Aziz Rehan, Lorberg Boris, Tampi Rajesh R
Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, USA.
Am J Geriatr Pharmacother. 2006 Dec;4(4):347-64. doi: 10.1016/j.amjopharm.2006.12.007.
Bipolar affective disorder is not uncommon in the elderly; prevalence rates in the United States range from 0.1% to 0.4%. However, it accounts for 10% to 25% of all geriatric patients with mood disorders and 5% of patients admitted to geropsychiatric inpatient units. These patients often present a tremendous treatment challenge to clinicians. They frequently have differing treatment needs compared with their younger counterparts because of substantial medical comorbidity and age-related variations in response to therapy. Unfortunately, the management of geriatric bipolar disorder has been relatively neglected compared with the younger population. There continues to be a scarcity of published, controlled trials in the elderly, and no treatment algorithms specific to bipolar disorder in the elderly have been devised.
The goal of this article was to review the current literature on both the pharmacologic and nonpharmacologic management of late-life bipolar disorder.
English-language articles written on the treatment of bipolar disorder in the elderly were identified. The first step in data collection involved a search for evidence-based clinical practice guidelines in the Cochrane Database of Systematic Reviews (up until the third quarter of 2006). Systematic reviews were then located in the following databases: MEDLINE (1966-September 2006), EMBASE (1980-2006 [week 36]), and PsycINFO (1967-September 2006 [week 1]). Additional use was made of these 3 databases in searching for single randomized controlled trials, meta-analyses, cohort studies, case-control studies, case series, and case reports. "Elderly," used synonymously with "geriatric," was defined as individuals aged > or =60 years. However, to take into account ambiguity in the nomenclature, the key words aged, geriatric, elderly, and older were combined with words indicating pharmacologic treatments such as pharmacotherapy; classes of medications (eg, lithium, antidepressants, antipsychotics, anticonvulsants, benzodiazepines); and names of selected individual medications (eg, lithium, valproic acid, lamotrigine, carbamazepine, oxcarbazepine, topiramate, gabapentin, zonisamide, clozapine, risperidone, olanzapine, quetiapine, ziprasidone, aripiprazole). These terms were then combined with the diagnostic terms bipolar disorder, mania, hypomania, depression, or bipolar depression. Finally, the terms ECT and psychotherapy were also queried in combination with indicators for age and diagnosis. A few articles on "older adults," usually defined as individuals aged 50 to 55 years, were also included. They may allow for possible extrapolation of data to the geriatric population. Additionally, several mixed-age studies were included for similar considerations. Case reports and case series were described for their potential heuristic value.
Unfortunately, there is a considerable dearth of literature involving evidence-based clinical practice guidelines and even randomized controlled trials in elderly individuals with bipolar disorder. Available options for the treatment of bipolar disorder (including those for mania, hypomania, depression, or maintenance) in the elderly include lithium, antiepileptics, antipsychotics, benzodiazepines, antidepressants, electroconvulsive therapy (ECT), and psychotherapy.
The data for the treatment of late-life bipolar disorder are limited, but the available evidence shows efficacy for some commonly used treatments. Lithium, divalproex sodium, carbamazepine, lamotrigine, atypical antipsychotics, and antidepressants have all been found to be beneficial in the treatment of elderly patients with bipolar disorder. Although there are no specific guidelines for the treatment of these patients, monotherapy followed by combination therapy of the various classes of drugs may help with the resolution of symptoms. ECT and psychotherapy may be useful in the treatment of refractory disease. There is a need for more controlled studies in this age group before definitive treatment strategies can be enumerated.
双相情感障碍在老年人中并不罕见；美国的患病率在0.1%至0.4%之间。然而，它占所有老年情绪障碍患者的10%至25%，以及老年精神科住院患者的5%。这些患者常常给临床医生带来巨大的治疗挑战。由于大量的内科合并症以及与年龄相关的治疗反应差异，他们与年轻患者相比往往有不同的治疗需求。不幸的是，与年轻人群相比，老年双相情感障碍的管理相对被忽视。针对老年人的已发表的对照试验仍然匮乏，并且尚未制定出针对老年双相情感障碍的治疗算法。
本文的目的是综述关于老年双相情感障碍药物和非药物管理的当前文献。
检索了关于老年双相情感障碍治疗的英文文章。数据收集的第一步是在Cochrane系统评价数据库（截至2006年第三季度）中搜索基于证据的临床实践指南。然后在以下数据库中查找系统评价：MEDLINE（1966年至2006年9月）、EMBASE（1980年至2006年[第36周]）和PsycINFO（1967年至2006年9月[第1周]）。在搜索单个随机对照试验、荟萃分析、队列研究、病例对照研究、病例系列和病例报告时，还额外使用了这3个数据库。“老年人”与“老年”同义，定义为年龄≥60岁的个体。然而，为了考虑命名中的模糊性，将关键词“年龄”、“老年”、“老年人”和“年长”与表示药物治疗的词汇（如药物疗法）、药物类别（如锂盐、抗抑郁药、抗精神病药、抗惊厥药、苯二氮䓬类）以及选定的个别药物名称（如锂盐、丙戊酸、拉莫三嗪、卡马西平、奥卡西平、托吡酯、加巴喷丁、唑尼沙胺、氯氮平、利培酮、奥氮平、喹硫平、齐拉西酮、阿立哌唑）相结合。然后将这些术语与诊断术语双相情感障碍、躁狂、轻躁狂、抑郁或双相抑郁相结合。最后，还结合年龄和诊断指标查询了术语“ECT”和“心理治疗”。还纳入了几篇关于“老年人”（通常定义为年龄在50至55岁之间）的文章。它们可能有助于将数据外推至老年人群。此外，出于类似考虑纳入了一些混合年龄的研究。描述病例报告和病例系列是因其潜在的启发价值。
不幸的是，涉及老年双相情感障碍患者基于证据的临床实践指南甚至随机对照试验的文献相当匮乏。老年双相情感障碍（包括躁狂、轻躁狂、抑郁或维持治疗）的可用治疗选择包括锂盐、抗癫痫药、抗精神病药、苯二氮䓬类、抗抑郁药、电休克治疗（ECT）和心理治疗。
老年双相情感障碍治疗的数据有限，但现有证据表明一些常用治疗方法有效。锂盐、丙戊酸钠、卡马西平、拉莫三嗪、非典型抗精神病药和抗抑郁药均已被发现对治疗老年双相情感障碍患者有益。虽然没有针对这些患者的具体治疗指南，但单一疗法随后联合各类药物治疗可能有助于症状缓解。ECT和心理治疗可能对难治性疾病的治疗有用。在能够列举出明确的治疗策略之前，这个年龄组需要更多的对照研究。
