Annemiek Dols

A report on older‐age bipolar disorder from the International Society for Bipolar Disorders Task Force

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).

Psychiatric and Medical Comorbidities: Results from a Bipolar Elderly Cohort Study

OBJECTIVE Bipolar disorder is associated with concurrent mental and physical disorders. Although well studied among younger adults, less is known about concurrent morbidity among older patients. This is important because comorbidity may increase with age and optimal treatment requires awareness of medical and psychiatric comorbidities. This study analyzed psychiatric and medical comorbidity in a Dutch bipolar elderly cohort. METHODS This cross-sectional descriptive study included demographic and clinical data on 101 bipolar patients aged 60 and over (mean age: 68.9 ± 7.8 years); 53.4% were women. Psychiatric diagnoses were confirmed by semistructured diagnostic interviews. Somatic history, including current somatic complaints, was obtained by interview. Medication and indicators of metabolic syndrome were obtained via record review. RESULTS Most patients received outpatient care. Bipolar I disorder was diagnosed in 56.4% of patients, and 75.6% had an onset of first affective symptoms before age 50. The prevalence rates of psychiatric comorbidities were low, except for lifetime alcohol dependence (24.8%) and abuse (13.9%). On average, there were 1.7 (SD: 1.6) medical comorbid conditions, predominantly hypertension (27.8%), arthrosis (29.1%), and allergies (25.6%). Polypharmacy was found in 31.7% of patients and metabolic syndrome in 28.7%. CONCLUSION Psychiatric comorbidity (especially anxiety disorders) was relatively uncommon, except for substance use disorder. Geriatric bipolar patients had on average two comorbid medical conditions and relatively high medication use. Findings underline the need to assess for comorbid conditions in bipolar elders, thereby enabling tailored treatment to optimize the general condition of these patients.

The prevalence of late-life mania: a review

Since there is a worldwide steady increase in the number of individuals living longer and an expected increase in the number of older adults who will be diagnosed with bipolar disorder, there is a growing need to better understand late‐life mania. We provide in this review a report of published studies focusing on the prevalence of late‐life mania in the community and in senior psychiatric care facilities.

Screening for metabolic syndrome in older patients with severe mental illness.

OBJECTIVE To evaluate metabolic screening of elderly patients with severe mental illness (SMI) in terms of newly detected metabolic abnormalities. METHODS Prospective evaluation of the metabolic screening outcome data of 100 consecutive elderly outpatients with SMI, all with universal access to health services. We gathered data on previous diagnoses of hypertension, diabetes, and dyslipidemia and assessed metabolic syndrome parameters. The findings were compared with those from a group of 124 healthy elderly. RESULTS In our patients with SMI (mean age: 69 years; 52% bipolar disorder, 48% schizophrenia), the frequency of metabolic syndrome was not higher compared with the healthy elderly. However, in 51% of the SMI sample, metabolic screening detected at least one metabolic abnormality in a patient with no prior history for that specific parameter. CONCLUSION Implementing routine screening for metabolic syndrome in elderly patients with SMI may reveal substantial rates of previously undetected metabolic abnormalities.

Psychiatric diagnoses underlying the phenocopy syndrome of behavioural variant frontotemporal dementia

Introduction The frontotemporal dementia (FTD) consortium criteria (2011) emphasise the importance of distinguishing possible and probable behavioural variant FTD (bvFTD). A significant number of possible patients with bvFTD do not show functional decline and remain with normal neuroimaging over time, thus exhibiting the bvFTD phenocopy syndrome. A neurodegenerative nature is unlikely but an alternative explanation is missing. Our aim was to detect psychiatric conditions underlying the bvFTD phenocopy syndrome after extensive evaluation. Methods We included patients with the bvFTD phenocopy syndrome whereby patients with probable bvFTD served as a control group. Patients had to have undergone both neurological and psychiatric evaluation. Their charts were reviewed retrospectively. Using both qualitative and quantitative methods, psychiatric and psychological conditions associated with the clinical syndrome were determined in both groups and their relative frequencies were compared. Results Of 181 suspected bvFTD cases, 33 patients with bvFTD phenocopy syndrome and 19 with probable bvFTD were included. Recent life events, relationship problems and cluster C personality traits were the most prevalent psychiatric/psychological conditions. The frequency of these conditions was higher in the group of patients with the bvFTD phenocopy syndrome (n=28) compared to the probable bvFTD group (n=9) (χ2 p<0.05). Conclusions This is the first study thoroughly exploring psychiatric causes of the bvFTD phenocopy syndrome, revealing that in most cases multiple factors played a contributory role. Our study gives arguments for neurological and psychiatric collaboration when diagnosing bvFTD. Prompt diagnosis of treatable psychiatric conditions is to be gained.

Relationship Between Hippocampal Volume, Serum BDNF, and Depression Severity Following Electroconvulsive Therapy in Late-Life Depression

Recent structural imaging studies have described hippocampal volume changes following electroconvulsive therapy (ECT). It has been proposed that serum brain-derived neurotrophic factor (sBDNF)-mediated neuroplasticity contributes critically to brain changes following antidepressant treatment. To date no studies have investigated the relationship between changes in hippocampal volume, mood, and sBDNF following ECT. Here, we combine these measurements in a longitudinal study of severe late-life unipolar depression (LLD). We treated 88 elderly patients with severe LLD twice weekly until remission (Montgomery–Åsberg Depression Rating Scale (MADRS) <10). sBDNF and MADRS were obtained before ECT (T0), after the sixth ECT (T1), 1 week after the last ECT (T2), 4 weeks after the last ECT (T3), and 6 months after the last ECT (T4). Hippocampal volumes were quantified by manual segmentation of 3T structural magnetic resonance images in 66 patients at T0 and T2 and in 23 patients at T0, T2, and T4. Linear mixed models (LMM) were used to examine the evolution of MADRS, sBDNF, and hippocampal volume over time. Following ECT, there was a significant decrease in MADRS scores and a significant increase in hippocampal volume. Hippocampal volume decreased back to baseline values at T4. Compared with T0, sBDNF levels remained unchanged at T1, T2, and T3. There was no coevolution between changes in MADRS scores, hippocampal volume, and sBDNF. Hippocampal volume increase following ECT is an independent neurobiological effect unrelated to sBDNF and depressive symptomatology, suggesting a complex mechanism of action of ECT in LLD.

Identifying bvFTD Within the Wide Spectrum of Late Onset Frontal Lobe Syndrome: A Clinical Approach

OBJECTIVE The behavioral variant of frontotemporal dementia (bvFTD) can be difficult to diagnose because of the extensive differential diagnosis, including many other diseases presenting with a frontal lobe syndrome. We aimed to identify the diagnostic spectrum causing a late onset frontal lobe syndrome and examine the quality of commonly used instruments to distinguish between bvFTD and non-bvFTD patients, within this syndrome. METHODS A total of 137 patients fulfilling the criteria of late onset frontal lobe syndrome, aged 45 to 75 years, were included in a prospective observational study. Diagnoses were made after clinical and neuropsychological examination, and neuroimaging and cerebral spinal fluid results were taken into account. Baseline characteristics and the scores on the Mini-Mental State Exam (MMSE), frontal assessment battery (FAB), Frontal Behavioral Inventory (FBI), and Stereotypy Rating Inventory (SRI) were compared between the bvFTD and the non-bvFTD group. RESULTS Fifty-five (40%) of the patients received a bvFTD diagnosis (33% probable and 7% possible bvFTD). Fifty-one patients (37%) had a psychiatric disorder, including 20 with major depressive disorder. Thirty-one patients received an alternative neurological, including neurodegenerative, diagnosis. MMSE and FAB scores were unspecific for a particular diagnosis. A score above 12 on the positive FBI subscale or a score above 5 on the SRI were indicative of a bvFTD diagnosis. CONCLUSION A broad spectrum of both neurological and psychiatric disorders underlies late onset frontal lobe syndrome, of which bvFTD was the most prevalent diagnosis in our cohort. The commonly used MMSE and the FAB could not successfully distinguish between bvFTD and non-bvFTD, but this could be achieved with the more specific FBI and SRI.

Do current national and international guidelines have specific recommendations for older adults with bipolar disorder? A brief report

Older adults with bipolar disorder (OABD) are a growing segment of patients with bipolar disorder (BD) for which specific guidelines are warranted. Although, OABD are frequently excluded from randomized controlled trials due to their age or somatic comorbidity, more treatment data from a variety of sources have become available in recent years. It is expected that at least some of this emerging information on OABD would be incorporated into treatment guidelines available to clinicians around the world.

The care needs of older patients with bipolar disorder

Objectives: With aging, bipolar disorder evolves into a more complex illness, with increasing cognitive impairment, somatic comorbidity, and polypharmacy. To tailor treatment of these patients, it is important to study their needs, as having more unmet needs is a strong predictor of a lower quality of life. Method: Seventy-eight Dutch patients with bipolar I or II disorder aged 60 years and older in contact with mental health services were interviewed using the Camberwell Assessment of Need in the Elderly (CANE) to assess met and unmet needs, both from a patient and a staff perspective. Results: Patients (mean age 68 years, range 61–98) reported a mean of 4.3 needs compared to 4.4 reported by staff, of which 0.8 were unmet according to patients and 0.5 according to staff. Patients frequently rated company and daytime activities as unmet needs. More current mood symptoms were associated with a higher total number of needs. Less social participation was associated with a higher total number of needs and more unmet needs. Conclusion: Older bipolar patients report fewer needs and unmet needs compared to older patients with depression, schizophrenia, and dementia. A plausible explanation is that older bipolar patients had higher Global Assessment of Functioning scores, were better socially integrated, and had fewer actual mood symptoms, all of which correlated with the number of needs in this study. The results emphasize the necessity to assess the needs of bipolar patients with special attention to social functioning, as it is suggested that staff fail to recognize or anticipate these needs.

Early- and Late-Onset Depression in Late Life: A Prospective Study on Clinical and Structural Brain Characteristics and Response to Electroconvulsive Therapy

OBJECTIVE The clinical profile of late-life depression (LLD) is frequently associated with cognitive impairment, aging-related brain changes, and somatic comorbidity. This two-site naturalistic longitudinal study aimed to explore differences in clinical and brain characteristics and response to electroconvulsive therapy (ECT) in early- (EOD) versus late-onset (LOD) late-life depression (respectively onset <55 and ≥55 years). METHODS Between January 2011 and December 2013, 110 patients aged 55 years and older with ECT-treated unipolar depression were included in The Mood Disorders in Elderly treated with ECT study. Clinical profile and somatic health were assessed. Magnetic resonance imaging (MRI) scans were performed before the first ECT and visually rated. RESULTS Response rate was 78.2% and similar between the two sites but significantly higher in LOD compared with EOD (86.9 versus 67.3%). Clinical, somatic, and brain characteristics were not different between EOD and LOD. Response to ECT was associated with late age at onset and presence of psychotic symptoms and not with structural MRI characteristics. In EOD only, the odds for a higher response were associated with a shorter index episode. CONCLUSION The clinical profile, somatic comorbidities, and brain characteristics in LLD were similar in EOD and LOD. Nevertheless, patients with LOD showed a superior response to ECT compared with patients with EOD. Our results indicate that ECT is very effective in LLD, even in vascular burdened patients.