Prevalence of bipolar disorder in a psychogeriatric population

Journal of Affective Elsevier

197

Disorders, 14 (1988) 197-201

JAD 00529

Prevalence of bipolar disorder in a psychogeriatric population Ramzy Yassa 1,2*3,Vasavan Nair 1*2q3, Christine and Lise Belzile ’ ’ Psychogeriatric

Nastase

I, Yves Camille 1

Unit, and ’ Research Department, Douglas Hospital Centre, Montreal, and -’ McGill Uniuersity, Montreal, Que., Canada

Que., Canada

(Received 18 September 1987) (Accepted 28 October 1987)

Summary Bipolar affective disorder arising for the first time in old age (60 years and over) has not been extensively studied. The authors present a prevalence study of mania arising after age 60. Of 217 patients admitted to our unit in a 2-year period, 10 (4.7%) showed symptoms of mania, using the DSM-III criteria. This constitutes 9.3% of 108 affective disorder patients admitted during the same period. An important factor in the precipitation of these attacks was marital discord, leading, in several cases, to separation, even in this age group.

Key words: Bipolar

disorder;

Late onset;

Prevalence

Introduction Bipolar disorder arising for the first time in older patients (60 years and over) has not been extensively studied. It is presumed that this disorder occurs mostly in young patients, usually from teens to the early fifties, with a peak incidence between 20 and 40 years (Perris and d’Elia, 1964; Fieve, 1975; Clayton, 1983). Recent reviews of the literature indicate that 90% of the patients become ill by the time they are 50 years old

(Clayton, 1983). Thus, it has been presumed that becoming manic after 60 years of age implies organicity, unless otherwise proven (Stotsky, 1973). This and the difficulty of obtaining a full historical background in those patients exhibiting manic symptoms may lead to the underdiagnosis of a potentially treatable condition (Spar et al., 1979). This paper aims at presenting a prevalence study of a psychogeriatric population in our hospital. Material and method

Address for correspondence: geriatric Unit, Douglas Hospital Verdun, Que. H4H lR3, Canada. 0165-0327/88/$03.50

R. Yassa, M.D., PsychoCentre, 6875 La Salle Blvd.,

0 1988 Elsevier Science Publishers

All the admissions (n = 217) to the psychogeriatric unit of Douglas Hospital for the 2-year period starting September 1, 1984, were evaluated

B.V. (Biomedical

Division)

198

for the presence of manic symptoms, as suggested by the DSM-III (1980) with the exception that we did not exclude mania caused by an organic mental disorder. To be included, the patient should have his/her index admission at age 65 or over and to have or have had a well-recorded episode of mania for the first time in life at age 60 or over. If the index admission did not indicate the presence of manic symptoms, the patient’s file was reviewed for the presence (or absence) of these symptoms. The following tests were conducted on all patients: SMAC 12, vitamin B12 and folic acid levels, thyroxine (T4). triiodothyronine (T3), thyroid-stimulating hormone (TSH), electroencephalogram as well as serologic tests to exclude syphilis. If manic symptoms are present or have been recorded in the patient’s history, a thorough questioning of the patient and a close relative is undertaken to determine previous history of manic or irrational behaviour prior to age 60. In addition to a full family history, we also investigated the possibility of precipitating events within the last 6 months prior to admission.

This constitutes 4.6% of all admissions to our unit and 9.3% of the 108 affective disorder patients admitted during the study period. The ratio of men to women was 1 : 1.5. The mean age of first manic episode was 70.7 (range 65-82, see Table 1 for details). It is to be noted, however, that while ten patients were included for study, only six had complete information regarding number of depressions and manias, as well as onset of each. Munifestutions of bipolar disorder Of the 14 manic episodes reported, ten were directly observed by the authors in the index period. We found three modes of manifestations in our patients’ clinical presentations: (1) Depression followed by mania (n = 6; patients l-6, Table 1). Six patients (60%) developed mania after a mean of 2.7 depressive attacks (range l-4). The duration between first onset of depression and first onset of mania varied between 1 and 26 years, with a mean of 12.3 years. (2) Recurrent manic and depressive symptoms (n = 2; patients 7 and 8, Table 1). Two women developed periods of alternating mania and depression after age 60. Mania was characterised by high energy, irrational behaviour, spending sprees and lasted between 3 and 6 weeks. These episodes alternated with depressive mood characterised by withdrawal, lack of appetite, fear of going out and fear of death (patient 7). Paranoid features characterised

Results Preculence of bipolar disorders ocer age 60 Ten patients (six women, four men) were found to suffer from bipolar disorder arising for the first time after age 60, during this 2-year survey period.

TABLE

1

DEMOGRAPHIC Patient

CHARACTERISTICS

OF THE BIPOLAR

POPULATION

(n = 10)

Present age

Sex

Age first depressed

Number of depressions before first mania (months in hospital)

Age first manic

67

F F F F M M F F M M

55 49

1 (4) 2 (4) 4 (20) 4 (7) 4 (19) 1 (3) Recurrent Recurrent _ _

65 69 70 72 74 x2 63 71

71 75 lb

76 82 6X

72 69 72 ~’ No depression

62 63

48 81 63

71 p* pr’

prior to manic episodes

depressions depressions

69

72

Mania/hypomania (no. of episodes)

Months hospital

2 2 2 1 Recurrent Recurrent 1 1

b 14 14 1 2 4 3 4

L

mania mania.

in

199

depression in patient 8. The premorbid personality of both women was described as being rigid, obsessive and meticulous. These episodes were reported to the authors by the children, husbands and physicians of both patients. (3) Mania as the first manifestation of bipolar disorder (n = 2, patients 9 and 10, Table 1). Two men developed manic symptoms characterised by euphoria, irritability, insomnia, increased psychomotor activity and delusions of grandeur. Post-manic depression developed in both patients, 3-4 weeks after admission. It should be noted that while all manias arose after age 60, only five of the patients were known to have had onset of their depressions after age 60. The symptoms of mania in our patient population were classical: hyperactivity and insomnia were present in all the patients; euphoria, flight of ideas and irrational behaviour were present in 60%, grandiose delusions and irritability in 30%, while paranoid delusions and mixed mania were present in 20%. Of the eight patients with previous depressive episodes, five had delusional depression and three endogenous depressive features. Agitation was manifested in five patients and psychomotor retardation in three. The coexistence of physical disease in these patients was noted in three patients. Two patients had diabetes mellitus of the adult onset type. Patient 5 in a suicidal attempt hit his skull with the blunt end of an axe. He also subsequently developed left hemiplegia. None of the patients had positive serologic tests (VDRL) or abnormal thyroid function tests. Vitamin B12 and folate were also normal in all patients. None of the patients had a positive family history of mania. However, three had a history of affective disorder in the immediate family, one had a history of heavy drinking and one had a son with antisocial behaviour. Treatment of the manic episodes consisted of haloperidol during the acute stage. Subsequently, lithium was the only treatment in six patients. At follow-up, 24 months later, two patients had died (one with myocardial infarction, the other from choking while eating), and a third patient was lost

to follow-up. Of the remaining seven patients, two had recurrences, one after discontinuing lithium and the other despite continuing to receive lithium carbonate. Five patients have been well stabilised with lithium alone. The lithium dose varied between 300 mg and 900 mg/day (mean 430 mg/ day). Precipitating events Seventy per cent of the patients had major changes in their lifestyles in the 6 months preceding the onset of mania. Familial discord and marital disruption were noted in four patients, disease of spouse in one, separation from the children and death of a brother in a sixth patient. Patient 5 was a successful businessman until he lost all his earnings in the stock market. (This was not related to his psychopathology, after repeated questioning to him and all his family members.) Then he became delusionally depressed and a manic attack followed. Discussion To our knowledge, this study represents the first period prevalence study of bipolar disorder in patients 60 years and over. Two previous studies (Shulman and Post, 1980; Glasser and Rabins, 1984) addressed this issue. However, the mean age of first manic episode in these studies was 58 and 51 years, respectively, i.e., 12 and 19 years earlier than our mean age at onset (70 years). In addition, both studies were retrospective, while we directly observed ten of the 14 manic episodes that were reported in the index period. Prevalence of mania in our study indicates that bipolar disorder arising for the first time after age 60 constitutes 4.6% of all admissions to our psychogeriatric unit over a 2-year period. This closely resembles the study conducted by Glasser and Rabins (1984) who found that mania represents 4.9% of admissions in the 60-and-over age group over a 5-year period. Thus, the prevalence of mania after age 60 is not as rare as was thought previously. Our study indicates that manic symptoms similar to those described in younger patients are the common presenting picture in older patients. This confirms the findings of Glasser and Rabins (1984)

200

who found that hyperactivity, decreased sleep and flight of ideas were the commonest clinical manifestations in over 60% of 42 cases. This contrasts with earlier authors who found that mood-incongruent paranoid delusions, irritability, depression and minor mental organic manifestations may characterise the late-onset mania more than the classical manifestations (Langley, 1975; Post, 1978). However, in a more recent review, Post (1982) concluded that these ‘atypical’ symptoms were not specific to late-onset mania but have also been reported in mania arising in all ages. Depression preceding the onset of mania has been reported in several studies. Perris (1966) developed the criterion of three consecutive depressive episodes of psychotic degree for a firm diagnosis of unipolar depression. However, several studies found that 5-18% of patients develop mania subsequent to recurrent depressive episodes (Winokur and Morrison, 1973; Dunner et al., 1976; Akiskal et al., 1978; Winokur and Wesner, 1987). In our study, six of 80 unipolar depressed patients (7.5% of patients) developed mania after a mean of 12.3 years from the first depressive episode. In our study, the coexistence of physical disease in the patients studied was not convincing. Although no detailed attempts were made to eliminate organic mental conditions, the patients showed no gross memory or intellectual deterioration during the whole study period. One patient attempted suicide by hitting his skull with an axe, and his brain scan showed bitemporal cerebral atrophy. However, prospective studies should be conducted to exclude any temporal relations between the onset of mania and organic conditions in old age, as suggested by previous authors (Shulman and Post, 1980; Glasser and Rabins, 1984). Five of the seven patients who had previous depressive episodes showed delusional depression. This is interesting in view of a recent study conducted by Weissman et al. (1984) who found that the prevalence of bipolar illness was six times as high among the relatives of delusionally depressed probands than among the relatives of non-delusionally depressed probands. One of the most striking features of our study is the consistent presence of precipitating events in the 6-month period prior to the manic episode. Of the ten patients, seven had events of such a magni-

tude that it disrupted their routine living arrangements. The most important event was the familial discord whereby the very essence of the marital relationship of the couple was seriously threatened. It is difficult to explain this finding and relate the loss to the subsequent reaction with mania in some patients. It may be regarded as a manic defense to such a loss (Klein, 1965; Eagles and Whalley, 1985) or an attempt to resolve a conflict involving aggression by the free expression of aggressive drive against an external object (Langley, 1975). Indeed, stressful life events have been found to be common precipitants of mania, even in younger patients (Leff et al., 1976; Hall et al., 1977; Rickarby, 1977; Ambelas, 1979; Dunner et al., 1979). An alternative explanation is that prodromal manic symptoms may be responsible for the conflicts and stress noted. Such prodromal symptoms frequently cause marital discord prior to the clinical manic presentation. Familial history of mania is more common in younger than in older patients (Hopkinson, 1964; Ghadirian et al., 1986). This study confirms this finding, and although the number is too small to draw conclusions, no history of mania in any family member was obtained. However, a history of depression and/or alcoholism was found in four patients (40%). Contrary to early reports (Rennie, 1941; Roth, 1955) the prognosis of mania in old age is good. This confirms more recent findings (Langley, 1975; Shulman and Post, 1980; Glasser and Rabins, 1984) that since the introduction of neuroleptics and lithium the patients respond to these medications, as they do in the younger age population. In our study, most of our patients were not hospitalised for a long period. Lithium can be given effectively in small doses to treat these patients. In conclusion, mania in old age is not as uncommon as was previously believed. The classical manic symptoms are the most common presenting features in this population while mixed manic symptoms may also occur. Precipitating events are relatively common before the onset of mania, as has been suggested by several previous authors. The prognosis of mania in this population is good with appropriate therapy, thus it is important to recognize the condition and treat it promptly.

201

Acknowledgement The authors wish to thank secretarial help.

Nicole

Daoust

for

References Akiskal, H.S., Bitar, A.H., Puzantien, V.R., Rosenthal, T.L. and Walker, P.W. (1978) The nosological status of neurotic depression. Arch. Gen. Psychiatry 35, 756-766. Ambelas, A. (1979) Psychologically stressful events in the precipitation of manic episodes. Br. J. Psychiatry 135, 15-21. American Psychiatric Association (1980) Diagnostic and Statistical Manual of Mental Disorders, Third edition. American Psychiatric Association, Washington, DC. Clayton, P.J. (1983) The prevalence and course of the affective disorders. In: J.M. Davis and J.W. Maas (Eds.), The Affective Disorders, American Psychiatric Press, Washington, DC, pp. 193-203. Dunner, D.L., Fleiss, J.L. and Fieve, R.R. (1976) The course of development of mania in patients with recurrent depression. Am. J. Psychiatry 133, 905-908. Dunner, D.L., Patrick, V. and Fieve, R.R. (1979) Life events at the onset of bipolar affective illness. Am. J. Psychiatry 136, 508-511. Eagles, J.M. and Shalley, L.J. (1985) Ageing and affective disorders: the age at first onset of affective disorders in Scotland, 1969-1978. Br. J. Psychiatry 147, 180-187. Fieve, R.R. (1975) New developments in manic-depressive illness. In: S. Arieti and G. Chrzanowski (Eds.), New Dimensions in Psychiatry: A World View, John Wiley and Sons, New York, pp. 4-25. Ghadirian, A.M., Lalinec-Michaud, M. and Engelsmann, F. (1986) Early and late onset of affective disorders: clinical and family characteristics. Ann. R. Coll. Physcns. Surg. Canada 19, 53-57. Glasser, M. and Rabins, P. (1984) Mama in the elderly. Age Ageing 13, 210-213. Hall, K.S., Dunner, D.L., Zeller, G. and Fieve, R.R. (1977) Bipolar illness: a prospective study of life events. Compr. Psychiatry 18, 497-502. Hopkinson, G. (1964) A genetic study of affective illness in patients over 50. Br. J. Psychiatry 110, 244-254.

Klein, M. (1965) A contribution to the psychogenesis of manic depressive state. In: J.D. Sutherland (Ed.), Contributions to Psychoanalysis, Hogarth Press, London. Langley, G.E. (1975) The functional psychoses. In: J.G. Howells (Ed.), Modern Perspectives in the Psychiatry of Old Age, Brunner Hazel, New York, pp. 326-355. Leff, J.P., Fischer, M. and Bertelsen, A. (1976) A cross national epidemiological study of mania. Br. J. Psychiatry 129, 428-442. Perris, C. (1966) A study of bipolar (manic depressive) and unipolar recurrent depressive psychoses. Acta Psychiatr. Stand. 42 (Suppl. 194) 15-42. Perris, C. and d’Elia, G. (1964) Pathoplastic significance of the premorbid situation in depressive psychoses. Acta Psychiatr. Stand. 40 (Suppl. 180), 87-100. Post, F. (1982) Affective disorders in old age. In: E.S. Paykel (Ed.), Handbook of Affective Disorders, Guilford Press, New York, pp. 393-402. Post, F. (1978) The functional psychoses. In: A.D. lsaacs and F. Post (Eds.), Studies in Geriatric Psychiatry, John Wiley and Sons, New York, pp. 76-94. Rennie, T.A.C. (1941) Prognosis in manic depressive psychosis. Am. J. Psychiatry 98, 801-804. Rickarby, G.A. (1977) Four cases of mania associated with bereavement. J. Nerv. Ment. Dis. 165, 255-262. Roth, M. (1955) The natural history of mental disorder in old age. J. Ment. Sci. 101, 281-301. Shulman, K. and Post, F. (1980) Bipolar affective disorder in old age. Br. J. Psychiatry 136, 26-32. Spar, J.E., Ford, C.V. and Liston, E.H. (1979) Bipolar affective disorder in aged patients. J. Clin. Psychiatry 40, 504-507. Stotsky, B.A. (1973) Psychoses in the elderly. In: C. Eisolorfer and W.E. Fann (Eds.), Psychopharmacology and Aging, Plenum Press, New York, pp. 193-203. Weissman, M.M., Prusoff, B.A. and Merikangas, K.A. (1984) Is delusional depression related to bipolar disorder? Am. J. Psychiatry 141, 892-893. Winokur, G. and Morrison, J. (1973) The Iowa 500: follow-up of 225 depressives. Br. J. Psychiatry 123, 543-548. Winokur, G. and Wesner, R. (1987) From unipolar depression to bipolar illness: 29 who changed. Acta Psychiatr. Stand. 76. 59-63.