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CLINICAL PRACTICE GUIDELINES              MANAGEMENT OF BIPOLAR DISORDER (2ND ED.)


            8.2.  Elderly

            Older adults make up 25% of all bipolar patients and this number is expected to increase along
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            with  the  world’s  ever-aging  population. Older  age  bipolar  disorder (OABD)  includes  both
            elderly patients whose bipolar disorder has commenced earlier in life and those who present
            for the first time in later life. There is sparse data on OABD, thus current guidelines recommend
            that first-line treatment of OABD should be similar to that for the general population with BD,
            whilst specifically paying attention to side effects, co-morbidities and specific risks in elderly
            patients. 113  In  particular,  careful  consideration  must  be  given  to  the  pharmacokinetic  and
            pharmacodynamic changes that occur in elderly patients.

            A double-blind RCT comparing lithium and valproate in older patients with BD reported that: 114,
            level I
                lithium was more effective than valproate based on YMRS scores at week nine (Cohen’s
                d=0.54, 95% CI 0.17 to 0.91)
                both lithium and valproate were equally tolerated with slightly more tremor with lithium

            On the other hand, a cohort study on lithium vs AAPs which included aripiprazole, quetiapine,
            risperidone, olanzapine and lurasidone for BD in older war veterans showed: 115, level II-2
                all-cause  discontinuation  rate  (lack  of  effectiveness,  loss to follow-up  and  AEs)  was
                significantly higher in lithium compared with AAPs
                NS difference in discontinuation rate due to AEs
                o  tremor,  renal  failure,  toxicity  and  bloating/swelling  were  more  often  reported  with
                  lithium  whilst  extrapyramidal  symptoms  (EPS),  sedation,  restlessness  and
                  hallucinations were more with AAPs

            In an RCT comparing lurasidone and placebo in older adults with bipolar I depression, the
            findings were: 116, level I
                in monotherapy -
                o  those on placebo who switched to lurasidone had better improvement in depressive
                  symptoms (reduction in MADRS score)
                o  no  increase  in  mean  weight  or  glycaemic  indices  and  low  rates  of  switching  to
                  hypomania or mania
                in adjunct with lithium or valproate –
                o  NS difference in reduction of MADRS score
                o  higher rate of akathisia and tremor were noted
                common  AEs  for  both  monotherapy  and  adjunctive  lurasidone  therapy  include
                headache, nasopharyngitis and insomnia

            8.3.  Children and Adolescents

            Paediatric bipolar disorder (PBD) is a diagnostic challenge as children have yet to achieve
            emotional, neurocognitive and physical maturity. A meta-analysis of 19 studies showed that
            the prevalence rate of bipolar spectrum disorders among young people below 21 years of age
            was 3.9% (95% CI 2.6% to 5.8%). 117, level III  Early diagnosis of BD is crucial but over-diagnosis
            comes with its risks of medical-related AEs and stigmatisation.

            Signs and symptoms of BD may overlap with symptoms of other psychiatric disorders that
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            may occur in young people e.g.
                ADHD
                conduct disorder
                disruptive mood dysregulation disorder
                oppositional defiant disorder
                schizophrenia
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