INTRODUCTION

Bipolar disorder (BD) encompasses a series of disturbances in emotion regulation, energy utilization, and thinking characterized by phases of mania (or hypomania) and depression that impair both the autonomy and quality of life of affected persons.1 In a neurobiological basis, BD includes mood disorders that can either be episodic or develop due to family history, being usually chronic and progressive.2 Patients with BD, particularly the geriatric population,3 often have multiple comorbidities that result in high morbidity and mortality rates.4

The prevalence of BD is estimated to be 1.0% to 2.0% in the general population. Among older adults, BD accounts for 5.0% to 19.0% of all psychiatric disorders, being one of the most frequent chronic conditions in psychogeriatric wards and the reason for up to 20.0% of hospital admissions.4 The aging of the population has led to an increase in the number of older people living with the disease.5

Recent reviews indicate a lack of specific clinical information and adequate diagnostic criteria for the older population. Data are scarce on the average time living with the disease, frequency of psychiatric hospitalizations, number of suicide attempts, and family psychiatric history.3

This study aimed to describe the clinical and psychiatric characteristics of a sample of older outpatients with BD.

METHODS

We conducted a cross-sectional study of individuals aged 60 years or older with a diagnosis of BD type I according to the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5),6 who were followed at the psychogeriatric outpatient clinic of the São Vicente de Paulo Hospital (Brasilia - DF, Brazil) for at least 1 year. Patients with BD type II, personality disorders, and dementia (clinical dementia rating [CDR] ≥ 1) were excluded, as well as individuals with BD type I exhibiting active manic symptoms, secondary mood disorders, history of traumatic brain injury, and organic brain syndrome. The hospital is a referral center for mental health care and admits patients from all over the Midwest of Brazil. Interviews and data collection were performed between April and August 2022.

Clinical and demographic data were obtained by a psychiatric interview with each patient and family members as well as by a review of medical records, as follows: age, sex, marital status, education level, self-reported comorbidities, regular physical activity, age of onset of BD symptoms (early — before 50 years of age; late — 50 years or older), length of time with the illness, number of psychiatric hospitalizations during BD follow-up (none, 1-3, and ≥4), occurrence and number of suicide attempts, current pharmacological treatment for BD, and family history of BD, including first-degree relatives.

Cognitive performance was assessed using the Mini-Mental State Examination (MMSE) corrected for years of education,7 CDR, and the Functioning Assessment Short Test for Older Adults with BD (FAST-0).8 The Young Mania Rating Scale (YMRS)9 and the Hamilton Depression Rating Scale (HAM-D)10 were used to identify individuals with active or residual BD symptoms. Inclusion in our analysis required presentation of a brain imaging scan to rule out structural changes suggestive of secondary causes of cognitive decline.11

Descriptive data analysis was performed, with categorical variables expressed as absolute and relative frequencies. Continuous variables were submitted to the Shapiro-Wilk normality test, being presented as mean (SD) when exhibiting normal distribution or as median (IQR) when exhibiting non-normal distribution.The study met the ethical standards of the Helsinki declaration, and all patients provided written informed consent.

RESULTS

Twenty older patients with BD were evaluated, with a mean age of 72 years, ranging from 62 to 90 years. All patients reported being retired, whereas 90.0% (n= 18) reported being physically inactive. Other demographic data are presented in Table 1.

TABLE 1

Clinical and demographic characteristics of study participants.

BMI: body mass index; BD: bipolar disorder; CDR: clinical dementia rating; MMSE: Mini-Mental State Examination; FAST-O: Functioning Assessment Short Test for Older Adults with bipolar disorder.

Overall, 80.0% (n= 16) reported having no clinical comorbidity. No patient had manic or depressive symptoms, even residual ones, at the time of the evaluation, as expressed by individual scores < 7 on either the HAM-D or the YMRS scale. Only one patient reported a previous suicide attempt. Only 6 patients had never been hospitalized for an acute psychiatric crisis, whereas 8 patients had 1 to 3 admissions and other 6 patients had 4 or more admissions. Most patients (75.0%; n= 15) had an early onset of the disease, whereas 25.0% (n = 5) had a late onset. Data regarding pharmacological treatment are presented in Table 1. Concerning specific treatment for BD, typical antipsychotics were used by 30.0% of patients, atypical antipsychotics by 70.0%, and mood stabilizers by 90.0%, with a frequent combination of antipsychotics and mood stabilizers (80.0%).

In the cognitive and functional assessments, 9 patients (45.0%) showed no cognitive decline (score = 0) according to the CDR scale, whereas 11 (55.0%) showed mild cognitive impairment (CDR= 0.5). In line, 85.0% of patients had low MMSE scores (mean score close to 22), since 85.0% (n= 17) had scores below the expected value for the corresponding education level. Regarding FAST-O, the mean score was 9.4 (SD, 5.4), with scores ranging from 0 to 21.

DISCUSSION

This study investigated the clinical and psychiatric characteristics of a group of older people with a diagnosis of BD followed up in an outpatient setting specializing in mood disorders.The main results demonstrated a predominance of female patients (65.0%) and a prevalence of individuals with early-onset disease (75.0%), multiple hospitalizations due to BD decompensation (70.0%), important cognitive decline, and absence of detectable manic or depressive symptoms during the assessments.

The cognitive performance observed in terms of MMSE and CDR scores calls attention for being an essential aspect in the health care of older patients with BD. The literature is controversial regarding this topic since there is no consensus on whether a general, gradual cognitive decline occurs rather than (or coped with) an important decline in specific domain(s) in these patients.7 The literature reports that patients with BD have greater dysfunction in processing speed at older ages than healthy individuals.12 A study evaluating neuropsychological performance throughout the adulthood lifespan suggested that older age is associated with a selective cognitive decline in BD in the attentional domain.13 Conversely, a study found that older patients with euthymic BD have poor cognitive function compared with their healthy peers, but with no worsening over time.14 Moreover, CDR scores ranged from 0 to 0.5 due to sample selection criteria. The patients had been on longitudinal follow-up for a long time and were pre-selected by the team because they were stable, which can explain the absence of manic or depressive symptoms as seen on the HAM-D and YMRS scales (scores < 7).

Concerning physical performance as assessed by FAST-O, the literature provides no specific cutoffs to grade functionality. Bonnin et al.15 suggested, for the original FAST scale, that scores from 0 to 11 denote patients with no impairment, scores from 12 to 20 indicate mild impairment, and a score of 21 or above is suggestive of moderate or even severe (if ≥40) functional impairment. In our sample, 65.0% (n= 13) of patients scored < 12, showing preserved functionality, while 30.0% (n = 6) were compatible with mild impairment, and only 5.0% (n= 1) showed moderate impairment. However, care should be taken when extrapolating these values to FAST-O, because FAST and FAST-O are different scales. The higher prevalence of late-onset cases observed in the current study may be explained by the sample being derived from a specialized hospital-level service, which concentrates refractory cases.

Psychiatric hospitalizations are common events among patients with BD. Non-adherence to pharmacotherapy is associated with increased hospitalizations,16 but that is beyond the scope of this study. Here, 70.0% of patients had been hospitalized, which reveals great morbidity associated with BD in older adults. It is notable that most of the patients have been treated for decades, and this scenario may reflect old psychiatric practices, characterized by fewer treatment options.17 For comparative purposes, the average number of hospitalizations expected for patients with BD type I over a lifetime was not found in the literature.

The current psychoactive pharmacotherapy was in agreement with recent guidelines.18 Considering that these patients have been on treatment for a long time, some were using typical antipsychotics, where one patient was even using long-acting haloperidol in combination with a mood stabilizer.

Although suicide attempts were reported, we believe that the self-reporting strategy used in the study might have led to underreporting.19 Our approach was based on questioning the patient during a clinical interview regardless of the presence of a relative or caregiver, what might have inhibited an accurate response.

It was noted that 35.0% of patients had a first-degree family history of BD, which was an expected result because of the high heritability reported. In addition, a genetic overlap between BD and other mental disorders is often observed.20

One of the limitations of this study is the small number of patients, being a convenience sample. All patients were recruited at the same facility, which increases the likelihood of sample bias. We acknowledge that the population described here may not faithfully represent the community-dwelling population of older patients with BD, who are followed up in less specialized centers.

CONCLUSION

Most patients with BD showed a cognitive decline according to MMSE (85.0%), had early-onset disease (75.0%) and were hospitalized at least once for BD decompensation (70.0%).This study presents a sample of older patients with BD, which has been an understudied age group among individuals with this psychiatric condition. Further studies in this area are imperative to better evaluate this growing population, but the selection made by this study can contribute to the literature by revealing frequency data about a field of psychogeriatrics that lacks in-depth investigation.

ACKNOWLEDGEMENTS

We would like to thank the study participants for their contribution and the Brazilian government research-funding agencies: Fundação de Apoio à Pesquisa do Distrito Federal (FAPDF), Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq), Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES), and Fundação de Ensino e Pesquisa em Ciências de Saúde (FEPECS).

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Notes

Author notes

Correspondence data Otávio de Tolêdo Nóbrega – Faculdade de Ceilândia, Universidade de Brasília – QNN 14 AE CEIL-SUL – Guariroba – CEP: 72220-140 – Ceilândia (DF), Brazil. E-mail: otavionobrega@unb.br

Conflict of interest declaration