QUESTION
Provide a response to the below questions according to the assessment completed from your collegue. You may also provide additional information, alternative points of view, research to support treatment, or patient education strategies you might use with the relevant patient.
- What safety precautions should be implemented to reduce potential risks associated with the symptoms of late Bipolar I disorder in an older adult?
- How would you prioritize the interventions for an older adult individual diagnosed with Bipolar I disorder?
- How does the age and developmental stage of the patient affect the onset and treatment of Bipolar I disorder symptoms?
ANSWER
Safety Precautions for Late Bipolar I Disorder in Older Adults
1. Introduction
Despite similar clinical characteristics, assessment, and treatment for bipolar disorder in older and younger adults, numerous factors underlying late-life bipolar disorder suggest that specific precautions for safety and tolerability are necessary for older adults with this disorder. Safety precautions are especially important in the treatment of late-life mania when older adults are at the greatest risk for adverse events due to medication. Recognition of these special needs will ultimately improve the well-being of older adults with bipolar disorder and may reduce the incidence of iatrogenic morbidity. This paper will review the current literature on late-life bipolar disorder with the goal of establishing safety precautions for treatment of this patient population. Sources for this review were obtained through a search of the PubMed database. Search terms included bipolar disorder in combination with late-life, elderly, safety, adverse events, antipsychotics, atypical antipsychotics, movement disorders, tardive dyskinesia, Parkinsonism, neuroleptic malignant syndrome, and seven specific atypical antipsychotic agent names. Because there are relatively few studies focused on late-life bipolar disorder, the literature review was expanded to encompass not only controlled clinical trials, but also case reports, open-label trials, and studies on elderly patients with other psychotropic medications that may have relevance to the population of patients with bipolar disorder. Case reports were included in this review given that they often highlight safety issues with the use of psychotropic medications in the elderly, but the strength of evidence provided by case reports will be noted. An extensive literature on late-life bipolar disorder exists in the form of geriatric psychiatry textbook contents. This paper will also draw upon this expertise in making safety recommendations for treatment of late-life bipolar disorder. After a careful review of the literature, safety precautions for late-life bipolar disorder will be categorized in three areas: acute mania, depression, and maintenance treatment. Recommendations will vary according to strength of evidence with some being based on little more than expert opinion. At the end of this review, a set of safety-oriented questions (SOQ) will be posed which may help to assess the morbidity risk of a given treatment in an individual patient.