Ng Bernardo, Camacho Alvaro, Lara Diogo R, Brunstein Miriam G, Pinto Olavo C, Akiskal Hagop S
International Mood Center, and Department of Psychiatry, University of California, San Diego, CA, USA.
J Affect Disord. 2008 Apr;107(1-3):307-15. doi: 10.1016/j.jad.2007.08.018. Epub 2007 Sep 21.
The concept of bipolar spectrum disorders has opened therapeutic opportunities for patients with atypical and complex affective conditions. The literature has recently described several commonalities in pathophysiological processes of bipolar disorders and dementia. However, this connection has been insufficiently appreciated at the clinical level, in part because affective dysregulation in the elderly and, particularly in the dementia setting, is typically attributed either to secondary depressive states or otherwise relegated to a neurologically understandable behavioral complication resulting from cerebral disease.
We selected a case series of 10 elderly patients with late-onset mood and related behavioral symptomatology and cognitive decline without past history of clear-cut bipolar disorder. Clinical features, temperament, cognition, family history and pharmacological response were assessed to identify prototypical patients to illustrate the complexities of the dementia-bipolar interface.
Mixed and depressive mood symptoms were most commonly observed and all patients had been premorbidly of hyperthymic, cyclothymic and/or irritable temperaments. Most patients had a family history of bipolar disorder or disorders related to the bipolar diathesis. Symptoms were often refractory to or aggravated by antidepressants and acetylcholinesterase inhibitors, whereas mood stabilizers and/or atypical antipsychotics were beneficial, promoting behavioral improvement in all treated patients and marked cognitive recovery in five.
Case series with retrospective methodology.
Patients with cognitive decline and frequent mood lability might be manifesting a late-onset bipolar spectrum disorder, which we posit as type VI. We further posit that dementia and/or other biopsychosocial challenges associated with aging might release latent bipolarity in such individuals. Antidepressants, even drugs targeting dementia, might aggravate the behavioral dysregulation in these patients. Evaluation of premorbid temperament and/or family history of bipolarity and related disorders might help in broadening the clinical and biological understanding of such patients, providing a rationale for better customized treatment along the lines of mood stabilization and avoidance of antidepressants.
双相谱系障碍的概念为非典型和复杂情感状况的患者带来了治疗机会。最近的文献描述了双相障碍和痴呆在病理生理过程中的一些共性。然而，这种联系在临床层面尚未得到充分认识，部分原因是老年人的情感失调，尤其是在痴呆背景下，通常被归因于继发性抑郁状态，或者被视为由脑部疾病导致的神经学上可理解的行为并发症。
我们选取了10例老年患者的病例系列，这些患者有迟发性情绪及相关行为症状和认知衰退，且既往无明确双相障碍病史。评估临床特征、气质、认知、家族史和药物反应，以确定典型患者，说明痴呆 - 双相界面的复杂性。
最常观察到混合性和抑郁性情绪症状，所有患者病前均具有情感高涨、环性心境和/或易激惹的气质。大多数患者有双相障碍或与双相素质相关疾病的家族史。症状对抗抑郁药和乙酰胆碱酯酶抑制剂往往无效或加重，而心境稳定剂和/或非典型抗精神病药有益，使所有接受治疗的患者行为改善，5例患者认知显著恢复。
采用回顾性方法的病例系列。
认知衰退且频繁情绪不稳定的患者可能表现为迟发性双相谱系障碍，我们将其定义为VI型。我们进一步认为，痴呆和/或与衰老相关的其他生物心理社会挑战可能使这些个体潜在的双相性显现出来。抗抑郁药，甚至是针对痴呆的药物，可能会加重这些患者的行为失调。评估病前气质和/或双相及相关障碍的家族史可能有助于拓宽对此类患者的临床和生物学理解，为基于心境稳定和避免使用抗抑郁药的更好的个体化治疗提供理论依据。
