Mohammed T. Abou-Saleh

Principles and Practice of Geriatric Psychiatry.Editors: Professor John R. M. Copeland, Dr Mohammed T. Abou-Saleh and Professor Dan G. BlazerCopyright & 2002 John Wiley & Sons LtdPrint ISBN 0-471-98197-4 Online ISBN 0-470-84641-086Mania: Clinical Features and ManagementS. Lehmann and P. RabinsJohns Hopkins Medical Institutions, Baltimore, MD, USADescriptions of manic syndromes in elderly patients publishedduring the 1960s and 1970s tended to emphasize differences inclinical features compared to younger manic patients. Post feltthat elderly manic patients had more depressive features and moremood-incongruent persecutory delusions, but were less likely tohave flight of ideas 1 . Slater and Roth noted that euphoric states inolder manic patients tended to be less ‘‘infectious’’ and had moreexpressed ‘‘hostility and resentment’’ 2 .More recent retrospective and prospective studies, on the otherhand, suggest that symptoms are actually quite similar across theage span. For example, two studies have reported that hyperactivity,insomnia and thought disorder (e.g. flight of ideas) occurin 60% of elderly manic patients. Other common manic symptomsinclude grandiose delusions, irritability, hypersexuality andparanoid delusions 3,4 . Similarly, a more recent study of 14patients over age 65 hospitalized with a first manic episodefound that 43% had psychotic features, including grandiose andpersecutory delusions 5 . In a prospective study comparing hospitalizedmanic patients over age 60 to those under age 40, nodifferences were found between young and old patients in the timecourse or outcome of the manic episode. However, the authorshad the clinical impression that younger patients tended toexperience a more severe illness than older patients. The authorsalso noted that more elderly patients relapsed into a depressiveepisode after discharge from the hospital 6 .There has been little research to date comparing elderly manicpatients with early- and late-onset bipolar disorder in terms ofclinical presentation, response to treatment or clinical course. Oneintriguing study of patients over age 60 hospitalized with bipolar,manic, mixed or depressed states found that elderly patients withlate-onset bipolar disorder were more likely to have psychoticfeatures compared to patients with early-onset bipolar disorder.However, early- and late-onset bipolar patients did not differ interms of pharmacological treatment, hospital stay length, orlikelihood to be admitted for a manic, mixed-state or depressedepisode 7 .Although several authors have noted that cognitive dysfunctionis common in elderly patients with mania, the relationshipbetween mania and dementia in older patients remains complex.Broadhead and Jacoby 6 found that 32% of elderly manic patientsscored within the demented range on a cognitive assessment, eventhough none of the patients had a history of progressiveintellectual decline. Moreover, there was no significant differencebetween manic patients with early- and late-onset bipolar disorderin terms of cognitive impairment. In a 5–7 year follow-up study of25 elderly patients previously hospitalized for acute mania, 32%had developed a clinically significant cognitive disorder 8 . Incontrast, an earlier 10 year follow-up study of 92 elderly patientswith mania found that only 3% had developed dementia 9 . Clearlythis is an area that warrants further study.TREATMENT AND MANAGEMENTA recent study of mental health service use by elderly patientswith bipolar disorder and unipolar major depression found thatthe bipolar patients used more case-management services, werethree times more likely to use partial hospitalization and threetimes more likely to have had at least one psychiatric hospitalizationover the 6 months prior to the assessment 10 . This studyhighlights the importance of effective treatment and mental healthmonitoring for elderly patients with bipolar disorder.As with younger patients, lithium carbonate is the mainstay ofpharmacological treatment in the older manic patient. There areclear changes in the pharmacokinetics of lithium with age, due toage-related decline in creatinine clearance. In people with no renaldisease there is a 30–50% decline in glomerular filtration rate(GFR) between the third and eighth decades. Since lithium isalmost exclusively excreted through the kidneys, this leads todecreased clearance of lithium with age. As a result, the biologicalhalf-life in the serum increases from 18 h in adolescents to 36 h inpeople over age 60 and may be even longer in elderly patients withrenal disease 11 .In addition, there is considerable agreement that both the toxicand therapeutic effects of lithium occur at lower plasma levels inthe elderly compared to younger patients. Plasma levels of lithiumthat would be considered therapeutic for a young manic patientcause delirium in some elderly patients. The reasons behind thisare unclear but it has been hypothesized that this phenomenonreflects an increase in brain sensitivity to lithium. Fine handtremor secondary to lithium also seems to occur more frequentlyin people over age 60 than in younger patients. In summary,therefore, it is prudent to begin elderly manic patients on lowerdoses of lithium than one would for younger patients, and to aimfor lower plasma levels of 0.5–0.6 mmol/l, even in the acute phaseof treatment. For long-term maintenance and prophylaxis, evenlower plasma levels of lithium of 0.4–0.5 mmol/l are often effectivefor this older age group.Studies of patients taking lithium over many years indicatethat lithium rarely causes changes in glomerular filtration rateor renal failure 12 . Furthermore, lithium does not appear todecline in efficacy over the lifespan 13 . However, for a variety ofreasons, some patients become unable to tolerate lithium asthey age. In these cases lithium treatment must be replaced orsupplemented by other mood-stabilizing medications. As withyounger patients, anticonvulsants such as carbamazepine,Principles and Practice of Geriatric Psychiatry, 2nd edn. Edited by J. R. M. Copeland, M. T. Abou-Saleh and D. G. Blazer&2002 John Wiley & Sons, Ltd