Manic-depressive illness is a brain disorder that produces significant changes in mood and can cause psychosis. Mania in the elderly occurs in three ways:
As patients get older.
Patients with pre-existing depression develop manic symptoms.
Patients who initially present with mania.
Research and Mania
Late life onset mania is relatively uncommon and may reveal underlying neurological diseases such as stroke and brain tumor. According to one study, about 5% of elderly psychiatric patients are manic. Also, among elderly patients with mania, 26% have no past record of mood disorder, 30% have pre-existing depression, 13% have past mania and 24% of them have organic brain disease.
Although the life expectancy of bipolar affective disorder patients is shorter compared to the general population because of suicide and alcoholism, many bipolar patients survive live to be in their 70s and 80s. The history of bipolar affective disorder in the elderly is still not clear, however if long term studies are taken into account, some bipolar patients have a shortening of cycles and increased severity of disease.
Unstable Bipolar Disorder Patients
Well-controlled bipolar patients become unstable for many reasons. Patients have worsening of symptoms because of medication non-compliance, medical issues, medical history, changes in symptoms over time, caregiver death, delirium, substance abuse and inter-current dementia. If there is acute worsening of symptoms in elderly bipolar patients, the patient requires careful evaluation to exclude delirium.
Elderly psychiatric patients often have high rates of alcohol and prescription sedative abuse that leads to delirium and agitated, delirious patients can appear manic. Psychoses, agitation, paranoia, sleep disturbance and hostility are symptoms common to both diseases. Delirious bipolar patients will have a prominent drop in the Mini-Mental Examination score from baseline but cooperative mania patients should have steady scores.
Discontinuation of Medication
Discontinuation of mood-stabilizing medication is an issue in elderly bipolar patients. Patients discontinue medicine for wide range of reasons. Some discontinue it because of new medical problems, others will due to the death of caregiver who distributed the medication and loss of support. It is of the utmost importance that blood levels be regularly monitored in all bipolar patients. Anti-manic agents may be discontinued during a serious medical illness and the patient can no longer take oral medication.
It is the job of physicians to ensure that there is no discontinuation of anti-manic agents for more than two or three days without the advice of a psychiatrist.
Bipolar patients will sometimes discontinue medication when the spouse or caregiver dies and the patient loses the much–needed psychosocial support. Primary care physicians will sometimes discontinue Lithium or Tegretol in some cases due to side effects even though both Lithium and Tegretol maintain mood stability.
Urine Collection and Nephrotoxicity
It is essential that patients have a 24 hour urine collection because patients with creatinine clearances below 50 ml per minute should be referred to a nephrologist. Many elderly bipolar patients with elevated BUN and creatinine who get lithium usually do not have lithium-induced nephrotoxicity. Elevated kidney function studies are normal in the elderly. It is important that Lithium, Tegretol or valproic acid not be discontinued because of medical issues unless an internist is consulted or an emergency has occurred.
Consultants should be informed that discontinuation of anti-manic agents will generally precipitate a relapse, according to one study. Acute mania will often destabilize medical problems of elderly bipolar patients which means stressed, manic elderly patients w with psychotic agitation may have to halt all medications (including cardiac medicines, and anti-hypertensives). It is important that the clinicians analyze the medical risk of sustained anti-manic therapy with respect to the medical risk of acute psychosis. Taking a decision such as this needs clear communication among medical specialists, psychiatrist, patient and family.
Unrecognized medical issues such as thyroid disease, hyperparathyroidism, theophylline toxicity can resemble mania. Other medications can also destabilize mood. There is no doubt that antidepressants and steroids more often provoke manic symptoms but ACE inhibitors, thyroid supplementation and AZT can also lead to mania in the elderly.
