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
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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
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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)
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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)
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Often associated with organic factors
White matter hyperintensities
Besga et al., 2011
Differences between
Younger and Elderly bipolar patients
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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
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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
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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
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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
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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
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Secondary mania resulting from
 Physical
illness
 Neurologic
 Endocrine
 Metabolic
 Antidepressant
Krauthammer and Klerman, 1978; Young et al., 2003
Pharmacological Treatment in Elderly
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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
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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
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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
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Psychoeducation
Family-Focused Treatment
Cognitive–behavioral therapy
Interpersonal therapy
Rouget and Aubry 2007
Psychoeducation
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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
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Mild depressive episode can usually gain benefit
from PE ; (hypo)manic symptoms limits its impact
Rouget and Aubry 2007