Hi there, Dr. Phelps,
I am wondering what the research says about a connection between bipolar disorder and Alzheimer's Disease.  My fraternal aunt was diagnosed bipolar about forty years ago, she is now in her eighties.  My dad had her committed,  thirty years ago.  It was too emotionally, and financially, draining for him so it expired.  She has not received treated since.  Recently, Elder Services took her to a doctor, who admitted her to a hospital, which led to a psychiatric evaluation, an AD diagnosis, and an assisted living placement. Unfortunately, they are not able to manage her behaviors, or her medications.  It is very difficult to separate out what symptoms/behaviors are due to what diagnosis.  It seems like important information to have, though, as we must find her an appropriate placement.  Please send any helpful information or advice, it is much appreciated!

Maria


Dear Maria --

When elders are having difficulty controlling their behaviors such that they can not manage in an assisted living facility, this sense of being difficult for nearly everyone, including relatives like you who are trying to help. You're asking an important question. 

First of all, one could reason that if your mother's behaviors are actually due to bipolar disorder, rather than Alzheimer's, at least in part, that this is good news, and that the bipolar disorder symptoms might therefore be amenable to treatment and have the potential to improve substantially. By comparison, the symptoms of Alzheimer's can be damp down somewhat, but so far, we do not know of treatments which can really stop the progression of the illness, let alone reverse some of the symptoms toward normal, as we believe some of the treatments for bipolar disorder can do.

Therefore, in my view, in general terms, when Alzheimer's and bipolar disorder might both be present, I think it is worth it aggressively treating the bipolar component to see how much improvement can be obtained. This includes, for example, uses some medications which can potentially shorten the patient's life by increasing the risk of a cardiovascular problems such as a heart attack. These medications include most of the currently used "antipsychotics".

However, often overlooked in this setting our medications which are not "antipsychotics" but which have known benefit in bipolar disorder. Although we generally try to avoid using lithium in the elderly, I still keep in reserve; but a medication with significant potential for benefit, even at low dose, if there is indeed a "bipolar component", is Depakote. Whereas we usually use 1000 mg and up in younger people, as little as 500 mg, and sometimes even less, can be useful in the elderly if they are having problems with aggression, irritability, disorganized behavior, and irregular sleep patterns.

One could also reason as follows: suppose there is no "bipolar component"; is there any reason to think that something like Depakote, or perhaps even the antipsychotic family (which probably represents a greater risk, and which many patients more strongly dislike, in my experience), might help anyway? Indeed, this is rather commonly tried "empirically", a jargon term used in medicine meaning use of a medication when there is no clear indication for it but just a suspicion that it might be helpful, a sort of "let's try it and see" approach.

As you already may understand from your question, the history of bipolar disorder in your family increases the need to think along these lines even if in her lifetime there was little indication of bipolar disorder in terms of mood symptoms. I hope this possibility you are raising proves to be of some use.

Dr. Phelps



Published September, 2007