Mohammed T. Abou-Saleh

474 PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRYorganic illness, rather than an idiopathic cause). These researchersdescribe manic symptoms that were secondary to drugs, infection,neoplasia, epilepsy and metabolic disturbances. The patients intheir study had a later onset of symptoms (average age of onset 41years) and fewer family members with affective illness than iscommonly reported in the literature describing bipolar subjects.Stasiek and Zetin 43 have updated Krauthammer and Klerman’soriginal study with additional organic causes of manic symptoms.These authors again emphasize the importance of looking for anorganic cause of mania when there is a negative family history foraffective disorder or a later onset to the bipolar disorder.Neurological disease, particularly cerebrovascular disease, isalso associated with secondary late-life mania 44–46 . Neuroimagingof manic geriatric patients has shown differences in the basalganglia morphology and the putamen volume when compared tocontrol subjects 47,48 .McDonald et al. demonstrate a correlation between bipolardisorder and subcortical hyperintensities, as evidenced onmagnetic resonance images in patients with the onset of manicsymptoms after the age of 50 years 49,50 . Only two of the 10 patientsin this study had a family history of affective disorders 49 . Thesignificance of subcortical hyperintensities has been debated,although they are thought to result from a focal loss of brainparenchyma, due to ischemia from any cause including hypertension,vasculopathy, atherosclerosis or thromboembolism 51 .Finally, Yassa et al. 52 find a low incidence of organic factorsprecipitating mania in an elderly population. However, seven oftheir 10 geriatric bipolar patients demonstrated a stressful event inthe 6 month period prior to their manic episode. None of thesepatients had a family history of affective disorders.AFFECTIVE DISORDERSIn summary, there is evidence from family studies and chromosomallinkage studies that manic depressive illness is transmittedgenetically and may have more than one mode of genetictransmission. There is also evidence from clinical studies thatthere may be a different etiology for bipolar disorder, which hasan onset early in life, compared to those which begin in olderadults. Late-onset mania is more often associated with organicprecipitants and, as in other types of mania, may be closelyassociated with stressful events. Patients with an earlier onset totheir symptoms more often have a family history of affectivedisorder. Clinically, patients who present with manic symptomsafter the age of 50 years should be given careful consideration foran organic cause to their symptoms, particularly if there is noevidence of affective disorders in other family members.REFERENCES1. Mendlewicz J, Rainer JD. 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