Mohammed T. Abou-Saleh

480 PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRYvalproate and clonazepam are being used more frequently as analternative or adjunct to lithium treatment 14 . Although systematicdata regarding the efficacy and toxicity ofcarbamazepine treatment in elderly manic patients are lacking,there are a few reports indicating that it can be safe andeffective in older patients 15 . The major risk of carbamazepine isthe rare occurrence of aplastic anemia or agranulocytosis 11 .However, many older patients have difficulty tolerating thismedication, due to its propensity to cause sedation and ataxia.In recent years valproate has been widely prescribed for theacute treatment of mania in both young and elderly patients withbipolar disorder. A case series study of seven older patients withlong-standing bipolar disorder who had failed to respond toconventional medications reported at least minimal improvementin six out of seven patients after valproate was added adjunctivelyto the medication regimen 16 . Two retrospective studies ofvalproate treatment of patients over age 60 hospitalized withmania found valproate effective in improving symptoms of maniaat serum levels of 31–106 mg/ml 17,18 . In another retrospective studyassessing the efficacy of lithium compared to valproate in patientsover age 55 hospitalized for mania, 38% of elderly patientsreceiving valproate were improved at discharge compared to 67%of patients receiving lithium. However, the authors note thatfewer patients on valproate therapy were within the therapeuticrange and valproate serum levels of 65–90 mg/ml correlated with abetter therapeutic response than did lower serum levels 19 .Gabapentin is a new anticonvulsant with gaba-ergic andglutaminergic properties that has been shown to have antimaniceffects and may be effective as an adjunctive agent in thetreatment of mania 20 . It has not yet been studied systematically inelderly patients. Similarly, in a mixed-age population of patientswith acute mania, olanzapine, a novel neuroleptic, was found tobe more effective than placebo 21 . Novel neuroleptics such asrisperidone and olanzapine have the potential to be particularlyuseful adjuncts in the treatment of mania in the elderly because oftheir lower rates of extrapyramidal side effects and tardivedyskinesia, compared with traditional neuroleptics 22 . As a result,they may be better tolerated by elderly manic patients thantraditional neuroleptics, such as haldol, for adjunctive treatmentof psychosis and agitation. More research is needed on both theshort- and long-term effects of these newer mood-stabilizing andantipsychotic medications in older persons.Finally, the clinical management of older patients with maniamust always include attention to psychosocial support issues andpsychotherapy. As with younger patients, individual counseling,emotional support and illness education are critical to a successfuloutcome. Additionally, involvement of family members andsignificant others in the acute treatment and long-term managementof the illness helps to ensure compliance with treatmentrecommendations and early detection of signs of relapse.REFERENCES1. Post F. The Clinical Psychiatry of Late Life. Oxford: Pergamon, 1965.2. Slater E, Roth M. In Mayer-Gross W, Slater E, Roth M (eds),Clinical Psychiatry, 3rd rev. edn. London: Baillière Tindall & Cassell,1977, pp 571–2, 600.3. Yassa R, Nair V, Nastase C et al. Prevalence of bipolar disorder in apsychogeriatric population. J Affect Disord 1988; B14B: 197–201.4. Glasser M, Rabins P. Mania in the elderly. Age Ageing 1983; 13, 210–13.5. Tohen M, Shulman KI, Satlin A. First-episode mania in late life. AmJ Psychiat 1994; 151: 130–2.6. Broadhead J, Jacoby R. Mania in older age: a first prospective study.Int J Geriatr Psychiat 1990; 5: 215–22.7. Wylie ME, Mulsant BH, Pollock BG et al. Age at onset in geriatricbipolar disorder. Am J Geriat Psychiat 1999; 7: 77–83.8. Dhingra U, Rabins PV. Mania in the elderly: a five to seven yearfollow-up. J Am Geriat Soc 1991; 39: 581.9. Stone K. Mania in the elderly. Br J Psychiat 1989; 155: 220–4.10. Bartelss SJ, Forester B, Miles KM, Joyce T. Mental health service useby elderly patients with bipolar disorder and unipolar majordepression. Am J Geriat Psychiat 2000; 8: 160–6.11. Jenike MA. Side effects of lithium. In Geriatric Psychiatry andPsychopharmacology. New York: Yearbook Medical, 1989: 85–6.12. Schou M. Forty years of lithium treatment. Arch Gen Psychiat 1997;54: 9–13.13. Murray N, Hopwood S, Balfour DJK et al. The influence of age onlithium efficacy and side effects in outpatients. Psychol Med 1983; 13:53–60.14. Keck PE, McElroy SL, Nemeroff CB. Anticonvulsants in thetreatment of bipolar disorder. J Neuropsychiat Clin Neurosci 1992;4: 395–405.15. Shulman KI, Herrmann N. The nature and management of mania inold age. Psychiat Clin N Am 1999; 22: 649–65.16. McFarland BH, Miller MM, Straumfjord AA. Valproate use in theolder manic patient. J Clin Psychiat 1990; 51: 479–81.17. Mordecai DJ, Sheikh JI, Glick ID. Brief report: divalproex for thetreatment of geriatric bipolar disorder. Int J Geriat Psychiat 1999; 14:494–6.18. Noaghiul S, Narayan M, Nelson JC. Divalproex treatment of maniain elderly patients. Am J Geriat Psychiat 1998; 6: 257–62.19. Chen ST, Altshuler LL, Melnyk KA et al. J Clin Psychiat 1999; 60:181–6.20. Ghaemi SN, Katzow JJ, Desai SP, Goodwin FK. Gabapentintreatment of mood disorders: a preliminary study. J Clin Psychiat1998; 59: 426–9.21. Tohen M, Jacobs TG, Grundy SL et al. Efficacy of olanzapine inacute bipolar mania: a double-blind, placebo-controlled study. ArchGen Psychiat 2000; 57: 841–9.22. Van Gerpen MW, Johnson JE, Winstead DK. Mania in the geriatricpatient population: a review of the literature. Am J Geriat Psychiat1999; 7: 188–202.23. Krauthammer C, Klerman GL. Secondary mania. Arch Gen Psychiat1978; 35: 1333–9.