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Late onset Mania
DR. RAVI SONIDM SR III
DEPT. OF GERIATRIC MENTAL HEALTHKGMU, LKO
1
Highlights Bipolarity in the elderly is heterogeneous and
require careful differential diagnosis
Medical assessment is essential
Mania runs atypical course in elderly
Cognitive impairment is a frequent concomitant of bipolar disorders in the elderly
2
Mania in elderly: Considerations
Whether late-onset manic episodes represent a different entity or they should or should not be considered differently for treatment
Why detailed evaluation of the first episode Mania in elderly is necessary? There is higher rate of Secondary Mania in elderly population Higher mortality rates of mania Relationship between affective disorders and dementia There are differences in treatment approaches
According to currently accepted definition, Cases over 50 years of age are considered as “late-onset”, and Cases over 60 years of age are considered as “very late-onset” manic
disorders Major confusion is with delirium The risk of dementia may increase in patients with geriatric mania Severe derangement may be detected in the cognitive functions of
patients during a manic episode.
3
4Differential Diagnosis of Mania in elderlies
The differential diagnosis is broad and includes:
• Bipolar manic and mixed states• Delirium• BPSD • Schizophrenia and schizophrenia like Psychosis• Schizoaffective disorder- Bipolar type• Drug intoxication, and• Mood disorder due to medical disorders
Phenomenology is not the same as Adults always So, differential diagnosis is very important
5
Kennedy GJ, 2008
Geriatric Mania or Late onset Mania
Late onset Mania: Early age at onset (recurrent mood disorder with
manic episode in later age) Late age of onset (first episode of Mania after 60
years of age) Mood disorders may be related to underlying
medical or neurological condition, substance use or psychotropic drugs (particularly antidepressant induced manic switch)
6
7Some Medical Causes of Mania Related Disorders/Substances
Neurologic Dementia Head injury CNS tumor Multiple sclerosis Stroke Epilepsy Wilson’s disease
Sleep apnea Vitamin B12 deficiency Endocrine
Hypo- or hyperthyroidism Hypercortisolemia
Infectious HIV Syphilis Lyme disease Viral encephalitis
Toxic Substances Medications
(corticosteroids, amphetamines, and other sympathomimetics, L-DOPA)
Forester et al. 2004
8Assessment Psychiatric, medical/neurological, treatment
history; Mental status examination; Physical/neurological examination; Clinical laboratory tests
Include TSH, folate, B12 ECG Neuroimaging, when indicated e.g.,
neurological signs/symptoms, late onset, different presentation from prior episodes, presence of vascular risk factors
9Epidemiology 5-18 % among geropsychiatric admissions Prevalence of Bipolar disorder is around 0.1 to 0.5%
among individuals 65 years and older Persons age 60 years and older constitute about 25% of
the population with bipolar disorder 6–8% of all new cases of bipolar disorder developing in
persons age 60 years and older The incidence of mania at age greater than 75 years is
around 2 per 100000 persons The distributions of the subtypes of a single depressive
episode or mania/bipolar disorder are remarkably similar for male and female patients aged over 65 years
Kessing LV. 2006, Azorin et al. 2010, Benedetti et al. 2008, Dhonju et al. 2014
Clinical Characteristics of Late onset Mania
Is different Studies have suggested that mania in old age is less
severe and manifests with more irritability, confusion, psychosis, and mixed features
higher levels of premorbid psychosocial functioning Family history of Bipolar illness is less common Comorbid medical illness is more common Persecutory delusion are more common in elderlies Typical flight of ideas is rare and inconsistent with the
patient’s mood The euphoria in elderly manic patients is not contagious Hostility is more prominent
Ipekcioglu et al. 2015
10
Differences between Early and Late onset mania
Lower rate of positive family history and prior psychiatric history Higher rate of association with cerebral organic disorder and
neurological comorbidities Higher rates and longer duration of hospitalization Slower improvement Higher rates of anxiety
Azorin et al. reported Late-onset bipolar illness as Secondary disorder, Expression of a lower vulnerability to the disease, Subform of pseudodementia, Risk factor for developing dementia, and Bipolar type VI (bipolarity in the context of dementia – like
processes)
Ipekcioglu et al. 2015, Azorin et al. 2010
11
Late onset Mania as a secondary Mania
Concept was elaborated by Krauthammer and Klerman to describe Subform of bipolar illness associated with wide variety of organic factors
Neurological illness (mostly cerebrovascular disorders) was found twice as frequent
Diagnosis of dementia is associated with increased risk of manic episodes at follow up.
Brain injury, epilepsy, brain tumors, encephalitis, and various forms of cerebral infection are found be associated with it
Neuroimaging: lesions in late onset mania Subcortical hyperintensities, Decreased cerebral blood flow, and Silent cerebral infarcts
Azorin et al. 2010
12
Late onset Bipolar illness (LOBI) as a “Bipolar Type VI”
Recently proposed to include LOBI into the bipolar spectrum under the “bipolar type VI” category
Could represent the various forms of LOBI, including Secondary disorders Bipolar liability revealed by dementing process Bipolar pseudodementia (the clinical picture may be close to
that of mixed or agitated depression) Created to address the commonalities in the
pathophysiological processes of bipolarity and dementia
Azorin et al. 2010
13
Treatment Cautious use of drugs while treating elderly because
Pharmacokinetic and pharmacodynamic changes that occur with ageing,
Frequent concomitant medical illnesses and their treatments,
Increase the risk of adverse events and drug interactions Management starts with thorough assessment for
medical/neurological illnesses that may be associated with manic symptoms
Valproate is better tolerated than lithium Lithium requires lower serum levels like 0.4-0.7 mEq/L
Azorin et al. 2010
14
Valproate and atypical antipsychotics can be the first choice
Carbamazepine causes more drug interactions Typical antipsychotics should be avoided
For maintenance therapy, use same drug with same dose which demonstrated efficacy in management of acute episode
ECT may be useful in patients who are refractory to drug treatment and in those who need rapid resolution of symptoms
Treatment
Azorin et al. 2010
15
16
Kennedy GJ, 2008
17
18Treatment Recommendations for Manic/Mixed States in Late Life 1st line: monotherapy - divalproex or lithium Partial responders - add atypical antipsychotic
medication - risperidone, quetiapine, olanzapine, possibly aripiprazole
For “treatment resistant” episode – consider clozapine or ECT
No evidence-based guidance on duration of treatment, time to wait before augmentation, or use of other mood stabilizing anticonvulsants
Young et al 2004
19Take Home message Manic illness in old age is heterogeneous. Older manic patients frequently have vascular
and neurological comorbidities, and are at risk for poor outcomes.
Management typically focuses on pharmacotherapy with mood stabilizers, and use of simplest possible regimen.
Pharmacokinetic changes can alter drug dosing. Cognitive impairment may reduce tolerability of
treatment.
King George’s Medical University UP, Lucknow King George’s Medical University UP, Lucknow INDIA INDIA 20