Evaluating Pharmacological Treatment Options in Elderly Patients With Bipolar Disorder Who Admitted to a University Hospital

Year 2011, , 1 - 12, 01.06.2011

Umut Altunöz Serav İlhan Rifat Ezgi Hatip Murat Çiçeklidağ , Mahmut Altaş Burcu Gümüştekin Ahmet Kakaç Tuğba Özel Kızıl Erguvan

https://doi.org/10.1501/Kriz_0000000325

Abstract

Objective: The aim of the present study is to evaluate pharmacological treatment options, common side effects and treatment compliance in elderly patients with type I Bipolar Disorder (BD) in the light of current literature. Method: The study sample (n=99) consisted of elderly patients (≥65 years old) who admitted to the psychiatry clinic of a university hospital between 2006-2011 and had the diagnosis of BD type-1. The patient files were examined and psychotropic agents which were used in the last visit were taken into account. Common side effects and treatment compliance were also evaluated. Results: Mood stabilisers (MS) were used by 74.4% of the patients, followed by second generation antipsychotics (SGAP) (71.7%), hypnotic-sedative andantidepressants (%27.2). Most commonly used MS were lithium (37.4%) and valproic acid (36.4%). 77.7% of the patients were on combination therapy, whereas 22.3% of them were on monotherapy. The most common combination was MS+SGAP (41.4%) and quetiapine was the most commonly used SGAP (41.4%). Tremor, increase in apetite, hypersomnia, forgetfulness, extrapyramidal side effects, gastrointestinal complaints, defatigation, weight gain and headache were the most commonly declared side effects. 8.1% of the patients were fully compliant, 54.5% were compliant, 31.3% were partially compliant and 6% were noncompliant to the treatment. Conclusions: This is the first study in Turkey which evaluated pharmacological treatment options in elderly patients with BD. This study emphasized that combination treatments were commonly preferred, lithium usage was as common as valproic acid, SGAP drugs were frequently preferred and the most common one was quetiapine. 62.6% of the patients had good compliance to the treatment. These results were consistent with previous studies on elderly and young BD patients. Prospective studies about the treatment of BD in the elderly and treatment guidelines in accordance with them are needed. agents (36.4%) and

Keywords

antipsychotics, bipolar disorder, geriatric psychiatry, psychopharmacology

Bir üniversite kliniğinde bipolar bozukluk tanısı ile izlenen yaşlı hastalarda farmakolojik tedavi seçimlerinin incelenmesi

Abstract

Amaç: Bu çalışmanın amacı bipolar bozukluğu (BB) olan yaşlı hastalarda tercih edilen psikofarmakolojik tedavileri, görülen başlıca yan etkileri ve ilaç uyumunu ilişkin yazın ışığında ortaya koymaktır.Yöntem: Çalışmanın örneklemini bir üniversite hastanesi psikiyatri kliniğine 2006-2011 yılları arasında başvuran BB Tip 1 tanısı almış, 65 yaş ve üzerinde olan 99 yaşlı hasta oluşturmuştur. Hastaların dosyaları incelenmiş ve her hastanın son kontrolünde kullanmakta olduğu ilaçlar, yan etkiler ve ilaç uyumu değerlendirilmiştir.Bulgular: Hastaların %74.4’ü duygudurum düzenleyici (DDD), %71.7’si ikinci kuşak antipsikotik (İKAP), %36.4’ü hipnotik-sedatif ilaç, %27.2’si ise antidepresan kullanmaktadır. DDD olarak en sık lityum (%37.4) ve valproik asit (%36.4) tercih edilmiştir. Hastaların %77.7’sinde kombinasyon tedavisi, %22.3’ünde monoterapi tercih edilmiştir. En sık (%41.4) DDD+İKAP kombinasyonu, İKAP olarak da hem kombine hem de monoterapide en sık ketiyapin (%41.4) kullanılmaktadır. Bildirilen başlıca yan etkiler tremor, iştah artışı, hipersomni, unutkanlık, ekstrapiramidal yan etkiler, gastrointestinal sistem yakınmaları, halsizlik, kilo artışı, baş ağrısıdır. İlaç

Keywords

antipsikotikler, bipolar bozukluk, geriyatrik psikiyatri, psikofarmakoloji

References

• Aizenberg D, Olmer A, Barak Y (2006) Suicide attempts amongst elderly bipolar patients. J Affect Disord, 91(1):91–94. Al Jurdi RK, Marangell LB, Petersen NJ, Martinez M, Gyulai L, Sajatovic M (2008) Prescription Patterns of Psychotropic Medications in Elderly Compared to Younger Participants Who Achieved a “Recovered” Status in the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD). Am J Geriatr Psychiatry, 16(11):922–933.
• Aziz R, Lorberg B, Tampi RR (2006) Treatments for Late-Life Bipolar Disorder. Am J Geriatr Pharmacother, 4(4):347-364.
• BALANCE investigators and collaborators, Geddes JR, Goodwin GM, Rendell J, Azorin JM, Cipriani A, ve ark (2010) Lithium plus valproate combination therapy versus monotherapy for relapse prevention in bipolar I disorder (BALANCE): a randomised open-label trial. Lancet, 375(9712):385-395.
• Beyer JL, Burchitt B, Gersing K, Krishnan KR (2008) Patterns of pharmacotherapy and treatment response in elderly adults with bipolar disorder. Psychopharmacol Bull, 41(1):102–114.
• Bhalerao S, Seyfried LS, Kim HM, Chiang C, Kavanagh J, Kales HC (2012). Mortality risk with the life bipolar disorder. J Geriatr Psychiatry Neurol, 25(1):29-36.
• Cares M, Powers R (1998) Concomitant rash and blood dyscrasias in geriatric psychiatry patients treated with carbamazepine. Ann Pharmacother, 32(9):884-887.
• Connolly KR, Thase ME (2011) The clinical management of evidence-based guidelines. Prim Care Companion CNS Disord, 13(4).
• Depp CA, Jeste DV (2004) Bipolar disorder in older adults: a critical review. Bipolar Disord, 6(5):343–367.
• Desai VC, Heaton PC, Kelton CM (2012) Impact of the Food and Drug Administration’s antipsychotic black box warning on psychotropic drug prescribing in elderly patients with dementia in outpatient and office-based settings. Alzheimers Dement, 8(5):453-457.
• Fountoulakis KN, Vieta TE. Treatment of bipolar disorder: a systematic review of available data and clinical perspectives. Int J Neuropsychopharmacol 2008; 11(7):999-1029.
• Fountoulakis KN, Vieta E, Sanchez-Moreno J, Kaprinis SG, Goikolea JM, Kaprinis GS (2005) Treatment guidelines for bipolar disorder: A critical review. Journal of Affective Disorders, 86(1):1–10.
• Gareri P, Falconi U, De Fazio P, De Sarro G (2000) Conventional and new antidepressant drugs in the elderly. Prog Neurobiol, 61(4):353-396.
• Ghaemi SN, Hsu DJ, Thase ME, Wisniewski SR, Nierenberg AA, Miyahara S, ve ark (2006) Pharmacological treatment patterns at study entry for the first 500 STEP-BD participants. Psychiatr Serv, 57(5):660-665.
• Ghaemi SN, Wingo AP, Filkowski MA, Baldessarini RJ (2008) Longterm antidepressant treatment in bipolar disorder: meta-analyses of benefits and risks. Acta Psychiatr Scand, 118(5):347–356.
• Gijsman HJ, Geddes JR, Rendell JM, Nolen WA, Goodwin GM (2004) Antidepressants for bipolar depression: A systematic review of randomized, controlled trials. Am J Psychiatry, 161(9):1537-1547.
• Gildengers A, Tatsuoka C, Bialko C, Cassidy KA, Al Jurdi RK (2012) Correlates of Treatment Response in Depressed Older Adults With Bipolar Disorder. J Geriatr Psychiatry Neurol, 25(1):37-42.
• Gildengers AG, Mulsant BH, Begley AE, McShea M, Stack JA (2005) A pilot study of standardized treatment in geriatric bipolar disorder. Am J Geriatr Psychiatry, 13(4): 319-323.
• Grunze HC (2008) Switching, induction of rapid cycling, and increased suicidality with antidepressants in bipolar patients: fact or overinterpretation? CNS Spectr, 13(9):790–795.
• Hirschfeld RM, Calabrese JR, Weissman MM, Reed M, Davies MA, Frye MA, ve ark (2003) Screening for bipolar disorder in the community. J Clin Psychiatry, 64(1):53–59.
• Houston JP, Tohen M, Degenhardt EK, Jamal HH, Liu LL, Ketter TA (2009) Olanzapine-divalproex combination versus divalproex monotherapy in the treatment of bipolar mixed episodes: a double-blind, placebo-controlled study. J Clin Psychiatry, 70(11):1540-1547.
• Juurlink DN, Mamdani MM, Kopp A, Rochon PA, Shulman KI, Redelmeier DA (2004) Drug- induced lithium toxicity in the elderly: a population- based study. J Am Geriatr Soc, 52(5):794-798. Kales HC, Kim HM, M, Seyfried LS, Chiang C, ve ark (2012) Risk of mortality among individual antipsychotics in patients with dementia. Am J Psychiatry, 169(1):71-79. Komossa
• K, Rummel-Kluge C, Hunger H, Schmid F, Schwarz S, Duggan L, ve ark (2010)
• Olanzapine versus other atypical antipsychotics for schizophrenia. Cochrane Database Syst Rev, (3): CD006654.
• Lala SV, Sajatovic M (2012) Medical and Psychiatric Comorbidities Among Elderly Individuals With Bipolar Disorder: A Literature Review. J Geriatr Psychiatry Neurol, 25(1):20-25.
• Lingam R, Scott J (2002) Treatment non- adherence in affective disorders. Acta Psychiatr Scand , 105(3):164–172.
• Madhusoodanan S, Bogunovic OJ (2004) Safety of benzodiazepines in the geriatric population. Expert Opin Drug Saf, 3(5):485-493.
• Madhusoodanan S, Brenner R, Gupta S, experience with aripiprazole treatment in ten elderly patients with schizophrenia or schizoaffective disorder: Retrospective case studies. CNS Spectr, 9(11):862-867.
• Maina G, Albert U, Salvi V, Mancini M, Bogetto F (2007) Valproate or olanzapine add-on to lithium: an 8-week, randomized, open-label study in Italian patients with a manic relapse. J Affect Disord, 99(1- 3):247-251.
• Matson JL, González ML, Smith KR, Terlonge C, Thorson RT, Dixon DR (2006) Assessing side effects of pharmacotherapy treatment of bipolar disorder: A 20-year review of the literature. Res Dev Disabil, 27(5):467–500.
• Moorhead SR, Young AH (2003) Evidence for a late onset bipolar-I disorder sub-group from 50 years. J Affect Disord, 73(3):271-277.
• Newcomer JW (2005) Second-generation (atypical) antipsychotics and metabolic effects: a comprehensive literature review. CNS Drugs, 19 (Suppl 1): 1-93.
• Nivoli AM, Colom F, Murru A, Pacchiarotti I, Castro-Loli P, González-Pinto A, ve ark (2011) New treatment guidelines for acute depression: a systematic review. J Affect Disord, 129(1-3):14-26. bipolar
• Onder G, Pedone C, Landi F, Cesari M, Della Vedova C, Bernabei R, ve ark (2002) Adverse drug reactions as cause of hospital admissions: results from the Italian Group of Pharmacoepidemiology in the Elderly (GIFA). J Am Geriatr Soc, 50(12):1962– 1968.
• Oostervink F, Boomsma MM, Nolen WA, EMBLEM Advisory Board (2009) Bipolar disorder in the elderly: different effects of age and of age of onset. J Affect Disord, 116(3):176-183.
• Perlick DA, Rosenheck RA, Kaczynski R, Kozma L (2004) Medication non-adherence in bipolar disorder: a patient centered review of research findings. Clin Approaches Bipolar Disord, 3(2):56–64.
• Pollock BG (1999) Adverse drug reactions of antidepressants in elderly patients. J Clin Psychiatry, 60 (suppl.20): 4-8.
• Rado J, Janicak PG (2010) Aripiprazole for late-life schizophrenia. Clin Interv Aging, 7(5):253- 258. Regier DA, Farmer ME, Rae DS, Myers JK, Kramer M, Robins LN, ve ark (1993) One-month prevalence of mental disorders in the United States and sociodemographic characteristics: the Epidemiologic Catchment Area study. Acta Psychiatr Scand, 88(1): 35–47.
• Ritchie C (2008) Psychopharmacology in the elderly. In Oxford Textbook of Old Age Psychiatry, Jacoby R, Oppenheimer C, Dening T, Thomas A (eds). 4th edition. Oxford: Oxford University Press, s.193-200.
• Rossom RC, Rector TS, Lederle FA, Dysken MW (2010) Are all commonly prescribed antipsychotics associated with greater mortality in elderly male veterans with dementia? J Am Geriatr Soc, 58(6):1027–1034. Sachs GS,
• Nierenberg AA, Calabrese JR, Marangell LB, Wisniewski SR, Gyulai L, ve ark (2007)Effectiveness of adjunctive antidepressant treatment for bipolar depression. N Engl J Med, 356(17):1711–1722.
• Sajatovic M (2002) Aging-related issues in bipolar disorder: a health services perspective. J Geriatr Psychiatry Neurol, 15(3):128–133.
• Sajatovic M, Blow FC, Kales HC, Valenstein M, Ganoczy D, Ignacio RV (2007) Age comparison of treatment adherence with antipsychotic medications among individuals with bipolar disorder. Int J Geriatr Psychiatry, 22(10):992-998.
• Sajatovic M, Calabrese JR, Mullen J (2008) Quetiapine for the treatment of bipolar mania in older adults. Bipolar Disord, 10(6): 662–671.
• Sajatovic M, Coconcea N, Ignacio RV, Blow FC, Hays RW (2008) Aripiprazole therapy in 20 older adults with bipolar disorder: a 12-week, open- label trial. J Clin Psychiatry, 69:41–46.
• Sajatovic M, Gildengers A, Al Jurdi RK, Gyulai L, Cassidy KA, Greenberg RL, ve ark (2011) Multisite, open-label, prospective trial of lamotrigine for geriatric bipolar depression: a preliminary report. Bipolar Disord, 13(3):294-302.
• Sajatovic M, Gyulai L, Calabrese JR, Thompson TR, Wilson BG, White R, ve ark (2005) Maintenance treatment outcomes in older patients with bipolar I disorder. Am J Geriatr Psychiatry, 13(4):305-311.
• Schneeweiss S, Setoguchi S, Brookhart A, Dormuth C, Wang PS (2007) Risk of death associated with the use of conventional versus atypical antipsychotic drugs among elderly patients. CMAJ, 176(5):627-632.
• Schneider L, Dagerman K, Insel P (2005) Risk of death with atypical antipsychotic drug treatment for dementia: meta-analysis of randomized placebo- controlled trials. JAMA, 294(15):1934–1943. Sheikh JI, Cassidy EL, Doraiswamy PM, Salomon RM, Hornig M, Holland PJ ve ark (2004) Safety and tolerability of sertraline in patients with late-life depression and comorbid medical illness J Am Geriatr Soc, 52(1):86-92.
• Shulman KI (2010) Lithium for older adults with bipolar disorder: Should it still be considered a first- line agent? Drugs Aging, 27(8):607-615.
• Shulman KI, Rochon P, Sykora K, Anderson G, Mamdani M, Bronskill S, ve ark (2003) Changing prescription patterns for lithium and valproic acid in old age: shifting practice without evidence. BMJ, 326(7396):960-961.
• Subramaniam H, Dennis MS, Byrne EJ (2007) The role of vascular risk factors in late onset bipolar disorder. Int J Geriatr Psychiatry, 22(8):733–737. Suppes T, Dennehy EB, Hirschfeld RM, Altshuler LL, Bowden CL, Calabrese JR, ve ark (2005) The Texas implementation of medication algorithms: update to the algorithms for treatment of bipolar I disorder. J Clin Psychiatry, 66(7):870-886.
• Suppes T, Vieta E, Liu S, Brecher M, Paulsson B; Trial 127 Investigators (2009) Maintenance treatment for patients with bipolar I disorder: results from a north american study of quetiapine in combination with lithium or divalproex (trial 127). Am J Psychiatry, 166(4):476-488.
• T.C. İlaç ve Eczacılık Genel Müdürlüğü: http://www.iegm.gov.tr
• Tohen M, Zarate CA Jr. Antipsychotic agents and bipolar disorder. J Clin Psychiatry 1998; 59 (Supp. 1): 38-48.
• Unutzer J, Simon G, Pabiniak C, Bond K, Katon W (1998) The treated prevalence of bipolar disorder in a large staff-model HMO. Psychiatr Serv, 49(8):1072–1078.
• US Food and Drug Administration (FDA) (2005) Deaths With Antipsychotics in Elderly Patients With Behavioral Disturbances, in Public Health Advisory. US Department of Health and Human Services.
• Vahip S (2010) Depresif Dönemin Sağaltımı. İki Uçlu Bozukluk Sağaltım Kılavuzu, Aydemir Ö, Uluşahin A, Akdeniz F (eds), İkinci sürüm, Ankara: Tuna Matbaacılık, s.41-62.
• Vasudev A, Thomas A (2010) Bipolar disorder’ in the elderly: What’s in a name? Maturitas, 66(3):231–235.
• Vieta E, Nolen WA, Grunze H, Licht RW, Goodwin GA (2005) European perspective on the Canadian guidelines for bipolar disorder. Bipolar Disord, 7 (Suppl 3):73-76.
• Wang PS, Schneeweiss S, Avorn J, Fischer MA, Mogun H, Solomon DH, ve ark (2005) Risk of death in elderly users of conventional vs. atypical antipsychotic medications. N Engl J Med, 353(22):2335-2341.
• Wooltorton E (2004) Olanzapine (Zyprexa): Increased incidence of cerebrovascular events in dementia trials. CMAJ, 170(9):1395.
• Yatham LN, Kennedy SH, O'Donovan C, Parikh SV, MacQueen G, McIntyre RS, ve ark (2006) Canadian Network for Mood and Anxiety Treatments (CANMAT) guidelines for the management of patients with bipolar disorder: update 2007. Bipolar Disord, 8(6):721-739.
• Young RC, Jain H, Kiosses DN, Meyers BS (2003) Antidepressant-associated mania in late life. Int J Geriatr Psychiatry, 18(5):421-424
• Young RC, Gyulai L, Mulsant BH, Flint A, Beyer J (2004) Pharmacotherapy of bipolar disorder in old age: Review and recommendations. Am J Geriatr Psychiatry, 12(4):342-357.
• Young RC (2005) Evidence-based pharmacological treatment of geriatric bipolar disorder. Psychiatr Clin North Am 2005; 28(4):837- 869.
• Young RC, Kiosses D, Heo M, Schulberg HC, Murphy C, Klimstra S, ve ark (2007) Age and ratings of manic psychopathology. Bipolar Disord, 9(3):301-304.
• Young RC, Schulberg HC, Gildengers AG, Sajatovic M, Mulsant BH, Gyulai L, ve ark. (2010) Conceptual and methodological issues in designing a randomized, controlled treatment trial for geriatric bipolar disorder: GERI-BD. Bipolar Disord 2010: 12: 56–67.