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2001). In contrast, studies including children with very short periods of mania/
depression and ˜˜continuous™™ symptoms of BP disorder have contradictory
responses to the mood stabilizers. However, more RCT studies with large samples
are indicated.


Summary
For the past decade it has become clear that children and adolescents may
experience DSM-IV BP syndromes. However, it appears that most of these chil-
dren and adolescents have shorter episodes of mania, hypomania, and depression,
higher prevalence of mixed and rapid episodes, and worse prognosis than their
adult counterparts. Epidemiological, follow-up, family, and treatment studies
have helped to validate the presence of BP disorder in children and adolescents
but further studies are needed, especially to validate the diagnosis of BP disorder in
youth, in particular those with very rapid or continuous mood lability. It is of
critical importance to be aware of the BP diagnosis in children and adolescents and
to be able to differentiate from other psychiatric disorders (e.g., ADHD, ODD)
because BP children and adolescents have a poor prognosis and are at risk for
suicide and development of other psychiatric conditions (e.g., substance abuse,
behavior problems) unless they have the appropriate treatment.


ACKNOWLEDGMENT

The authors would like to thank Carol Kostek for her assistance with the manu-
script preparation.


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11


Atypical features of bipolarity in old age
Kenneth I. Shulman
University of Toronto Sunnybrook and Women™s, Toronto, Ontario, Canada




Introduction
Studying an elderly cohort confers several special advantages compared to younger
or mixed-age populations. In the first instance, one has available a lifelong clinical
course that has already unfolded. This allows for tracking of age of onset and
describing long-term clinical patterns in a way that is much more practical than
extensive prospective studies of younger patients. Second, genetic patterns of
inheritance can be more fully explored as the exposure in first-degree relatives,
especially children and siblings, will be much longer than in studies of younger
probands. Third, an elderly cohort offers the opportunity to study lesions of the
brain, thus casting more light on localization and pathogenesis, which can be
extrapolated back to potential neurophysiological patterns in younger bipolars.
Finally, outcome studies of the elderly can reveal differential rates of mortality and
psychosocial vulnerability which can be compared to controls, other mood dis-
orders, and neuropsychiatric conditions of late life.


Atypical features
These special aspects of study in the elderly result in features of bipolarity which
are quite different from the usual cohorts of bipolar disorder whose mean age of
onset is in the early 20s (Weissman et al., 1991). Not surprisingly, atypical features
described in this chapter will include:
(1) late age of onset
(2) prolonged latency from first depression to first mania
(3) high prevalence of neurologic comorbidity
(4) presence of cognitive impairment
(5) poor outcome characterized by increased mortality and finally increased
nosologic confusion related to the presence of neurologic comorbidity and
the similarity of secondary mania to other neurological conditions with
disinhibition syndromes (Shulman, 1997)
Cambridge University Press, 2005.
#
253 Atypical features of bipolarity in old age


Age of onset and clinical course
Age of onset can be an important variable that distinguishes subtypes of mania and
bipolar disorder in order to improve understanding of underlying pathogenesis
(Young and Klerman, 1992). While the vast majority of bipolar disorders in a
general population occur early in life (Goodwin and Jamison, 1984), elderly
bipolar patients report a mean age of onset of mood disorder which ranges from
age 40 to 47 years and an onset of mania that ranges from age 51 to 60 years (Chen
et al., 1998). This latter group used a cut-off for ˜˜late onset™™ at 60 years but Wylie
et al. (1999) have suggested that median age at onset in mixed-age patients could
reasonably be used as a cut-off point between early and late onset. Clearly, the
mean age of onset is also influenced by the cut-off for the age considered ˜˜elderly™™.
In the Wylie et al. (1999) sample, their ˜˜elderly™™ bipolar patients were over the age
of 60 and had a median age of onset of approximately 50 years. While no clear-cut
convention for ˜˜late onset™™ has been established in an elderly population, the work
by Wylie et al. (1999) suggests that an age of approximately 50 years would seem a
reasonable marker for future use. Using this cut-off for a late-onset group of
elderly bipolar patients, they found an increased prevalence of psychotic features
and an increase in cerebrovascular risk factors.
In another study of elderly bipolar subjects with a mean age of 74 years, an
increase in vascular comorbidity was found in a late-onset group defined by a cut-
off point of age 50 years (Hays et al., 1998). In this study, despite the elderly cohort
and late-onset subjects, the proportion of patients with a positive family history
was extremely high (83%), even for the late-onset group. Generally, within an
elderly bipolar population, there has been a trend towards a higher rate of positive
family history in those with an earlier age of onset (Hays et al., 1998; Stone, 1989).
For elderly individuals with comorbid neurological disorders there is a tendency to
have a lower rate of family history (Tohen et al., 1994). However even in the
neurological subgroup of patients, a significant positive family history in first-
degree relatives still applies at approximately 30%.
In a Finnish study, the annual rate of hospitalization by age for all bipolar patients
has been recorded by Rasanan et al. (1998). Although the peak 1-year incidence
occurred in middle age for both sexes, almost 20% of all first admissions for mania still
occurred after the age of 60. This is consistent with the bimodal distribution found in a
number of bipolar studies (Angst, 1978; Petterson, 1977; Sibisi, 1990). Two studies
(Spicer et al., 1973; Sibisi, 1990) found the highest inception rates for males to be in
late life and for females the inception rates tended to be highest in middle age or later.
Whether age of onset is determined by episode or hospitalization can make a
significant difference. Community surveys such as the Epidemiologic Catchment
Area (ECA) study (Weissman et al., 1991) and the National Comorbidity Study
(Kessler et al., 1997) report the mean age of onset of bipolar disorders as 21 years.
254 K. I. Shulman


This is in stark contrast to the previous data based primarily on first admission.
Generally, in mixed-age studies of manic inpatients, the mean age of onset is 30
years (Goodwin and Jamison, 1990; Tohen et al., 1990). It is noteworthy that very
few elderly bipolar patients are reported to have experienced their first manic
episode before the age of 40 (Snowdon, 1991; Shulman et al., 1992). A number of
theories have attempted to explain the discrepancy between the early onset of
community-based studies and the relatively late onset of hospitalized elderly
bipolar patients. Bipolar patients may ˜˜burn out™™ or die by the time they reach

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