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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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