Mohammed T. Abou-Saleh

482 PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRYsuggested from their study that elderly men with coarse brainchanges as a result of stroke, head trauma and other neurologicalconditions, appear to be most vulnerable to developing mania. KitStone 11 reported that 24% of his elderly patients developed maniafollowing some sort of cerebral insult. In their comparative studyof young and old manic patients, Broadhead and Jacoby 12 foundthat 20% of their elderly patients had first manic episodes thatwere closely related temporally to cerebral organic disease, incontrast to none in the younger manic group. In other words,manic episodes in late life may derive not only from apredisposition to bipolar disorder but also from cerebralpathological changes, and therefore the prognosis of thebrain disease may determine the prognosis of mania in thesepatients.Shukla et al. 22 studied 20 patients with mania after headinjury. They suggest a significant relationship between posttraumaticseizures and development of mania. Elderly individualsare more prone to falls and subsequently at a higher risk fordeveloping mania after head injuries. In a recent magneticresonance imaging (MRI) study of elderly manic patients,McDonald and Blazer 23 found an increased incidence of subcorticalhyperintensities in the right middle third of the brainparenchyma.Young and Falk 13 noted a less vigorous response to lithium inolder than in younger manic patients. This difference, based onage, was even more impressive since their sample maximum agewas 66 with a mean of 36 years. Their data suggest that increasedage may be associated with attenuation of aspects of manicpsychopathology and response to pharmacotherapy. Himmelochet al. 24 , in a study of 81 bipolar patients over the age of 55,demonstrated that neurological status rather than age is thecritical factor determining the natural course of the illness.Neurological status not only determined the evolution of chronicmania; it also predicted poor treatment response and lithiuminducedneurotoxicity.Despite the possible difference in the clinical presentation andresponse to treatments of mania in young and old age, evidenceindicates a good therapeutic response to lithium for both an acutemanic episode and prophylaxis in elderly patients, but closemonitoring is required, with particular attention to interactionswith other illness and medications. Contrary to the general belief,the prognosis of mania in old age is good and comparable to thatof the young manic patient.REFERENCES1. Grof P, Angst J, Haines T. The clinical course of depression: practicalissues. In Angst J, ed., Classification and Prediction of Outcome inDepression. New York: F. K. 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Bipolar affective disorder in old age. Br JPsychiat 1980; 136: 26–32.21. Glasser M, Rabins P. Mania in the elderly. Age Ageing 1984; 13: 210–13.22. Shukla S, Cook BL, Mukherjee S et al. Mania following head injury.Am J Psychiat 1987; 144: 93–6.23. McDonald and Blazer 1990.24. Himmelhoch JM, Neil JF, May SJ et al. Age, dementia, dyskinesiaand lithium response. Am J Psychiat 137: 941–5.