A descriptive study of older bipolar disorder residents living in New York City's adult congregate facilities.

The research community is placing greater emphasis on understanding geriatric bipolar disorder across a variety of settings, as numerous questions remain unanswered about many aspects of the illness and its impact on patients’ lives (e.g., lifetime course, psychiatric and medical comorbidity, mortality, etc.) (1-3). As the overall population ages in the United States, and as the number of elderly with severe mental illness grows, there is a need to better characterize this population in order to better understand the service needs of this group (4-6). Among the few studies that have been conducted on elderly bipolar disorder patients in community (epidemiological) or clinical outpatient settings, prevalence rates vary between 0.15% and 9%. There have been relatively consistent findings that elderly bipolar disorder patients have significant cognitive and functional impairment. These patients also seem to have less substance abuse than a younger cohort (7, 8). In other health domains, findings have been less consistent. For example, compared to younger patients, elderly bipolar disorder patients appear to use similar inpatient and greater outpatient services in a veterans setting, but less inpatient and outpatient services (except case management) in a community health setting (7, 8). A few studies examining the relationship between symptom severity and age also have had mixed findings: in two separate studies, Young, et al. (9) found no decrease in overall severity with age among a mixed-age sample of manic bipolar disorder patients, but this was in contrast to Broadhead and Jacoby (10), who did find decreased overall severity with age among manic bipolar disorder patients. Given the dearth of information on elderly bipolar disorder patients— and virtually none on those dwelling in Adult Congregate Facilities [(ACFs) described below]— it is important to better characterize the health status and needs of this population. ACF is an umbrella term whose precise definition varies somewhat from state to state, but which generally refers to senior-based housing that is publicly supported, provides apartments, suites and/or rooms for residents receiving some form of state assistance and who may need support in personal care or daily activities (11). Generally, these settings accept residents aged 55 years or older, although younger residents may be accepted if they meet physical or mental disability eligibility requirements. ACFs typically provide unskilled support, such as resident monitoring, congregate meals, and certain personal care services, but do not provide skilled nursing or other medical care. The size and organization of ACFs can vary substantially: while large metropolitan regions and states (e.g., New York, California) may have large ACFs housing up to several hundred residents, ACFs can also consist of small group home settings. For a more detailed description of New York's ACFs, see the New York Department of Health (DOH) website: www.health.ny.gov/facilities/adult_care. In 2002, the state of New York undertook a large evaluation of the state's ACFs due to concerns related to a steady change in the population over the past 30 years: although originally oriented toward supportive care for the elderly, approximately 25–30% of the resident population has a psychiatric disability, with a substantial proportion also having medical comorbidities (11). The state evaluation was initiated in order to better understand the needs of these residents, and to determine if the ACF setting was adequately in meeting those needs (11). Under state contract, New York Presbyterian Hospital conducted evaluations of over 2,600 ACF residents between February 2003 and February 2004, examining a full spectrum of resident health status, preferences, needs, and services. In order to meet the needs of the state contract, a large number of residents had to be assessed within a one-year period of time. A full report of the New York ACF project can be found at: www.health.ny.gov/facilities/adult_care/workgroup_report/10-2002/report.htm. The goal of this analysis was to better characterize the demographic and health-related features of the geriatric bipolar disorder residents of these New York ACFs. Based on chart diagnoses of bipolar disorder, we conducted an estimate of the prevalence of the illness among the full sample of residents. We then analyzed data from a subgroup of 100 residents who were either elderly (age ≥ 60) or young (age 18-49), comparing them across (i) demographic characteristics, (ii) clinical features (cognitive status, chronic disease burden, and medical status), (iii) benefit and service use, and (iv) medication use. Based on other studies of geriatric bipolar disorder and the nature of the adult home population, we expected that the prevalence of bipolar disorder would be 5–9%, with lower education levels than those found in other studies of general or outpatient bipolar populations. We also expected higher rates of cognitive impairment and increased medical burden. Between the two age groups, we expected the elderly sample to have greater cognitive impairment and medical burden; a larger number of services and medications used (and more classes); and greater sensory impairment. Given other studies [e.g., Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD)] showing lower lithium use among elderly patients, and the potential for lithium to worsen cognitive status among the elderly, we expected lower rates of lithium use among this group compared to the young cohort (6, 12)