Managing bipolar affective disorder (BPAD) presents challenges, particularly when optimising therapeutic regimens (Depp & Jeste, Reference Depp and Jeste2004). Psychiatrists aim to achieve remission of symptoms with effective prescribing of medication and appropriate psychosocial interventions. Prescribing challenges are accentuated in older adults (≥65 years), where frailty, comorbidity, and pharmacokinetic changes increase vulnerability to side effects (Gottlieb, Reference Gottlieb2004). While lithium remains an effective maintenance treatment, comorbidities such as renal dysfunction may restrict its use (Rej et al., Reference Rej, Elie, Mucsi and Looper2015). Although multiple international guidelines exist, such as those from the National Institute for Health and Care Excellence (NICE), the Canadian Network for Mood and Anxiety Treatments (CANMAT), and the International Society for Bipolar Disorders (ISBD), few offer specific recommendations for patients (≥65 years) due to the absence of dedicated trials (Yatham et al., Reference Yatham, Kennedy and Parikh2018; NICE, 2014; Goodwin et al., Reference Goodwin, Haddad, Ferrier, Aronson, Barnes and Cipriani2016; Taylor et al., Reference Taylor, Barnes and Young2018; Sajatovic et al., Reference Sajatovic, Madhusoodanan and Coconcea2005).

This service evaluation aimed to describe the prevalence and type of psychotropic medications prescribed to clinically stable outpatients aged ≥65 years with BPAD, to inform local practice. We reviewed 62 clinical files of patients with a confirmed diagnosis of BPAD based on ICD-11 criteria (9). Patients were included if they were under regular psychiatric follow-up and clinically stable, defined as absence of an acute affective episode, no hospital admissions, and no medication changes for at least three months prior to review. Files with incomplete data or unclear diagnoses were excluded. The final sample comprised 48 patients, with a mean age of 79.7 years (range 66–93); 77% were female, and 65% had BPAD II.

Lithium was the most frequently prescribed mood stabiliser (63%), followed by sodium valproate (25%). Overall, 87% of patients were prescribed a mood stabiliser. Lithium doses were lower than those reported in younger populations with a mean dose of 328 mg (Al Jurdi et al., Reference Al Jurdi, Marangell, Petersen, Martinez, Gyulai and Sajatovic2008; Beyer et al., Reference Beyer, Burchett, Gersing and Krishnan2008). Only 10% of the cohort were maintained on monotherapy, with the majority requiring two or more agents.

Antipsychotics were more commonly prescribed in BPAD I (82%) than BPAD II (58%), with olanzapine most frequent. Quetiapine was prescribed at higher doses in BPAD I than II. Antidepressant use was high (60%), especially in BPAD II, and nearly half the sample received sedative-hypnotic medication, mainly Z-drugs.

To our knowledge, this is the first such report from an Irish psychogeriatric outpatient setting. Our findings highlight several deviations from guideline expectations for maintenance treatment of BPAD. Combination therapy was predominant and mood stabiliser doses were lower than typically recommended, differing from guideline recommendations derived from younger adults, where monotherapy is usually adequate (Yatham et al., Reference Yatham, Kennedy and Parikh2018; NICE, 2014; Taylor et al., Reference Taylor, Barnes and Young2018). There was also a higher reliance on antipsychotics, likely reflecting the need to achieve or maintain remission safely with lower mood stabiliser doses. Finally, sedative use exceeded guideline caution, illustrating real-world challenges of managing sleep disturbance and anxiety in older adults (American Geriatrics Society, 2019).

Three additional observations are notable. First, lithium use in this Irish cohort was higher than in comparable reports from the United States, where concerns about renal safety often lead to under-prescription (Al Jurdi et al., Reference Al Jurdi, Marangell, Petersen, Martinez, Gyulai and Sajatovic2008; Beyer et al., Reference Beyer, Burchett, Gersing and Krishnan2008). Second, monotherapy was rarely sufficient, underlining the complexity of maintenance treatment in later life. Third, the relatively high use of sedatives raises safety concerns, particularly regarding falls and cognition (American Geriatrics Society, 2019; Sajatovic et al., Reference Sajatovic, Madhusoodanan and Coconcea2005).

Although this was a single-site evaluation without outcome measures or statistical comparisons, it highlights the pressing need for tailored prescribing guidelines for older adults with BPAD. Future multisite evaluations with larger cohorts will be important to improve generalisability.

In summary, this service evaluation provides a snapshot of prescribing practices in the maintenance treatment of older adults with BPAD within an Irish outpatient setting. We hope it offers a useful reference point for clinicians and contributes to the case for age-specific guidance in this underrepresented population.