1. 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
高雄長庚紀念醫院 復健及社區精神科主治醫師 黃毓琦

2. 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

3. 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

4. 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

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

6. 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

7. 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

8. 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

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

10. 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

11. 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

12. 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

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

14. 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