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Bipolar symptoms, somatic burden and functioning in older-age bipolar disorder: A replication study from the global aging & geriatric experiments in bipolar disorder database (GAGE-BD) project
Abstract
Objectives
The Global Aging & Geriatric Experiments in Bipolar Disorder Database (GAGE‐BD) project pools archival datasets on older age bipolar disorder (OABD). An initial Wave 1 (W1; n = 1369) analysis found both manic and depressive symptoms reduced among older patients. To replicate this finding, we gathered an independent Wave 2 (W2; n = 1232, mean ± standard deviation age 47.2 ± 13.5, 65% women, 49% aged over 50) dataset.
Design/Methods
Using mixed models with random effects for cohort, we examined associations between BD symptoms, somatic burden and age and the contribution of these to functioning in W2 and the combined W1 + W2 sample (n = 2601).
Results
Compared to W1, the W2 sample was younger ( p < 0.001), less educated ( p < 0.001), more symptomatic ( p < 0.001), lower functioning ( p < 0.001) and had fewer somatic conditions ( p < 0.001). In the full W2, older individuals had reduced manic symptom severity, but age was not associated with depression severity. Age was not associated with functioning in W2. More severe BD symptoms (mania p ≤ 0.001, depression p ≤ 0.001) were associated with worse functioning. Older age was significantly associated with higher somatic burden in the W2 and the W1 + W2 samples, but this burden was not associated with poorer functioning.
Conclusions
In a large, independent sample, older age was associated with less severe mania and more somatic burden (consistent with previous findings), but there was no association of depression with age (different from previous findings). Similar to previous findings, worse BD symptom severity was associated with worse functioning, emphasizing the need for symptom relief in OABD to promote better functioning.
... Initial GAGE-BD findings from W1, suggested that both BD manic and depressive symptom severity appear to be reduced in older age [18]. Also, in the replication study in W2 it was found that older age was significantly associated with slightly less severe symptoms of mania while depressive symptoms were not found to be related to older age [19]. ...
... Additionally, OABD women present with an earlier age of onset of BD than OABD men. Remarkably, in the replication study (W2) it was found that depression was associated with an older age but only among men [19]. In light of these results, sex should be considered a primary factor when analyzing OABD data. ...
... So, in W1, older age had a stronger relationship with functioning, whereas in W2, younger age showed a stronger relationship with functioning. In the combined sample these seemed to cancel each other out [19]. More somatic comorbidities were not associated with reduced functioning in W1 [18], and this lack of an association between somatic comorbidities and functioning was also replicated with W2 analysis [19]. ...
Purpose of Review
Findings from the Global Aging & Geriatric Experiments in Bipolar Disorder (GAGE-BD) project, including sociodemographic and clinical information from older age bipolar disorder (OABD) and healthy participants around the globe (approximately N = 5000) were reviewed. Data was collected in multiple waves to create a large integrated dataset.
Recent Findings
BD does not seem to fade with age. BD subtype and early/late onset did not show significant differences in daily functioning. Physical comorbidities were more frequent in OABD compared with controls. Women with OABD had an earlier age at onset and more psychiatric hospitalizations.
Summary
GAGE-BD is the largest OABD cohort. Dataset results offer a unique and comprehensive resource for understanding the long-term trajectory of BD and the specific needs of this population. Findings are vital for guiding future research and improving care strategies for aging individuals with BD.
... Recently findings from the GAGE-BD project suggest some changes in the clinical pattern during the aging process. For instance, while some clinical features appear to be less severe (like manic episodes and psychotic symptoms) [9,10] other factors emerge more prominent, such as suicide attempts, depressive symptoms, mixed episodes, somatic comorbidities, premature death, impairment in psychosocial functioning and cognitive dysfunction or dementia [10][11][12][13][14][15]. In addition, some reports have detected differences according to the age of onset (early vs late), in which late onset showed poorer cognitive outcomes and higher cerebrovascular risk [16]. ...
... Recently findings from the GAGE-BD project suggest some changes in the clinical pattern during the aging process. For instance, while some clinical features appear to be less severe (like manic episodes and psychotic symptoms) [9,10] other factors emerge more prominent, such as suicide attempts, depressive symptoms, mixed episodes, somatic comorbidities, premature death, impairment in psychosocial functioning and cognitive dysfunction or dementia [10][11][12][13][14][15]. In addition, some reports have detected differences according to the age of onset (early vs late), in which late onset showed poorer cognitive outcomes and higher cerebrovascular risk [16]. ...
... (www.preprints.org) | NOT PEER-REVIEWED | Posted: 4 June 2024 doi:10.20944/preprints202406.0129.v110 ...
Background: Older adults with bipolar disorder (OABD) are individuals aged 50 years and older with bipolar disorder (BD). People with BD may have fewer coping strategies or resilience. A long course of the disease, such as in OABD, could impact the development of resilience strategies, but this remains under-researched in OABD. Therefore, this study aims to assess resilience levels within the OABD and explore associated factors, hypothesizing that resilience could improve psychosocial functioning, wellbeing and quality of life of OABD patients. Methods: This study sampled 33 OABD patients from the OABD cohort at the Bipolar and Depressive Disorders Unit of Hospital Clinic of Barcelona. This was an observational, descriptive and cross-sectional study. Demographic and clinical variables as well as psychosocial functioning, resilience and cognitive reserve were analyzed. Resilience was measured using the CD-RISC-10. Non-parametric tests were used for statistical analysis. Results: The average CD-RISC-10 score was 25.67 points (SD 7.87). Resilience negatively correlated with the total number of episodes (p = 0.034), depressive episodes (p = 0.001), and the FAST (p < 0.001). Participants with normal resilience had a lower FAST (p = 0.046), a higher CRASH (p = 0.026), and more EOBD (p = 0.037) compared to those with low resilience. Conclusions: OABD individuals may exhibit lower resilience levels which correlate with more psychiatric episodes, particularly the number of depressions and worse psychosocial functioning and cognitive reserve. Better understanding and characterization of resilience could aid in early identification of patients requiring additional support to foster resilience and enhance OABD management.
... Recently, findings from the Global Aging & Geriatric Experiments in Bipolar Disorder (GAGE-BD) project suggest some changes in the clinical pattern during the aging process. For instance, while some clinical features appear to be less severe (such as manic episodes and psychotic symptoms) [9,10], other factors emerge as more prominent; such as suicide attempts, depressive symptoms, mixed episodes, somatic comorbidities, premature death, impairment in psychosocial functioning and cognitive dysfunction or dementia [10][11][12][13][14][15]. In addition, some reports have detected differences according to the age of onset (early vs. late), in which late onset showed poorer cognitive outcomes and higher cerebrovascular risk [16]. ...
... Recently, findings from the Global Aging & Geriatric Experiments in Bipolar Disorder (GAGE-BD) project suggest some changes in the clinical pattern during the aging process. For instance, while some clinical features appear to be less severe (such as manic episodes and psychotic symptoms) [9,10], other factors emerge as more prominent; such as suicide attempts, depressive symptoms, mixed episodes, somatic comorbidities, premature death, impairment in psychosocial functioning and cognitive dysfunction or dementia [10][11][12][13][14][15]. In addition, some reports have detected differences according to the age of onset (early vs. late), in which late onset showed poorer cognitive outcomes and higher cerebrovascular risk [16]. ...
Background: Older adults with bipolar disorder (OABD) are individuals aged 50 years and older with bipolar disorder (BD). People with BD may have fewer coping strategies or resilience. A long duration of the disease, as seen in this population, could affect the development of resilience strategies, but this remains under-researched. Therefore, this study aims to assess resilience levels within the OABD population and explore associated factors, hypothesizing that resilience could improve psychosocial functioning, wellbeing and quality of life of these patients. Methods: This study sampled 33 OABD patients from the cohort at the Bipolar and Depressive Disorders Unit of the Hospital Clinic of Barcelona. It was an observational, descriptive and cross-sectional study. Demographic and clinical variables as well as psychosocial functioning, resilience and cognitive reserve were analyzed. Resilience was measured using the CD-RISC-10. Non-parametric tests were used for statistical analysis. Results: The average CD-RISC-10 score was 25.67 points (SD 7.87). Resilience negatively correlated with the total number of episodes (p = 0.034), depressive episodes (p = 0.001), and the FAST (p < 0.001). Participants with normal resilience had a lower psychosocial functioning (p = 0.046), a higher cognitive reserve (p = 0.026), and earlier onset (p = 0.037) compared to those with low resilience. Conclusions: OABD individuals may have lower resilience levels which correlate with more psychiatric episodes, especially depressive episodes and worse psychosocial functioning and cognitive reserve. Better understanding and characterization of resilience could help in early identification of patients requiring additional support to foster resilience and enhance OABD management.
... 30 Replicated findings from the Global Aging & Geriatric Experiments in Bipolar Disorder (GAGE-BD) database studies found that bipolar disorder symptom severity is associated with poorer functioning in OABD, highlighting the importance of aggressively targeting symptoms regardless of age. 31,32 The current findings provide support on the choice of pharmacologic treatment options to effectively improve symptoms and functioning across the lifespan for people with bipolar disorder, while being well tolerated. ...
Introducción: El Trastorno Afectivo Bipolar (TAB) se caracteriza por fluctuaciones del estado de ánimo. Su mal pronóstico se relaciona con elevadas tasas de suicidio y conductas autolesivas. Sólo el 38% de los chilenos son diagnosticados y reciben atención adecuada. El objetivo es calcular la tasa de egreso hospitalario (TEH) por Trastorno Afectivo Bipolar en el periodo 2018-2021 en Chile. Materiales y métodos: Estudio descriptivo transversal observacional sobre egresos hospitalarios por TAB durante los años 2018 - 2021 en Chile (n=10.323), según sexo, grupo etario, promedio días de hospitalización y clasificación diagnóstica. No fue requerido un comité de ética Resultados: Se obtuvo una TEH de 14,68 por 100.000 habitantes. La TEH del período para el sexo femenino fue de 18,77 y para el sexo masculino fue de 10,42. El grupo etario de 20 - 44 años obtuvo la mayor TEH de 31,81. El diagnóstico “Trastorno Afectivo Bipolar, No Especificado” presenta un mayor porcentaje de hospitalización con un 42,94%( 4.433). Discusión: Diversos hitos, como la crisis sanitaria, generaron repercusiones en la salud mental de las personas. La alta TEH en mujeres se puede asociar a factores biológicos y sociales. El grupo etario con mayor TEH coincide con la edad debut del TAB. Es importante indagar los egresos reportados con diagnóstico de TAB no especificado, probablemente asociado a falta de psiquiatras en la urgencia, errores en los registros y el no contar con un sistema estandarizado de diagnóstico de patologías de salud mental.
Objective: To ascertain the prevalence and predictors of physical health comorbidities in older adults with bipolar disorder.
Methods: The authors conducted a systematic review and narrative synthesis of peer-reviewed journal articles reporting on physical health comorbidities in older adults (aged ≥50) with a diagnosis of bipolar disorder. The Mixed Methods Appraisal Tool (MMAT) assessed study quality.
Results: 23 papers reporting on 19 studies met the inclusion criteria. The literature on diabetes, obesity and renal disease was inconclusive. There was some tentative evidence to higher rates of cardiovascular disease and some forms of cancer in older adults with bipolar disorder in comparison to the general population, but this requires further investigation. We identified no studies looking at oral health.
Limitations: The quality ratings of the identified research were generally low. Very few studies included a comparison sample from the general population or controlled for key covariates in their analysis.
Conclusion: Existing literature provides tentative evidence that some physical health comorbidities are elevated in older adults with bipolar disorder. Clinicians should consider interventions that improve the physical health of this group, alongside the chronic mental health difficulties they experience.
Objectives:
The distinction between bipolar I disorder (BD-I) and bipolar II disorder (BD-II) has been a topic of long-lasting debate. This study examined differences between BD-I and BD-II in a large, global sample of OABD, focusing on general functioning, cognition and somatic burden as these domains are often affected in OABD.
Methods:
Cross-sectional analyses were conducted with data from the Global Aging and Geriatric Experiments in Bipolar Disorder (GAGE-BD) database. The sample included 963 participants aged ≥50 years (714 BD-I, 249 BD-II). Sociodemographic and clinical factors were compared between BD subtypes including adjustment for study cohort. Multivariable analyses were conducted with Generalized Linear Mixed Models (GLMMs) and estimated associations between BD subtype and 1) general functioning (GAF), 2) cognitive performance (g-score) and 3) somatic burden, with study cohort as random intercept.
Results:
After adjustment for study cohort, BD-II patients more often had a late onset ≥50 years (p=0.008) and more current severe depression (p=0.041). BD-I patients were more likely to have a history of psychiatric hospitalization (p<0.001) and current use of anti-psychotics (p=0.003). Multivariable analyses showed that BD subtype was not related to GAF, cognitive g-score or somatic burden.
Conclusion:
BD-I and BD-II patients did not differ in terms of general functioning, cognitive impairment or somatic burden. Some clinical differences were observed between the groups, which could be the consequence of diagnostic definitions. The distinction between BD-I and BD-II is not the best way to subtype OABD patients. Future research should investigate other disease specifiers in this population.
Objective
Some individuals with bipolar disorder (BD) experience manic and depressive symptoms concurrently, but data are limited on symptom mixity in older-age bipolar disorder (OABD). Using the Global Aging & Geriatric Experiments in Bipolar Disorder Database, we characterized mixity in OABD and associations with everyday function.
Methods
The sample (n=805), from 12 international studies, included cases with both mania and depression severity ratings at a single timepoint. Four mixity groups were created: asymptomatic (A), mixed (Mix), depressed only (Dep) and manic only (Man). Generalized linear mixed models used mixity group as the predictor variable; cohort was included as a random intercept. Everyday function was assessed with the Global Assessment of Functioning score.
Results
Group proportions were Mix (69.6%; n=560), followed by Dep (18.4%; n=148), then A (7.8%; n=63), then Man (4.2%; n= 34); levels of depression and mania were similar in Mix compared to Dep and Man, respectively. Everyday function was lowest in Mix, highest in A, and intermediate in Man and Dep. Within Mix, severity of depression was the main driver of worse functioning. Groups differed in years of education, with A higher than all others, but did not differ by age, gender, employment status, BD sub-type, or age of onset.
Conclusions
Mixed features predominate in a cross-sectional, global OABD sample and are associated with worse everyday function. Among those with mixed symptoms, functional status relates strongly to current depression severity. Future studies should include cognitive and other biological variables as well as longitudinal designs to allow for evaluation of causal effects.
Objectives:
Persistent functional impairment is common in bipolar disorder (BD) and is influenced by a number of demographic, clinical, and cognitive features. The goal of this project was to estimate and compare the influence of key factors on community function in multiple cohorts of well-characterized samples of individuals with BD.
Methods:
Thirteen cohorts from 7 countries included n=5,882 individuals with BD across multiple sites. The statistical approach consisted of a systematic uniform application of analyses across sites. Each site performed a logistic regression analysis with empirically derived "higher versus lower function" as the dependent variable and selected clinical and demographic variables as predictors.
Results:
We found high rates of functional impairment, ranging from 41-75%. Lower community functioning was associated with depressive symptoms in 10 of 12 of the cohorts that included this variable in the analysis. Lower levels of education, a greater number of prior mood episodes, presence of a comorbid substance use disorder, and a greater total number of psychotropic medications were also associated with low functioning.
Conclusions:
The bipolar clinical research community is poised to work together to characterize the multi-dimensional contributors to impairment and address the barriers that impede patients' complete recovery. We must also identify the core features which enable many to thrive and live successfully with BD. A large-scale, worldwide, prospective longitudinal study focused squarely on BD and its heterogeneous presentations will serve as a platform for discovery and promote major advances toward optimizing outcomes for every individual with this illness.
Data regarding older age bipolar disorder (OABD) are sparse. Two major groups are classified as patients with first occurrence of mania in old age, the so called “late onset” patients (LOBD), and the elder patients with a long-standing clinical history, the so called “early onset” patients (EOBD). The aim of the present literature review is to provide more information on specific issues concerning OABD, such as epidemiology, aetiology and treatments outcomes. We conducted a Medline literature search from 1970–2021 using the MeSH terms “bipolar disorder” and “aged” or “geriatric” or “elderly”. The additional literature was retrieved by examining cross references and by a hand search in textbooks. With sparse data on the treatment of OABD, current guidelines concluded that first-line treatment of OABD should be similar to that for working-age bipolar disorder, with specific attention to side effects, somatic comorbidities and specific risks of OABD. With constant monitoring and awareness of the possible toxic drug interactions, lithium is a safe drug for OABD patients, both in mania and maintenance. Lamotrigine and lurasidone could be considered in bipolar depression. Mood stabilizers, rather than second generation antipsychotics, are the treatment of choice for maintenance. If medication fails, electroconvulsive therapy is recommended for mania, mixed states and depression, and can also be offered for continuation and maintenance treatment. Preliminary results also support a role of psychotherapy and psychosocial interventions in old age BD. The recommended treatments for OABD include lithium and antiepileptics such as valproic acid and lamotrigine, and lurasidone for bipolar depression, although the evidence is still weak. Combined psychosocial and pharmacological treatments also appear to be a treatment of choice for OABD. More research is needed on the optimal pharmacological and psychosocial approaches to OABD, as well as their combination and ranking in an evidence-based therapy algorithm.
People with bipolar disorder frequently experience persistent residual symptoms, problems in psychosocial functioning, cognitive impairment, and poor quality of life. In the last decade, the treatment target in clinical and research settings has focused not only on clinical remission, but also on functional recovery and, more lately, in personal recovery, taking into account patients' well-being and quality of life. Hence, the trend in psychiatry and psychology is to treat bipolar disorder in an integrative and holistic manner. This literature review offers an overview regarding psychosocial functioning in bipolar disorder. First, a brief summary is provided regarding the definition of psychosocial functioning and the tools to measure it. Then, the most reported variables influencing the functional outcome in patients with bipolar disorder are listed. Thereafter, we include a section discussing therapies with proven efficacy at enhancing functional outcomes. Other possible therapies that could be useful to prevent functional decline and improve functioning are presented in another section. Finally, in the last part of this review, different interventions directed to improve patients' well-being, quality of life, and personal recovery are briefly described.
Objective:
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.
Methods:
The International Society of Bipolar Disorders OABD task force compiled and compared recommendations from current national and international guidelines that specifically address geriatric or older individuals with BD (from year 2005 onwards).
Results:
There were 34 guidelines, representing six continents and 19 countries. The majority of guidelines had no separate section on OABD. General principles for treating OABD with medication are recommended to be similar to those for younger adults, with special caution for side effects due to somatic comorbidity and concomitant medications. Therapeutic lithium serum levels are suggested to be lower but recommendations are very general and mostly not informed by specific research evidence.
Conclusions:
There is a lack of emphasis of OABD-specific issues in existing guidelines. Given the substantial clinical heterogeneity in BD across the life span, along with the rapidly expanding population of older individuals worldwide, and limited mental health workforce with geriatric expertise, it is critical that additional effort and resources be devoted to studying treatment interventions specific to OABD and that treatment guidelines reflect research findings. Copyright © 2016 John Wiley & Sons, Ltd.
The construction of a depression rating scale designed to be particularly sensitive to treatment effects is described. Ratings of 54 English and 52 Swedish patients on a 65 item comprehensive psychopathology scale were used to identify the 17 most commonly occurring symptoms in primary depressive illness in the combined sample. Ratings on these 17 items for 64 patients participating in studies of four different antidepressant drugs were used to create a depression scale consisting of the 10 items which showed the largest changes with treatment and the highest correlation to overall change. The inner-rater reliability of the new depression scale was high. Scores on the scale correlated significantly with scores on a standard rating scale for depression, the Hamilton Rating Scale (HRS), indicating its validity as a general severity estimate. Its capacity to differentiate between responders and non-responders to antidepressant treatment was better than the HRS, indicating greater sensitivity to change. The practical and ethical implications in terms of smaller sample sizes in clinical trials are discussed.
Numerous studies have documented high rates of functional impairment among bipolar disorder (BD) patients, even during phases of remission. However, the majority of the available instruments used to assess functioning have focused on global measures of functional recovery rather than specific domains of psychosocial functioning. In this context, the Functioning Assessment Short Test (FAST) is a brief instrument designed to assess the main functioning problems experienced by psychiatric patients, particularly bipolar patients. It comprises 24 items that assess impairment or disability in six specific areas of functioning: autonomy, occupational functioning, cognitive functioning, financial issues, interpersonal relationships and leisure time.
101 patients with DSM-IV TR bipolar disorder and 61 healthy controls were assessed in the Bipolar Disorder Program, Hospital Clinic of Barcelona. The psychometric properties of FAST (feasibility, internal consistency, concurrent validity, discriminant validity (euthymic vs acute patients), factorial analyses, and test-retest reliability) were analysed.
The internal consistency obtained was very high with a Cronbach's alpha of 0.909. A highly significant negative correlation with GAF was obtained (r = -0.903; p < 0.001) pointing to a reasonable degree of concurrent validity. Test-retest reliability analysis showed a strong correlation between the two measures carried out one week apart (ICC = 0.98; p < 0.001). The total FAST scores were lower in euthymic (18.55 +/- 13.19; F = 35.43; p < 0.001) patients, as compared with manic (40.44 +/- 9.15) and depressive patients (43.21 +/- 13.34).
The FAST showed strong psychometrics properties and was able to detect differences between euthymic and acute BD patients. In addition, it is a short (6 minutes) simple interview-administered instrument, which is easy to apply and requires only a short period of time for its application.
The present study aims to identify pathways between psychiatric network symptoms and psy-chosocial functioning and their associated variables among functioning clusters in the general population. A cross-sectional web-based survey was administered in a total of 3,023 individuals in Brazil. The functioning clusters were derived by a previous study identifying three different groups based on the online Functioning Assessment Short Test. Networking analysis was fitted with all items of the Patient-Reported Outcomes Measurement Information System for depression and for anxiety (PROMIS) using the mixed graphical model. A decision tree model was used to identify the demographic and clinical characteristics of good and low functioning. A total of 926 (30.63%) subjects showed good functioning, 1,436 (47.50%) participants intermediate functioning , and 661 (21.86%) individuals low functioning. Anxiety and uneasy symptoms were the most important nodes for good and intermediate clusters but anxiety, feeling of failure, and depression were the most relevant symptoms for low functioning. The decision tree model was applied to identify variables capable to discriminate individuals with good and low functioning. The algorithm achieved balanced accuracy 0.75, sensitivity 0.87, specificity 0.63, positive predictive value 0.63 negative predictive value 0.87 (p < 0.001), and an area under the curve of 0.83 (95%CI:0.79-0.86, p < 0.01). Our results show that individuals who present psychological distress are more likely to experience poor functional status, suggesting that this subgroup should receive a more comprehensive psychiatric assessment and mental health care.
Objective
Harmonizing different depression severity scales often requires creation of categorical variables that may decrease the sensitivity of the measure. Our aim was to compare the associations between categorical and continuous and harmonized measures of depression and global functioning in a large dataset of older age patients with bipolar disorder (OABD).
Method
In the Global Aging & Geriatric Experiments in Bipolar Disorder Database (GAGE-BD) the 17-item Hamilton Depression scale (HAM-D), Montgomery Asberg Depression Rating Scale (MADRS) or the Center for Epidemiological Studies Depression scales (CES-D) was used to assess current depressive symptoms, while the Global Assessment of Functioning (GAF) assessed functional status. Data were harmonized from 8 OABD studies (n = 582). In each subsample, the relationship of depression severity as a continuous and categorical measure was compared to GAF. In the total sample, harmonized ordinal depression categories were compared to GAF.
Results
Effect size and variance explained by the model for the categorical measure in the total sample was higher than both the categorical and continuous measure in the CES-D subsample, higher than the categorical but lower than the continuous measure in the HAM-D subsample, and lower than both the categorical and continuous measures in the MADRS subsample.
Limitations
All included studies have different inclusion and exclusion criteria, study designs, and differ in aspects of sociodemographic variables.
Conclusions
Associations were only slightly larger for the continuous vs categorical measures of depression scales. Harmonizing different depression scales into ordinal categories for analyses is feasible without losing statistical power.
Objectives:
Antipsychotic drugs (APS) are widely used to treat patients with bipolar disorder (BD), but there is limited information in older-age bipolar disorder (OABD). This analysis of the Global Aging & Geriatric Experiments in Bipolar Disorder Database (GAGE-BD) investigated characteristics of OABD patients prescribed APS vs. those not prescribed APS.
Experimental design:
The observational analysis used baseline, cross-sectional data from 16 international studies for adults aged ≥ 50 years with BD comprising 1,007 individuals with mean age 63.2 years (SD = 9.0), 57.4% women, and mean age of onset 31.6 years (SD = 15.0). The dependent variable was current APS treatment status. The independent variables included demographic and clinical variables, and a random effect for study, that were included in generalized mixed models.
Principal observations:
46.6% of individuals (n = 469) were using APS. The multivariate model results suggest that those treated with APS were younger (p = 0.01), less likely to be employed (p < 0.001), had more psychiatric hospitalizations (p = 0.009) and were less likely to be on lithium (p < 0.001). Of individuals on APS, only 6.6% of those (n = 27) were on first-generation antipsychotics (FGAs) and experienced a greater burden of psychiatric hospitalizations (p = 0.012).
Conclusions:
APS are widely prescribed in OABD, observed in nearly half of this sample with great variation across sites. Individuals with OABD on APS have more severe illness, more frequent hospitalizations and are more often unemployed vs. those not on APS. Future studies need to examine longitudinal outcomes in OABD prescribed APS to characterize underlying causal relationships.
Objectives
: To compare the prevalence of physical morbidities among men and women with older adult bipolar disorder (OABD), and men with and without OABD.
Methods
: Cross-sectional analysis of the collaborative Global Aging & Geriatric Experiments in Bipolar Disorder (GAGE-BD) database and non-OABD data from the Health In Men Study. OABD defined as bipolar disorder among adults aged ≥ 50 years. Outcomes of interest were diseases affecting the cardiovascular, respiratory, gastrointestinal, renal, musculoskeletal and endocrinological systems.
Results
: We examined 1407 participants with OABD aged 50 to 95 years, of whom 787 were women. More women than men showed evidence of morbidities affecting the respiratory, gastrointestinal, musculoskeletal and endocrinological systems. More men with than without OABD showed evidence of cardiovascular, renal and endocrinological diseases.
Conclusions
: GAGE-BD data showed that physical morbidities affect more women than men with OABD, and more men with than without OABD. The underlying reasons for these differences require clarification.
Objective
Literature on older-age bipolar disorder (OABD) is limited. This first-ever analysis of the Global Aging & Geriatric Experiments in Bipolar Disorder Database (GAGE-BD) investigated associations among age, BD symptoms, comorbidity, and functioning.
Methods
This analysis used harmonized, baseline, cross-sectional data from 19 international studies (N = 1377). Standardized measures included the Young Mania Rating Scale (YMRS), Hamilton Depression Rating Scale (HAM-D), Montgomery-Asberg Depression Rating Scale (MADRS), and Global Assessment of Functioning (GAF).
Results
Mean sample age was 60.8 years (standard deviation [SD] 12.2 years), 55% female, 72% BD I. Mood symptom severity was low: mean total YMRS score of 4.3 (SD 5.4) and moderate to severe depression in only 22%. Controlled for sample effects, both manic and depressive symptom severity appeared lower among older individuals (p’s < 0.0001). The negative relationship between older age and symptom severity was similar across sexes but was stronger among those with lower education levels. GAF was mildly impaired (mean = 62.0, SD = 13.3) and somatic burden was high (mean = 2.42, SD = 1.97). Comorbidity burden was not associated with GAF. However, higher depressive (p < 0.0001) and manic (p < 0.0001) symptoms were associated with lower GAF, most strongly among older individuals.
Conclusions
Findings suggest an attenuation of BD symptoms in OABD, despite extensive somatic burden. Depressive symptom severity was strongly associated with worse functioning in older individuals, underscoring the need for effective treatments of BD depression in older people. This international collaboration lays a path toward a better understanding of aging in BD.
Bipolar disorder has a yearly prevalence of 2%. Other mental and physical conditions occur with bipolar disorder, which is also associated with an increased risk of suicide. Treatment is complex and relies on lithium or intermittent use of antipsychotic drugs.
Objective
There is a dearth of research about the aging process among individuals with bipolar disorder (BD). One potential strategy to overcome the challenge of interpreting findings from existing limited older‐age bipolar disorder (OABD) research studies is to pool or integrate data, taking advantage of potential overlap or similarities in assessment methods and harmonizing or cross‐walking measurements where different measurement tools are used to evaluate overlapping construct domains. This report describes the methods and initial start‐up activities of a first‐ever initiative to create an integrated OABD‐focused database, the Global Aging & Geriatric Experiments in Bipolar Disorder Database (GAGE‐BD) project.
Methods
Building on preliminary work conducted by members of the International Society for Bipolar Disorders OABD taskforce, the GAGE‐BD project will be operationalized in 4 stages intended to ready the dataset for hypothesis‐driven analyses, establish a consortium of investigators to guide exploration and set the stage for prospective investigation using a common dataset that will facilitate a high degree of generalizability.
Results
Initial efforts in GAGE‐BD have brought together 14 international investigators representing a broad geographic distribution and data on over 1,000 OABD. Start‐up efforts include communication and guidance on meeting regulatory requirements, establishing a Steering Committee to guide an incremental analysis strategy, and learning from existing multi‐site data collaborations and other support resources.
Discussion
The GAGE‐BD project aims to advance understanding of associations between age, BD symptoms, medical burden, cognition and functioning across the life‐span and set the stage for future prospective research that can advance understanding of OABD.
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Objectives:
Patients with bipolar disorder (BD) show specific cognitive impairments, especially in the domains of attention, executive functioning and memory. Social and occupational problems seem to exist in 30-60% of BD patients. This study analysed the relationship between cognitive and social functioning in older age BD (OABD) patients.
Methods:
This study included 63 OABD patients (aged > 60). Cognitive functioning was measured by an extensive neuropsychological assessment including global cognitive functioning, attention, learning and memory, executive functioning and verbal fluency. Social functioning, was obtained by clinical interview, including global social functioning, meaningful contacts and social participation. Linear regression analyses were conducted between cognitive performance and social functioning and the role of depression severity and disease duration was explored.
Results:
Global social functioning, number of meaningful contacts and social participation were not interrelated. Global cognitive functioning, learning and memory and executive functioning were positively associated with global social functioning. No associations were found between cognitive functioning and social participation or meaningful contacts. Depression severity and disease duration were no effect modifiers.
Limitations:
Limitations include the use of a sample with relatively low cognitive and social impairments and the use of a cross-sectional research design.
Conclusions:
Global social functioning judged by the clinician was found to be independent of social functioning defined by the number of social contacts and social participation as reported by the patient. Global social functioning was related to cognitive functioning. An integrative treatment intervention including cognitive training and addressing social functioning may improve daily functioning in OABD patients.
Objectives:
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).
Methods:
This task force report addresses the unique aspects of OABD including epidemiology and clinical features, neuropathology and biomarkers, physical health, cognition, and care approaches.
Results:
The report describes an expert consensus summary on OABD that is intended to advance the care of patients, and shed light on issues of relevance to BD research across the lifespan. Although there is still a dearth of research and health efforts focused on older adults with BD, emerging data have brought some answers, innovative questions, and novel perspectives related to the notion of late onset, medical comorbidity, and the vexing issue of cognitive impairment and decline.
Conclusions:
Improving our understanding of the biological, clinical, and social underpinnings relevant to OABD is an indispensable step in building a complete map of BD across the lifespan.
The CES-D scale is a short self-report scale designed to measure depressive symptomatology in the general population. The items of the scale are symptoms associated with depression which have been used in previously validated longer scales. The new scale was tested in household interview surveys and in psychiatric settings. It was found to have very high internal consistency and adequate test- retest repeatability. Validity was established by pat terns of correlations with other self-report measures, by correlations with clinical ratings of depression, and by relationships with other variables which support its construct validity. Reliability, validity, and factor structure were similar across a wide variety of demographic characteristics in the general population samples tested. The scale should be a useful tool for epidemiologic studies of de pression.
The construction of a depression rating scale designed to be particularly sensitive to treatment effects is described. Ratings of 54 English and 52 Swedish patients on a 65 item comprehensive psychopathology scale were used to identify the 17 most commonly occurring symptoms in primary depressive illness in the combined sample.
Ratings on these 17 items for 64 patients participating in studies of four different antidepressant drugs were used to create a depression scale consisting of the 10 items which showed the largest changes with treatment and the highest correlation to overall change.
The inter-rater reliability of the new depression scale was high. Scores on the scale correlated significantly with scores on a standard rating scale for depression, the Hamilton Rating Scale (HRS), indicating its validity as a general severity estimate. Its capacity to differentiate between responders and non-responders to antidepressant treatment was better than the HRS, indicating greater sensitivity to change. The practical and ethical implications in terms of smaller sample sizes in clinical trials are discussed.
This analysis aimed to show whether symptoms of either pole change in their persistence as individuals move through two decades, whether such changes differ by age grouping, and whether age of onset plays an independent role in symptom persistence.
Participants in the National Institute of Mental Health (NIMH) Collaborative Depression Study (CDS) who completed at least 20 years of follow-up and who met study criteria for bipolar I or schizo-affective manic disorder, before intake or during follow-up, were divided by age at intake into youngest (18-29 years, n=56), middle (30-44 years, n=68) and oldest (>44 years, n=24) groups.
The persistence of depressive symptoms increased significantly in the two younger groups. Earlier ages of onset were associated with higher depressive morbidity throughout the 20 years of follow-up but did not predict changes in symptom persistence. The proportions of weeks spent in episodes of either pole correlated across follow-up periods in all age groupings, although correlations were stronger for depressive symptoms and for shorter intervals.
Regardless of age at onset, the passage of decades in bipolar illness seems to bring an increase in the predominance of depressive symptoms in individuals in their third, fourth and fifth decades and an earlier age of onset portends a persistently greater depressive symptom burden. The degree to which either depression or manic/hypomanic symptoms persist has significant stability over lengthy periods and seems to reflect traits that manifest early in an individual's illness.
An eleven item clinician-administered Mania Rating Scale (MRS) is introduced, and its reliability, validity and sensitivity are examined. There was a high correlation between the scores of two independent clinicians on both the total score (0.93) and the individual item scores (0.66 to 0.92). The MRS score correlated highly with an independent global rating, and with scores of two other mania rating scales administered concurrently. The score also correlated with the number of days of subsequent stay in hospital. It was able to differentiate statistically patients before and after two weeks of treatment and to distinguish levels of severity based on the global rating.
Reliable quantitative ratings of chronic medical illness burden have proved to be difficult in geropsychiatric practice and research. Thus, the purpose of the study was to demonstrate the feasibility and reliability of a modified version of the Cumulative Illness Rating Scale (CIRS; Linn et al., 1968) in providing quantitative ratings of chronic illness burden. The modified CIRS was operationalized with a manual of guidelines geared toward the geriatric patient and for clarity was designated the CIRS(G). A total of 141 elderly outpatient subjects (two medical clinic groups of 20 each, 45 recurrent depressed subjects, 21 spousally bereaved subjects, and 35 healthy controls) received comprehensive physical examinations, reviews of symptoms, and laboratory testing. These data were then used by nurse practitioners, physician's assistants, and geriatric psychiatrists to compute CIRS(G) ratings of chronic illness burden. As hypothesized, analysis of variance demonstrated significant differences among groups with respect to total medical illness burden, which was highest among medical clinic patients and lowest in control subjects. Good interrater reliability (i.e., intraclass correlations of 0.78 and 0.88 in a subsample of 10 outpatients and a separate group of 10 inpatients, respectively) was achieved for CIRS(G) total scores. Among medical clinic patients, a significant correlation was found, as expected, between CIRS(G) chronic illness burden and capability as quantified by the Older Americans Activities of Daily Living Scale; and between CIRS(G) scores and physicians' global estimates of medical burden. Finally, with repeated measures of illness burden approximately 1 year from symptom baseline, significant rises were detected, as expected. The current data suggest that the CIRS(G) can be successfully applied in medically and psychiatrically impaired elderly subjects, with good interrater reliability and face validity (credibility).
The Inventory for Depressive Symptomatology (IDS) is a new measure of depressive signs and symptoms. Both self-report and clinician-rated versions are under development. The IDS-SR (self-report) was completed by 289 patients, 285 of whom were outpatients. Unipolar major depression (n = 174), bipolar disorder (n = 44), euthymic (S/P unipolar or bipolar) depression (n = 33), and other psychiatric disorders (n = 38) were included. The IDS-SR had good internal reliability (coefficient alpha = 0.85), and significantly correlated with both the Hamilton Rating Scale for Depression (HRSD) (r = 0.67) and the Beck Depression Inventory (BDI) (r = 0.78). The clinician-rated IDS (IDS-C) was administered to 82 outpatients (75 with unipolar or bipolar disorder, 5 with other psychiatric disorders, and 2 euthymic (S/P unipolar) depressions). Coefficient alpha (0.88) suggested strong internal consistency. The IDS-C correlated highly with both the HRSD (r = 0.92) and the BDI (r = 0.61). Discriminant and factor analyses provided evidence for construct validity for both the IDS-C and IDS-SR. Both scales significantly differentiated endogenous from nonendogenous depression defined by Research Diagnostic Criteria (RDC). Factor structures for the IDS-SR revealed four factors: mood/cognition, anxiety, selected endogenous symptoms, and hyperphagia-hypersomnia. The IDS appears applicable to both inpatients and outpatients with endogenous, atypical, and nonendogenous major depression, and may have utility with dysthymics.
: A Cumulative Illness Rating Scale, designed to meet the need for a brief, comprehensive and reliable instrument for assessing physical impairment, has been developed and tested. The scale format provides for 13 relatively independent areas grouped under body systems. Ratings are made on a 5-point “degree of severity” scale, ranging from “none” to “extremely severe.” Findings, in terms of reliability and validity, reflect statistical significance at the P < .01 level. As a rapid assessment technique which is objective and easily quantified, the scale is well suited to a variety of research uses.
The Charlson Comorbidity Index, a popular tool for risk adjustment, often is constructed from medical record abstracts or administrative data. Limitations in both sources have fueled interest in using patient self-report as an alternative. However, little data exist on whether self-reported Charlson Indices predict mortality.
We sought to determine whether a self-reported Charlson Index predicts mortality, its performance relative to indices derived from administrative data, and whether using study-specific weights instead of Charlson's original weights enhances model fit.
We surveyed 7761 patients admitted to a university medical service over the course of 4 years and extracted their administrative data. We constructed 6 different Charlson indices by using 2 weighting schemes (original Charlson weights and study-specific weights) and 3 different datasources (ICD-9CM data for index hospitalization, ICD-9CM data with a 1-year look-back period, and patient self-report of comorbidities.) Multivariate models were constructed predicting 1-year mortality, log total costs, and log length of stay.
The 6 measures of the Charlson index all predicted 1-year mortality. Models with age and gender, with or without diagnosis-related group, had approximately the same predictive power regardless of which of the 6 Charlson indices were used. Nevertheless, there were small improvements in model fit using administrative data versus self-report, or study-specific versus original weights. All models obtained areas under the receiver operating curve of 0.70 to 0.77.
Overall, self-reported Charlson indices predict 1-year mortality comparably with indices based on administrative data. Administrative data may offer some small improvements in predictive ability and may be preferred when readily available.
Physical health burden among older men and women with bipolar disorder: results from the Gage-Bd Collaboration
- O P Almeida
- A Dols
- Maj Blanked
Almeida OP, Dols A, Blanked MAJ, et al. Physical health burden
among older men and women with bipolar disorder: results from the
Gage-Bd Collaboration. Am J Geriatr Psychiatr. 2022;30(6):727-732.
https://doi.org/10.1016/j.jagp.2021.12.006
Bipolar I and bipolar II subtypes in older age: results from the global aging and geriatric experiments in bipolar disorder (GAGE-BD) project
- A J Beudners
- F Klaus
- A A Kok
Beudners AJ, Klaus F, Kok AA, et al. Bipolar I and bipolar II subtypes
in older age: results from the global aging and geriatric experiments
in bipolar disorder (GAGE-BD) project. Bipolar Disord. 2023;25(1):
43-55. https://doi.org/10.1111/bdi.13271