David Baxter PhD
Late Founder
Older. With bipolar.
By Stephanie Stephens
Bipolar Hope, Spring 2008 issue
A new medical specialty emerges
No sour grapes for David Zagorsky?the acronym GRAPES means something quite the opposite for this vibrant 63-year-old living in seaside Del Mar, California.
Zagorsky participated several times in a cognitive program that taught him to incorporate these words into his daily life: ?Gentle, Relaxation, Accomplishment, Pleasure, Exercise, and Social.? GRAPES, he says, are great motivation. ?Just do a little of each. For example, walking to the local convenience store accomplishes both the exercise and social components.?
Sometimes you?ll need to dig deeper, Zagorsky admits. ?When you?re really down, challenge yourself, and say, ?I?m going to get up at a certain time and move on with my day. I?ve just got to do it.? You give in to this illness, and you?re done.? He knows that maturity means being able to handle what is often a full plate. ?Go to work on behalf of other people to escape your own misery.?
The determined and reflective Zagorsky, diagnosed with bipolar I at age 24, is a dedicated facilitator at the peer-to-peer Depression and Bipolar Support Alliance (DBSA), San Diego chapter. He relies upon his ?three-legged stool??medical management, a skilled therapist whom he trusts, and his family and friends. These friends include his DBSA group, which meets each Monday ?because illness does not know vacation and it?s not a walk-in-the-park illness, but one that is chronic and cyclical,? he says. ?You never know when it?s going to sneak up on you again, so be aware of ?gradations,? those subtle changes.?
Not far away in Solana Beach, California, Zagorsky?s friend, Don Bottomley, DO, MPH, manages bipolar II. Now 81, he was finally diagnosed in 1992 at 66 (though he was diagnosed with major depression in 1962 and reflects poignantly on a frustrating, sometimes exasperating childhood). ?At that point, I don?t think bipolar disorder really had that much of a ?history.?? After initially denying his bipolar II diagnosis, Bottomley recognized ?those ?steeplechase? symptoms?up and down. I was angry that I?d not been receiving the right combination of medications.?
Indeed, Bottomley often felt isolated in his journey down the long and winding road toward the truth, consulting several psychiatrists along the way. This caring, retired physician has been hospitalized 16 times, quit work as a skilled occupational therapist and pharmacist in 1982, and reluctantly accepted disability.
Along with being older, Bottomley is definitely wiser, sharing his sage advice ?to get organized, keep life simple, and don?t drink alcohol or use any other drugs. Also, don?t wear ?bipolar? like a badge,? he insists. ?It?s your disorder, not an excuse for doing something wrong. Sometimes people say, ?It?s not me, it?s my ?bipolarism.? No, it?s still you.?
Meet Geri-BD
It?s known in psychiatric circles as ?Geri-BD,? says Robert C. Young, MD, professor in the Department of Psychiatry, Weill Medical College of Cornell University, and attending physician in psychiatry at New York Presbyterian Hospital. ?Most of what little is known in geriatric patients is about type I bipolar disorder, which is ?severe,? says Young. ?There are other forms, such as type II, which are ?milder? in some ways, but research has mainly focused on type I in older people.?
Young?s longstanding research interest is in optimizing the use of medicine for treatment of older people with severe mood disorders. While less is known about milder forms, severe bipolar disorder in elder adults seems to fall into three categories. He defines these as:
Sometimes, as in Bottomley?s case, it?s a frustrating work in progress. ?On average, the time from first onset of symptoms and real diagnosis is ten years, and it takes another ten to manage bipolar disorder and devise the correct ?recipe? of medications,? Depp explains.
Moreover, an individual diagnosed in his or her 20s, who sustains the disorder for 40 years, will typically manifest certain medical comorbidities (the effects of all other diseases an individual patient might have other than the primary disease of interest). ?Those patients could have cardiovascular disease, diabetes, or other chronic illnesses, frequently because of lifestyle choices?a patient may smoke, for instance,? Depp states. ?Additionally, managing medications for bipolar?plus other illnesses?creates a more ?complicated? patient.?
While age and experience might appear to be advantages in living with bipolar disorder, Young says various factors unfortunately can get in the way. ?Physical disorders tend to accumulate, perhaps more frequently in bipolar patients than in depressed patients without bipolar disorder,? he explains. ?Life expectancy may be reduced in elders with bipolar disorder compared to those who are depressed.?
Of course, consumers in general know that cognitive impairment, dementia, and Alzheimer?s disease are increasingly more common as we live longer?those with bipolar are not exempt. ?There is some indication that memory problems and other neuropsychological functions become more prevalent in older adults with bipolar disorder,? Depp confirms.
Top management
On the ?upside,? Depp cites limited data that suggest that as older adults, ?patients may spend less time experiencing active symptoms and the mania is most likely less severe.? Broader surveys of epidemiological data, he says, show that older people are less depressed and less stressed. ?Middle age is the time of most frequent depression due to acute stressors of taking care of kids or parents and working,? he says. According to Depp, older adults are also less likely to undertake dangerous activities, abuse substances, and experience interpersonal conflicts.
Here?s one couple who would agree with this assessment. Janelle Warden, 69, is the wife of Cyrus, 71, who has bipolar disorder; the two live in Satellite Beach, Florida. She says having the disorder is ?better? for Cy now than when he was younger. This, she says, is partially because it?s ?out in the open.? Also, ?back then? she worked and he stayed at home??something that wasn?t heard of at that time.?
Older people who have bipolar are often better at managing illness, says Depp. This is because they?ve most likely tried self-management strategies such as exercise and sufficient sleep, are adherent to medications, and like David Zagorsky, have found a health care professional in whom they have faith and trust.
Young offers this take-to-heart advice. ?Learn about your disorder?remember that it is a ?disease??and its treatment, and talk to your family and primary care doctor and psychiatrist. Psychiatrists with specialized experience in older adults may be members of the American Association for Geriatric Psychiatry (AAGP) or the International Psychogeriatric Association (IPA). Collaborate with your psychiatrist in keeping track of what has been tried and what was the result, and what hasn?t been tried. Treatments can reduce symptoms and keep them away?if something has helped and is tolerable, stick with it until your doctors say to change it. Keep your medical health the best it can be.?
Also, be open to talking, a very important part of working with your doctors, Young advises. ?It encompasses encouragement and education, and recommendations to keep your daily schedule regular.? However, talk therapy alone is considered insufficient for most bipolar patients, he says. ?Researchers are hoping to learn about whether certain styles of talking can best help certain patients.?
Then, of course, there are the benefits of getting together. Elders can benefit from support networks and also from those close to them who are able to recognize the early onset of symptoms and can step in to help, Depp says. Moreover, though not all mature adults embrace the Internet, it remains a remarkable resource. Depp encourages these individuals ?to learn to be smart consumers.? In fact, he says, ?many become ?experts? in their disorder because they know more, since the landscape of bipolar treatment has changed in the last few years.?
Both psychiatric specialists agree that late diagnosis?such as Bottomley?s?is not the rule. Depp believes ?a patient could have been treated for depression for a long time, then suddenly have a manic episode. However, it is rare for an elder adult who?s never had any sort of psychiatric diagnosis to suddenly show up as having bipolar. One must rule out a medical or neurological condition and aggressively pursue the diagnosis that could be caused by certain drugs such as steroids, or strokes.?
Major meds
Of course, there are always exceptions to every rule. Some patients with bipolar ?get better as they age, but I have gotten worse,? says Nancy Tingley, 65, of Bradford Pennsylvania. Diagnosed 10 years ago with bipolar I, she now states that she is ?mixed,? often exhibiting both mania and depression simultaneously.
?People with bipolar disorder are the only people that understand this,? she asserts, recalling her bipolar ?resume.? She was initially treated for anxiety, once gained 130 pounds on medications, experienced heart failure, and now takes three prescriptions daily. Tingley, a retired nurse, faces up-to-four-hour panic attacks and sleep apnea as well. And like Bottomley, she has obsessive-compulsive disorder. She?s willing to share advice about self-care, and she?s certainly no quitter.
?Find a good psychiatrist and follow his orders, taking your medications as you?re told. Join a support group if you can,? Tingley recommends. She also knits as a hobby and takes walks. ?I used to do aerobics but now I don?t have good balance,? she admits. When living seasonally in Florida, she likes to swim.
Like many, Tingley has struggled to make peace with her medications. This is the smart choice, says Young, for it?s easy to be judgmental about medications when side-effects rule. ?Symptoms of depression or of mania can both alter attitudes toward treatment, causing a patient to say, ?Nothing can help? or ?I don?t need help,? respectively,? he says. ?This can complicate matters, but when patients improve, these attitudes often change.?
Young believes an increasing number of medications may be helpful for many patients, including older adults. ?To be helpful, medications must be used at the right doses and for long enough. You must be able to tolerate them?so that means trying them carefully. Also, for patients with severe symptoms in episodes of depression or mania, electroconvulsive therapy is safe, works rapidly, and with modern procedures can be well tolerated as regards memory.?
Many patients with bipolar disorder are treated with multiple medications, Young acknowledges. ?Sometimes this is the result of careful trials, and the medications are actually needed. But sometimes one medication is added to another without enough thought.? In older patients, multiple medications or polypharmacy are likely to cause side effects, he says.
?You must keep trying for the right meds,? says Janelle Warden. ?Many times, earlier in his diagnosis, Cy was over-medicated, sedated, and went around like a zombie,? his wife remembers, saying she ?was saddened? by this state of affairs. However, ?the right therapy is good, too,? she adds. ?All are unique minds.?
Patience is a must and faith helps tremendously, Janelle Warden adds. ?I turned Cy over to God and am just now seeing the results, all in God?s timing.?
As in most situations, humor helps. Laugh at your previous antics and keep on laughing, suggests Clayton Buck, 57, of Calgary, Alberta, who with a very high, Mensa-level I.Q., was diagnosed with bipolar II in 2006. ?My symptoms started in my early teens,? he says. ?Too many loved ones, plus myself, thought I should pull myself out of my depressions. Hindsight says differently?so be it. I coped reasonably well with my undiagnosed condition, in spite of the wreckage I left in my wake.?
Buck, who is also a recovering compulsive gambler, hopes that people his age who have bipolar II ?will accept it and find the right mental health team to direct, educate, and most important, listen to you.
?Self-analyze your behaviors,? he continues. ?Create social, emotional, and spiritual support groups and find or renew your spiritual strength. Keep a ?gratitude list? at all mood levels. Educate your family about genetic links and early detection.?
And don?t be shy, advises Janelle Warden. ?Do not be afraid to let people know you have bipolar disorder?it makes life a little easier. It?s nothing to be ashamed of. Those with bipolar disorder just have a brain that works differently than the rest of us.?
Stephanie Stephens is an award-winning journalist, specializing in health, who lives in California and New Zealand.
By Stephanie Stephens
Bipolar Hope, Spring 2008 issue
A new medical specialty emerges
No sour grapes for David Zagorsky?the acronym GRAPES means something quite the opposite for this vibrant 63-year-old living in seaside Del Mar, California.
Zagorsky participated several times in a cognitive program that taught him to incorporate these words into his daily life: ?Gentle, Relaxation, Accomplishment, Pleasure, Exercise, and Social.? GRAPES, he says, are great motivation. ?Just do a little of each. For example, walking to the local convenience store accomplishes both the exercise and social components.?
Sometimes you?ll need to dig deeper, Zagorsky admits. ?When you?re really down, challenge yourself, and say, ?I?m going to get up at a certain time and move on with my day. I?ve just got to do it.? You give in to this illness, and you?re done.? He knows that maturity means being able to handle what is often a full plate. ?Go to work on behalf of other people to escape your own misery.?
The determined and reflective Zagorsky, diagnosed with bipolar I at age 24, is a dedicated facilitator at the peer-to-peer Depression and Bipolar Support Alliance (DBSA), San Diego chapter. He relies upon his ?three-legged stool??medical management, a skilled therapist whom he trusts, and his family and friends. These friends include his DBSA group, which meets each Monday ?because illness does not know vacation and it?s not a walk-in-the-park illness, but one that is chronic and cyclical,? he says. ?You never know when it?s going to sneak up on you again, so be aware of ?gradations,? those subtle changes.?
Not far away in Solana Beach, California, Zagorsky?s friend, Don Bottomley, DO, MPH, manages bipolar II. Now 81, he was finally diagnosed in 1992 at 66 (though he was diagnosed with major depression in 1962 and reflects poignantly on a frustrating, sometimes exasperating childhood). ?At that point, I don?t think bipolar disorder really had that much of a ?history.?? After initially denying his bipolar II diagnosis, Bottomley recognized ?those ?steeplechase? symptoms?up and down. I was angry that I?d not been receiving the right combination of medications.?
Indeed, Bottomley often felt isolated in his journey down the long and winding road toward the truth, consulting several psychiatrists along the way. This caring, retired physician has been hospitalized 16 times, quit work as a skilled occupational therapist and pharmacist in 1982, and reluctantly accepted disability.
Along with being older, Bottomley is definitely wiser, sharing his sage advice ?to get organized, keep life simple, and don?t drink alcohol or use any other drugs. Also, don?t wear ?bipolar? like a badge,? he insists. ?It?s your disorder, not an excuse for doing something wrong. Sometimes people say, ?It?s not me, it?s my ?bipolarism.? No, it?s still you.?
Meet Geri-BD
It?s known in psychiatric circles as ?Geri-BD,? says Robert C. Young, MD, professor in the Department of Psychiatry, Weill Medical College of Cornell University, and attending physician in psychiatry at New York Presbyterian Hospital. ?Most of what little is known in geriatric patients is about type I bipolar disorder, which is ?severe,? says Young. ?There are other forms, such as type II, which are ?milder? in some ways, but research has mainly focused on type I in older people.?
Young?s longstanding research interest is in optimizing the use of medicine for treatment of older people with severe mood disorders. While less is known about milder forms, severe bipolar disorder in elder adults seems to fall into three categories. He defines these as:
- Those who have had bipolar disorder their whole lives, and now they?re having more of it. ?That?s a well established pattern,? says Young.
- Those who have had one or more episodes of ?unipolar? major depression early in life, for example, before 60, and then have one or more manic episodes later in life. ?It?s a change in polarity,? he says.
- Those who develop manic and depression symptoms late in life. People with late onset of bipolarity tend to have less family history of mood disorder and more frequent medical/neurological disorders or treatments that can cause mood problems, Young explains.
Sometimes, as in Bottomley?s case, it?s a frustrating work in progress. ?On average, the time from first onset of symptoms and real diagnosis is ten years, and it takes another ten to manage bipolar disorder and devise the correct ?recipe? of medications,? Depp explains.
Moreover, an individual diagnosed in his or her 20s, who sustains the disorder for 40 years, will typically manifest certain medical comorbidities (the effects of all other diseases an individual patient might have other than the primary disease of interest). ?Those patients could have cardiovascular disease, diabetes, or other chronic illnesses, frequently because of lifestyle choices?a patient may smoke, for instance,? Depp states. ?Additionally, managing medications for bipolar?plus other illnesses?creates a more ?complicated? patient.?
While age and experience might appear to be advantages in living with bipolar disorder, Young says various factors unfortunately can get in the way. ?Physical disorders tend to accumulate, perhaps more frequently in bipolar patients than in depressed patients without bipolar disorder,? he explains. ?Life expectancy may be reduced in elders with bipolar disorder compared to those who are depressed.?
Of course, consumers in general know that cognitive impairment, dementia, and Alzheimer?s disease are increasingly more common as we live longer?those with bipolar are not exempt. ?There is some indication that memory problems and other neuropsychological functions become more prevalent in older adults with bipolar disorder,? Depp confirms.
Top management
On the ?upside,? Depp cites limited data that suggest that as older adults, ?patients may spend less time experiencing active symptoms and the mania is most likely less severe.? Broader surveys of epidemiological data, he says, show that older people are less depressed and less stressed. ?Middle age is the time of most frequent depression due to acute stressors of taking care of kids or parents and working,? he says. According to Depp, older adults are also less likely to undertake dangerous activities, abuse substances, and experience interpersonal conflicts.
Here?s one couple who would agree with this assessment. Janelle Warden, 69, is the wife of Cyrus, 71, who has bipolar disorder; the two live in Satellite Beach, Florida. She says having the disorder is ?better? for Cy now than when he was younger. This, she says, is partially because it?s ?out in the open.? Also, ?back then? she worked and he stayed at home??something that wasn?t heard of at that time.?
Older people who have bipolar are often better at managing illness, says Depp. This is because they?ve most likely tried self-management strategies such as exercise and sufficient sleep, are adherent to medications, and like David Zagorsky, have found a health care professional in whom they have faith and trust.
Young offers this take-to-heart advice. ?Learn about your disorder?remember that it is a ?disease??and its treatment, and talk to your family and primary care doctor and psychiatrist. Psychiatrists with specialized experience in older adults may be members of the American Association for Geriatric Psychiatry (AAGP) or the International Psychogeriatric Association (IPA). Collaborate with your psychiatrist in keeping track of what has been tried and what was the result, and what hasn?t been tried. Treatments can reduce symptoms and keep them away?if something has helped and is tolerable, stick with it until your doctors say to change it. Keep your medical health the best it can be.?
Also, be open to talking, a very important part of working with your doctors, Young advises. ?It encompasses encouragement and education, and recommendations to keep your daily schedule regular.? However, talk therapy alone is considered insufficient for most bipolar patients, he says. ?Researchers are hoping to learn about whether certain styles of talking can best help certain patients.?
Then, of course, there are the benefits of getting together. Elders can benefit from support networks and also from those close to them who are able to recognize the early onset of symptoms and can step in to help, Depp says. Moreover, though not all mature adults embrace the Internet, it remains a remarkable resource. Depp encourages these individuals ?to learn to be smart consumers.? In fact, he says, ?many become ?experts? in their disorder because they know more, since the landscape of bipolar treatment has changed in the last few years.?
Both psychiatric specialists agree that late diagnosis?such as Bottomley?s?is not the rule. Depp believes ?a patient could have been treated for depression for a long time, then suddenly have a manic episode. However, it is rare for an elder adult who?s never had any sort of psychiatric diagnosis to suddenly show up as having bipolar. One must rule out a medical or neurological condition and aggressively pursue the diagnosis that could be caused by certain drugs such as steroids, or strokes.?
Major meds
Of course, there are always exceptions to every rule. Some patients with bipolar ?get better as they age, but I have gotten worse,? says Nancy Tingley, 65, of Bradford Pennsylvania. Diagnosed 10 years ago with bipolar I, she now states that she is ?mixed,? often exhibiting both mania and depression simultaneously.
?People with bipolar disorder are the only people that understand this,? she asserts, recalling her bipolar ?resume.? She was initially treated for anxiety, once gained 130 pounds on medications, experienced heart failure, and now takes three prescriptions daily. Tingley, a retired nurse, faces up-to-four-hour panic attacks and sleep apnea as well. And like Bottomley, she has obsessive-compulsive disorder. She?s willing to share advice about self-care, and she?s certainly no quitter.
?Find a good psychiatrist and follow his orders, taking your medications as you?re told. Join a support group if you can,? Tingley recommends. She also knits as a hobby and takes walks. ?I used to do aerobics but now I don?t have good balance,? she admits. When living seasonally in Florida, she likes to swim.
Like many, Tingley has struggled to make peace with her medications. This is the smart choice, says Young, for it?s easy to be judgmental about medications when side-effects rule. ?Symptoms of depression or of mania can both alter attitudes toward treatment, causing a patient to say, ?Nothing can help? or ?I don?t need help,? respectively,? he says. ?This can complicate matters, but when patients improve, these attitudes often change.?
Young believes an increasing number of medications may be helpful for many patients, including older adults. ?To be helpful, medications must be used at the right doses and for long enough. You must be able to tolerate them?so that means trying them carefully. Also, for patients with severe symptoms in episodes of depression or mania, electroconvulsive therapy is safe, works rapidly, and with modern procedures can be well tolerated as regards memory.?
Many patients with bipolar disorder are treated with multiple medications, Young acknowledges. ?Sometimes this is the result of careful trials, and the medications are actually needed. But sometimes one medication is added to another without enough thought.? In older patients, multiple medications or polypharmacy are likely to cause side effects, he says.
?You must keep trying for the right meds,? says Janelle Warden. ?Many times, earlier in his diagnosis, Cy was over-medicated, sedated, and went around like a zombie,? his wife remembers, saying she ?was saddened? by this state of affairs. However, ?the right therapy is good, too,? she adds. ?All are unique minds.?
Patience is a must and faith helps tremendously, Janelle Warden adds. ?I turned Cy over to God and am just now seeing the results, all in God?s timing.?
As in most situations, humor helps. Laugh at your previous antics and keep on laughing, suggests Clayton Buck, 57, of Calgary, Alberta, who with a very high, Mensa-level I.Q., was diagnosed with bipolar II in 2006. ?My symptoms started in my early teens,? he says. ?Too many loved ones, plus myself, thought I should pull myself out of my depressions. Hindsight says differently?so be it. I coped reasonably well with my undiagnosed condition, in spite of the wreckage I left in my wake.?
Buck, who is also a recovering compulsive gambler, hopes that people his age who have bipolar II ?will accept it and find the right mental health team to direct, educate, and most important, listen to you.
?Self-analyze your behaviors,? he continues. ?Create social, emotional, and spiritual support groups and find or renew your spiritual strength. Keep a ?gratitude list? at all mood levels. Educate your family about genetic links and early detection.?
And don?t be shy, advises Janelle Warden. ?Do not be afraid to let people know you have bipolar disorder?it makes life a little easier. It?s nothing to be ashamed of. Those with bipolar disorder just have a brain that works differently than the rest of us.?
Stephanie Stephens is an award-winning journalist, specializing in health, who lives in California and New Zealand.
