ORIGINAL ARTICLE
Functional Impairment in Older Adults With Bipolar Disorder
Merc Comes, RN, MSc, PsyN,* Adriane Rosa, PhD, Maria Reinares, PhD,*
Carla Torrent, PhD,* and Eduard Vieta, MD, PhD*
Abstract: Data describing bipolar disorder in older adults people are scarce,
particularly with regard to functional status. This observational, comparative
study assessed psychosocial functioning in 33 euthymic older adults with bipolar
disorder compared with 30 healthy controls. In addition, we evaluated the associ-
ation between clinical variables and poor functioning in the patient group. The
mean age of the group was 68.70 years. Patients with bipolar disorder experi-
enced poorer psychosocial functioning (19.15 11.36) than healthy controls
(5.17 3.72; p = 0.0001), as assessed using the Functioning Assessment Short
Test. Significant differences between the groups were found for specific domains
of functioning: autonomy, occupational functioning, cognitive functioning, finan-
cial issues, and interpersonal relationships (p = 0.0001, respectively). The largest
variation was observed in overall functioning (Cohens d = 0.63). The number of
previous hospitalizations was strongly associated with poor overall functioning
(F = 7.217, p = 0.002). Older patients with bipolar disorder had a greater func-
tional impairment than the healthy control group. Implementation of novel
rehabilitation models is critical to help patients manage their illness.
Key Words: Bipolar disorder, elderly, older adult bipolar disorder,
functional impairment, psychosocial functioning
(J Nerv Ment Dis 2017;00: 0000)
C urrently, Spain, in common with other European countries, is
experiencing a gradual ageing of its population. Since the begin-
ning of the 20th century, the population more than 65 years old has
increased sevenfold. In 2002, Spain was the fourth leading European
country in terms of the highest percentage of population more than
65 years old (17.7% of the total population). It is estimated that by
2052, there will be nearly 2 billion people older than 60 among the
world's population. In Spain, in particular, this percentage is expected
to reach 37.6% of the population (World population ageing: 19502050).
The increase in life expectancy may be associated with an in-
crease in dependence. Although we are aware that this is not exclusively
a phenomenon seen in elderly individuals, at this stage of life, condi-
tions related to lack of physical, psychological, and intellectual
autonomy are, generally, more common. Moreover, older patients with
chronic diseases may be far more dependent that the elderly population
in general (Barrio Cantalejo et al., 2006).
*Bipolar Disorders Program, Institute of Neurosciences, Hospital Clinic, University
of Barcelona, IDIBAPS, Centro de Investigacin en Red de Salud Mental
(CIBERSAM), Spain; Laboratory of Molecular Psychiatry, Hospital de
Clnicas de Porto Alegre; Department of Pharmacology, Universidade Federal
do Rio Grande do Sul, Porto Alegre; and Bipolar Disorders Program and
INCT for Translational Medicine, Hospital de Clnicas de Porto Alegre,
Universidade Federal do Rio Grande do Sul, Brazil.
Send reprint requests to Eduard Vieta, MD, PhD, Bipolar Disorders Unit, Institute of
Neuroscience, Hospital Clinic, Villarroel 170, 9-0, Barcelona 08036, Catalonia,
Spain. Email: evieta@clinic.ub.es.
Authors contributions:
M. C., M. R., C. T., and A. R. carried out the collection of data. M. C. and A. R.
performed the data analysis and interpretation. M. C., A. R., and M. R. drafted the
manuscript. M. C. and A. R. performed the design of the study.
E. V. conceived of the study and participated in its design and coordination. All authors
read and approved the final manuscript.
Copyright 2017 Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0022-3018/17/00000000
DOI: 10.1097/NMD.0000000000000683
The Journal of Nervous and Mental Disease Volume 00, Number 00, Month 2017
Copyright 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Because of this increase in life expectancy, the number of adults
with psychiatric pathologyand particularly bipolar disorder (BD)is
on the rise (Seitz et al., 2010). Some studies have found prevalence rates
from 0.1% to 0.4% in patients older than 65 years (Van Gerpen et al.,
1999). There is increasing concern about the resources needed for an
integrated caring approach (Depp et al., 2006).
BD has been classically described as a chronic illness with an
episodic course. BD is a growing public health problem, often leading
to functional impairment with an increased significant caregiver burden
and substantial use of health care resources, with increased mortality
rates (Depp and Jeste, 2004; Reinares et al., 2006). In addition, BD
has been ranked as one of the leading causes of disability among
the physical and psychiatric disorders (Catal-Lpez et al., 2013). A
number of studies have shown substantial functional impairment
among adults with BD, even in clinical remission (Calabrese et al.,
2003; Goetz et al., 2007; Rosa et al., 2008; Strakowski et al.,
2000; Tohen et al., 2000). A review of 17 long-term studies of
psychosocial outcome in BD has shown that 30 to 60% of patients
had psychosocial dysfunction, as measured by impairment in
employment and social functioning (MacQueen et al., 2001). It has
been observed that functional impairment affects not only young
people but also older patients (Van Gerpen et al., 1999). However,
the impact of bipolar illness on older adults and its relationship
with psychosocial functioning have received little attention (Nivoli
et al., 2014). In fact, a recent report by a National Institute of
Mental Health workgroup on affective disorders has repeatedly
cited the relative lack of information about BD in elderly patients
compared with late-life unipolar depression (Untzer et al., 2002).
Some authors have shown a lower quality of well-being measures
and poor functioning in distinct life domains in middle-aged/older
patients with BD compared with healthy controls (Depp et al., 2006).
Considering the high proportion of patients with BD who are
middle-aged and the fact that the elderly will increase dramatically over
the next several decades, there is a need to consolidate our under-
standing about late-life BD (Depp and Jeste, 2004; Depp et al.,
2004). Therefore, the aims of this study were to assess the psychosocial
functioning of this specific population and to determine the various
clinical markers that can moderate or predict response of overall
functioning. We hypothesized that the experimental group will show
a greater level of disability and dependency in comparison to the
control group.
METHODS
Study Design
This was an observational, cross-sectional, and comparative
study of psychosocial functioning in patients with BD who were attend-
ing the Bipolar Disorders Program of the Hospital Clnic at the Univer-
sity of Barcelona, Spain. The Barcelona Bipolar Disorders Program has
a multidisciplinary approach and involves an assessment, monitoring of
symptoms, and treatment prescribed for all the patients. The program
sees patients who come from a designated catchment area in Barcelona
and patients who are sent to the program as a reference center for
difficult-to-treat cases. The patients were followed up regardless of
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Comes et al. The Journal of Nervous and Mental Disease Volume 00, Number 00, Month 2017

the hospital facility that they attend (inpatient unit, outpatient clinic, or Statistical Methods
emergency department) (Vieta, 2011a, 2011b). The statistical analysis was performed with the Statistical Pack-
age for Social Sciences software, version 18.0. Differences between
groups on the FAST scores and continuous variables were performed
Subjects by Student's t-test whereas chi-square was used to detect differences
The inclusion criteria were a) age 55 years or more, b) fulfilled on nominal variables. The effect sizes were also calculated to find the
the Diagnostic and Statistical Manual of Mental Disorders, Fourth difference between the groups in terms of standard deviation. Pearson
Edition (DSM-IV) criteria for bipolar I or bipolar II disorder, and c) met correlation coefficients were also conducted to assess correlations
euthymia criteria defined as a score of 8 or less on the 17-item Hamilton between continuous variables and functioning. One-way analysis of
Depression Rating Scale (17-HDRS) (Hamilton, 1960, 1980) and a score variance was performed to assess differences between nominal vari-
less than 7 on the Young Mania Rating Scale (YMRS) (Colom et al., ables and FAST total score. On the basis of these results, for the patient
2002; Young et al., 1978) for at least 3 months. group, a linear regression model was carried out to identify the best
As BD is a severe and disabling illness, the cutoff of aging in this predictors of overall functioning. In this model, all nominal and contin-
population has been defined as 55 years old for some authors (Morselli uous clinical variables that were significantly related with the overall
et al., 2004). Therefore, this cutoff point was a priori considered in our FAST score were introduced.
study sample.
RESULTS
Controls The sample is composed of 33 older adults with BD in euthymia
The healthy controls, defined as subjects with no psychiatric or (defined by 17-HDRS scores less than 7 and YMRS scores less than
neurological history, were screened from a pool of healthy volunteers 8) and 30 healthy controls. Patients were 69 8.51 years old, whereas
who were 55 years and older. It was also ensured that none in the control controls were 66 7.13 (F = 1.097; p = 0.254). There were no dif-
group had a first-degree relative with BD. The control group included a ferences between patients and controls regarding sex and age. Other
representative sample of workers, homeworkers, and some hospital demographic and illness characteristics of the sample are presented
staff that lived in the same geographic area of the patients. in Table 1.
Patients experienced poorer overall psychosocial functioning
(19.15 11.36) than healthy controls (5.17 3.72; F = 32.237,
Assessments p = 0.0001). As shown in Table 2, they experienced lower functioning
Both the Structured Clinical Interview for DSM-IV Axis I and compared with the control group in the following domains: autonomy
Axis II were administered to confirm diagnosis (First et al., 1997). (F = 23.866, p = 0.0001), occupational functioning (F = 526.149,
Sociodemographic, clinical, and pharmacological data were collected p = 0.0001), cognitive functioning (F = 32.889, p = 0.0001), financial
through an interview with the patient and by examination of clinical issues (F = 32.889, p = 0.0001), and interpersonal relationships
records. Data collected included age, sex, level of education, marital (F = 0.330, p = 0.0001). Regarding leisure time, the differences
status, age at onset, number of previous total episodes, number of hypo/
manic, mixed and depressive episodes, and number of hospitalizations.
Manic symptoms were assessed through the YMRS. The TABLE 1. Demographic and Clinical Variables in Older Adults With
Spanish version of the YMRS is a useful, reliable, and valid rating BD and Healthy Controls
scale (Colom et al., 2002). The YMRS is one of the most widely used
assessment instruments in mania evaluation. It is an 11-item, clinician- Healthy
administered rating scale used to assess the severity of mania for either Patients With BD Controls
clinical or research purposes (Young et al., 1978).
Depressive symptoms were assessed using the 17-HDRS, an n = 33 n = 30
instrument that is highly well validated and has been extensively used Mean SD Mean SD
in clinical research to assess depression (Hamilton, 1960, 1980).
Functional impairment was assessed using the Functioning Age 68.70 8.51 66.4 7.13
Assessment Short Test (FAST). It is a valid and reliable instrument, Age at onset of illness 31.60 13.57
easy to apply, and only requires a short time to administer (36 minutes). 17-HDRS 1.35 2.42
It was developed for the clinical evaluation of the main difficulties pre- YMRS 0.68 1.49
sented by psychiatric patients and has been validated in several languages No. total episodes 18.63 16.17
for patients with BD (Rosa et al., 2007, 2008). The FAST scale consists No. depressive episodes 9.81 14.59
of 24 items, which allow the assessment of six specific areas of function- No. manic episodes 5.45 12.60
ing: autonomy, occupational functioning, cognitive functioning, finan- No. hospitalizations 1.88 1.71
cial issues, interpersonal relationships, and leisure time. Items are rated
using a 4-point scale (0, no difficulty; 1,mild difficulty; 2,moderate dif- n % n %
ficulty; and 3, severe difficulty). The overall FAST cutoff was greater
Male 16 47.1 14 46.7
than 11, as high scores indicate poor functioning. The FAST score can
range from 0 to 72, where 72 indicates the lowest overall functioning Married 14 43.8
(Rosa et al., 2007). A trained rater, blind to the subject's group, adminis- Living situation (own family) 17 51.5 16 64
tered the FAST. Bipolar type I 21 63.6
All patients were treated pharmacologically for BD by trained Lifetime history of psychotic symptoms 14 45.2
psychiatrists according to the Bipolar Disorders Program protocols Active work 14 43.8
(Vieta, 2011a, 2011b). Depressive onset 23 69.7
The study was approved by the Hospital Clinic of Barcelona Family history of affective disorder 15 50.0
ethics committee. After receiving a complete verbal description of the Axis I comorbidity 20 69.0
study, written informed consent was obtained from all the participants.

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The Journal of Nervous and Mental Disease Volume 00, Number 00, Month 2017 Functioning in Older Adults with BD

TABLE 2. FAST Total and Specific Domains in Older Patients With BD in Euthymia (n = 33) and Healthy Controls (n = 30)

Healthy Controls Older Patients With BD

Mean SD Mean SD Student's t p Cohen's d
Overall functioning 5.17 3.72 19.15 11.36 6.687 0.001 0.63
Occupational functioning 0.60 0.97 7.64 7.01 5.708 0.001 0.57
Autonomy 0.33 0.76 2.76 3.15 4.283 0.001 0.41
Cognitive functioning 0.13 0.51 1.10 1.74 3.025 0.001 0.35
Financial issues 0.13 0.51 1.10 1.74 3.025 0.001 0.35
Interpersonal relationships 2.50 3.10 4.45 3.38 2.396 0.568 0.29
Leisure time 1.47 1.28 2.12 1.47 1.598 0.019 0.19

between groups did not reach statistical significance (F = 7.080,
p = 0.116). Moreover, the largest variation was observed in overall
functioning (Cohens d = 0.63) with a moderate size effect followed
by occupational functioning (Cohens d = 0.57). The relationship between
overall functioning and sociodemographic and clinical variables in the
older adults with BD was explored. The overall FAST score was signif-
icantly associated with depressive symptoms (r = 0.451, p < 0.001),
manic symptoms (r = 0.397, p = 0.002), and number of previous hos-
pitalizations (r = 0.568, p = 0.002). Furthermore, a linear regression
model was performed to identify predictors of poor functioning in the
bipolar sample. Overall functioning was associated with only number
of previous hospitalizations; this model explained 50% of the variance
as shown in Table 3 (F = 7.217, df = 21, p = 0.002).
DISCUSSION
This cross-sectional study was carried out to assess functional
impairment in older patients with BD compared with healthy controls.
We also investigated the association between demographic and clinical
variables and poor functioning. Our main findings were as follows:
a) older adults with BD showed lower psychosocial functioning than
healthy controls in distinct life domains such as autonomy, occupational
functioning, cognitive functioning, interpersonal relationships, and
financial issues; b) the largest variation was observed in the overall
functioning followed by the occupational functioning; and c) the
number of previous hospitalizations was strongly associated with poor
overall functioning.
In this study, older adult patients with BD had lower psychoso-
cial functioning compared with healthy controls, which suggests the
importance of assessing functioning in this specific population. BD in
older adults represents a chronically disabling condition, with minimal
improvement in psychosocial functioning between episodes (Gildengers
et al., 2013; Simon et al., 2007; Tohen et al., 2003). Particularly, older pa-
tients with BD experience more comorbid physical illness (hypertension,
hyperlipidemia, diabetes, heart disease, pulmonary disease, and thyroid
disorder) and polypharmacy therapy, which may lead to a greater chro-
nicity and dysfunction. In addition, ageing has been associated with poor
TABLE 3. Linear Regression Model of Functional Impairment in
Older Adults With BD
Baseline Variable Regression Coefficient 95% CI p has been associated with greater functional recovery and with more
Overall functioning
Manic symptoms 1.957 0.3104.223 0.087
Depressive symptoms 1.152 0.5522.856 0.174
Hospitalizationsa 3.657 1.6955.620 0.001
CI indicates confidence interval.
a
F = 7.217, df = 21, p = 0.002.
neurocognitive performance, particularly processing speed dysfunction
and poor executive functioning, which explains, in part, low rates of psy-
chosocial functioning (Lewandowski et al., 2013; Martino et al., 2008).
With regard to occupational functioning, less than half of the bi-
polar sample were actively working or working full time, highlighting
the morbidity and severity of the illness. Evidence has also shown that
older patients with BD with the presence of axis I comorbidity and a
higher number of depressive episodes are more likely to experience pro-
longed unemployment than those without such factors (Zimmerman
et al., 2010). In addition, cumulative episodes predict future relapses
and, consequently, may be related to poor outcome (MacQueen et al.,
2003, 2004; Rosa et al., 2009). The theoretical framework of the course
of BD described by Post (1993) suggests that the recurrence of episodes
and longer duration of illness may contribute to persistent biochemical
changes in specific areas of the brain, which may explain, in part,
functional decline in this psychiatric population (Post, 1993;
Young et al., 1993).
Functional impairment is influenced by poor cognitive per-
formance in young (Bonnn et al., 2010) and old patients with BD
(Cholet et al., 2014; Lewandowski et al., 2013). In the current study,
we found significant differences in cognitive function, as assessed by
FAST, between groups. Similarly, using the same instrument, Rosa
et al. (2009) had also found poor cognitive functioning in adult patients
with BD. Impairment in memory, attention, and planning has been
reported in patients with BD, and these deficits may play a crucial
role on performing daily activities (Martinez-Arn et al., 2009).
Unfortunately, in our study, cognitive functioning was not assessed
with a battery of cognitive tests but only with the FAST. Weisenbach
et al. (2014) found that there was a double burden of aging and disease
on reported ability to perform physical tasks as well as a positive asso-
ciation between number of years ill and lower ratings of health-related
quality of life. To sum up, these data indicated that older adults patients
with BD represent highly vulnerable individuals who experience diffi-
culties with independent living skills, self-care, and others activities.
Furthermore, a number of previous studies have shown a strong
relationship between depressive symptoms and poor functioning (Frye
et al., 2006; MacQueen et al., 2003; Tohen et al., 2006). In this regard,
Judd et al. (2005) found that functional impairment increased signifi-
cantly with each increment in depressive symptom severity, even when
the symptoms were not severe enough to fulfill criteria for a depressive
episode. Similarly, an improvement of one level in depression severity
days per month of being able to participate in daily activities (Simon
et al., 2007). Despite this, the impact of subclinical depressive
symptoms on functional impairment has often been underestimated
in the clinical practice. Nevertheless, these findings suggest that the
aggressive treatment of subclinical depressive symptoms is critical
to reach mood stabilization, preventing relapses and consequently
improving functional recovery (Altshuler et al., 2002; McCall and
Kintziger, 2013).

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Comes et al. The Journal of Nervous and Mental Disease Volume 00, Number 00, Month 2017
Although the management of BD has been mostly provided by
psychiatry in the past, interdisciplinary teams can provide a range of
services from case management to health and illness management
(Bauer et al., 2009; Mueser et al., 2010). For instance, community
psychiatric nurses are increasingly being involved in the provision of
care for this group of patients (Vieta, 2005).
Given that BD negatively affects the psychosocial functioning
and there is little research in older adults, the effective implementation
of novel programs is fundamental to help patients to better manage
their illness.
There are several limitations that should be considered when
interpreting the results of this study. First, our study was recruited
from a tertiary hospital where many complex patients are enrolled,
which may limit the generalizability of our findings to the whole
bipolar population. Second, we did not evaluate cognitive function
by means of neuropsychological tests; therefore, the influence of poor
cognition on outcome cannot be ruled out. Third, we did not evaluate
physical comorbidity; therefore, we could discard the impact of this
on functioning. Fourth, our design was cross-sectional, and these data
do not allow analysis of the cause-and-effect relationships among the
variables studied and different areas of functioning. Longitudinal
studies are needed to define the exact relationship between specific
domains of functioning and clinical factors. Finally, the small sample
size resulted in limited power to look at interaction effects among
the domains.
Despite these limitations, a strength of our study was the inclu-
sion of carefully diagnosed and well-characterized age-comparable
groups of patients with BD and healthy controls. Our findings show
the negative impact of BD on psychosocial functioning in older patients
with BD and the need for developing therapeutic interventions in
this population.
Future studies, should take into account the early intervention
alongside treatment and rehabilitation of patients with BD from
the onset of the illness and risk population. Community psychiatric
nurses are increasingly being involved in the provision of care for mental
health promotion and prevention policies and activities.
DISCLOSURE
This work was supported by the Instituto de Salud Carlos III,
Centro de Investigacin en Red de Salud Mental (CIBERSAM) as well
as Grups Consolidats de Recerca 2014 SGR 398 (to E. V.). Other
sources of support were a research grant from the Spanish Ministry of
Economy and Competitiveness (PI12/01880) PN 20132016 (to M. C.).
In addition, the study was partially supported by the postdoctoral fellow-
ship Beatriu de Pins granted by the Agency for Management of University
and Research Grants (AGAUR), Agency of the Secretariat of Universities
and Research under the Department of Economy and Knowledge of
the Catalan Government (Generalitat de Catalunya), and the Marie
CurieCOFUND actions of the Seventh Framework Programme of Re-
search and Technological Development of the European Union (to M. R.).
The present study was performed at the Bipolar Disorder Program,
CIBERSAM, Hospital Clinic of Barcelona. Dr Carla Torrent was funded
by the Spanish Ministry of Economy and Competitiveness, Instituto Carlos
III, through a Miguel Servet postdoctoral contract (CPI14/00175) and
an FIS (PI 12/01498). Dr Torrents project was also supported in part
by a 2014 NARSAD, Independent Investigator Grant from the Brain &
Behavior Research Foundation (grant no. 22039).
The authors declare no conflict of interest.
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