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Objective: Prior studies have examined chronic conditions in older adults with prevalent epilepsy, but rarely among those with incident epilepsy. Identifying the chronic conditions with which older adults present at epilepsy incidence assists with the evaluation of disease burden in this patient population and informs coordinated care development. The aim of this study was to identify preexisting chronic conditions with excess prevalence in older adults with incident epilepsy compared to those without. Methods: Using a random sample of 4 999 999 fee‐for‐service Medicare beneficiaries aged >65 years, we conducted a retrospective cohort study of epilepsy incidence in 2019. Non‐Hispanic Black and Hispanic beneficiaries were oversampled. We identified preexisting chronic conditions from the 2016–2018 Medicare Beneficiary Summary Files and compared chronic condition prevalence between Medicare beneficiaries with and without incident epilepsy in 2019. We characterized variations in preexisting excess chronic condition prevalence by age, sex, and race/ethnicity, adjusting for the racial/ethnic oversampling. Results: We observed excess prevalence of most preexisting chronic conditions in beneficiaries with incident epilepsy (n = 20 545, weighted n = 19 631). For stroke, for example, the adjusted prevalence rate ratio (APRR) was 4.82 (99% CI:4.60, 5.04), meaning that, compared to those without epilepsy, beneficiaries with incident epilepsy in 2019 had 4.82 times the stroke prevalence. Similarly, beneficiaries with incident epilepsy had a higher prevalence rate for preexisting neurological conditions (APRR = 3.17, 99% CI = 3.08–3.27), substance use disorders (APRR = 3.00, 99% CI = 2.81–3.19), and psychiatric disorders (APRR = 1.98, 99% CI = 1.94–2.01). For most documented chronic conditions, excess prevalence among beneficiaries with incident epilepsy in 2019 was larger for younger age groups compared to older age groups, and for Hispanic beneficiaries compared to both non‐Hispanic White and non‐Hispanic Black beneficiaries. Significance: Compared to epilepsy‐free Medicare beneficiaries, those with incident epilepsy in 2019 had a higher prevalence of most preexisting chronic conditions. Our findings highlight the importance of health promotion and prevention, multidisciplinary care, and elucidating shared pathophysiology to identify opportunities for prevention. [ABSTRACT FROM AUTHOR]

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. Key points: With the global population of older adults increasing rapidly, it is important to understand how older adults with bipolar disorder (BD) differ from younger adults.This replication analysis using a large global dataset focused on older‐age bipolar disorder (OABD) and examined associations of older age, BD symptoms, somatic burden and functioning.Older age was associated with less severe mania and more somatic burden but there was no association of depression with age.Worse BD symptom severity was associated with worse functioning, emphasizing the need for symptom relief in OABD to promote better functioning. [ABSTRACT FROM AUTHOR]

Objects: Studies of older age bipolar disorder (OABD) have mostly focused on "younger old" individuals. Little is known about the oldest OABD (OOABD) individuals aged ≥70 years old. The Global Aging and Geriatric Experiments in Bipolar Disorder (GAGE‐BD) project provides an opportunity to evaluate the OOABD group to understand their characteristics compared to younger groups. Methods: We conducted cross‐sectional analyses of the GAGE‐BD database, an integrated, harmonized dataset from 19 international studies. We compared the sociodemographic and clinical characteristics of those aged <50 (YABD, n = 184), 50–69 (OABD, n = 881), and ≥70 (OOABD, n = 304). To standardize the comparisons between age categories and all characteristics, we used multinomial logistic regression models with age category as the dependent variable, with each characteristic as the independent variable, and clustering of standard errors to account for the correlation between observations from each of the studies. Results: OOABD and OABD had lower severity of manic symptoms (Mean YMRS = 3.3, 3.8 respectively) than YABD (YMRS = 7.6), and lower depressive symptoms (% of absent = 65.4%, and 59.5% respectively) than YABD (18.3%). OOABD and OABD had higher physical burden than YABD, especially in the cardiovascular domain (prevalence = 65% in OOABD, 41% in OABD and 17% in YABD); OOABD had the highest prevalence (56%) in the musculoskeletal domain (significantly differed from 39% in OABD and 31% in YABD which didn't differ from each other). Overall, OOABD had significant cumulative physical burden in numbers of domains (mean = 4) compared to both OABD (mean = 2) and YABD (mean = 1). OOABD had the lowest rates of suicidal thoughts (10%), which significantly differed from YABD (26%) though didn't differ from OABD (21%). Functional status was higher in both OOABD (GAF = 63) and OABD (GAF = 64), though only OABD had significantly higher function than YABD (GAF = 59). Conclusions: OOABD have unique features, suggesting that (1) OOABD individuals may be easier to manage psychiatrically, but require more attention to comorbid physical conditions; (2) OOABD is a survivor cohort associated with resilience despite high medical burden, warranting both qualitative and quantitative methods to better understand how to advance clinical care and ways to age successfully with BD. Key points: Limited knowledge of older and oldest older age bipolar disorder derived from limited sample sizes.The Global Aging and Geriatric Experiments in Bipolar Disorder consortium provided international data to compare younger age, older age, and oldest older age people with BDInternational sites (n = 14) provided data on patients aged <50 (n = 184 YABD), 50–69 (n = 881 OABD), and ≥70 (n = 304 OOABD) to assess differences among three groupsOABD and OOABD represent distinct cohorts within BD and differ in sociodemographic and clinical characteristics from YABD in general. OOABD individuals may be easier to manage psychiatrically but require more attention to their comorbid physical conditions. OOABD likely is a survivor cohort associated with resilience despite high medical burden, warranting future study using both qualitative and quantitative methods to better understand what makes OOABD resilient, how to advance clinical care and age successfully with BD. [ABSTRACT FROM AUTHOR]

Objective: The current literature on employment in older adults with bipolar disorder (OABD) is limited. Using the Global Aging and Geriatric Experiments in Bipolar Disorder Database (GAGE‐BD), we examined the relationship of occupational status in OABD to other demographic and clinical characteristics. Methods: Seven hundred and thirty‐eight participants from 11 international samples with data on educational level and occupational status were included. Employment status was dichotomized as employed versus unemployed. Generalized linear mixed models with random intercepts for the study cohort were used to examine the relationship between baseline characteristics and employment. Predictors in the models included baseline demographics, education, psychiatric symptom severity, psychiatric comorbidity, somatic comorbidity, and prior psychiatric hospitalizations. Results: In the sample, 23.6% (n = 174) were employed, while 76.4% were unemployed (n = 564). In multivariable logistic regression models, less education, older age, a history of both anxiety and substance/alcohol use disorders, more prior psychiatric hospitalizations, and higher levels of BD depression severity were associated with greater odds of unemployment. In the subsample of individuals less than 65 years of age, findings were similar. No significant association between manic symptoms, gender, age of onset, or employment status was observed. Conclusion: Results suggest an association between educational level, age, psychiatric severity and comorbidity in relation to employment in OABD. Implications include the need for management of psychiatric symptoms and comorbidity across the lifespan, as well as improving educational access for people with BD and skills training or other support for those with work‐life breaks to re‐enter employment and optimize the overall outcome. [ABSTRACT FROM AUTHOR]

Background: Studies examining end‐of‐life (EOL) care in older cancer patients are scarce, and prior studies have not accounted for gradients of cognitive impairment (COG‐I). We examine EOL care patterns across COG‐I gradients, hypothesizing that greater COG‐I severity is associated with lower odds of receiving aggressive EOL care. Methods: Using data from the linked Surveillance Epidemiology and End Results (SEER) ‐Medicare ‐Minimum Data Set (MDS) 3.0, we identified patients with nursing facility stays (NFS) and who died with metastatic cancer from 2013 to 2017. Markers of aggressive EOL care were: cancer‐directed treatment, intensive care unit admission, >1 emergency department visit, or >1 hospitalization in the last 30 days of life, hospice enrollment in the last 3 days of life, and in‐hospital death. In addition to descriptive analysis, we conducted multivariable logistic regression analysis to evaluate the independent association between COG‐I severity and receipt of aggressive EOL care. Results: Of the 40,833 patients in our study population, 49.2% were cognitively intact; 24.4% had mild COG‐I; 19.7% had moderate COG‐I; and 6.7% had severe COG‐I. The percent of patients who received aggressive EOL care was 62.6% and 74.2% among those who were cognitively intact and those with severe COG‐I, respectively. Compared with cognitively intact patients, those with severe COG‐I had 86% higher odds of receiving any type of aggressive EOL care (adjusted odds ratio (aOR): 1.86 (95% confidence interval: 1.70–2.04)), which were primarily associated with higher odds of in‐hospital death. The odds of in‐hospital death associated with severe COG‐I were higher among those with short‐ than with long‐term stays (aOR:2.58 (2.35–2.84) and aOR:1.40 (1.17–1.67), respectively). Conclusions: Contrary to our hypothesis, aggressive EOL care in older metastatic cancer patients with NFS was highest among those suffering severe COG‐I. These findings can inform the development of interventions to help reduce aggressive EOL care in this patient population. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

This article discusses a study that examines the activation of specific subsets of monocytes and macrophages in patients with schizophrenia (SCZ) and bipolar disorder (BPD) who are taking medication. The study found that both SCZ and BPD patients have higher proportions of proinflammatory monocytes and macrophages compared to normal controls. The study suggests that this enhanced activation may contribute to the development of atherosclerosis. The study also indicates that while antipsychotic and antidepressant treatments may normalize some aspects of immune dysregulation, they do not fully address the activation of specific monocyte and macrophage phenotypes. Further research is needed to better understand the implications of this dysregulation for cardiovascular disease. [Extracted from the article]

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 for the development of a better understanding of aging in BD. [ABSTRACT FROM AUTHOR]

Obesity, aging, and pathophysiology of schizophrenia (SCZ) may collectively contribute to the gray matter loss in brain regions of SCZ. We attempted to examine the association between volumes of specific brain regions, body mass index (BMI), inflammatory markers, and clinical features in older SCZ patients.Method: Clinically stable outpatients with schizophrenia (DSM-IV) aged ≥50 years were recruited to undergo whole-brain magnetic resonance imaging. We measured patients' plasma levels of soluble tumor necrosis factor receptor-1, soluble interleukin (IL)-2 receptor (sIL-2R), IL-1β, and IL-1 receptor antagonist (IL-1Ra). Clinical data were obtained from medical records and interviewing patients along with their reliable others.Results: There were 32 patients with mean age 58.8 years in this study. Multivariate regression analysis found only higher BMI significantly associated with lower volume of total gray matter, bilateral orbitofrontal and prefrontal cortexes, and the right hippocampal and frontal cortexes. Increased intensity of residual symptoms (higher Positive and Negative Syndrome Scale scores) was related to lower volumes of frontal lobe, prefrontal cortex, insula, hippocampus, left hemisphere amygdala, and total white matter. The lower volume of left anterior cingulum was associated with older age and higher sIL-2R plasma level; and higher IL-1Ra level was associated with greater right anterior cingulate volume. Older age at illness onset was significantly associated with the smaller right insula volume.Conclusions: Higher BMI, more residual symptoms, and inflammatory activity in IL-2 and IL-1 systems may play a role in gray matter loss in various brain regions of schizophrenia across the life span. [ABSTRACT FROM AUTHOR]

Objective: The objective of the study was to assess level of knowledge and attitudes of SUDEP among people living with epilepsy (PLWE) and healthcare workers providing epilepsy care in Uganda. Methods: This cross‐sectional study of 48 PLWE and 19 epilepsy care providers used a tailored questionnaire to evaluate epilepsy and SUDEP knowledge, frequency of SUDEP discussion, reasons for not discussing SUDEP, timing of SUDEP discussions, and perceived patient reactions to being provided information on SUDEP. Results: Median PLWE sample age was 25 (IQR; 19‐34) years, 10 (20.8%) were male, median age of onset of epilepsy 12 (IQR; 6‐18) years. Half of the PLWE reported that they had never heard of SUDEP. Most PLWE desired detailed information regarding SUDEP and preferred this information during the subsequent visits. Healthcare provider sample mean age was 35.7 (22.8) years, 12 (63.2%) were male and composed of 4 physicians (21.1%). Only 15% (3/20) of providers discussed SUDEP with their patients while 85% (17/20) have never discussed it. The main reasons for not discussing SUDEP were not knowing enough about SUDEP (89.5%) and no adequate support network available (30%). Providers that discussed SUDEP (100%) reported that negative reactions were the most common patient response. Significance: In this Ugandan sample, most PLWE are not aware of SUDEP and epilepsy care providers rarely discuss SUDEP with their patients or patient caregivers. Negative reactions to SUDEP discussions are common but not universal. There is an urgent need for epilepsy educational programs in clinics and targeted communities addressing SUDEP. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the effects of once-daily valbenazine (40 or 80 mg/d) in older and younger adults with tardive dyskinesia (TD).Methods: Data were pooled from three 6-week, randomized, double-blind, placebo-controlled (DBPC) studies (KINECT [NCT01688037], KINECT 2 [NCT01733121], and KINECT 3 [NCT02274558]) and two long-term studies (KINECT 3 extension and KINECT 4 [NCT02405091]). Outcomes analyzed in older and younger participants (55 years or older and younger than 55 years, respectively) included Abnormal Involuntary Movement Scale (AIMS) response (threshold of greater than or equal to 50% improvement from baseline in total score [items 1 to 7]) and Clinical Global Impression of Change-Tardive Dyskinesia (CGI-TD) response (score 2 or less ["very much improved" or "much improved"]). Safety assessments included treatment-emergent adverse events (TEAEs).Results: At week 6 (end of DBPC treatment), the percentage of participants who met the AIMS response threshold was higher with valbenazine versus placebo in both subgroups: 55 years or older (80 mg/d, 39.7% [P < .001]; 40 mg/d, 28.6% [P < .01]; placebo, 9.7%); younger than 55 years (80 mg/d, 39.5% [P < .001]; 40 mg/d, 20.0% [P > .05]; placebo, 10.8%). The percentage of participants with CGI-TD response was also higher with valbenazine versus placebo: 55 years or older (80 mg/d, 41.3% [P < .01]; 40 mg/d, 30.2% [P > .05]; placebo, 19.4%); younger than 55 years (80 mg/d, 39.5% [P < .05]; 40 mg/d, 35.3% [P < .05]; placebo, 18.5%). Responses at week 48 (end of long-term treatment, combined doses) were as follows: 55 years or older (AIMS, 70.7%; CGI-TD, 82.8%); younger than 55 years (AIMS, 58.7%; CGI-TD, 72.3%). No significant differences between older and younger subgroups were found for AIMS or CGI-TD response. No new safety signals or TEAEs of clinical concern were found in older participants who received long-term treatment.Conclusions: Valbenazine improved TD and was generally well tolerated in older and younger adults. [ABSTRACT FROM AUTHOR]

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 four 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 multisite 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 the understanding of OABD. [ABSTRACT FROM AUTHOR]

Objective: To assess depressive symptom outcomes in a pooled sample of epilepsy self‐management randomized controlled trials (RCTs) from the Managing Epilepsy Well (MEW) Network integrated research database (MEW DB). Methods: Five prospective RCTs involving 453 adults with epilepsy compared self‐management intervention (n = 232) versus treatment as usual or wait‐list control outcomes (n = 221). Depression was assessed with the nine‐item Patient Health Questionnaire. Other variables included age, gender, race, ethnicity, education, income, marital status, seizure frequency, and quality of life. Follow‐up assessments were collapsed into a visit 2 and a visit 3; these were conducted postbaseline. Results: Mean age was 43.5 years (SD = 12.6), nearly two‐thirds were women, and nearly one‐third were African American. Baseline sample characteristics were mostly similar in the self‐management intervention group versus controls. At follow‐up, the self‐management group had a significantly greater reduction in depression compared to controls at visit 2 (P < .0001) and visit 3 (P = .0002). Quality of life also significantly improved in the self‐management group at visit 2 (P = .001) and visit 3 (P = .005). Significance: Aggregate MEW DB analysis of five RCTs found depressive symptom severity and quality of life significantly improved in individuals randomized to self‐management intervention versus controls. Evidence‐based epilepsy self‐management programs should be made more broadly available in neurology practices. [ABSTRACT FROM AUTHOR]

The timely introduction of risk-mitigating strategies could circumvent most of the complications that OABD might experience in association with the COVID-19 pandemic (Table 1). The implementation of public health measures designed to limit the spread of coronavirus disease 2019 (COVID-19) has been applied particularly stringently to people at high risk of complications, such as individuals older than 70 years and people with concurrent health morbidities like chronic respiratory or cardiovascular diseases. Future research should clarify this issue and determine whether the direct and indirect effects of the COVID-19 pandemic have affected the course of OABD. [Extracted from the article]

Background: A minimal clinically important difference has not been established for the Abnormal Involuntary Movement Scale in patients with tardive dyskinesia. Valbenazine is a vesicular monoamine transporter 2 inhibitor approved for the treatment of tardive dyskinesia in adults. Efficacy in randomized, double-blind, placebo-controlled trials was defined as the change from baseline in Abnormal Involuntary Movement Scale total score (sum of items 1-7).Objectives: To estimate an minimal clinically important difference for the Abnormal Involuntary Movement Scale using valbenazine trial data and an anchor-based method.Methods: Data were pooled from three 6-week double-blind, placebo-controlled trials: KINECT (NCT01688037), KINECT 2 (NCT01733121), and KINECT 3 (NCT02274558). Valbenazine doses were pooled for analyses as follows: "low dose," which includes 40 or 50 mg/day; and "high dose," which includes 75 or 80 mg/day. Mean changes from baseline in Abnormal Involuntary Movement Scale total score were analyzed in all participants (valbenazine- and placebo-treated) with a Clinical Global Impression of Change-Tardive Dyskinesia or Patient Global Impression of Change score of 1 (very much improved) to 3 (minimally improved).Results: The least squares mean improvement from baseline to week 6 in Abnormal Involuntary Movement Scale total score was significantly greater with valbenazine (low dose: -2.4; high dose: -3.2; both, P < 0.001) versus placebo (-0.7). An minimal clinically important difference of 2 points was estimated based on least squares mean changes in Abnormal Involuntary Movement Scale total score in participants with a Clinical Global Impression of Change-Tardive Dyskinesia score ≤3 at week 6 (mean change: -2.2; median change: -2) or Patient Global Impression of Change score ≤3 at week 6 (mean change: -2.0; median change: -2).Conclusions: Results from an anchor-based method indicate that a 2-point decrease in Abnormal Involuntary Movement Scale total score may be considered clinically important. © 2019 The Authors. Movement Disorders published by Wiley Periodicals, Inc. on behalf of International Parkinson and Movement Disorder Society. [ABSTRACT FROM AUTHOR]

Objectives: Despite the growing numbers and proportion of older adults with bipolar disorder (OABD), there are very limited guidelines for the use of lithium with its double‐edged potential for effectiveness and toxicity in this population. The primary aims of this Delphi survey were: (a) To determine the place of lithium among the preferred choices for maintenance treatment of OABD. (b) To provide detailed clinical guidelines for the safe and effective use of lithium in OABD. Methods: In the face of limited evidence, the Delphi survey method was used to achieve consensus by a group of 25 experts in OABD from nine countries. An oversight committee monitored and analyzed the results of each survey and formulated more focused questions with each subsequent iteration. Results: A 100% response rate was achieved for all three iterations of the survey. Lithium was the preferred choice for maintenance monotherapy in OABD. Serum levels of 0.4‐0.8 mmol/L were recommended for ages 60‐79 and serum levels of 0.4‐0.7 mmol/L were recommended for ages 80 and over. Specific recommendations achieved consensus for second line monotherapy as well as for other drugs to be used in combination with lithium if necessary. Guidelines for routine monitoring of lithium in OABD were provided for laboratory investigations and clinical assessments. Conclusions: Lithium remains the preferred choice for maintenance monotherapy in OABD. Laboratories should report the therapeutic range for serum levels of lithium separately for older adults. [ABSTRACT FROM AUTHOR]

Summary: Objective: Despite advances in care, many people with epilepsy have negative health events (NHEs) such as accidents, emergency department visits, and poor quality of life. “ Self‐ management fo r people wi th epilepsy and a history of negative health events” (SMART) is a novel group format epilepsy self‐management intervention. A community participatory approach informed the refinement of SMART, which was then tested in a 6‐month randomized controlled trial of SMART (n = 60) versus waitlist control (WL, n = 60). Methods: Participants were adults aged ≥18 years with epilepsy and an NHE within the past 6 months (seizure, accident, self‐harm attempt, emergency department visit, or hospitalization). Assessments were conducted at screening, baseline, 10 weeks, and 24 weeks (6 months). Primary outcome was 6‐month change in total NHE count. Additional outcomes included depression on the nine‐item Patient Health Questionnaire and Montgomery‐Asberg Depression Rating Scale, quality of life on the 10‐item Quality of Life in Epilepsy, functioning on the 36‐item Short‐Form Health Survey, and seizure severity on the Liverpool Seizure Severity Scale. Results: Mean age was 41.3 years (SD = 11.82), 69.9% were African American, 74.2% were unemployed, and 87.4% had an annual income < US$25 000; 57.5% had a seizure within 30 days of enrollment. Most NHEs were seizures. Six‐month study attrition was 14.2% overall and similar between arms. Individuals randomized to SMART had greater reduction in total median NHEs from baseline to 6 months compared to WL (P = 0.04). SMART was also associated with improved nine‐item Patient Health Questionnaire (P = 0.032), Montgomery‐Asberg Depression Rating Scale (P = 0.002), 10‐item Quality of Life in Epilepsy (P < 0.001), and 36‐item Short‐Form Health Survey (P = 0.015 physical health, P = 0.003 mental health) versus WL. There was no difference in seizure severity. Significance: SMART is associated with reduced health complications and improved mood, quality of life, and health functioning in high‐risk people with epilepsy. Additional efforts are needed to investigate potential for scale‐up. [ABSTRACT FROM AUTHOR]

Objectives: More than 50% of people with bipolar disorder will be age 60 years or older by 2030. There is a need for more data to guide assessment and treatment in older age bipolar disorder (OABD); however, interpretation of findings from small, single‐site studies may not be generalizable and there are few large trials. As a step in the direction of coordinated large‐scale OABD data collection, it is critical to identify which measurements are currently used and identify potential gaps in domains typically assessed. Methods: An international group of OABD experts performed a systematic literature review to identify studies examining OABD in the past 6 years. Relevant articles were assessed to categorize the types of clinical, cognitive, biomarker, and neuroimaging OABD tools routinely used in OABD studies. Results: A total of 53 papers were identified, with a broad range of assessments. Most studies evaluated demographic and clinical domains, with fewer studies assessing cognition. There are relatively few biomarker and neuroimaging data, and data collection methods were less comprehensively covered. Conclusion: Assessment tools used in the recent OABD literature may help to identify both a minimum and a comprehensive dataset that should be evaluated in OABD. Our review also highlights gaps where key clinical outcomes have not been routinely assessed. Biomarker and neuroimaging assessment could be further developed and standardized. Clinical data could be combined with neuroimaging, genetic, and other biomarkers in large‐scale coordinated data collection to further improve our understanding of OABD phenomenology and biology, thereby contributing to research that advances care. [ABSTRACT FROM AUTHOR]

Introduction: The evidence base regarding characteristics of older adults with bipolar disorder (BD) remains limited. The NIH-funded multicenter study Acute Pharmacotherapy of Late-Life Mania (GERI-BD) assessed various clinical domains before and during mood stabilizer treatment in older adults participating in a 9-week, double-blind randomized controlled trial. We describe the rationale for selecting these instruments.Methods: Domains and instruments were selected on the basis of the study design and the participants. The investigators' experience in clinical trials involving young adults with BD or older adults with major depressive disorder, along with open studies of older adults with BD, contributed to the selection process.Results: We identified domains and selected instruments that could be used to assess the participants given their diagnostic, treatment history, and medical and mood state characteristics. They were also intended to measure tolerability and efficacy and permit examination of potential moderating and mediating factors.Conclusions: Decisions regarding the assessment domains to be included in the clinical trial highlight the challenges facing researchers studying drug treatments for older adults with BD, or more generally, mood disorders. We suggest that the domains and instruments selected by GERI-BD investigators constitute a "toolbox" that can be customized for other investigators. Copyright © 2017 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Objective Epilepsy is a common neurological condition that is often associated with stigmatizing attitudes and negative stereotypes among the general public. This randomized controlled trial ( RCT) tested two new communication approaches targeting epilepsy stigma versus an education-alone approach. Methods Two brief stigma-reduction videos were developed, informed by community stakeholder input; one highlighted role competency in people with epilepsy; the other highlighted social inclusion of people with epilepsy. A control video was also developed. A Web-based survey using a prospective RCT design compared effects of experimental videos and control on acceptability, perceived impact, epilepsy knowledge, and epilepsy stigma. Epilepsy knowledge and stigma were measured with the Epilepsy Knowledge Questionnaire ( EKQ) and Attitudes and Beliefs about Living with Epilepsy ( ABLE), respectively. Results A total of 295 participants completed the study. Mean age was 23.1 ( standard deviation = 3.27) years; 59.0% were male, and 71.4% were white. Overall, respondents felt videos impacted their epilepsy attitudes. EKQ scores were similar across videos, with a trend for higher knowledge in experimental videos versus control (p = 0.06). The role competency and control videos were associated with slightly better perceived impact on attitudes. There were no differences between videos on ABLE scores (p = 0.568). There were subgroup differences suggesting that men, younger individuals, whites, and those with personal epilepsy experience had more stigmatizing attitudes. Significance This RCT tested communication strategies to improve knowledge and attitudes about epilepsy. Although this initial effort will require follow-up, we have demonstrated the acceptability, feasibility, and potential of novel communication strategies to target epilepsy stigma, and a Web-based approach for assessing them. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Aims To directly compare the 1-year stability of Mini-Mental State Examination ( MMSE) score and Saint Louis University Mental Status ( SLUMS) examination score and correlate score changes with demographic variables, clinical factors, and functional domains. Methods A sample of 304 study participants was recruited from residential and clinical settings in Ohio. Follow-up assessments were administered after 1 year with a retention rate of 92% (n = 281). Functional domains included the Instrumental Activities of Daily Living ( IADL) scale. Results MMSE and SLUMS scores correlated with each other ( r = 0.65, P < 0.001) and with two functional measures, including the IADL ( r = 0.27, r = 0.24, P < 0.001). However, the MMSE and SLUMS frequently placed the same subject into different categories. Rates of reversion and conversion varied between the two tests. The 1-year changes in MMSE raw score correlated with changes in three functional domains as well as age ( P < 0.05), while SLUMS raw score changes did not correlate with any functional measures. Conclusion Our large, longitudinal data set allowed us to compare the tests' stability, which differed between the SLUMS and MMSE. The MMSE may be more sensitive than the SLUMS to 1-year cognitive changes influencing functional abilities. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Objectives This analysis of screening and baseline data from an ongoing trial examined self-report versus automated adherence monitoring and assessed the relationship between bipolar disorder (BD) symptoms and adherence in 104 poorly adherent individuals. Methods Adherence was measured with the Tablets Routine Questionnaire (TRQ) and the Medication Event Monitoring System (MEMS). Symptoms were measured with the Montgomery-Åsberg Depression Rating Scale (MADRS), the Young Mania Rating Scale (YMRS), and the Brief Psychiatric Rating Scale (BPRS). Results The mean age of the sample was 46.3 years [standard deviation (SD) = 9.41 years], with 72% (n = 75) women and 71% (n = 74) African American subjects. Adherence improved from screening to baseline, with a mean missed drug proportion measured by TRQ of 61.43% (SD = 26.48%) versus a baseline mean of 46.61% (SD = 30.55%). The mean proportion of missed medication using MEMS at baseline was 66.43% (SD = 30.40%). The correlation between TRQ and MEMS was 0.47. The correlation between a single index drug and all BD medications was 0.95. Symptoms were generally positively correlated with TRQ (worse adherence = more severe symptoms), but in most instances was only at a trend level (p > 0.05), with the exception of the correlations between baseline TRQ and MADRS and BPRS, which were positive ( r = 0.20 and r = 0.21, respectively) and significant (p ≤ 0.05). Conclusions In patients with BD, monitoring increased adherence by 15%. MEMS identified 20% more non-adherence than self-report. Using a standard procedure to identify a single index drug for adherence monitoring may be one way to assess global adherence in patients with BD receiving polypharmacy treatment. Greater BD symptom severity may be a clinical indicator to assess for adherence problems. [ABSTRACT FROM AUTHOR]

Objective In spite of growing numbers of older people, there are few treatment studies on late-life bipolar disorder (BD). This was a 12-week prospective, open-label trial to assess efficacy and tolerability of adjunct asenapine in non-demented older adults (≥60 years) with sub-optimal previous response to BD treatments. Methods Asenapine was initiated at 5 mg/day and titrated as tolerated. Effects on global psychopathology were measured with Clinical Global Impression, bipolar version (CGI-BP), and the Brief Psychiatric Rating Scale (BPRS). Mood polarity severity was measured with the Hamilton Depression Rating Scale, Montgomery Asberg Depression Rating Scale, and Young Mania Rating Scale. Other outcomes included the World Health Organization Disability Assessment Schedule II. Results Fifteen individuals were enrolled (mean age 68.6, SD 6.12; 53% female; 73% Caucasian, 13% African American, and 7% Asian). There were 4/15 (27%) individuals who prematurely terminated the study, whereas 11/15 (73%) completed the study. There were significant improvements from baseline on the BPRS ( p < 0.05), on CGI-BP overall ( p < 0.01), and on CGI-BP mania ( p < 0.05) and depression ( p < 0.01) subscales. The mean dose of asenapine was 11.2 ( SD 6.2) mg/day. The most common reported side effects were gastrointestinal discomfort ( n = 5, 33%), restlessness ( n = 2, 13%), tremors ( n = 2, 13%), cognitive difficulties ( n = 2, 13%), and sluggishness ( n = 2, 13%). Conclusions Older people with BD had global improvements on asenapine. Most reported adverse effects were mild and transient, but adverse effects prompted drug discontinuation in just over one quarter of patients. Although risks versus benefits in older people must always be carefully considered, asenapine may be a treatment consideration for some non-demented geriatric BD patients. Copyright © 2014 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Objectives Attitudes towards medication are believed to be important for medication adherence and social factors are believed to have effects on attitudes. Only a limited literature has focused on how attitudes to medication may correlate with social factors relevant to medication adherence among individuals with bipolar disorder ( BPD). This secondary analysis of baseline data from a longitudinal study examined the relationships between attitudes towards mood stabilizers and psychosocial variables. Methods Community mental health clinic patients (n = 122) were assessed on the outcome variable of medication attitudes as measured by the Attitudes towards Mood Stabilizers Questionnaire ( AMSQ). Independent variables included education as well as standardized measures of psychiatric symptom severity, alcohol and drug problem severity, health locus of control (the belief that one's health is self-determined versus determined by factors outside of one's own control), and psychosocial support. A hierarchical multiple regression model evaluated the relationship between AMSQ and these variables. Results More positive medication attitudes were seen in individuals with higher levels of social support and in those who held a stronger belief that their health outcomes are determined by others, such as family or clinicians. Education, symptom severity, alcohol problem severity and drug problem severity were not significant attitudinal correlates. Conclusions Attitudes towards mood stabilizers are correlated with both the support a person receives from others in their social network and how much a person believes others can influence his or her health. Clinicians need to be aware of the importance of the social environment as it relates to medication attitudes and more research is needed on how treatment attitudes may actually translate into medication adherence behavior. [ABSTRACT FROM AUTHOR]

Objective Using the database of the National Institute of Mental Health-sponsored acute treatment of late life mania study (GERI-BD), we assessed the role of social support in the presentation of late life bipolar mania. Methods In the first 100 subjects randomized in geriatric BD, we explored the demographic, clinical, and social support characteristics (assessed using the Duke Social Support Index) and aspects of manic presentation. We selected two dependent variables: symptom severity, as determined by the Young Mania Rating Scale (YMRS) at baseline, and duration of episode. We selected nine potential independent variables on the basis of Pearson correlation coefficients. We derived two final models using multiple regression analysis employing an iterative process. Results In our severity model, being married was associated with a higher YMRS score ( p = 0.05), whereas higher social interaction scores with non-family members were associated with a lower YMRS score ( p = 0.011). In the episode duration model, longer duration was associated with a higher Hamilton Depression Rating Scale score ( p = 0.03) and higher social interaction scores with non-family members ( p = 0.0003), younger age ( p = 0.04), higher number of persons in one's family social network ( p = 0.017), and higher instrumental support scores ( p = 0.0062). Conclusions In late life mania, more social interaction with one's community appears to be associated with less severe symptoms at presentation for treatment, however, it can also be associated with slightly longer the duration of episode. Two aspects of the Duke Social Support Index are associated with a shorter episode duration prior to seeking treatment: being part of a larger family network and a having a higher level of instrumental support prior to treatment. The Instrumental Support Subscale measures the degree of assistance that is available for the respondent in performing daily tasks. These findings suggest that in older adults with BD, close social interactions and support are important in limiting the length of the illness episode prior to treatment. Social interactions involving non-family members may be less important in moderating the intensity of the symptoms at presentation. Copyright © 2014 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Objectives Since there is a worldwide steady increase in the number of individuals living longer and an expected increase in the number of older adults who will be diagnosed with bipolar disorder, there is a growing need to better understand late-life mania. We provide in this review a report of published studies focusing on the prevalence of late-life mania in the community and in senior psychiatric care facilities. Methods We conducted a search of PubMed and Psychinfo databases using combinations of the keywords bipolar, manic/a, manic depression, elderly, and older including English-language reports presenting quantitative data on the prevalence of mania in adults over the age of 50 years. Results Eighteen out of 188 potentially eligible studies met our inclusion criteria, with most studies focusing on psychiatric inpatient samples. The overall prevalence of late-life mania was estimated to be 6.0% in the reported 1,519 older psychiatric inpatients. In elderly inpatients with bipolar disorder, the mean prevalence of late-onset mania was 44.2%. For other relevant care facilities, no firm conclusions could be drawn. Conclusions Late-life mania is not rare in older psychiatric inpatients and late-onset mania is associated with increased somatic comorbidity in patients aged 50 years and older. Several hypotheses regarding the relationship between somatic illness and late-life mania in the elderly have been proposed and studies on this relationship and the prevalence of late-life mania in different senior psychiatric care facilities deserve specific attention in future research projects. [ABSTRACT FROM AUTHOR]

Sajatovic M, Levin J, Tatsuoka C, Micula-Gondek W, Fuentes-Casiano E, Bialko CS, Cassidy KA. Six-month outcomes of customized adherence enhancement (CAE) therapy in bipolar disorder. Bipolar Disord 2012: 14: 291-300. © 2012 The Authors. Journal compilation © 2012 John Wiley & Sons A/S. Background: There are few psychosocial interventions specifically focused on improved treatment adherence in people with bipolar disorder (BD). Customized adherence enhancement (CAE) is a needs-based, manualized approach intended to improve medication adherence in individuals with BD. This was a six-month prospective trial of a CAE among 43 medication non-adherent individuals with BD who were receiving treatment in a community mental health clinic (CMHC). Methods: CAE was flexibly administered in modules applied as indicated by an initial adherence vulnerabilities screening. Screening identified reasons for non-adherence and modules were then administered using pre-set criteria. CAE effects were evaluated at six-week, three-month, and six-month follow-up. The six-month follow-up was our primary time point of interest. The primary outcome was change from baseline in adherence using the Tablets Routine Questionnaire (TRQ) and pill counts. Secondary outcomes included change from baseline in BD symptoms [Hamilton Depression Rating Scale (HAM-D), Young Mania Rating Scale (YMRS), and Brief Psychiatric Rating Scale (BPRS)]. Results: Subjects completed 86% of scheduled sessions, with only two individuals (5%) not participating in any sessions. The number of dropouts at six months was 12 (28%). Mean baseline non-adherence by TRQ was 48% [standard error (SE) 4.8%] missed tablets within the previous week and 51% (4.1%) missed tablets within the previous month. At six-month follow-up, mean TRQ non-adherence improved to 25% (6.8%) missed tablets for the previous week (p = 0.002) and 21% (5.5%) for the previous month (p < 0.001). Symptoms improved, with a change in the baseline mean (SE) BPRS of 43.6 (1.8) versus an endpoint of 36.1 (2.3) (p = 0.001), and baseline mean (SE) HAM-D of 17.8 (1.1) versus an endpoint of 15.3 (1.6) (p = 0.044). Conclusion: CAE was associated with improvements in adherence, symptoms, and functional status. Controlled trials are needed to confirm these preliminary findings. [ABSTRACT FROM AUTHOR]

Objective: Given the paucity of information available regarding standardized ratings of depression symptoms in bipolar manic states, and in particular those in older adults, we explored depression ratings in symptomatic participants in a multicenter study of treatment of bipolar I disorder in late life.Methods: Baseline data was obtained from the first 100 patients enrolled in an NIMH-funded, 9-week, randomized, double-blind RCT comparing treatment with lithium or valproate in patients of age 60 years and older with Type I Bipolar mania or hypomania. This multi-site study was conducted at six academic medical centers in the United States and enrolled inpatients and outpatients with a total Young Mania Rating Scale (YMRS) score of 18 or greater. Depressive symptoms were evaluated with the Hamilton Depression Rating Scale (HAM-D) and the Montgomery-Asberg Depression Rating Scale (MADRS). The criterion for at least moderate bipolar depressive symptoms was the European College of Neuropsychopharmacology (ECNP) Consensus Meeting definition of HAM-D 17 total score >20.Results: Eleven percent of patients had mixed symptoms defined by depression scale severity according to ECNP criterion. In the overall sample, total scores on the two depression scales were highly correlated. Total YMRS scores of this mixed symptom group were similar to the remainder of the sample.Conclusions: These preliminary findings suggest that moderate to severe depressive symptoms occur in about one in ten bipolar manic elders. Future studies are needed to further evaluate symptom profiles, clinical correlates, and treatments for bipolar older adults with combined manic and depressive symptoms. [ABSTRACT FROM AUTHOR]

Sajatovic M, Gildengers A, Al Jurdi RK, Gyulai L, Cassidy KA, Greenberg RL, Bruce ML, Mulsant BH, Ten Have T, Young RC. Multisite, open-label, prospective trial of lamotrigine for geriatric bipolar depression: a preliminary report. Bipolar Disord 2011: 13: 294-302. © 2011 The Authors. Journal compilation © 2011 John Wiley & Sons A/S. This is a multisite, 12-week, open-label trial of lamotrigine augmentation in 57 older adults (≥ 60 years; mean ± SD age = 66.5 ± 6.7 years) with either type I or type II bipolar depression. Primary outcome measure was change from baseline on the Montgomery-Åsberg Depression Rating Scale (MADRS). Secondary outcome measures included Hamilton Depression Rating Scale (HAM-D), Clinical Global Impression-Bipolar version (CGI-BP), and the WHO-Disability Assessment Schedule II (WHO-DAS II). The Udvalg for Kliniske Undersøgelser (UKU) was used to assess side effects. A total of 77.2% of the study subjects had bipolar I disorder. The mean (SD) lamotrigine dose was 150.9 (68.5) mg/day. There was significant improvement in the MADRS, HAM-D, CGI-BP, and in most domains on the WHO-DAS II. For patients for whom final MADRS score was available: 31 (57.4%) met remission criteria and 35 (64.8%) met response criteria. There were 19/57 (33.3%) who dropped out of the study prematurely, with 6 dropouts due to adverse events (4 cases of rash, 1 manic switch, and 1 hyponatremia). Two cases of rash were possibly drug related and were resolved with drug discontinuation. The most common UKU adverse effects were reduced sleep duration (n = 14, 24.6%), weight loss (n = 12, 21.1%), increased dream activity (n = 12, 21.1%), polyuria/polydipsia (n = 11, 19.3%), weight gain (n = 9, 15.8%), diminished sexual desire (n = 9, 15.8%), increased sleep (n = 9, 15.8%), lassitude/fatigue (n = 8, 14%), and unsteady gait (n = 8, 14%). No significant changes in electrocardiogram or laboratory tests were observed. In bipolar depressed elders, lamotrigine was associated with improvement in depression, psychopathology, and functional status. There was a moderate number of adverse events, although relationship of adverse events (particularly falls) to study medication could not be clearly determined in this uncontrolled trial. Controlled studies are needed to further evaluate efficacy and tolerability of lamotrigine therapy in geriatric bipolar depression. [ABSTRACT FROM AUTHOR]

Gildengers AG, Mulsant BH, Al Jurdi RK, Beyer JL, Greenberg RL, Gyulai L, Moberg PJ, Sajatovic M, Ten Have T, Young RC, The GERI-BD Study Group. The relationship of bipolar disorder lifetime duration and vascular burden to cognition in older adults.Bipolar Disord 2010: 12: 851-858. © 2010 The Authors. Journal compilation © 2010 John Wiley & Sons A/S. We describe the cognitive function of older adults presenting with bipolar disorder (BD) and mania and examine whether longer lifetime duration of BD is associated with greater cognitive dysfunction. We also examine whether there are negative, synergistic effects between lifetime duration of BD and vascular disease burden on cognition. A total of 87 nondemented individuals with bipolar I disorder, age 60 years and older, experiencing manic, hypomanic, or mixed episodes, were assessed with the Dementia Rating Scale (DRS) and the Framingham Stroke Risk Profile (FSRP) as a measure of vascular disease burden. Subjects had a mean (SD) age of 68.7 (7.1) years and 13.6 (3.1) years of education; 50.6% (n = 44) were females, 89.7% (n = 78) were white, and 10.3% (n = 9) were black. They presented with overall and domain-specific cognitive impairment in memory, visuospatial ability, and executive function compared to age-adjusted norms. Lifetime duration of BD was not related to DRS total score, any other subscale scores, or vascular disease burden. FSRP scores were related to the DRS memory subscale scores, but not total scores or any other domain scores. A negative interactive effect between lifetime duration of BD and FSRP was only observed with the DRS construction subscale. In this study, lifetime duration of BD had no significant relationship with overall cognitive function in older nondemented adults. Greater vascular disease burden was associated with worse memory function. There was no synergistic relationship between lifetime duration of BD and vascular disease burden on overall cognition function. Addressing vascular disease, especially early in the course of BD, may mitigate cognitive impairment in older age. [ABSTRACT FROM AUTHOR]

This is a review of adherence determinants in bipolar disorder based on published prospective studies. Patient, treatment, and systems-level adherence determinants are summarized. The review concludes with recommendations on approaches that may minimize nonadherence. MEDLINE, PsychINFO, and the Cochrane Database were searched using key terms of adherence, compliance, or persistence, combined with terms of bipolar disorder, bipolar depression, or mania. Publications were filtered for randomized clinical trials (RCTs). Due to low yields of RCTs, we additionally included prospective nonrandomized clinical and epidemiologic studies, and prospective studies of severe mental illness that had a focus on adherence as an outcome and reported data separately for bipolar disorder. A targeted review of the broader bipolar literature provided background for concluding remarks. Twenty-two publications were identified describing RCTs with a specific population of bipolar disorder and a measure of adherence. Additional prospective nonrandomized studies were also identified. Studies identified three major categories of factors important to adherence: patient, treatment, and systems-associated factors. Patient factors include selected demographic features, symptom severity and phase of illness, presence of past suicide attempts, psychiatric comorbidity, illness and treatment duration, and relationship with providers. Treatment factors include type and intensity of pharmacotherapy and psychotherapy. Systems-level factors include differential levels of care access and costs. There is an overall lack of RCTs, and few prospective studies, on patient and systems-related determinants of adherence. Treatment-related determinants of adherence have the most evidence to date; however, would benefit from larger studies with diverse populations. Careful assessment of treatment adherence (including partial adherence) should be included in all prospective bipolar treatment studies, and studies should be conducted to prospectively evaluate interventions to minimize nonadherence. [ABSTRACT FROM AUTHOR]

Young RC, Schulberg HC, Gildengers AG, Sajatovic M, Mulsant BH, Gyulai L, Beyer J, Marangell L, Kunik M, Ten Have T, Bruce ML, Gur R, Marino P, Evans JD, Reynolds CF III, Alexopoulos GS. Conceptual and methodological issues in designing a randomized, controlled treatment trial for geriatric bipolar disorder: GERI-BD. Bipolar Disord 2010: 12: 56–67. © 2010 The Authors. Journal compilation © 2010 John Wiley & Sons A/S. Aim: This report considers the conceptual and methodological concerns confronting clinical investigators seeking to generate knowledge regarding the tolerability and benefits of pharmacotherapy in geriatric bipolar disorder (BD) patients. Method: There is continuing need for evidence-based guidelines derived from randomized controlled trials that will enhance drug treatment of geriatric BD patients. Therefore, we present the complex conceptual and methodological choices encountered in designing a multisite clinical trial and the decisions reached by the investigators with the intention that study findings be pertinent to, and can facilitate, routine treatment decisions. Results: Guided by a literature review and input from peers, the tolerability and antimanic effects of lithium and valproate were judged to be the key mood stabilizers to investigate with regard to treating bipolar I disorder manic, mixed, and hypomanic states. The patient selection criteria are intended to generate a sample that not only experiences common treatment needs but also represents the variety of older patients seen in university-based clinical settings. The clinical protocol guides titration of lithium and valproate to target serum concentrations, with lower levels allowed when necessitated by limited tolerability. The protocol emphasizes initial monotherapy. However, augmentation with risperidone is permitted after three weeks when indicated by operational criteria. Conclusions: A randomized, controlled trial that both investigates commonly prescribed mood stabilizers and maximizes patient participation can meaningfully address high-priority clinical concerns directly relevant to the routine pharmacologic treatment of geriatric BD patients. [ABSTRACT FROM AUTHOR]

Objectives Herbal and nutritional compounds (HNC) are widely used among geriatric populations with depression, however little data exists on HNC use in older populations with bipolar disorder. The goal of this study was to evaluate orally- ingested HNC use in individuals with bipolar disorder and with major depression. Methods This was a cross-sectional analysis of self-reported factual knowledge of HNC, individual perspective on efficacy and safety of HNC, patterns of HNC use, and discussion of HNC with health care providers in 50 older adults with bipolar disorder and 50 older adults with major depression. Results In this sample, approximately 30% of older individuals with depression or bipolar disorder used orally- ingested HNC. Over 40% of older adults believed that HNC is FDA-regulated and 14-20% preferred to take HNC compared to physician-prescribed psychotropic medications. Use of HNC was more common among older adults with bipolar disorder (44%) compared to older adults with major depression (16%, p = 0.003). The majority of older adults with mood disorders (64%) had not discussed use of HNC with their treating physicians. Conclusion Orally ingested HNC was used by nearly one in three older adults with mood disorders, and was more common among those with bipolar disorder compared to those with major depression. Most individuals did not discuss HNC use with their physicians. Clinicians need to assess for HNC use, particularly with respect to potential drug-drug interactions. Copyright © 2009 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Objectives: A post hoc analysis of pooled data from two quetiapine monotherapy clinical trials was conducted to evaluate the efficacy and tolerability of quetiapine therapy (twice daily, 400–800 mg/day) among bipolar manic adults aged 55 years and older. The primary efficacy endpoint was the change from baseline in Young Mania Rating Scale (YMRS) total score at Day 21. A secondary endpoint was change from baseline in YMRS score at Day 84. Methods: A total of 407 patients made up the safety population, consisting of 59 older adults (aged ≥55 years) and 348 younger adults. A total of 403 patients made up the efficacy population, consisting of 59 older adults and 344 younger adults. Efficacy outcomes were analyzed using covariance models (ANCOVA); descriptive statistics are presented for safety outcomes. Results: Both older and younger individuals treated with quetiapine had significant improvement from baseline on YMRS scores compared with placebo-treated patients. The older adult group demonstrated a sustained reduction in YMRS score compared with placebo that was apparent by Day 4 of treatment. For the quetiapine treatment groups, the most common adverse effects (at a frequency ≥10%) were dry mouth, somnolence, postural hypotension, insomnia, weight gain, and dizziness in older adults, and dry mouth, somnolence, and insomnia in younger adults. For the placebo treatment groups, insomnia was the most common adverse event in both older and younger adults. Conclusions: This secondary analysis suggests that quetiapine represents a potentially useful treatment option among older adults with bipolar I mania. Studies with a primary focus of geriatric bipolar mania, and including larger patient numbers, are needed to confirm these findings. [ABSTRACT FROM AUTHOR]

Objective Adjunctive anticonvulsant medications may benefit some individuals with schizophrenia, however data on adjunct anticonvulsants in older adults with schizophrenia is limited. This prospective, 12-week open label study evaluated adjunct extended-release valproate semisodium (divalproex) in 20 older adults with schizophrenia. Methods The study was conducted at an academic psychiatry clinic in the mid-western United States. Participants were self-referred from posted advertisements or referred by clinic practitioners. Extended-release valproate semisodium was added onto antipsychotic treatment. Individuals with active substance use disorders or active significant medical comorbidity were excluded. Primary outcome measures included the Positive and Negative Syndrome Scale (PANSS), Geriatric Depression Scale (GDS) and Global Assessment Scale (GAS). Tolerability was evaluated via patient self-reported side effects, change from baseline in body weight and change on abnormal movement scales. Results Patients (mean age 61 years, range 49.8–79.2 years) had significant reductions in psychosis scores as measured by the Positive and Negative Syndrome Scale (PANSS) p < 0.01, as well as in global functioning as measured by the Global Assessment Scale (GAS) p < 0.01 and depression as measured by the Geriatric Depression Scale (GDS) p < 0.05. Mean dose of extended-release valproate semisodium was 587.50 mg/day SD ± 247.02. Extended-release valproate semisodium was well tolerated in this older adult population. The primary adverse effect was sedation, which appeared to be relatively dose and titration-speed dependent. Weight change was not significant. Conclusion While extended-release valproate semisodium appears efficacious and well tolerated in older adults with schizophrenia, data from larger, controlled trials is needed. Copyright © 2007 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Introduction In spite of circumstances that precipitate high use of anticonvulsants in geriatric populations, there is a paucity of data on the use of antiepileptic drugs in elderly patients with psychiatric and neurological disorders. Methods Reports of lamotrigine therapy in elderly patients with epilepsy, bipolar disorder (BD), or dementia were identified by conducting an electronic search of major publication databases. Abstracts and presentations from professional meetings were searched as were the bibliographies of relevant articles. Results Fourteen reports were identified, and included well-controlled prospective trials, retrospective analyses, and case reports of lamotrigine treatment. Controlled trials in elderly patients with epilepsy demonstrate efficacy and tolerability comparable to gabapentin. Improvement in bipolar depressive symptoms, improvement in core manic symptoms, and delay in mood relapse was reported in geriatric patients with BD. Preliminary case studies in patients with dementia note improvement in cognition and symptoms of agitation and depression. Conclusion Review of the available literature suggests lamotrigine is effective and well tolerated in elderly patients with epilepsy and relatively well-tolerated and may be effective in delaying mood relapse, particularly in the depressive pole, in patients with BD. While very limited literature suggests that lamotrigine may be effective and relatively well-tolerated in patients with dementia, further studies are needed. Copyright © 2007 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Introduction Comorbidity patterns and correlates among older adults with bipolar disorder (BPD) are not well understood. The aim of this analysis was to examine the prevalence of comorbid PTSD and other anxiety disorders, substance abuse and dementia in a population of 16,330 geriatric patients with BPD in a Veterans Health Administration administrative database. Methods Patients were identified from case registry files during Federal Fiscal Year 2001(FY01). Comorbidity groups were compared on selected clinical characteristics, inpatient and outpatient health resource use, and costs of care. Results Four thousand six hundred and sixty-eight geriatric veterans with BPD were comorbid for either substance abuse, PTSD and other anxiety disorder, or dementia (28.6% of all veterans with BPD age 60 or older). Mean age of all veterans in the four comorbidity groups was 70.0 years (±SD 7.2 years). Substance abuse was seen in 1,460 (8.9%) of elderly veterans with BPD, while PTSD was seen in 875 (5.4%), other anxiety disorders in 1592 (9.7%), and dementia in 741 (4.5%) of elderly veterans. Individuals with substance abuse in this elderly bipolar population are more likely to be younger, minority, unmarried and homeless compared to elderly bipolar populations with anxiety disorders or dementia. Inpatient use was greatest among geriatric veterans with BPD and dementia compared to veterans with BPD and other comorbid conditions. Conclusion Clinical characteristics, health resource use and healthcare costs differ among geriatric patients with BPD and comorbid anxiety, substance abuse or dementia. Additional research is needed to better understand presentation of illness and modifiable factors that may influence outcomes. Copyright © 2006 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Objectives: Atypical antipsychotic medications are a relatively new, increasingly prominent component of the treatment armamentarium for bipolar disorder. Information on adherence with antipsychotics among individuals with bipolar disorder in general, and atypical antipsychotics in particular, is currently quite limited. Using data from the VA National Psychosis Registry, we examined adherence with antipsychotic medications among patients with bipolar disorder (n = 73,964). Methods: Antipsychotic medication adherence among veterans with bipolar disorder was evaluated using the medication possession ratio and categorizing patients into three groups: fully adherent, partially adherent and non-adherent. We compared characteristics of bipolar patients who received versus those who did not receive antipsychotic medication, and also identified predictors of poor adherence with antipsychotic medications. Results: Approximately 45% (n = 32,993) of all individuals with bipolar disorder were prescribed antipsychotic medication. Individuals who were prescribed antipsychotic medications were younger and more often had comorbid substance abuse or post-traumatic stress disorder compared to individuals with bipolar disorder who were not prescribed antipsychotic medication. Just over half (51.9%) of individuals appear to be fully adherent with antipsychotic medications, while 48.1% of individuals are either partially adherent or non-adherent with antipsychotic medications. Factors associated with treatment non-adherence were younger age, minority ethnicity, comorbid substance abuse and homelessness. Conclusions: Treatment non-adherence is a major issue for close to half of individuals with bipolar disorder prescribed antipsychotic medication. Additional studies are needed to better understand treatment adherence within the full range of pharmacologic therapies among individuals with bipolar disorder. [ABSTRACT FROM AUTHOR]

Background It has been reported that 10% of all patients with bipolar disorder develop their illness after the age of 50, with bipolar disorder accounting for 5–19% of mood disorder presentations in the elderly. There has been a growing awareness regarding the manifestation of bipolar disorder among older adults due to both changes in national demographics, and developing sophistication in the treatment of bipolar illness. A persistent problem in our understanding of management of late life bipolar disorder is the paucity of research and rigorous published studies on the psychopharmacology of this condition. Objective This paper reviews medication treatments, non-medication biological therapies, and psychosocial interventions for bipolar disorder in late life with a particular emphasis on age related modifiers of treatment. Methods Findings are based upon review of the current literature. Results There are multiple, significant gaps in our knowledge of bipolar disorder in late life which have important implications in the optimum treatment of elderly individuals with bipolar illness. Conclusion There are a number of areas of needed future research in late life bipolar disorder. Copyright © 2002 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Objective This report is an analysis of gender related differences in clinical characteristics and hospital based health resource utilization among older adults with schizophrenia and schizoaffective disorder in an acute care, state hospital over a one-year period. Methods This retrospective record review is an analysis of age of illness onset, psychiatric and medical comorbidity, hospital utilization, and psychotropic medication use. Results There were a total of 66 individuals with either schizophrenia or schizoaffective disorder. Mean age of this group was 55.2 ± 4.62 years. Women were significantly over-represented among individuals with late onset schizophrenia and schizoaffective disorder. Men with schizophrenia had more comorbid substance abuse compared to women with schizophrenia (p < 0.05). Women and men did not differ significantly in hospital length of stay, amount or type of antipsychotic medication prescribed, or in utilization of seclusion/restraint in hospital. Both genders had substantial utilization of antipsychotic medication. Use of conventional antipsychotic medication monotherapy was always associated with use of anti-extrapyramidal symptom (anti-EPS) medication, while use of atypical antipsychotic medication monotherapy was more rarely associated with use of anti-EPS medication. Conclusions In later life, women and men may have some areas of differing health care needs. Women in particular may benefit from psychoeducational approaches that address the experience of psychiatric illness of relatively recent onset (for example, symptom identification and acceptance of illness). Men may benefit from particular emphasis on treatment of comorbid substance abuse disorders. Copyright © 2002 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Objective . The objective was to analyze outcome of clozapine therapy in elderly patients with treatment refractory primary psychosis. Design . This was an open-label clozapine trial in elderly patients. Patient psychopathology was assessed before and after clozapine therapy. Setting . A psychiatry service at a large urban/suburban Veterans Administration Medical Center. Patients . Inpatients and outpatients age 65 years or older with primary psychotic disorders established to be resistant to conventional antipsychotic therapy (Kane et al ., 1988). Ten patients met study inclusion criteria out of a total of 134 patients receiving clozapine at the Cleveland VAMC (7.5%). Mean age of the group was 70.6 years. Measures . Patients were rated with the Brief Psychiatric Rating Scale (BPRS; Overall and Gorham, 1962). Additional data on patient demographics, comorbid non-psychiatric diagnoses and concurrent psychotropic medication were collected via chart review. Results . Mean clozapine dosage was 204 mg/day for a mean duration of 430 days. 7/10 patients had some degree of clinical improvement and 3/10 patients had significant improvement documented by BPRS change of 20% or greater. Patients had a mean of 1.4 comorbid physical illnesses, which were not worsened by clozapine therapy. 4/10 patients discontinued clozapine therapy due to adverse effects or inability to comply with bloodwork; however, only 2/10 were truly treatment intolerant. Conclusions . Clozapine is a useful alternative treatment option for elderly individuals with refractory primary psychosis. As in younger patients, inability to tolerate drug-related adverse effects or weekly bloodwork may lead to drug discontinuation. © 1997 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

An editorial is presented on the study focusing on recommendations for safe and effective use of lithium in older adults with bipolar disorder. It expresses the view that laboratories should provide a separate therapeutic range for serum lithium levels in maintenance treatment of the adults with the disorder.

The article focuses on anxiety comorbidity in individuals with bipolar disorder and in older adults with bipolar disorder (OABD). It states that anxiety comorbidity in OABD are often overlooked and clinicians evaluating older people with BD need to assess for anxiety comorbidity. It mentions that research needs to be done to better understand how anxiety is related to BP across the life-span.

Calabrese JR, Keck PE Jr, Bowden CL, Ketter TA, Sachs G, Findling RL, Sajatovic M. A US perspective of the CANMAT bipolar guidelines.Bipolar Disord 2005: 7 (Suppl. 3): 70–72.© Blackwell Munksgaard, 2005 [ABSTRACT FROM AUTHOR]

Objectives: There is limited information on the characteristics of older adults with bipolar disorder (OABD) treated with lithium, along with safety concerns about its use by older adults. The aim of the present study is to describe the demographic and clinical characteristics of OABD receiving lithium therapy, using data from the Global Ageing & Geriatric Experiments in Bipolar Disorder (GAGE-BD)., Experimental Procedures: Cross-sectional analysis of the GAGE-BD dataset to determine differences and similarities between lithium users and non-users. We analysed data from 986 participants aged 50 years or older (mean age 63.5 years; 57.5% females) from 12 study sites. Two subgroups ('Lithium'; 'Non-lithium') were defined according to the current prescription of lithium. We compared several outcomes between these groups, controlling for age, gender, and study site., Results: OABD treated with lithium had lower scores on depression rating scales and were less likely to be categorised as with moderate or severe depression. There was a lower proportion of lithium users than non-users among those with evidence of rapid cycling and non-bipolar psychiatric diagnoses. Assessment of global cognitive state and functionality indicated better performance among lithium users. The current use of antipsychotics was less frequent among lithium users, who also reported fewer cardiovascular comorbidities than non-users., Conclusion: We found several potentially relevant differences in the clinical profile of OABD treated with lithium compared with those treated with other mood stabilisers. However, the interpretation of the present results must take into account the methodological limitations inherent to the cross-sectional approach and data harmonisation., (© 2022 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

This is a review of adherence determinants in bipolar disorder based on published prospective studies. Patient, treatment, and systems-level adherence determinants are summarized. The review concludes with recommendations on approaches that may minimize nonadherence. MEDLINE, PsychINFO, and the Cochrane Database were searched using key terms of adherence, compliance, or persistence, combined with terms of bipolar disorder, bipolar depression, or mania. Publications were filtered for randomized clinical trials (RCTs). Due to low yields of RCTs, we additionally included prospective nonrandomized clinical and epidemiologic studies, and prospective studies of severe mental illness that had a focus on adherence as an outcome and reported data separately for bipolar disorder. A targeted review of the broader bipolar literature provided background for concluding remarks. Twenty-two publications were identified describing RCTs with a specific population of bipolar disorder and a measure of adherence. Additional prospective nonrandomized studies were also identified. Studies identified three major categories of factors important to adherence: patient, treatment, and systems-associated factors. Patient factors include selected demographic features, symptom severity and phase of illness, presence of past suicide attempts, psychiatric comorbidity, illness and treatment duration, and relationship with providers. Treatment factors include type and intensity of pharmacotherapy and psychotherapy. Systems-level factors include differential levels of care access and costs. There is an overall lack of RCTs, and few prospective studies, on patient and systems-related determinants of adherence. Treatment-related determinants of adherence have the most evidence to date; however, would benefit from larger studies with diverse populations. Careful assessment of treatment adherence (including partial adherence) should be included in all prospective bipolar treatment studies, and studies should be conducted to prospectively evaluate interventions to minimize nonadherence., (© 2010 Blackwell Publishing Ltd.)