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Optimizing the Treatment of Bipolar Disorder in Older Adults

August 22, 2018
Martha Sajatovic, MD

Demographic Shifts Creating Larger Geriatric Population

The world’s population of people aged 60 years and older has doubled since 1980, and, for the first time ever, the number of adults aged 65 years and older is expected to exceed the number of children under 5 by 2020.

Considering such demographic trends, Martha Sajatovic, MD, believes mental health clinicians need to be educated about mood disorders in older adults, even if they are not specifically practicing geriatric psychiatry.

“It’s my opinion, and I think a number of clinicians agree, that as a field we need to be more familiar with working with older people,” said Dr. Sajatovic, Professor of Psychiatry and Neurology and Willard Brown Chair in Neurological Outcomes, Case Western Reserve University School of Medicine, Cleveland, Ohio.

Sajatovic session box“People are living longer. Unfortunately, the downside of that is…we have more years that we’re dealing with different kinds of chronic health conditions.”

Dr. Sajatovic will speak at the annual Psych Congress conference about one such condition—bipolar disorder (BD), which often affects older adults and younger adults differently.

Although the research is somewhat limited, studies have suggested the manic symptoms of BD are often—but not always—attenuated or milder in older adults, compared with younger people with BD. Older people may also be more irritable and may experience physical complications related to BD more frequently. Conversely, depressive symptoms are generally the same in the two groups.

Older people with bipolar depression may think more slowly and may have difficulty concentrating or focusing on things, which sometimes leads to a misdiagnosis of dementia or Alzheimer’s disease, said Dr. Sajatovic, a practicing clinician who has performed research and clinical care in the field for more than 20 years.

“That’s another reason why it’s really important for clinicians to at least have some familiarity with what mood disorders look like in elderly people,” she added.

Also Coming up at Psych Congress 2018:

Clearing Up Confusion About Cannabis Therapeutics
Looking at Depression Through an Evolutionary Lens
A New Generation of Depression Treatment Approaches

Taking a thorough clinical history is critical in distinguishing between bipolar depression and dementia, she said. She suggests clinicians ask about patients’ previous mood-related symptoms, mania, and bouts of depression, including postpartum depression. Women with BD are particularly prone to postpartum mood disorders, and there used to be much less appreciation of those conditions, she said.

Some people have a misconception about BD—that it burns out or goes away as people age, Dr. Sajatovic said, adding that the data do not suggest that is true.

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Despite the differences between older and younger people with BD, the US Food and Drug Administration (FDA) does not differentiate between the groups for pharmacological treatments.

In addition, very few published clinical trials have focused on older adults with bipolar disorder (OABD), Dr. Sajatovic said. She knows of only one such randomized, controlled clinical trial, and she will discuss it in her Psych Congress presentation. That research, funded by the US National Institute of Mental Health, compared lithium with divalproex in people aged 60 years and older who have type 1 bipolar mania.

Many clinicians believe lithium should not be used in older people—a concept which Dr. Sajatovic hopes to also address in her presentation, titled “Bipolar Disorder in Later Life.”

“I think our understanding in recent years is a bit more nuanced than that,” she said. “I think we just have to be careful how we use it, but it can actually be a highly effective medication for older age bipolar disorder.”

Data has suggested that lithium can preserve or protect cognitive functioning, and the US National Institutes of Health is funding more research on the topic, Dr. Sajatovic noted.

“I think that’s an area that everybody can get behind,” she said. “It potentially has properties that can really help brain health and, again, given the demographic changes that we’re seeing globally, I think that’s very exciting.”

Her talk will also cover medication safety and tolerability issues and interactions between psychiatric medications and other types of drugs in the OABD population.

Generally, “older people are much more likely to have side effects, and tend to tolerate the drug less well,” Dr. Sajatovic said. “A rule of thumb to treat older people is to start low and go slow with drugs. I would also throw in a third one—­don’t stop too soon.”

Register now for Psych Congress 2018, taking place Oct. 25-28 in Orlando, Fla.

As is the case with the general population of people with BD, there is little data on nonpharmacological interventions that may help OABD. Social support is one element that has been shown to be beneficial, Dr. Sajatovic said.

In her talk, she will present some data from a study that she was involved in, on a self-management program designed to help people with serious mental illness and comorbid health conditions manage their health. BD and other chronic serious mental illness generally shorten a person’s life span by 1 to 2 decades, Dr. Sajatovic said.


World Health Organization. Are you ready? What you need to know about ageing. World Health Day 2012. Accessed July 17, 2018.

Young RC, Mulsant B, Sajatovic M, et al. GERI-BD: a randomized double-blind controlled trial of lithium and divalproex in the treatment of mania in older patients with bipolar disorder. The American Journal of Psychiatry. 2017;174(11):1086-1093.

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