Dec 4, 2019
Martha Sajatovic, MD, conducts a Masterclass lecture on
older-age bipolar disorder from the
Psychopharmacology Update in Cincinnati. The meeting was
sponsored by Global
Academy for Medical Education and Current Psychiatry.
Sajatovic is professor of psychiatry and of neurology at Case
Western Reserve University in Cleveland. She also directs the
Neurological and Behavioral Outcomes Research Center at University
Hospitals Cleveland Medical Center.
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- Older–age bipolar disorder (OABD), defined as a person aged 60
years or older with bipolar disorder, makes up one-quarter of
bipolar patients. It is a heterogeneous population that includes
early- and late-onset disease. Late onset is diagnosed when a
person has a manic or hypomanic episode at or after the age of 50
- Bipolar depression in later life has long been seen as a
“special population,” and the treatment has been extrapolated from
larger clinical trials of younger patients.
- Late–onset bipolar disorder usually has attenuated manic
episodes and depressive episodes are prolonged and severe. In OABD,
the patients are more likely to have multiple morbidities, which
makes medication management more complex.
- People with bipolar disorder lose 1-2 decades of life, compared
with the general population.
- No medications are specifically approved by the Food and Drug
Administration for bipolar disorder or bipolar depression in older
adults. However, the treatment follows general geriatric psychiatry
principles: Start low and go slow.
International guidelines on treating bipolar
- Starting low means using half or even less of the recommended
dose that a clinician would use in mixed-aged populations. Titrate
slowly to allow the person time to acclimate to side effects that
usually resolve. Bipolar disorder is a chronic disease, so
medication adherence is paramount. Adherence can be jeopardized
when a person experiences excessive side effects from the beginning
- First-line treatment for bipolar depression in OABD include
or quetiapine (Seroquel)
with low dosing and slow titration. This recommendation is
supported by data from a post hoc analysis of the clinical trial
data of lurasidone for bipolar depression.
- Lithium is also recommended and underused. The level should be
lower for OABD; an appropriate target for older adults with bipolar
disorder is 0.4-0.8 mEq/L, especially in people who are older and
- Lamotrigine (Lamictal)
also is helpful and fairly well tolerated.
- Clinicians need to be attentive to a patient’s medical
comorbidities and psychosocial support to enhance adherence and
improve outcomes. This approach would entail working closely with
primary care clinicians and using an integrative approach as the
medical comorbidities will influence the success of bipolar
Sajatovic M and Chen P. Geriatric bipolar disorder. Psychiatr Clin North
Am. 2011 Jun 3;34(2):319-33.
Eyler LT et al. Understanding aging in bipolar disorder by
integrating archival clinical research datasets. Am J Geriatric
Psychiatry. 2019 Oct;27(10):1122-34.
Shulman Kl et al. Delphi survey about using lithium in OABD.
Disord. 2019 Mar;21(2):117-23.
Forester BP. Safety and effectiveness of long-term treatment
with lurasidone in older adults with bipolar depression: Post hoc
analysis of a 6-month, open-label study. Am J Geriatr
Psychiatry. 2018 Feb;26(2):150-9.
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