高雄長庚紀念醫院 復健及社區精神科主治醫師 黃毓琦 老人躁鬱疾患之評估與治療 2015. 06.05 高雄長庚紀念醫院 復健及社區精神科主治醫師 黃毓琦

Bipolar disorder Chronic mental disorder characterized by alternating episodes of depression, euthymia, (hypo)mania and mixed states Onset age usually under the age of 30 years 90% of bipolar patients have become ill by the age of 50 15 times higher suicide risk among bipolar patients than in the general population Bauer et al., 2002; Hirschfeld et al., 2003; Harris and Barraclough 1997

Bipolar disorder 10% of the population may develop bipolar disorder for the first time after 50 years of age 8% and 9% of patients with bipolar disorder were aged 65 years and 60 years or over at the time of first contact with mental health services Rapid cycling was more prominent in elderly patients Oostervink et al., 2009; Almeida and Fenner, 2002; Kennedy et al., 2005

Late onset bipolar disorder (LOB) Lower familial rate of bipolar disorder than EOB More medical and neurological comorbidity LOB mania is generally associated with fewer manic symptoms which are milder More likely to have irritable behavioral characteristics Tendency toward treatment resistance, and a higher mortality rate Depp and Jeste, 2004; Cassano, 2000; Sajatovic, 2002a

Late onset bipolar disorder (LOB) Often associated with organic factors White matter hyperintensities Besga et al., 2011

Differences between Younger and Elderly bipolar patients Mania in the elderly is less severe Modified Manic State Rating Scale (MMSRS) : elderly group scored lower than a younger group Young Mania Rating Scale (YMRS) : elderly patients had lower scores on the items increased activity-energy language-thought disorder sexual interest Blackburn et al., 1997; Broadhead and Jacoby, 1990; Young and Falk, 1989

Differences between Younger and Elderly bipolar patients The mean time between the first episode of depression and the onset of mania 17 years in the elderly group 3 years in the younger group More elderly than younger manic patients had suffered three or more depressions before their first mania Elderly manic patients were more likely to relapse into depression after mania Broadhead and Jacoby, 1990; Calabrese, et l., 2003

Differences between Younger and Elderly bipolar patients Compared to elderly subjects, the younger ones were imprisoned more frequently (11.4% versus 28.2%) Elderly manic patients were less likely to be treated with antipsychotics after discharge than younger patients Broadhead and Jacoby, 1990

Differential diagnosis Secondary mania resulting from Physical illness Neurologic Endocrine Metabolic Antidepressant Krauthammer and Klerman, 1978; Young et al., 2003

Pharmacological Treatment in Elderly Pharmacokinetic and pharmacodynamic changes Increased risk of drug interactions 96% of prescriptions had a potential for drug–drug interactions Average of eight drugs prescribed for each patient Vasudev et al., 2008

Pharmacological Treatment Lithium in older adults is often more complicated by potential adverse effects Anticonvulsants are increasingly used in the management of bipolar disorder in older adults High use of antidepressants in the elderly group who were cycling (40%) McDonald, 2000; Aziz et al., 2000; Shulman et al., 2003; Sajatovic, 2005a, Vasude and Thomas, 2010

Pharmacological Treatment Typical antipsychotics is particularly problematic in the elderly because of higher risk of cardiovascular problems and movement disorders An increased incidence of mortality has been reported in elderly patients with dementia-related psychosis treated with atypical antipsychotics Atypical antipsychotics in older adults with bipolar disorder although potential benefit must be balanced against the potential risks of treatment Sajatovic2005a, 2002b, 2005b; Young et al., 2004; FDA 2006; Aziz et al, 2006a

Psychological intervention Psychoeducation Family-Focused Treatment Cognitive–behavioral therapy Interpersonal therapy Rouget and Aubry 2007

Psychoeducation Individual or group format by various health professionals (physicians, clinical psychologists, nurses or social workers) Outpatient settings During an euthymic phase ensure a better assimilation of the information dispensed prophylactic treatment for relapse Mild depressive episode can usually gain benefit from PE ; (hypo)manic symptoms limits its impact Rouget and Aubry 2007