COMMENTARY

Managing Bipolar Disorder in the Elderly

Stephen M. Strakowski, MD

Disclosures

August 16, 2017

Hello. I'm Stephen M. Strakowski, chair of the Department of Psychiatry at the new Dell Medical School at the University of Texas in Austin. Thank you all for tuning in to this webcast. I really do appreciate those of you who watch these webcasts regularly and send in comments. Please continue to do so.

Today I want to talk about bipolar disorder in the elderly—probably more technically correct, mania in the elderly. There have been a couple of recent papers to address this topic, which is an area we really don't know enough about. One of these papers is by Martha Sajatovic, MD, at Case Western; it was published in the journal Bipolar Disorders.[1] The other is by Tamar Katz, MD, at McLean Hospital, and it appeared in Current Treatment Options in Psychiatry.[2] Both are useful resources.

As I've talked about in another webcast, bipolar disorder is typically an illness of young people. The mean age of onset is usually in the late teens to perhaps early 20s, and it's fairly unusual for it to occur after about age 35. In the recent STEP-BD program, two thirds of cases started by age 18.[3] There is a high rate of suicide in these young people, making bipolar one of the more lethal of psychiatric disorders.

However, mania does occur in people over 50, which is now considered the elderly population in these studies. (This is a struggle for me, being 55, and I continue vainly to refuse to join AARP.) There's some debate about whether "elderly" should be defined as persons over 50 or over 60, but this becomes academic because after age 35, it's unusual for bipolar to start anew.

These 50-year-old bipolar patients possess some interesting and different challenges. When patients present with mania after 50, there are two different perspectives to consider. One is that they are bipolar patients who had a typical age of onset and managed to successfully navigate through life to be around at 50. Given that bipolar disorder is associated with a younger age of death by about 10 years, this sometimes is no small feat for these patients. The second perspective is that these patients developed a first manic episode, and those probably represent a very different group from the bipolar patients who've managed to live this long.

About 5% of new bipolar cases occur in this older age group.[4] In general, when you are faced with a patient like this, your assumption should be that this is a so-called secondary mania—not from bipolar disorder the genetic illness, per se, but one that is more likely to have a medical cause. The first line of business with someone with a new onset of mania in this age group is to work very diligently to identify causes.

There are a number of potential causes, and at some level, virtually anything that can affect the brain has some potential to create mania, although, as discussed in the previous webcasts, depression is far more likely to be the induced mood episode. Nonetheless, secondary mania has been associated with various types of brain injury, from trauma to stroke, subarachnoid bleeds, or other hemorrhages. Usually, injuries that occur within and disrupt ventral prefrontal networks are thought to be an underlying cause of bipolar disorder. Bipolar disorder has been associated with some brain diseases like multiple sclerosis, epilepsy, Huntington's (if it occurs in someone whose symptoms have started somewhat later in life), and, though relatively rare, normal-pressure hydrocephalus.

A new manic episode may be the first symptoms or presentation of someone with an evolving dementia. Symptoms with delirium can often look like mania, and the two are sometimes confused; in the case of delirium, though, there is a loss of sensorium and understanding of where you are. Unfortunately, mania can produce delirium, and that becomes a very important differential, as delirium can be lethal.

Systemic diseases like Cushing syndrome, hyperthyroidism, vitamin B12 deficiencies, and hemodialysis have been reported to produce manic episodes. Regarding infectious diseases, any virus such as HIV that crosses the blood-brain barrier (BBB) and causes encephalitis or other related conditions should be considered in the differential. In the old days, we worried a lot about neurosyphilis, and though it has become less common, the disease periodically rebounds.

Perhaps the most important thing in an older person presenting with manic symptoms is to really take a close look at all of the medications they're on.

Finally, perhaps the most important thing in an older person presenting with manic symptoms is to really take a close look at all of the medications they're on. There are some obvious ones like stimulants, or perhaps antidepressants or steroids, that cause manic symptoms. Virtually anything that can cross the BBB should at least be considered. Often, the first intervention is to simplify the patient's medication regimen.

One of the challenges is that as we get older, we may no longer tolerate at age 75 the same medications we took when we were in our 50s because our metabolism is not as efficient. Additionally, if someone with a history of bipolar disorder has a new manic episode, you can't assume that medications aren't part of it as well.

One of the difficulties of caring for older patients with bipolar disorder is that, like any aging adult, they have developed an accumulation of medical problems. Unfortunately, bipolar disorder increases a person's risk of developing almost every major medical illness, including cardiovascular disease, cerebrovascular disease, cancers, and metabolic diseases such as diabetes.[5] There is also evidence that dementia may be more likely in patients with a history of bipolar disorder.[6] These conditions also accumulate in an older person with a typical onset of bipolar illness and may precipitate a new manic or depressive episode later in life, despite having been stabilized for many years.

When working with older patients with manic, bipolar, posttraumatic, or depressive symptoms, it is very important to spend extra time ruling out potential medical precipitants of someone who has bipolar disorder or a new cause of mania.

As our aging population increases, more people with bipolar disorder are, fortunately, making it into this group, as are those who will develop secondary mania. Despite this fact, we still don't know a lot about treatment differences between younger and older adults. Generally speaking, treatment paradigms for younger adults are translated to older patients. For example, there's very little understood about specific cognitive therapies you might use for depressed older bipolar patients that take into account the circumstances of aging, or the challenges that life throws at you as you get into your 70s and 80s, such as the loss of family and friends.

Regarding treatment challenges, the second piece, which I already alluded to, is that as you age, your ability to tolerate a medicine you might have been on for 20 years may decline, necessitating either a change in dose or medication approach. The old adage all of us learned in residency about "starting low and going slow" really does apply to older patients. I typically will find the lowest preparation available—ideally at least half the typical adult starting dose—and if necessary and possible, I may even cut the lowest dose in half if there's no urgency to get a condition managed.

Unfortunately, there just aren't a lot of trials available, and we don't have good data for alternative approaches. To date, because they've been around a long time, we know that both lithium and divalproex appear to be generally well tolerated and generally effective in older age groups. Both of these drugs have fairly simple metabolic profiles, which is helpful when you have to manage interactions with a lot of other medications and patients with multiple medical conditions.

Lithium, for example, is fully metabolized by the kidney, and there are relatively few other drugs that interact with renal metabolism for its use to become a problem. There may be a slight advantage to lithium over other treatments in this age group for that reason. Additionally, the blood levels of lithium are meaningful, which helps to monitor dosing as people age.

Lamotrigine has one positive augmentation trial in treating bipolar disorder.[7] It is very well tolerated and serves as a useful second addition or may have even a primary role in older people depending on tolerance.

Electroconvulsive therapy (ECT) moves up in most treatment paradigms in older patients because, paradoxically, despite the stigma, it is often better tolerated and is useful for treating both phases of bipolar illness. It may be useful in someone with an underlying medical problem or drug intolerance. ECT is something you should keep in mind and probably lower your threshold of using it in older patients compared with someone who's a lot younger.

Be careful with carbamazepine—it has so many drug-drug interactions. Because older patients tend to accumulate medications, I generally don't recommend it as a first line for older patients. However, it may be considered in some patients. Carbamazepine does require careful monitoring, as a patient who has been on it for years may suddenly start having interactions due to metabolic changes.

Similarly, benzodiazepines can cause a lot of problems, including oversedation and falls, particularly in patients in their 70s and 80s. Patients on benzodiazepines should be carefully monitored.

The atypical antipsychotics are widely used in younger people, but there's a black box warning against their use in elderly patients with dementia because of the increased risk for sudden death and a possible increased risk for cerebrovascular accidents.[8] Again, this may be less of a concern in younger patients in their 50s, but we need to carefully consider whether an atypical antipsychotic is the best choice for patients in their 70s and 80s—particularly those with symptoms of dementia.

There is probably not a lot of difference among use of the atypical antipsychotics in elderly patients with bipolar disorder or those with secondary mania. It becomes a choice of side-effect profiles versus the various accumulated medical illnesses the patient may have, and attempting to identify the ones that are least likely to be a problem. For example, if someone has cardiac arrhythmias or conduction problems, ziprasidone is not the best choice. Similarly, if a patient has diabetes and is obese, then olanzapine is probably not the best option.

We use side-effect profiles assuming that efficacy in general is probably not dissimilar. There have been a couple of post-hoc analyses of randomized clinical trials of lurasidone and quetiapine in which the elderly patients were examined separately.[9,10] These studies showed that both drugs were successful and well tolerated, suggesting that, as a class, atypical antipsychotics probably can be used with all of the caveats we've discussed.

It's clear that we really need more research on bipolar disorder in the elderly, particularly given the increasing aging population. My hope is that some of the younger psychiatrists watching this webcast will consider a research career focusing on understanding bipolar disorder in older patients. There's simply not enough information on how we manage these patients separately, and I encourage you to think about it. The two papers I mentioned at the beginning of this webcast are great resources for anyone interested in learning more about this topic.

Again, I want to thank you for watching this and our other webcasts. We're always looking for good topic suggestions. If you want to write in and suggest other topics you would like us to discuss, that would be wonderful. Thank you very much.

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