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Management of Bipolar Disease in the Elderly M. Cornelia Cremens, MD Director of Inpatient Geriatric Consultation Division of Medicine and Psychiatry Massachusetts General Hospital Sunday August 3, 2008 9:00 - 9:50 am Concerns of Older Adults „ Quality of life ‹ Mental and physical health fundamental to a more meaningful life ‹ Many more issues in late life ‹ How to avoid – early treatment/prevention ‹ Increasing numbers struggling with mental health issues Good news „ Most seniors enjoy good mental health Psychiatric illness is not part of normal aging ‹ NIMH 1:5 diagnosed with mental illness ‹ „ Growing population mentally ill 65+ 20 million in 1970 (7 million) ‹ 65+ predicted 70 million in 2030 (15 million) ‹ Mental Health Issues in Aging Most common psychiatric disorders in late-life  Anxiety (includes phobias and OCD)  Cognitive impairment and delirium (Alzheimer’s disease)  Mood disorders (depression and bipolar)  Range of severity from problematic-severe • Suicide highest in this age group Older Adults Avoid Psychiatrists „ Mental health services underutilized  Stigma  Denial  Lack of services, access outreach  Poor coordination of services and follow-up Psychiatric Evaluation of Older Adults „ „ „ Psychiatric assessment  Rule out pre-morbid psychiatric illness  Rule out co-morbid medical illness Functional Assessment  ADLs • mobility, dressing, hygiene, feeding and toileting  IADLs • independent living, shopping, cooking, telephone, housekeeping (light), medications, finances, transportation Evaluation  Complete history  Psychiatric, medical, neurological What is different in evaluation? „ Evaluation Complete history, • Prior clinicians, medical records, medications • often need family to give history  Psychiatric, medical, neurological  „ Psychiatric assessment Rule out pre-morbid psychiatric illness  Rule out co-morbid medical illness  Evaluation of Function „ Functional assessment ‹ Activities of daily living  ‹ Feeding, Bathing, Dressing, Transferring, Toileting Instrumental activities of daily living   Finances, Telephone, Medications, Shopping, Cooking Housework, Ambulating, Laundry Presentation of Illness „ Often atypical may present as ‹ Falls Behavioral changes ‹ Behavioral changes ‹ Cognitive deficits ‹ Functional losses  incontinence ‹ Non-specific signs and symptoms Evaluation of Older Patients „ „ „ Cognition ‹ Assessment Mini-Mental State Exam (Folstein) Affect ‹ Sleep Interest Guilt Energy ‹ Concentration Appetite ‹ Psychomotor activity ‹ Suicide Psychosis Medications, get a list „ „ „ „ „ „ „ „ Bring the bottles in to appointment Current list Names of prescribers Dates on bottles Over the counter Herbal Borrowed from a friend Old medications, saved Most commonly prescribed „ „ „ „ Cardiovascular  Diuretic  Antihypertensive  Vasodilator  Digoxin Psychotropic Analgesic  narcotic  antiarthritic Laxative  antispasmodic Common culprits „ „ „ „ „ „ „ Over the counter sleeping pills  PM combinations Allergy medications, antihistamines Cough syrup, alcohol or dextromethorphan Cold preparations, pseudoephedrine Narcotics Illicit drugs, cocaine, MJ Alcohol, intoxication or withdrawal More culprits, prescribed Any medication or substance „ Dopaminergic medications „ Steroids „ Stimulants „ Benzodiazapines „ Cardiac medications „ Herbal preparations „ Psychosis „ Common Types of Psychosis ‹ Delirium ‹ Dementia ‹ Depression ‹ Mania Psychosis „ DSM-IV definition one or more of: ‹ Hallucinations ‹ Delusions ‹ Disorganized speech ‹ Disorganized or catatonic behavior Psychosis „ „ „ „ „ „ Dementia Delusional disorder Charles Bonnet Syndrome ‹ confused with psychosis ‹ poor response to medications Rule out ‹ alcoholism ‹ substance abuse Prescribed drugs Illicit drugs Demographics of Bipolar Illness in the elderly population Epidemiology ‹ Underreported or not diagnosed „ Prevalence „ 1% general population ‹ 1.2-1.3% 1-year community based ‹ Bipolar Illness Bipolar illness - onset often early in life „ 10% of patient with BPI onset >50 years „ First onset of mania or hypomania is rare in the elderly „ Patient often presents with depression first „ Not usually hypomania or mania „ Bipolar Illness „ „ Associated with or complicated by  cognitive impairment  substance abuse  co-morbid illness  history of depression Secondary mania due to medical conditions or neurological disorders is diagnosed more frequently especially with dementia