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Assessment of Bi-polar Spectrum Assessment of Bi-polar Spectrum Disorder in Older AdultsDisorder in Older Adults

Cynthia Zubritsky, PhD & Karen Fortuna, MSWCynthia Zubritsky, PhD & Karen Fortuna, MSWCenter for Mental Health Policy and Services Research,Center for Mental Health Policy and Services Research,

University of PennsylvaniaUniversity of Pennsylvania

Pennsylvania 3rd Annual Suicide Prevention Conference, Pennsylvania 3rd Annual Suicide Prevention Conference, State CollegeState College

September 2009September 2009

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OverviewOverviewWhat 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?

33

What are the issues?What are the issues?

Older Adults and Suicide

44

Older Adult DemographicsOlder 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)

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Percentage of the U.S. Population Age Percentage of the U.S. Population Age 65 and Older, 1900 to 205065 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 projections.

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Older Adult SuicideOlder 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).

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Suicide Rates by Gender & AgeSuicide Rates by Gender & Age

(World Health Organization, 2005)

• Suicide rates among individuals 75 years and older are about three times higher than those under 25 years of age.

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Which older adults are at the highest risk for suicide?

Suicide Determinants in Older Adults

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Suicide Determinants in Older Suicide Determinants in Older Adults: Physical IllnessAdults: 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)

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Suicide Determinants in Older Suicide Determinants in Older Adults: Loss/Social SupportAdults: Loss/Social Support

Negative life events/loss

Lack of social support

Unmarried status

Bereavement

Family discord

(Conwell et al., 2002)

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Suicide Determinants in Older Suicide Determinants in Older Adults: Personality TraitsAdults: 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).

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Suicide Determinants in Older Suicide Determinants in Older Adults: Mental IllnessAdults: 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).

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Bi-polar Spectrum DisorderBi-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)

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Bi-polar Spectrum DisorderBi-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)

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Criteria for BSDCriteria for BSD

The criteria for a manic BSD episode includes elevated mood and three of the following symptoms:

1. Exaggerated self-esteem; 2. Less need for sleep; 3. Highly talkative; 4. Racing thoughts; 5. Distractibility; 6. Goal-orientated activity; and7. Distorted judgment.

(American Psychiatric Association, 2000)

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Criteria for BSDCriteria for BSDCriteria 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)

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Does untreated Bi-polar Spectrum Disorder increase suicide risk for older adults?

l Suicide and Bi-polar Spectrum Disorder (BSD)

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Suicide and Bi-polar Spectrum Suicide and Bi-polar Spectrum Disorder (BSD)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 15-20 times more than that

of the general populationof the general population (McElroy et al., 2006).

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Suicide and BSDSuicide 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).

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Has BSD in older adults been studied?

BSD Prevalence in Older Adults

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Research on the Prevalence of Research on the Prevalence of BSD in Older AdultsBSD 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 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 years24.8 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 years35 and 45 years (N = 25,460) (Shi et al., McCombs, 2004).

In a geropsychiatric inpatient unit, the average age of onset was 43.9 years43.9 years (N=48) (Sajatovic et al., 2005).

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Research on the Prevalence of Research on the Prevalence of BSD in Older AdultsBSD in Older Adults

2).Prevalence Rates of BSD in Older Adults2).Prevalence Rates of BSD in Older Adults

.08%08% of adults over age 65 screened positive for BSD (Klap et al., 2003).

5-12%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%5-19% of mood disorders in older adults (Cassano, et al., 2000).

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Has BSD in older adults been studied?

l BSD Assessment in Older Adults

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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.

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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).

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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?

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Research StudyResearch 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)

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BSD Screening Instruments Reviewed

1) Altman Self Rating Scale2) Bi-polar Depression Rating

Scale 3) Chronorecord 4) Diagnostic Assessment for the

Severely Handicapped5) Hypomania Checklist6) Hypomanic Personality Scale 7) Mood Disorder Questionnaire8) Bi-polar Spectrum Diagnostic

Scale9) Million Clinical Multiaxial

Inventory

10) Oxford Happiness Scale11) Internal State Scale12) Self-Report Manic Inventory; 13) Structured Clinical Interview for Mood Spectrum14) DSM-IV Structured Clinical Interview15) The MINI-International Nueropsychiatric Interview16) The Mania Rating Scale17) World Health Organization Composite International Diagnostic Interview

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U.S. Studies U.S. Studies Fifteen U.S. studies included individuals under the age of 65 (93.7%).Fifteen U.S. studies included individuals under the age of 65 (93.7%).

1 study included older adults 65 years or older (6.2%). 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)

94%

6%

Under the age of 65 65 years and over

* Based on age range reported

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Mean Age of Sample Mean Age of Sample in U.S. Studiesin 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

Age 51+ 0% 0

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International Studies International Studies

Percentage of Older Adults Included in International Studies Sample Populations

(N=18, n=13)

92%

8%

Under the age of 65 65 years and over

12 (92%) studies included individuals under the age 12 (92%) studies included individuals under the age of 65. of 65.

1 (8%) study included individuals over the age of 65. 1 (8%) study included individuals over the age of 65.

* Based on age range reported

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Mean Age of Sample in Mean Age of Sample in International StudiesInternational 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

Age 51+ 0% 0

3333

Mean Age of Sample in all StudiesMean 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

Age 51+ 0% 0

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FindingsFindings

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. Average age of sample population; 2. Presentation of illness; 3. Stigmatization and stereotyping; 4. Memory; and 5. Language and formatting.

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What are the barriers to reducing What are the barriers to reducing suicide among older adults with BSD? suicide among older adults with BSD?

Barriers

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Barrier: Average Age of Sample Barrier: Average Age of Sample PopulationPopulation

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.

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BarrierBarrier: BSD Presentation : 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).

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BarrierBarrier: BSD Presentation : 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).

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Barrier: Stigmatization and Barrier: Stigmatization and StereotypingStereotyping

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).

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Barrier: MemoryBarrier: 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)

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Barrier: Language and Formatting Barrier: Language and Formatting BarriersBarriers

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).

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What can be done? What can be done?

BSD Assessment in Older Adults:

Prospective Review

4343

BSA Assessment in Older Adults 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.

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Focus GroupFocus Group

Eleven older adults with mood disorders participated in a focus group to complete and discuss the modified Bi-polar 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

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FindingsFindings

• 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

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Results: Clinical CharacteristicsResults: Clinical Characteristics

• 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

Symptoms identified by older adults with a moderate to high probability of a BSD diagnosis included the following.

4747

Focus Group Discussion Results: Focus Group Discussion Results: Consumer ResponseConsumer 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.

4848

Consumer Input into DesignConsumer 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.

4949

Consumer Input into DesignConsumer 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).

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RecommendationsRecommendations

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.

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