half of this century creates a compelling need to address this gap.

Social support in late life mania: GERI-BD

OBJECTIVE

Using the database of the National Institute of Mental Health-sponsored acute treatment of late life mania study (GERI-BD), we assessed the role of social support in the presentation of late life bipolar mania.

METHODS

In the first 100 subjects randomized in geriatric BD, we explored the demographic, clinical, and social support characteristics (assessed using the Duke Social Support Index) and aspects of manic presentation. We selected two dependent variables: symptom severity, as determined by the Young Mania Rating Scale (YMRS) at baseline, and duration of episode. We selected nine potential independent variables on the basis of Pearson correlation coefficients. We derived two final models using multiple regression analysis employing an iterative process.

RESULTS

In our severity model, being married was associated with a higher YMRS score (p = 0.05), whereas higher social interaction scores with non-family members were associated with a lower YMRS score (p = 0.011). In the episode duration model, longer duration was associated with a higher Hamilton Depression Rating Scale score (p = 0.03) and higher social interaction scores with non-family members (p = 0.0003), younger age (p = 0.04), higher number of persons in one's family social network (p = 0.017), and higher instrumental support scores (p = 0.0062).

CONCLUSIONS

In late life mania, more social interaction with one's community appears to be associated with less severe symptoms at presentation for treatment, however, it can also be associated with slightly longer the duration of episode. Two aspects of the Duke Social Support Index are associated with a shorter episode duration prior to seeking treatment: being part of a larger family network and a having a higher level of instrumental support prior to treatment. The Instrumental Support Subscale measures the degree of assistance that is available for the respondent in performing daily tasks. These findings suggest that in older adults with BD, close social interactions and support are important in limiting the length of the illness episode prior to treatment. Social interactions involving non-family members may be less important in moderating the intensity of the symptoms at presentation.

Characteristics associated with inpatient versus outpatient status in older adults with bipolar disorder

OBJECTIVES

This is an exploratory analysis of ambulatory and inpatient services utilization by older persons with type I bipolar disorder experiencing elevated mood. The association between type of treatment setting and the person's characteristics is explored within a framework that focuses upon predisposing, enhancing, and need characteristics.

METHOD

Baseline assessments were conducted with the first 51 inpatients and 49 outpatients 60 years of age and older, meeting criteria for type I bipolar disorder, manic, hypomanic, or mixed episode enrolled in the geriatric bipolar disorder study (GERI-BD) study. We compared participants recruited from inpatient versus outpatient settings in regard to the patients' predisposing, enabling, and need characteristics.

RESULTS

Being treated in an inpatient rather than an outpatient setting was associated with the predisposing characteristic of being non-Hispanic caucasian (odds ratio [OR]: 0.1; P = .005) and past history of treatment with first-generation antipsychotics (OR: 6.5; P < .001), and the need characteristic reflected in having psychotic symptoms present in the current episode (OR: 126.08; P < .001).

CONCLUSION

Ethnicity, past pharmacologic treatment, and current symptom severity are closely associated with treatment in inpatient settings. Clinicians and researchers should investigate whether closer monitoring of persons with well-validated predisposing and need characteristics can lead to their being treated in less costly but equally effective ambulatory rather than inpatient settings.

Acute bipolar I affective episode presentation across life span

OBJECTIVES

There is a paucity of evidence on bipolar I acute symptoms' presentation in the elderly individuals compared to younger patients. The current literature provides little, and at times conflicting, information on age-related bipolar disorder (BD) symptom presentation. This article aims to compare symptom profile by age group among patients with bipolar I in an acute affective episode as evaluated in outpatient settings.

METHODS

The current analyses include all Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) participants with a lifetime diagnosis of bipolar I disorder. We compared the presence and severity of acute mood elevation (mania and hypomania) and acute depression symptoms between younger (20-59 years old) and older individuals (older than or equal to 60 years).

RESULTS

With the exception of distractibility, all acute depression symptoms presented with comparable frequency and severity between younger and older individuals. No statistical significance was found regarding the presence of psychotic symptoms between the 2 groups, with symptoms reported by 11.2% of younger versus 9.4% older individuals, χ(2) (1, N = 1541) = 0.03, P = .74. No significant effects were found for mood elevation severity between the 2 age groups. Psychotic symptoms were reported in 12.7% versus 15.2%, χ(2) (1, N = 658) = 0.07, P = .65, and irritability in 97.7% versus 97.8%, χ(2) (1, N = 651) = 0.00, P = 1.00, in the younger and older group, respectively.

CONCLUSION

We found no statistically significant association between age and symptoms presentation of acute depression and mood elevation among patients with BD I. Acute BD I affective states present with similar profile and severity in old and young patients.

Depression symptom ratings in geriatric patients with bipolar mania

OBJECTIVE

Given the paucity of information available regarding standardized ratings of depression symptoms in bipolar manic states, and in particular those in older adults, we explored depression ratings in symptomatic participants in a multicenter study of treatment of bipolar I disorder in late life.

METHODS

Baseline data was obtained from the first 100 patients enrolled in an NIMH-funded, 9-week, randomized, double-blind RCT comparing treatment with lithium or valproate in patients of age 60 years and older with Type I Bipolar mania or hypomania. This multi-site study was conducted at six academic medical centers in the United States and enrolled inpatients and outpatients with a total Young Mania Rating Scale (YMRS) score of 18 or greater. Depressive symptoms were evaluated with the Hamilton Depression Rating Scale (HAM-D) and the Montgomery-Asberg Depression Rating Scale (MADRS). The criterion for at least moderate bipolar depressive symptoms was the European College of Neuropsychopharmacology (ECNP) Consensus Meeting definition of HAM-D 17 total score >20.

RESULTS

Eleven percent of patients had mixed symptoms defined by depression scale severity according to ECNP criterion. In the overall sample, total scores on the two depression scales were highly correlated. Total YMRS scores of this mixed symptom group were similar to the remainder of the sample.

CONCLUSIONS

These preliminary findings suggest that moderate to severe depressive symptoms occur in about one in ten bipolar manic elders. Future studies are needed to further evaluate symptom profiles, clinical correlates, and treatments for bipolar older adults with combined manic and depressive symptoms.

Geriatric bipolar disorder

Because the elderly are the fastest growing segment of the population, the number of older adults with bipolar disorder is increasing. Geriatric bipolar disorder is relatively rare, with an estimated lifetime prevalence of 0.5% to 1%, although approximately 4% to 17% of older patients in clinical psychiatric settings have bipolar disorder. Bipolar elders are disproportionately affected by medical burden. Given the complex nature of this disorder, comorbidity, and behavioral disturbances, various interventions may be indicated, including pharmacotherapies, electroconvulsive therapy, psychotherapies, and integrated care models. Additional research is needed to better understand the epidemiology, phenomenology, and treatment of geriatric bipolar disorder.

Multisite, open-label, prospective trial of lamotrigine for geriatric bipolar depression: a preliminary report

AIMS

This is a multisite, 12-week, open-label trial of lamotrigine augmentation in 57 older adults (≥ 60 years; mean ± SD age = 66.5 ± 6.7 years) with either type I or type II bipolar depression.

METHODS

Primary outcome measure was change from baseline on the Montgomery-Åsberg Depression Rating Scale (MADRS). Secondary outcome measures included Hamilton Depression Rating Scale (HAM-D), Clinical Global Impression-Bipolar version (CGI-BP), and the WHO-Disability Assessment Schedule II (WHO-DAS II). The Udvalg for Kliniske Undersøgelser (UKU) was used to assess side effects.

RESULTS

A total of 77.2% of the study subjects had bipolar I disorder. The mean (SD) lamotrigine dose was 150.9 (68.5) mg/day. There was significant improvement in the MADRS, HAM-D, CGI-BP, and in most domains on the WHO-DAS II. For patients for whom final MADRS score was available: 31 (57.4%) met remission criteria and 35 (64.8%) met response criteria. There were 19/57 (33.3%) who dropped out of the study prematurely, with 6 dropouts due to adverse events (4 cases of rash, 1 manic switch, and 1 hyponatremia). Two cases of rash were possibly drug related and were resolved with drug discontinuation. The most common UKU adverse effects were reduced sleep duration (n = 14, 24.6%), weight loss (n = 12, 21.1%), increased dream activity (n = 12, 21.1%), polyuria/polydipsia (n = 11, 19.3%), weight gain (n = 9, 15.8%), diminished sexual desire (n = 9, 15.8%), increased sleep (n = 9, 15.8%), lassitude/fatigue (n = 8, 14%), and unsteady gait (n = 8, 14%). No significant changes in electrocardiogram or laboratory tests were observed.

CONCLUSIONS

In bipolar depressed elders, lamotrigine was associated with improvement in depression, psychopathology, and functional status. There was a moderate number of adverse events, although relationship of adverse events (particularly falls) to study medication could not be clearly determined in this uncontrolled trial. Controlled studies are needed to further evaluate efficacy and tolerability of lamotrigine therapy in geriatric bipolar depression.

The relationship of bipolar disorder lifetime duration and vascular burden to cognition in older adults

OBJECTIVES

  We describe the cognitive function of older adults presenting with bipolar disorder (BD) and mania and examine whether longer lifetime duration of BD is associated with greater cognitive dysfunction. We also examine whether there are negative, synergistic effects between lifetime duration of BD and vascular disease burden on cognition.

METHODS

  A total of 87 nondemented individuals with bipolar I disorder, age 60 years and older, experiencing manic, hypomanic, or mixed episodes, were assessed with the Dementia Rating Scale (DRS) and the Framingham Stroke Risk Profile (FSRP) as a measure of vascular disease burden.

RESULTS

  Subjects had a mean (SD) age of 68.7 (7.1) years and 13.6 (3.1) years of education; 50.6% (n = 44) were females, 89.7% (n = 78) were white, and 10.3% (n = 9) were black. They presented with overall and domain-specific cognitive impairment in memory, visuospatial ability, and executive function compared to age-adjusted norms. Lifetime duration of BD was not related to DRS total score, any other subscale scores, or vascular disease burden. FSRP scores were related to the DRS memory subscale scores, but not total scores or any other domain scores. A negative interactive effect between lifetime duration of BD and FSRP was only observed with the DRS construction subscale.

CONCLUSIONS

  In this study, lifetime duration of BD had no significant relationship with overall cognitive function in older nondemented adults. Greater vascular disease burden was associated with worse memory function. There was no synergistic relationship between lifetime duration of BD and vascular disease burden on overall cognition function. Addressing vascular disease, especially early in the course of BD, may mitigate cognitive impairment in older age.