In the next several decades, the health care community will have to prepare for sharply ramped-up service needs for older adults, including those with chronic mental conditions. In both younger and geriatric persons, bipolar disorder (BD) may be misdiagnosed or underdetected. Existing data suggest that standard medications may be useful, but clinicians need to consider and manage multiple medical and cognitive comorbidities when working with the elderly population. This slideshow provides an overview of key issues relevant to geriatric BD as it relates to comorbidity.
Physical illnesses are common in the elderly, with an average of 3 or 4 medical conditions. This population is particularly vulnerable to metabolic syndrome (up to 50%), hypertension (45% to 69%), diabetes mellitus (18% to 31%), and cardiovascular disease (9% to 49%) [see Reference 8 here] Cardiovascular comorbidity partially explains the increased rates of cerebrovascular disease in late-life BD, and vascular events may be etiologically involved in late-onset BD. Cardiovascular and other medical conditions probably arise from a combination of factors, including biological stressors inherent to BD (eg, inflammation, oxidative stress), lifestyle (eg, dietary habits, physical activity, substance use), and psychotropic medication exposure (eg, antipsychotics, mood stabilizers).
Interdisciplinary care with primary care physicians and medical specialists can help ensure regular screening, diagnosis, and treatment. For example, assessment of mood symptoms in elderly patients might start with a careful history taken from the patient and collaborative sources. Evaluation should focus on mood, anxiety, and cognitive and neuropsychiatric symptoms as well as on assessment for comorbidities, use of new medications or herbal/alternative supplements, and adherence to prescribed medications.
Cognitive dysfunction affects many older BD patients, and it is often associated with functional disability. Although impairment exists in multiple domains, including attention, executive function, processing speed, working memory, and verbal memory, it is unclear whether dysfunction is comparatively more severe in older BD patients. As with medical comorbidity, cognitive dysfunction has a number of causes in BD, including inflammatory and oxidative processes. Medications with higher anticholinergic burden may be a contributing factor (eg, certain antipsychotics), as may be substance use and cardiovascular disease.
Clinical presentation of geriatric BD must be interpreted cautiously, since most study samples are cross-sectional and are probably survivor cohorts. Existing therapies (eg, cholinesterase inhibitors) have not been effective in treating cognitive dysfunction, although lithium may be a therapeutic candidate. Clinicians could start by using treatments with both large-scale randomized controlled trial (RCT) evidence in adults and some data in older adults, followed by medication with evidence of fewer risks. Conclusions and treatment recommendations based on the extant literature must be tempered with consideration.
Psychiatric comorbidities are less common in geriatric patients with BD than in younger adults with BD. Since there are higher rates of familial transmission in early-onset cases and late-onset cases are usually more associated with neurological comorbidity, it is possible that early-onset BD and the late onset variant are different illnesses. Clinical presentation and course of illness in later life also vary. Older patients may have more severe depressive episodes and less severe manic episodes than younger patients.