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Bipolar Disorders. 2023;00:1–12.
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1wileyonlinelibrary.com/journal/bdi
DOI: 10.1111/bdi.13368
REVIEW
Functioning in older adults with bipolar disorder: A report
on recommendations by the International Society of bipolar
disorder (ISBD) older adults with bipolar disorder (OABD) task
force
Laura Montejo1 | Melis Orhan2 | Peijun Chen3,4 | Lisa T. Eyler5,6 |
Ariel Gildengers7 | Anabel Martinez- Aran1,8 | Paula Villela Nunes9 |
Andrew T. Olagunju10 | Regan Patrick11,12 | Eduard Vieta1,8 | Annemiek Dols13 |
Esther Jimenez1
1Bipolar and Depressive Disorders Unit, Hospital Clinic of Barcelona, Institute of Neurosciences (UB Neuro), Institut d'Investigacions Biomèdiques August Pi i
Sunyer (IDIBAPS), Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Instituto de Salud Carlos III (ISCIII), Barcelona, Spain
2Department of Old Age Psychiatry, GGZ inGeest, Amsterdam, the Netherlands
3Department of Psychiatry, Geriatric Research, Education, and Clinical Center, VA Northeast Ohio Health System Cleveland VA Medical Center, Cleveland,
Ohio, USA
4Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
5Department of Psychiatry, Universit y of California San Diego, La Jolla, California, USA
6Desert- Pacific Mental Illness Research Education and Clinical Center, VA San Diego Healthcare, San Diego, California, USA
7Department of Psychiatry, Universit y of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
8Departament de Medicina, Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona (UB), Barcelona, Spain
9Department of Psychiatry, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, SP, Brazil
10Department of Psychiatry and Behavioral Neurosciences, McMaster University/St Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
11Departments of Neuropsychology & Geriatric Psychiatry, McLean Hospital, Belmont, Massachusetts, USA
12Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
13Department of Psychiatry, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht, the Netherlands
This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium,
provided the original work is properly cited.
© 2023 The Authors. Bipolar Disorders published by John Wiley & Sons Ltd.
Laura Montejo an d Melis Orhan sh ould both be considered as f irst author s. Esther Jimenez and A nnemiek Dols sh ould be conside red joint senior authors.
Correspondence
Eduard Vieta, Bipolar and Depressive
Disorders Unit, Hospital Clinic, Institute
of Neuroscience, University of Barcelona,
IDIBAPS, CIBERSAM, C/Villarroel, 170.
08036 Barcelona, Spain.
Email: evieta@clinic.cat
Abstract
Objectives: Despite the importance of psychosocial functioning impairment in Bipolar
Disorder (BD), its role among Older Adults with BD (OABD) is not well known. The
development of guidelines for the assessment of psychosocial functioning helps to fa-
cilitate a better understanding of OABD and can lead to better tailored interventions
to improve the clinical outcomes of this population.
Methods: Through a series of virtual meetings, experts from eight countries in the
International Society of Bipolar Disorder (ISBD) on OABD task force developed rec-
ommendations for the assessment of psychosocial functioning.
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MONTEJO et al.
1 | INTRODUC TION
1.1 | Case study
“Mr. A is a 65- year- old man, diagnosed with bipolar disorder type II.
He was diagnosed at age 37 years. In addition to experiencing recur-
ring affective episodes, he complains of poor memory (e.g., forgetting
appointments) and experiences trouble keeping up with household
routines. Due to not opening the mail and forgetting important things
like paying bills, he has experienced financial problems. He has also
stopped drivin g due to attentional def icit s, which in turn limit s the dis-
tance he can travel from home and has made him feel like his world
has become really small. He often experiences difficulty with planning
and organization wh ich has led him to give up work . Perhaps related to
the lithium use, he experiences severe tremor and has trouble writing
legibly. During his depressive episodes, he often withdraws from social
contact. As a result, he has lost friendships over the years and often
feels lonely. When he experiences affective episodes, he frequently
cancels his clinical appointments, which hinders his prompt access to
support services.”
1.2 | Introduction
Bipolar disorder (BD) is a severe mood disorder that is defined by ep-
isodes of mania or hypomania, alternating with depressive episodes
and euthymic phases,1 and heterogeneous cognitive and functional
impairment.2 The International Society of Bipolar Disorder (ISBD)
task force on older adults with bipolar disorder (OABD) has defined
OABD as individuals with BD over the age of 50.3 OABD accounts
for approximately 25% of the BD population. This group of patients
exhibits different clinical and psychosocial features compared to
younger adults3 and may need appropriately tailored approaches to
the management of symptoms and associated functional disability.
OABD take on different characteristics and may be more complex,4
so they can be considered a special population, thereby warranting
specific approaches and recommendations.5
BD is a disabling mental illness, with 60% of patients exhibiting
some degree of functional impairment.6 Even between mood epi-
sodes, many patients with BD experience residual mood symptoms,
as well as social and cognit ive dysfunctio n7 that have nega tive conse-
quences f or daily life. A recen t population- based st udy demonstr ated
that BD patients, at first contact with psychiatry, had lower odds
of having achieved the highest educational level, being employed,
cohabitating, and being married in addition to not having achieved
the highest quartile of income, compared with the general popula-
tion. Importantly, patients showed a significantly decreased ability
to enhance their socioeconomic functioning during the 23 years of
follow- up compared to controls.8 Considering the relative chronicity
of BD, impaired daily functioning is regarded as a core feature of
the disease.9 In addition, treatment efforts tend to focus on allevi-
ating clinical symptoms, with comparatively less emphasis on imple-
menting concrete strategies aimed at promoting functional stability
or recovery. It has been estimated that after symptomatic recovery,
only 40% of adults with BD achieve functional recovery.10,11 This
suggests that once the mood episode has remitted, a large propor-
tion of people with BD continue to experience functional problems
in areas such as occupational performance, social relationships, and
interests or hobbies, which in turn undermine daily routines, well-
being, and quality of life. In a cohort of 173 subjects prospectively
followed after hospitalization for their first episode of mania, 98% of
participants achieved syndromal recovery, 72% achieved symptom-
atic recovery, and only 43% functional recovery.12
Research on functioning across the lifespan is relatively sparse
and therefore, the picture of BD in later life is not well understood.3
The case study of Mr. A (mentioned above) illustrates the potentially
diffuse functional impact of OABD, both directly and indirectly. As
life expectancy increases and the population ages, the prevalence
of BD- related disability among older adults is expected to increase
due to various factors associated with aging, such as a decreasing
social network size, loss of support from family members, reduced
mobility, increased presence of somatic comorbidities, and other
aging- related issues.13 Older age has also been associated with
lower psychosocial functioning in BD.14 In fact, when psychosocial
Results: We present (1) a conceptualization of functioning in OABD and differences
compared with younger patients; (2) factors related to functioning in OABD; (3) cur-
rent measures of functioning in OABD and their strengths and limitations; and, (4)
other potential sources of information to assess functioning.
Conclusions: The task force created recommendations for assessing functioning in
OABD. Current instruments are limited, so measures specifically designed for OABD,
such as the validated FAST- O scale, should be more widely adopted. Following the
proposed recommendations for assessment can improve research and clinical care in
OABD and potentially lead to better treatment outcomes.
KEYWORDS
functioning, older adults with bipolar disorder, recommendations
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MONTEJO et al.
functioning has been compared with younger adult BD patients,
worse global psychosocial functioning in OABD, as measured by the
functioning assessment short test (FAST) scale,15 was observed in
the areas of occupational functioning, cognitive performance, and
leisure time.16 The potentially accelerated cognitive decline and
increased presence of somatic comorbidities can negatively im-
pact functioning, quality of life, and well- being to a greater extent
than younger patients. Moreover, a correlation between marked
functional impairment in OABD patients and the number of hospi-
talizations was reported.17 These findings collectively support the
notion that multiple aspects of BD are associated with the function
of OABD and highlight the need for the assessment and introduction
of appropriate interventions soon after the onset of the disorder,
even among OABD.18
It is clear that OABD is a multidimensional disorder. To obtain an
accurate picture of the current state of OABD patients, it is essential
that clinical, psychosocial, medical, and cognitive factors are consid-
ered when assessing the function of OABD. In this paper, we aim to
give an overview of the different aspects of functioning in OABD,
review currently used assessment methods and their limitations, as
well as offer recommendations for research and clinical practice re-
garding the function of OABD.
2 | METHODS AND MATERIALS
The OABD ISBD Task Force is a collaboration of international ex-
pert s from many countries whose main scientific interest is the study
of OABD. The present work was developed by 11 experts in the field
from the following countries: Brazil, Canada, the Netherlands, Spain,
and the United States. Due to the gap in literature on psychosocial
functioning in OABD, it was proposed to combine knowledge from
experts from all over the world. It was carried out through virtual
meetings where the main issues addressed in the present work were
reviewed, discussed, and agreed upon to shape the recommenda-
tions. It was not necessary to use any standardized formal methods
for consensus given the high level of agreement among members.
3 | FUNCTIONING IN OABD
3.1 | Definition of functioning
Functioning is a complex construct that involves many interac-
tions and activities in personal, occupational, and recreational con-
texts.19,11 ,2 0 Despite the importance of psychosocial functioning in
BD, there is no clear consensus regarding its definition. Different
definitions of psychosocial functioning were examined without
reaching a consensus.21 The experts highlighted the definition pro-
vided by the International Classification of Functioning, Disability
and Health (ICF). The ICF identifies three levels of human function-
ing: functioning at the level of the body or body part, the whole per-
son, and the whole person in a social context. This definition adds
to the understanding of what patients with a certain health condi-
tion can do in a standard environment (their level of capacity), and
what they actually do in their usual environment (their performance
level). In fact, it has been working on the development of ICF core
sets for BD, specifically designed with the goal of providing a useful
standard that can be applied in research, clinical practice, and teach-
ing.22 Subsequent international consensus identified a total of 38
ICF categories to be included in the Comprehensive Core Set for BD
of which 19 ICF categories were chosen as the most significant to
constitute the Brief Core Set for BD.23 Disability, therefore, involves
dysfunction at one or more of these same levels: impairments, activ-
ity limitations, and participation restrictions.24
3.2 | Psychosocial functioning
Studies conducted in OABD demonstrate that psychosocial func-
tioning is limited in this population in a large number of areas, such
as autonomy, independence, economic management, occupational
performance, and interpersonal relationships.17, 25 A recent analy-
sis combining a multitude of data from different countries showed
moderate impairments in psychosocial functioning, measured by the
Global Assessment of Functioning (GAF26) scale, as well as a high
association of depressive and manic symptoms with lower psycho-
social functioning.27 Indeed, it is also described that more severe
depression, somatic comorbidities, and impaired cognition were all
associated with lower functioning in OABD.28, 29 Moreover, findings
from the Global Aging & Geriatric Experiments in Bipolar Disorder
(GAGE- BD) study30 suggest that greater severity of symptoms in BD
is associated with worse functioning in OABD.31
3.3 | Activities of daily living and functioning
Instrumental activities (IADL) and advanced activities of daily liv-
ing (AADL) are also likely to be impaired in older populations and
could reflect the impact of the disease on one's autonomy. They are
necessary for living and functioning independently in society (e.g.,
cooking a meal, shopping, cleaning the house).32 Education, work,
leisure activities, and participation in social networks or community
would constitute AADL. Studies using observation- based- in- home
assessment have shown decreased ADL ability in OABD.33,34,28
Performance in IADL was found to be associated with lower levels
of autonomy in OABD when compared to a healthy control group.33
In younger adult BD patients, no relation was found between self-
reported and observation- based measures of ADL ability, indicat-
ing a difference in the perspective between patients and clinicians.
This underlines the importance of including both self- reported and
observation- based measures since they seem to provide distinct but
complementary information.35 The assessment of ADL should also
be included for OABD patients since it captures functioning in activ-
ities of daily living beyond psychosocial functioning, in a population
at increased risk for impairment of these abilities.
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MONTEJO et al.
3.4 | Somatic comorbidities, medication use, and
functioning
Somatic comorbidity is highly prevalent in OABD, as well as more
frequent when compared to healthy older adults and younger indi-
viduals with BD.27,36,37,38,39 It is estimated that OABD suffer from
an average of three or four somatic diseases, including hyperten-
sion, metabolic syndrome, cardiovascular disease, diabetes mel-
litus, endocrine abnormalities, arthritis, and respiratory disease
(4%– 15%), among others.3,40,41 In a recent study, cardiovascular
disease was present in nearly half of all OABD individuals belong-
ing to the GAGE- BD sample.27 This slightly differed from earlier
findings42 that found that the most frequently observed somatic
conditions were obesity, migraine, hypertension, hyperlipidemia,
and asthma. They also reported an association between elevated
somatic comorbidity burden and several clinical features of BD,
including a higher rate of lifetime mood episodes. In the afore-
mentioned GAGE- BD sample, greater somatic burden was not as-
sociated with poorer functioning.26 Similarly, another report did
not find that somatic comorbidity was associated with functioning
and there did not appear to be an association between medica-
tion load, comorbidity, age, and adherence.43 However, interpreta-
tion of these findings should take into account the possibility of a
“healthy survivor effect” where individuals who die prematurely
or are too ill to participate in research studies may bias sample
characteristics in favor of older adults who are doing relatively
well. In addition, some longitudinal reports detected a more rapid
accumulation of chronic physical illness over time and a lower
self- perception of physical health in OABD.38 Thus, results on
the specific relationship between somatic burden and functioning
are controversial, but since the frequency and somatic illness and
poorer physical health might increase the complexity of OABD
and could have a significant impact on functioning, this association
deserves attention either in research or clinical practice.
3.5 | Cognitive performance and functioning
It is estimated that roughly 40% of OABD present cognitive dys-
function,44,45 exhibiting deficits in almost all cognitive domains, es-
pecially in memory, attention, processing speed, working memory,
and executive functions.46 ,47 Since cognitive dysfunction often oc-
curs on a permanent basis and may worsen throughout the course
of BD,48,49 one may argue that BD may have an increased negative
effect on self- care activities in daily life (i.e., ADL) as well as on psy-
chosocial functioning. An earlier study50 revealed that self- care abili-
ties of a group of OABD were worse when compared with a healthy
control group. Different aspects of cognitive functioning are related
to abilities for self- care.51, 52 Likewise, instrumental activities of daily
living (IADL) have been associated with processing speed and execu-
tive functions.32
Considering cognitive heterogeneity, it has been widely re-
ported that middle- aged samples of people with BD display
different profiles of cognitive dysfunction: a group with a pre-
served cognitive performance, a selectively impaired group with
deficits in certain cognitive domains, and, finally, a third group pre-
senting with a broader and more severe range of cognitive dys-
function.53– 55 A similar distribution has been observed in OABD,
although with different nuances in which the intermediate group
already demonstrated impairment in all cognitive domains and a
smaller group of patients exhibited severe cognitive dysfunction.44
This same heterogeneity has been found regarding psychosocial
functioning, which seems to be related to cognitive performance.56
Specifically in older adults, OABD with an intact cognitive profile
are indistinguishable from controls in terms of psychosocial func-
tioning, demonstrating that psychosocial functioning also shows
diverse profiles.57 Better cognitive performance at baseline has
been associated with lower dependence and less need for support
with IADLs at follow- up.27
Social functioning, understood as those capacities or abilities
to maintain, establish, and participate in social activities and in-
terpersonal relationships, is one of the areas commonly affected
by cognitive dysfunction.58 ,5 9,13 Specifically, impairments in at-
tention, verbal memory, and executive functions have been asso-
ciated with poorer social functioning as measured by the Social
and Occupational Functioning Assessment Scale (SOFAS) and the
FAST- O subscales.60,61
4 | ASSESSMENT OF FUNCTIONING
One of the challenges of understanding functioning in patients with
BD is the great heterogeneity of instruments available for its assess-
ment. These vary in terms of domains, number of items, method of
administration, and scoring criteria, among others.62 This limits the
harmonization of results and prevents the drawing of strong con-
clusions about functional performance in this group of patients.
Psychosocial functioning in the elderly has unique characteristics
that are distinct from the younger population, making it neces-
sary to consider these differences in order to achieve an accurate
knowledge about functioning and its implications for the design of
interventions.
4.1 | Main limitations of the current instruments
The assessment of functioning in OABD presents potential limitations,
especially driven by the available instruments. Overall, the main limi-
tations are related to the fact that there are no specific instruments
targeted for assessing functioning in OABD. Thus, the available alter-
natives for assessment are as follows: (1) scales validated in BD but not
in older adults, (2) scales that assess functioning in the general popula-
tion, or (3) instruments validated for older adults but not specific for
BD. A recent systematic review63, aimed at quantifying which scales
are being used to assess f unctioning in OABD, concluded that the most
frequent scale was the GAF, which is not specific for BD. In contrast,
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MONTEJO et al.
few studies used scales that are validated in BD, such as The Strauss–
Carpenter scale (SCS) or the FAST- O scale.61
4.2 | Currently used assessment instruments
Commonl y used scales fo r assessing func tioning are not sp ecifically de -
veloped to assess areas of functional impairment in BD or are designed
for monitoring health levels in whole communities. This is the case, for
example, for the frequently used GAF.3 A previous systematic review,
despite it was not specifically focused in OABD, demonstrated a high
utilization of GAF and FAST scales for assessment functioning, in both
observational and interventional studies. In addition, it emphasized the
use of specific domains such as work, social, family, relationships, and
its relation with cognitive functioning and clinical variables.64
4.2.1 | GAF
The GAF65 is the most commonly used clinician rating scale to meas-
ure disability, at least in the United States.66 This scale has the limi-
tation that it provides a total score without differentiating between
functional areas, and its results are highly influenced by the pres-
ence of clinical, but not somatic symptoms. Scores range from 0 to
100, with higher scores indicating better levels of functioning. The
GAF assesses psychological, social, and occupational functioning,
and, due to its quick and easy administration, it is frequently used
by clinicians. However, the GAF scale is not specifically validated for
the assessment of people with BD, therefore, some specific func-
tioning areas cannot be represented by using this instrument, thus
preventing a complete description of the level of functioning. The
rating can be based on information such as an interview or ques-
tionnaire, medical records, or information from caregivers or close
relatives.
4.2.2 | FAST and FAST- O
The functioning assessment short test (FAST)15 was developed for
the clinical evaluation of functional impairment presented by pa-
tients diagnosed with BD. This easy- to- apply and brief scale was de-
signed based on an earlier reported definition of functioning,19 and
includes the assessment of the most important domains affected in
BD: autonomy, occupational and cognitive functioning, finance man-
agement, interpersonal relationships, and leisure time. Additionally,
it provides different cut- off values in order to differentiate catego-
ries of severity of functional impairment.6 The FAST is sensitive
to change and is currently used in many randomized clinical trials
to test the impact of interventions on functional capacity.67 FAST
score ranges from 0 to 72, with higher scores indicating worsening
function.
Since the FAST is not specifically applicable for the older adult
population, an adaptation of the FAST scale has been developed
and validated for adults over 50 years, the FAST- O61 that aims
to more accurately capture potential alterations in functioning
among older people.61 The main changes were made to the domain
of occupational functioning since it is common to find a high pro-
portion of retired adults among older adults. Hence, the domain of
occupational functioning was replaced by the domain of “societal
functioning,” which also includes activities such as volunteer work
or taking care of grandchildren. The FAST- O is an indicator of a
patient's current level of daily functioning, and therefore focuses
on performance.
4.2.3 | WHODAS 2.0
The use of the World Health Organization Disability Assessment
Schedule 2.0 (WHODAS 2.0)68 is also recommended by DSM- 5. The
WHODAS 2.0 is a clinician- rated instrument that assesses function-
ing and disability independently of clinical diagnosis. It assesses six
independent areas of functioning: (1) Cognition— understanding
and communicating; (2) Mobility— moving and getting around; (3)
Self- care— hygiene, dressing, eating, and staying alone; (4) Getting
along— interacting with other people; (5) Life activities— domestic
responsibilities, leisure, work, and school; (6) Participation— joining
in community activities. It provides an overall score and also by func-
tioning areas. It assesses disability using a Likert scale from 0 (no
difficulty) to 5 (extreme difficulty). The higher the total score, the
greater disability. The time frame is the past 30 days and the num-
ber of days of experienced difficulty is also considered. It includes a
total of 36 items but it is also available in a 12- item version. It also
has informant- rated versions. Finally, although it was not initially de-
signed for BD, it has subsequently been validated for this popula-
tion, resulting in suitable psychometric properties when applied to
patients with BD.69
4.2.4 | UPSA
The UPSA scale (UCSD Performance- based skills assessment)70
is focused on the ability to perform interactive and social tasks
such as planning, understanding, finances, communication skills,
mobility, and home management through an ecological approach,
including tasks directly related to daily functioning. It is scored
from 0 to 100, with higher scores indicating worse performance.
Scores are performance- based rather than self- or clinician- rated.
It tends to be very highly correlated with measures of cognitive
performance, but may not capture unique aspects of functioning
over and above those driven by cognitive dysfunction. This scale
has some potential limitations such as the lack of updating on
how some items are assessed (i.e., no use of technologies in the
tasks) which may hinder an adequate representation of function-
ing in modern times. In addition, the content of some items may be
highly biased by cultural components, hampering a real represen-
tation of the actual patient's performance.
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MONTEJO et al.
4.2.5 | SOFAS
The SOFAS71 evaluates social, psychological, and occupational func-
tioning through a hypot hetical health- disease continuum. In contrast
to the GAF scale, the development of the SOFAS scale arose from
the need to assess global functioning, but not necessarily due to
psychiatric clinical symptoms. Moreover, the scale does not include
items designed to assess impairment or difficulties due to physical or
medical conditions. It is quick and easy to use by means of a single
overall score from 0 to 100 in which a higher score indicates bet-
ter performance. It does not provide information on functioning in
separate areas, and it was not designed for the assessment of people
with mental health problems.
4.2.6 | VRFCAT
The Virtual Reality Functional Capacity Assessment Tool
(VRFC AT)72 uses a realistic virtual environment to assess the cur-
rent level of functioning. The VRFCAT assesses a subject's abil-
ity to complete instrumental activities associated with a shopping
trip, including searching the pantry at home, making a shopping
list, taking the correct bus to the grocery store, shopping in the
store, paying for groceries, and returning home. The alternate
forms are a unique feature of this assessment, and the scenarios
have the potential to be updated and cross- culturally adapted in
geographical regions where computer use, public transportation,
and grocery stores are common. In previous studies, the VRFCAT
has demonstrated high test– retest reliability and shown sensitivity
to functional impairment. However, it is required to have a com-
puter in order to conduct this test and the subject needs to be
minimally familiar with the use of a keyboard or mouse is neces-
sary. It does not provide information about interpersonal relation-
ships or social functioning and was not validated specifically for
OABD.
4.2.7 | AMPS
The assessment of motor and process skills (AMPS73) evaluates
the performance and quality of execution in ADL in a natural,
task- relevant environment (i.e., home) through different familiar
tasks for the patient (preparing a snack, performing household
activities, getting dressed, shopping for food, etc.).73 The AMPS
assesses the motor and process skills including a total of 16 ADL
motor items and 20 ADL process skill items, and thus uses an eco-
logical approach. The scoring is based on observation of the pa-
tient per forming daily life tasks on a Liker t scale from 4 to 1, where
lower scores indicate poor performance. It also allows for culture-
relevant evaluation while remaining free from cross- cultural bias.
Its administration does not require special equipment. AMPS is
destined for younger adult BD patients,74 but it is not specifi-
cally validated for OABD. Despite the previous advantages, this
scale presents some limitations. It is designed to be applied only
by occupational therapists and it takes a bit longer for applying
(30– 40 mins) than most other instruments. Despite its high
ecological value, the fact that it should be performed in a real
environment may increase the available resources (time, employees)
thus decreasing the practicality or effectiveness of its use.
4.2.8 | SAS
The Social Adjustment Scale (SAS75) consists of 54 items that are
divided into four areas of social functioning: work activities includ-
ing work for pay, housewife/househusband, or student (work), spare
time and leisure activities (spare), and personal relationships. Higher
scores on the SAS reflect poorer functional adjustment. While it
offers an assessment of functioning in different roles, assessment
takes longer than with other instruments. The SAS has also been
validated for healthy older adults,76 but has not been validated yet in
patients with BD (Table 1).
4.3 | Other potential sources of information
As mentioned earlier, there is a great variability in the assess-
ment of functioning. The choice for one scale or another could
determine differences in functional performance frequently found
among studies. The current instruments have limitations that pre-
vent comprehensive assessment of OABD. Frequently, function-
ing assessment scales are not fully applicable for OABD patients,
whereas they mostly include areas that are less important for
them. For instance, occupational functioning in the case of paid
work or volunteer work may not apply to those with OABD. When
addressing older adults, including adults over 50 years old, a high
heterogeneity can be found in the occupational area, given that
some patients will be within working age while other patients
could be retired. In this sense, it is also important to collect infor-
mation beyond work performance, that is, related to involvement
in community activities such as volunteering, caring for family
members, or organizing activities. Further OABD- tailored instru-
ments targeted to assess functioning are needed to enhance re-
search in this field and clinical management.
4.3.1 | Ecological momentary assessment
A novel source of information concerning functioning in OABD can
be found in ecological momentary assessment (EMA). EMA refers
to a range of assessment methods that share several features: they
use repeated sampling, they assess close in time to the actual ex-
perience, and the subject is in their natural environment during the
assessment. EMA offers multiple advantages, where it is thought
to be less biased by cognitive dysfunction or current mood. EMA
methods have been demonstrated to be effective in monitoring
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MONTEJO et al.
TAB LE 1 Description, strengths, and limitations of the current scales for assessing functioning.
Scale Description Strengths Limitations
GAF • It assesses global functioning considering psychological,
social, and occupational factors along a hypothetical
health- disease continuum (1– 100).
• It assesses functioning considering the last 12 months.
• Rated from 0 to 100. Higher scores indicate better
functioning.
• Applied by a clinician.
• Brief to
administer.
• No specific
training is
required.
• Designed for
mental illness'
functioning.
• It is not divided by areas and
provides a single total score.
• The score is highly influenced
by the presence of clinical
symptomatology.
• The assessment period is broad.
• Not designed specifically for BD.
• It does not provide thresholds of
severity.
• It is not specifically focused on
elderly.
FAST and
FAST- O
• It assesses psychosocial functioning in six areas: autonomy,
occupational functioning, cognitive functioning, financial,
interpersonal, and leisure.
• Clinician- administered instrument.
• It takes approximately 15 minutes of application.
• It assesses the severity of the difficulties in a Likert scale
from none to several difficulties. Scored from 0 to 72 in
which the higher score, the worse functioning.
• The assessment period corresponds to the last 15 days.
• It provides
information on six
domains of daily
living.
• It provides not
only an overall
score, but also
a score for each
domain.
• Brief and easy to
apply.
• Specially
designed for
mental disorders
and well- validated
for BD.
• There is a version
adapted to OABD.
• The results show
the level of actual
functioning
independently of
the clinical status
of the patient.
• It has different
validated cut-
off points to
differentiate the
severity of the
impairment.
• It requires a brief training for
administering and scoring.
WHODAS
2.0
• It is a measure that assesses disability in adults aged
18 years and older.
• Six functioning areas including cognition, mobility, self- care,
interpersonal relationships, life activities, and participation
in community activities
• Includes a total of 36 items. Each item contains a 5- point
Likert scale (from No Difficulty to Extreme Difficulty).
The number of days the patient had that difficulty is also
considered.
• It assesses functioning in the past 30 days.
• It is administered by a clinician.
• It has a brief (12-
item) and a self-
applied version.
• It allows rating an
overall disability
score and also by
functioning areas.
• It also includes
physical and
general health
factors.
• Easy to access.
• Validated for BD
• Long administration time.
• Administration and scoring
training is required.
• Tool not specifically focused on
older ages.
(Continues)
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MONTEJO et al.
mood changes and cognitive impairment.77, 78 In addition to using
objective and accurate data, these kinds of tools provide real- time
information, eliminating, thus, recall biases due to retrospective re-
ports.79, 80 The assessment is brief and can be used by patients dur-
ing their daily routines. However, there is limited standardization of
measures or scoring. EMA has been used as a research tool mostly,
although there is good potential for clinical application. Up until now,
EMA has been used in the assessment of younger adults with BD,
but not OABD.
4.3.2 | Caregivers or relatives as informants
Although OABD can be reliable informants of their actual level of
functioning, in some cases, collateral information may contribute to
increase the reliability and validity of the assessment. To overcome
this, it is essential for the clinician to consider the need for enriching
information with external informants (i.e., relatives, caregivers) who
spend enough time with the patient to accurately describe their daily
functioning.
Scale Description Strengths Limitations
UPSA • Role playing test that assesses ability in different areas
based on living skills, such as finance, communication,
organization or planning, mobility, and home management.
• Interviewer administered.
• Scored from 0 to 100, lower scores indicate better
performance.
• Evaluates functioning at the moment of the assessment.
• It is a highly
ecological
assessment,
including tasks
that are related to
daily functioning.
• It evaluates
functioning
considering
different domains.
• A brief version
is available
(UPSA- B).
• It is long to administer and the
clinician may be trained in its
administration and scoring.
• The results could be influenced by
cognitive status.
• It has a strong cultural bias.
• Some items are outdated.
• Not specifically designed for
mental illness nor BD.
• It is not specifically focused on
older ages.
SOFA S • It is a measure of functioning focused on social and
occupational skills.
• It includes impairments caused by physical and psychiatric
disorders.
• Scores range from 0 to 100, in which lower scores
represent lower functioning.
• Only considers performance at the moment of the
assessment.
• Easy and quick to
apply.
• No specific
training is
required.
• It is only focused on two areas of
functioning.
• Provides a single overall score, not
divided by domains.
• Not specific for mental health.
• It is not specifically focused on
older ages.
VR FC AT • It uses a realistic virtual environment focused on
instrumental activities
• The assessment is computerized
• It considers functional performance at the moment of the
assessment.
• Scores are based on time, errors, and progression
• No specific
training is
required.
• Real- life
situations are
used in the
assessment
• Easy to apply
when a computer
is available
• Availability of a computer is
required
• It is not specifically focused on
older adults
• It does not take into account
social aspects of functioning
AMPS • Evaluates the performance and quality of execution in ADL
• Measures functioning through familiar tasks for the patient
• Scores are based on observation
• Free from cross-
cultural bias
• Uses a natural,
task- relevant
environment
• Administration
does not require
special equipment
• It is not specifically validated for
OABD
• Designed to be applied only by
occupational therapists
• Takes longer to apply than other
instruments
SAS • It measures social adjustment in four areas
• It is self- rated
• Higher scores reflect poorer adjustment
• It is developed
for patients
with depressive
symptoms
• It is validated in
older adults
• Applying takes longer than other
instruments
• It is not specifically focused on
bipolar disorder
Abbreviations: AMPS: Assessment of Motor and Process Skills; FAST: Functioning Assessment Short Test; GAF: Global Assessment of Functioning;
SAS: Social Adjustment Scale SOFAS: Social and Occupational Functioning Assessment Scale; UPSA: UCSD Performance- based skills assessment;
VRFCAT: Virtual Reality Functional Capacity Assessment Tool; WHODAS 2.0: World Health Organization Disability Assessment Schedule 2.0.
TAB LE 1 (Continued)
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9
MONTEJO et al.
5 | FUTURE RECOMMENDATIONS
5.1 | General recommendations
Current available data suggest that OABD has distinguishing fea-
tures that merit special attention. Therefore, assessment of psycho-
social may differ from those used for younger people with BD.
First, OABD are particularly vulnerable to experiencing func-
tional impairment in different domains, even when they are in clin-
ical remission. Thus, it is important to include the assessment of
functioning into routine clinical practice, albeit especially during
full or partial remission from mood symptoms if possible. It is also
suggested to regularly repeat measurements, recommended every
6 months or after every clinical application, to make reliable esti-
mates of the current level of functioning. Moreover, in the context
of psychological interventions or clinical trials, it is encouraged to
include the assessment of functioning at least at baseline point
and post- intervention evaluation. Additionally, including repeated
measures of functioning in the follow- up point, after treatment
completion (i.e., 1 year after the inclusion or starting the interven-
tion), would be helpful to determine whether the potential changes
related to the treatment are maintained over the long term and to
monitor the evolution of functional performance.
As aforementioned, functioning includes different domains, such
as autonomy, interpersonal relationships, and social functioning.
Therefore, it is important to include multiple areas of functioning
in any assessment, and most existing scales are either global rating
scales or are not entirely relevant for OABD. It is, therefore, import-
ant to consider the use of instruments validated for the assessment
of people with BD and that have been adapted for use among older
adults. The FAST- O is the instrument that better fits this profile at
the time of writing.
Since functioning is a complex construct, it is important to in-
clude various sources of information in addition to self- report, such
as caregivers. As cognitive functioning is associated with other as-
pects of functioning,81 especially verbal memory,82 the inclusion of
objective cognitive measures may be helpful. Regarding the multidi-
mensionality of functioning, even with using a validated instrument,
clinicians should be aware of any other domains that may have an
impact on a patient's level of functioning at the moment of the as-
sessment. Data on functioning and OABD remain sparse, so that it is
important for clinicians and researchers to harmonize their assess-
ments in order to facilitate research on this topic. The recommenda-
tions are summarized in Table 2.
5.2 | Assessment of functioning: Adaptation and
development of instruments
The assessment of functioning is essential for obtaining an integral
and holistic approach of the patient. Most often used instruments
are not applicable to the older patient population. New assessment
instruments should be specifically designed and validated for OABD,
and existing instruments should be adapted where possible. These
instruments should include the above- mentioned factors that im-
pact functioning in OABD. In addition, some homogenization in the
use of instruments to assess functioning is recommended, in order
to harmonize data between different countries or centers and fa-
cilitate research on this topic.29 In that sense, this task force recom-
mends the use of FAST- O61 as it has potential advantages compared
to other scales: (1) it is designed and validated for BD, (2) it has an
adapted version for older ages, (3) it collects the domains of func-
tioning mainly affected in BD, and (4) it is brief and easy to apply.
5.3 | Combining different sources of information
Due to the complexity of the concept “functioning,” different infor-
mation sources should be combined when possible. For instance, it
would be helpful to collect the information of a reliable informant,
such as a caregiver or a relative. Moreover, the combination of self-
report instruments with clinician- based rating scales might provide
useful information. To do so, it might be helpful to also use the ex-
pertise of different mental health care professionals, like neuropsy-
chologists and nurses.
5.4 | Development of treatment strategies
Although more work is needed, some groups are already working on
adapting treatments to improve the functioning of OABD patients.
For example, a recent study has focused on the adaptation of the
Functional Remediation program in bipolar patients,83,84 which has
been proven to be effective in BD, for the older population with
TAB LE 2 Quick guide for addressing assessment of functioning
in OABD.
Including the assessment of functioning as a routine in clinical
practice to achieve better understanding of the patient's status
is advisable.
It is advisable to asse ss functioning regularly (e.g., every 6 months or
every year) for monitoring its evolution.
It is recommended to use those instruments that include the largest
number of functioning domains in the assessment such as
autonomy, interpersonal relationships, social involvement and
leisure time, etc.
The use of instruments specifically designed for BD and adapted for
older adults is highly recommended. The FAST- O is currently the
only scale that meets these requirements.
Clinicians should try to include, whenever possible, other sources of
information, such as reliable informants (caregivers or relatives),
to assess functioning in OABD to avoid bias due to lack of insight
or cognitive dysfunction, for instance.
Consider cognitive performance in the assessment of functioning, as
the two constructs are strongly associated.
Concerning research, clinicians should try to homogenize and
harmonize data to facilitate research and increase its quality.
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10
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MONTEJO et al.
BD (NCT05186337 ). 85 A cognitive remediation intervention was
also adapted for OABD using a program that includes cognitive re-
mediation, physical exercise, and social encounters with peers.86
Researchers are also looking into biomarkers and predictors of re-
sponse to cognitive and functional remediation.87
6 | CONCLUSIONS
The construct of daily functioning is complex. However, psycho-
social functioning should be considered a core feature of OABD.
As also illustrated by the case study in Section 1.1, the aging pro-
cess involves a series of social, somatic, and cognitive changes
that affect different aspects of everyday function in OABD when
compared with younger adults with BD. Psychosocial functioning
performance in OABD is still understudied and there is a lack of
consensus on how to assess and address it in OABD. Special con-
sideration should be given to the differentiating factors in OABD
to achieve a better understanding of functioning of this group of
patients, especially the chronicity of the disease, medical comor-
bidities, and the presence of depressive episodes. In summary, we
recommend (1) the use of scales that are specifically designed for
BD and adapted for older adults and also include functioning in
multiple domains instead of providing a single global score; (2) com-
pleting the information with a variety of sources (such as reliable
informants); (3) include functioning in the clinical assessment and
assess it periodically, and (4) homogenize and harmonize data to
facilitate research. A better understanding of psychosocial func-
tioning in OABD will contribute to guiding the development of in-
terventions designed to maintain or improve the daily function and
quality of life of OABD.
ACKNOWLEDGMENTS
This research was supported by CIBER - Consorcio Centro de
Investigación Biomédica en Red- (CB07/09/0004), Instituto de Salud
Carlos III, Spanish Ministry of Science and Innovation. EJ and LM
thank the support of the Spanish Ministry of Science and Innovation
(PI20/00060) integrated into the Plan Nacional de I + D + I and co-
financed by the ISCIII- Subdirección General de Evaluación and
the Fondo Europeo de Desarrollo Regional (FEDER); the Instituto
de Salud Carlos III; the CIBER of Mental Health (CIBERSAM); the
Secretaria d'Universitats i Recerca del Departament d'Economia i
Coneixement (2021 SGR 01358); and the CERCA Programme. EV
thanks t he support of the S panish Ministr y of Science and Innovation
(PI18/00805, PI21/00787) integrated into the Plan Nacional de
I + D + I and co- financed by the ISCIII- Subdirección General de
Evaluación and the Fondo Europeo de Desarrollo Regional (FEDER);
the Instituto de Salud Carlos III; the Secretaria d'Universitats i
Recerca del Departament d'Economia i Coneixement (2017 SGR
1365), the CERCA Programme, and the Departament de Salut de
la Generalitat de Catalunya for the PERIS grant SLT006/17/00357.
Thanks to the support of the European Union Horizon 2020 re-
search and innovation program (EU.3.1.1. Understanding health,
wellbeing and disease: Grant No 754907 and EU.3.1.3. Treating and
managing disease: Grant No 945151). LTE acknowledges support
from the VA Desert- Pacific Mental Illness Research Education and
Clinical Center.
CONFLICT OF INTEREST STATEMENT
RP receives partial salary support from Biogen Inc. and NIH/NIA,
both unrelated to the current manuscript. EV has received grants
and served as consultant, advisor, or CME speaker for the following
entities: AB- Biotics, AbbVie, Adamed, Angelini, Biogen, Boehringer-
Ingelheim, Celon Pharma, Compass, Dainippon Sumitomo Pharma,
Ethypharm, Ferrer, Gede on Richter, GH Research, G laxo- Smith Kline,
Janssen, Lundbeck, Medincell, Merck, Novartis, Orion Corporation,
Organon, Otsuka, Roche, Rovi, Sage, Sanofi- Aventis, Sunovion,
Takeda, and Viatris, outside the submitted work. PC, AD, LTE, AG,
EJ, LM, MO, AO, and PVN have nothing to disclose.
DATA AVAI L ABI LI TY S TATE ME NT
Data sharing not applicable to this article as no datasets were gener-
ated or analysed during the current study.
ORCID
Laura Montejo https://orcid.org/0000-0003-4407-9454
Melis Orhan https://orcid.org/0000-0002-6760-2917
Ariel Gildengers https://orcid.org/0000-0001-9216-988X
Paula Villela Nunes https://orcid.org/0000-0001-5323-2110
Andrew T. Olagunju https://orcid.org/0000-0003-1736-9886
Eduard Vieta https://orcid.org/0000-0002-0548-0053
Annemiek Dols https://orcid.org/0000-0003-1964-0318
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How to cite this article: Montejo L, Orhan M, Chen P, et al.
Functioning in older adults with bipolar disorder: A report on
recommendations by the International Society of bipolar
disorder (ISBD) older adults with bipolar disorder (OABD)
task force. Bipolar Disord. 2023;00:1-12. doi:10.1111/
bdi.13368
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