Download Assessment of Bipolar Spectrum Disorder in Older Adults

Assessment of Bi-polar Spectrum
Disorder in Older Adults
Cynthia Zubritsky, PhD & Karen Fortuna, MSW
Center for Mental Health Policy and Services Research,
University of Pennsylvania
Pennsylvania 3rd Annual Suicide Prevention Conference,
State College
September 2009
1
Overview
What are the issues?
Which older adults are at the highest risks for suicide?
Does untreated Bi-polar Spectrum Disorder (BSD)
increase suicide risk for older adults?
Has BSD in older adults been studied?
What are the barriers to reducing suicide among older
adults with BSD?
What can be done?
2
What are the issues?
Older Adults and
Suicide
3
Older Adult Demographics
People 65 years and older are the fastest
growing age group in the United States.
44.5 million people are over the age of 75 and
by 2050 they will number almost 50 million.
(NCHS, 2005)
4
Percentage of the U.S. Population Age
65 and Older, 1900 to 2050
Changes in the age distribution of people 65 and older in the U.S. population over the last century and
projected through 2050. Source: U.S. Census Bureau, Decennial Census, Population Estimates and
5
projections.
Older Adult Suicide
Although older adults comprised only 12% of the U.S.
population in 2004, people aged 65 and older accounted
for 16% of suicide deaths (Centers for Disease Control and
Prevention, 2005).
There are approximately 15 older adult suicides per day
or 1 older adult suicide every 95 minutes (American
Association of Suicidology, 2004).
6
Suicide Rates by Gender & Age
• Suicide rates among individuals 75 years and older are about three times
higher than those under 25 years of age.
(World Health Organization, 2005)
7
Which older adults are at the highest
risk for suicide?
Suicide Determinants
in Older Adults
8
Suicide Determinants in Older
Adults: Physical Illness
Physical illness contributes to suicide in almost 70% of
victims over 60 years of age.
Illnesses that often contribute to a higher suicide risk
• HIV/AIDS
• Huntington’s Disease
• Multiple Sclerosis
• Peptic ulcer
• Renal disease
• Spinal cord injury
• Lupus
(Conwell, Duberstein & Caine, 2002)
9
Suicide Determinants in Older
Adults: Loss/Social Support
Negative life events/loss
Lack of social support
Unmarried status
Bereavement
Family discord
(Conwell et al., 2002)
10
Suicide Determinants in Older
Adults: Personality Traits
Personality traits linked to older adult suicide include
shyness, seclusiveness, hypocondriasis, hostility, and
independence (Conwell et al.,2002).
A history of suicide attempts places older adults at a
higher risk for suicide completion (Alexopoulos, Bruce, Hull et
al., 1999).
Substance use disorders increase suicide risk for older
adults (Conwell et al., 2002).
11
Suicide Determinants in Older
Adults: Mental Illness
Untreated, severe mental illnesses substantially
increases the risk of suicide (Rihmer & Kiss, 2002).
Mood disorders are the most common mental illness that
result in older adult suicide (Conwell et al., 2002).
12
Bi-polar Spectrum Disorder
BSD causes shifts in an individual’s mood, perception,
energy level, and ability to function effectively.
BSD includes both Bi-polar Disorder I and II.
(American Psychiatric Association, 2000)
13
Bi-polar Spectrum Disorder
Bi-polar I Disorder is characterized by episodes of mania
that alternate between episodes of depression or mixed
states.
Bi-polar II Disorder is presented as frequent episodes of
depression and mild symptoms of mania or hypomania.
(American Psychiatric Association, 2000)
14
Criteria for BSD
The criteria for a manic BSD episode includes elevated
mood and three of the following symptoms:
1.
2.
3.
4.
5.
6.
7.
Exaggerated self-esteem;
Less need for sleep;
Highly talkative;
Racing thoughts;
Distractibility;
Goal-orientated activity; and
Distorted judgment.
(American Psychiatric Association, 2000)
15
Criteria for BSD
Criteria for a depressive BSD episode include five or more
of the following symptoms present during a 2-week period:
1. Weight gain or weight loss;
2. Depressed mood;
3. Loss of interests in activities that were once
enjoyable;
4. Insomnia or hypersomnia;
5. Loss of energy;
6. Loss of concentration skills;
7. Thoughts of suicide; and
8. Negative feelings of guilt and worthlessness.
(American Psychiatric Association, 2000)
16
Does untreated Bi-polar Spectrum Disorder
increase suicide risk for older adults?
l Suicide and Bi-polar
Spectrum Disorder (BSD)
17
Suicide and Bi-polar Spectrum
Disorder (BSD)
Most research on older adult suicide has targeted
depression, not BSD (Aizenberg, Olmer, & Barak, 2006).
There is an increased risk of suicide among patients with
BSD, estimated at 17-19%, or 15-20 times more than that
of the general population (McElroy et al., 2006).
18
Suicide and BSD
BSD in older adults is most commonly misdiagnosed as
depression (Angst & Cassano, 2005; Ghaemi et al., 2000).
Misdiagnosis + lack of treatment in individuals with BSD
is considered a major risk factor for suicide.
The majority of deaths by suicide are among older adults
with BSD (Charney et al., 2003).
19
Has BSD in older adults been studied?
BSD Prevalence in Older
Adults
20
Research on the Prevalence of
BSD in Older Adults
The diagnosis of late-life Bi-polar Disorder is an especially
neglected and understudied of research.
Research that does exist has reported conflicting findings
1). Age of Onset
It was reported that the mean age for the onset of BSD
ranges from 24.8 to 34.8 years (N=38,000) (Weissman et al.,
1996).
It was later reported that the mean age of onset is between
35 and 45 years (N = 25,460) (Shi et al., McCombs, 2004).
In a geropsychiatric inpatient unit, the average age of
onset was 43.9 years (N=48) (Sajatovic et al., 2005).
21
Research on the Prevalence of
BSD in Older Adults
2).Prevalence Rates of BSD in Older Adults
.08% of adults over age 65 screened positive for BSD (Klap
et al., 2003).
5-12% of geriatric psychiatry admissions were individuals
with BSD (N = 217) (Van Gerpen, Johnson & Winstead, 1999).
Bi-polar Disorder accounts for an estimated 5-19% of mood
disorders in older adults (Cassano, et al., 2000).
22
Has BSD in older adults been studied?
l BSD Assessment in
Older Adults
23
Assessment of Bi-polar
Spectrum Disorder in Older Adults
The presentation of the BSD in older adults is different
than in younger adults (Cassano et al., 2000; Kessing, 2006).
BSD diagnostic screening instruments designed to
identify BSD symptoms in older adults may provide a
more accurate diagnosis.
24
Assessment of Bi-polar
Spectrum Disorder in Older Adults
Most suicides occur when individuals are actively
experiencing symptoms.
Accurate diagnosis using a BSD diagnostic screening
instruments designed for older adults can increase the
likelihood that proper treatment can begin and target
BSD symptoms (Thase, 2005).
25
Research Questions
1.
Do diagnostic screening tools designed to identify BSD
in older adults exist?
2.
Are characteristics of older adults with BSD explored in
screening instruments that are commonly used in the
general adult population?
26
Research Study
1.
A literature review was conducted to identify validated
BSD diagnostic screening instruments (1978 to 2008).
 17 commonly used BSD screening tools (1985-
2008)
 21 national studies (53.8% of 39 studies)
 18 international studies (46.2% of 39 studies)
27
BSD Screening Instruments Reviewed
1) Altman Self Rating Scale
2) Bi-polar Depression Rating
Scale
3) Chronorecord
4) Diagnostic Assessment for the
Severely Handicapped
5) Hypomania Checklist
6) Hypomanic Personality Scale
7) Mood Disorder Questionnaire
8) Bi-polar Spectrum Diagnostic
Scale
9) Million Clinical Multiaxial
Inventory
10) Oxford Happiness Scale
11) Internal State Scale
12) Self-Report Manic Inventory;
13) Structured Clinical Interview
for Mood Spectrum
14) DSM-IV Structured Clinical
Interview
15) The MINI-International
Nueropsychiatric Interview
16) The Mania Rating Scale
17) World Health Organization
Composite International
Diagnostic Interview
28
U.S. Studies
Fifteen U.S. studies included individuals under the age of
65 (93.7%).
1 study included older adults 65 years or older (6.2%).
Percentage of Older Adults Included in
National Studies Sample Population
(N=21, n=16)
6%
94%
Under the age of 65
* Based on age range
reported
65 years and over
29
Mean Age of Sample
in U.S. Studies
National
(N = 21, n=16)
%
n
Under 21
18.7%
3
Age 21-30
0%
0
Age 31-40
37.5%
6
Age 41-50
43.7%
7
0%
0
Age 51+
30
International Studies
12 (92%) studies included individuals under the age
of 65.
1 (8%) study included individuals over the age of 65.
Percentage of Older Adults Included in International
Studies Sample Populations
(N=18, n=13)
8%
92%
* Based on age
range reported
Under the age of 65
65 years and over
31
Mean Age of Sample in
International Studies
International
(N = 18, n=13)
%
n
Under 21
7.6%
1
Age 21-30
30.7%
4
Age 31-40
30.7%
4
Age 41-50
30.7%
4
0%
0
Age 51+
32
Mean Age of Sample in all Studies
National & International
(N=39, n = 29
%
n
Under 21
13.7%
4
Age 21-30
13.7%
4
Age 31-40
34.4%
10
Age 41-50
37.9%
11
0%
0
Age 51+
33
Findings
Screening instruments designed to identify BSD in
older adults have not been developed.
There were re-occurring barriers in the screening
instruments reviewed that may prevent a correct
diagnosis of BSD in older adults:
1.
2.
3.
4.
5.
Average age of sample population;
Presentation of illness;
Stigmatization and stereotyping;
Memory; and
Language and formatting.
34
What are the barriers to reducing
suicide among older adults with BSD?
Barriers
35
Barrier: Average Age of Sample
Population
The validation studies rarely included older
adults.
Not including older adults in the validation studies
may decrease the likelihood of the diagnostic
accuracy of the instrument for older adults.
36
Barrier: BSD Presentation
1) Individuals who only partially fulfill the criteria for
having BSD, are commonly unrecognized, particularly
in special populations (Cassano et al., 2000).
2) Persons with late onset BSD tend to experience
only mild elation of mood and delusions resulting in a
misdiagnosis of depression or dementia (Cassano et al.,
2000).
3) Older adults with BSD show fewer psychotic
symptoms (Kessing, 2006).
37
Barrier: BSD Presentation
4) Older adults may present symptoms of anxiety (Turnbull,
1989) and depression differently than other age groups
(Gallo, Robins & Anthony, 1999).
5) Co-occurring physical disorders are common among
this population (Charney et al., 2003). Clinicians who do not
have knowledge of working with older adults may view
mental health symptoms as physical health symptoms.
6) Older adults experience higher levels of mixed states
(Bauer et al., 2002).
38
Barrier: Stigmatization and
Stereotyping
An individual’s feelings of stigmatization related to
mental illness may alter the older adults’ self-report of
their symptoms (Sirey et al., 2001).
Clinicians who do not have knowledge of working with
older adults may view mental health symptoms as
physical health symptoms or as a normal part of aging.
(Surgeon General’s Report on Mental Health, 1999).
39
Barrier: Memory
Older adults may have a problem remembering their
symptoms since some symptoms of mental illnesses that
are common among the aging population affect memory,
such as Alzheimer’s Disease and Depression.
– Memory loss may make reporting symptoms difficult
and/or inaccurate.
(American Psychiatric Association, 2000)
40
Barrier: Language and Formatting
Barriers
All screening tools were in 12-point font, which may be
difficult for older adults with vision problems to read.
Most screening instruments were in English, and
individuals who speak and/or read other languages may
not be able to complete a self-report screening tool.
• 52% of adults older than 50 years old speak English
“less than well” (US Census Bureau, 2000).
41
What can be done?
BSD Assessment in Older
Adults:
Prospective Review
42
BSA Assessment in Older Adults
 A prospective review was conducted to identify
unrecognized characteristics of older adults who have
BSD.
– A prospective review is a small study that enables researchers to
explore research questions without conducting a large scale
study.
 The Bi-polar Spectrum Disorder Scale, developed by
Ghaemi, was modified and designed specifically for older
adults based on an extensive literature review and the
clinical expertise of the researchers.
43
Focus Group
Eleven older adults with
mood disorders
participated in a focus
group to complete and
discuss the modified Bipolar Spectrum Disorder
Scale.
1 - African-American
9 - Caucasian
1 - Other
Average age - 63 years
Range - 50-80 years old
6 - Male
5 - Female
4 - screened positive for
BSD
44
Findings
• Average age at diagnosis was 49 years
• First BSD symptoms – 42 years
• Gap may be a result of:
• Under and misdiagnosis of BSD
• Low rates of mental health service utilization
45
Results: Clinical Characteristics
Symptoms identified by
older adults with a moderate to
high probability of a BSD
diagnosis included the
following.
• Vivid dreams, emotions,
and realistic nightmares
• Feelings of unhappiness
and helplessness
• Physical pains
• Increased levels of hostility,
aggressiveness, and
irritability
• Impaired ability to function
in a community or social
setting
• Racing thoughts
Less frequently associated
features of BSD included the
following.
• Reports of a family history
of mental illness
• Increased sexual activity
• Increased sociability with
friends, family, relatives, or
strangers
46
Focus Group Discussion Results:
Consumer Response
 9 participants reported that the screening tool was
confusing.
 9 participants repeatedly stated that they needed extra
clarification on directions.
Directions to complete the screening tool should be
clearly marked in large font.
47
Consumer Input into Design
General consensus that the participants were not clear if
they should report their thoughts and behaviors at the
moment or in their entire lifetime.
The participants stated that they have great difficulty
remembering lifetime symptoms.
48
Consumer Input into Design
Participants suggested that their history of moods could
be reported in two time periods.
Participants did not believe that the question related to
increased sexual activity was relevant because they are
older and because side effects of their medications
(reduced interest in sexuality).
49
Recommendations
1.
Development of an age-specific screening tool and/or
2.
Validation of existing screening tools with older adult
populations.
The development of effective screening instruments
will reduce misdiagnosis and/or under-diagnosis of
BSD in older adults; the resultant appropriate and
effective treatment should reduce suicide-related
deaths of older adults with BSD.
50
References
Aizenberg, D., Olmer, A., & Barak, Y. (2006). Suicide attempts amongst elderly bipolar patients.
Journal of Affective Disorders, 91, 91-94.
Alexopoulos, G. S., Bruce, M. L., Hull, J., Sirey, J. A., & Kakuma, T. (1999). Clinical
determinants of suicidal ideation and behavior in geriatric depression. Archives of General
Psychiatry. 56, 1048-1053.
American Association of Suicidology. (2004). Elderly Suicide Fact Sheet.
American Psychiatric Association. (2000). DSM-IV-TR: Diagnostic and statistical manual of
mental disorders. Washington, DC: American Psychiatric Association.
Angst J, & Cassano, G. (2005). The mood spectrum: Improving the diagnosis of bipolar disorder.
Bipolar Disorder. 7, 4, p. 4-12.
Bauer, M., Vojta, C., Kinosian, B., Altshuler, L., & Glick, H. (2000). The internal state scale:
Replication of its discriminating abilities in a multisite, public sector sample. Bipolar
Disorders. 2 ,4, p. 340–346
Cassano, G., McElroy, S., Brady, K., & Nolen, G. (2000). Current issues in the identification and
management of bipolar spectrum disorders in “special populations.” Journal of Affective
Disorder. 59, p. 69-79.
Centers for Disease Control and Prevention, National Center for Injury Prevention and Control.
Web-based Injury Statistics Query and Reporting System (WISQARS) [online]. (2005)
[accessed June 25, 2009]. Available from URL: www.cdc.gov/ncipc/wisqars.
51
References
Charney, D., et al. (2003). Depression and bipolar support alliance consensus statement on the unmet needs in
diagnosis and treatment of mood disorders in late life. Archives of General Psychiatry. 60, p.664-672.
Conwell, Y., Duberstein, P. R., & Caine, E. D. (2002). Risk factors for suicide in later life. Biological Psychiatry.
52, 193-204.
Gallo, J., Rabins, P., & Anthony, J. (1999). Sadness in older persons: 13-year follow-up of a community sample
in Baltimore, Maryland. Psychological Medicine. 29, p. 341-350.
Ghaemi, S, Boiman, E, & Goodwin, F. (2000). Diagnosing bipolar disorder and the effect of antidepressants: A
naturalistic study. Journal of Clinical Psychiatry. 61, 10, p. 804-817.
Hirschfeld, R., Calabrese, J., Weissman, M., et al. (2003). Screening for bipolar disorder in the community.
Journal of Clinical Psychiatry. 64, p.53–59.
Kessing, LV, Søndergård L, Kvist K, & Andersen, P. (2005). Suicide risk inpatients treated with lithium.
Archives of General Psychiatry, 62: 860-6.
Kessler, R., Andrews, G., & Mroczek, D. (1998). The world health organization composite international
diagnostic interview short form (CIDI-SF). World Health Organization: Geneva.
McElroy, S., Kotwal, R., Kaneria, R., & Keck, P. (2006) Antidepressants and suicidal behavior in bipolar
disorder. Bipolar Disorder. Oct; 8 (5 Pt 2): 596-617.
52
References
Mental Health: A Report of the Surgeon General. Rockville, Md, US Department of Health and Human Services,
Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National
Institutes of Health, National Institute of Mental Health, 1999
Rihmer, Z., & Kiss, K. (2002). Bipolar disorders and suicidal behavior. Bipolar Disorders, 4, 21-25.
Sajatovic, M., Bingham, C. R., Campbell, E. A., & Fletcher, D. F. (2005). Bipolar disorder in older adult
inpatients. The Journal of Nervous and Mental Disease, 193, 417-419.
Sajatovic, M., Davies, M., & Hrouda, D. (2004). Enhancement of treatment adherence among patients with
bipolar disorder. Psychiatric Services. 55, p. 264-269.
Sirey, J., et al. (2001). Perceived Stigma as a Predictor of Treatment Discontinuation in Young and Older
Outpatients With Depression. American Journal of Psychiatry. 158, p. 479-481.
Shi L, Thiebaud P, McCombs JS. (2004) The impact of unrecognized bipolar disorders for patients treated for
depression with antidepressants in the fee-for-services California Medicaid (Medi-Cal) program. Journal of
Affective Disorder, 82:373–383.
Thase, M. (2005). Bipolar depression: Issues in diagnosis and treatment. Harvard Review of Psychiatry,
13(5):257-71.
Turnbull, J.M. (1989). Anxiety and physical illness in the elderly. Journal of Clinical Psychiatry 50, pp. 40–45.
Van Gerpen, M. W., Johnson, J. E., & Winstead, D. K. (1999). Mania in the geriatric patient population: A
review of the literature. American Journal of Geriatric Psychiatry, 7, 188–202.
53