Mania in Late Life

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Source: American Journal of Psychiatry 149:7, July 1992

Authors: Robert Young, M.D. and Gerald Klerman, M.D.

Category: Review

Summary: The authors review diagnosis and classification of Bipolar disorder including incidence and prevalence of mania in the elderly. This paper emphasizes the limited number of systematic studies available, however they do explore the existing literature and discuss several aspects of psychopathology and how each relates to age and age-onset. Included in there analysis of Bipolar disorder are manic affective features, dysphoria and mixed states, delusions/psychotic features, and cognitive dysfunction. This paper focuses on late-onset bipolar noting trends and/or studies that are appropriate to this target group.

Diagnosis/classification/prevalence/incidence:

Types of bipolar include

• Type I: hospitalized at least once for mania plus history of depression
• Type II: not-hospitalized due to hypomania plus history of depression
• Type III:' cyclothymia' fluctuations in mood without mania or severe depression
• Type IV: Mania is associated with illnesses or medications
• Type V: Major depression with strong family hx of bipolar Type VI: Hx of mania but no depression 'uni polar mania'

Prevalence: 5% of diagnosis of elderly patients referred for treatment of affective illness. This however represents recurrent early-life illness and late-onset.

Incidence: Limited data. Conflicting reports. Both sexes show the association with age was weaker for mania than for depression.

Etiology: Probands with late onset bipolar disorder have a lower rate of affective disorder among their relatives than do probands with early onset. Drugs of abuse have been associated with cases of mania in which age of onset is greater than 40 years. Manic patients aged greater than or equal to 60 with onset of first manic episode after age 58 had antidepressant pharmicotherapy associated with their index episode more often than elderly manic patients with onset at an earlier age. Manic symptoms can occur with cerebrovascular disease, as well as other focal brain lesions. Right-side lesions have been particularly implicated in the pathogenesis of mania.

1. Manic affective features: Slater and Roth have stated that many cases of mania in the elderly are 'milder' than in younger patients. Although this is only from clinical impressions. Older patients tended to have lower GAFs when symptomatic.
2. Dysphoria and mixed states: Post has suggested that older manic patients exhibit concomitant depressive features more often than younger patients.
3. Delusions and other psychotic features: Post has stated that compared to younger patients, geriatric manic patients more often have persecutory delusions that are not mood-congruent. Again though this is only a clinical observation. Rosen et al. Has reported a negative association between psychotic symptoms and late onset bipolar pt.s.
4. Cognitive Dysfunction: Broadhead and Jacoby have stated that a greater proportion of elderly than of young manic patients performed in the demented range on the Kendrick neuropsychological battery. In a retrospective study, those who were older than 58 yrs. at the time of the first manic episode more often showed evidence of cognitive dysfunction in routine clinical evaluations when they were acutely symptomatic than did patients with earlier onset.
5. Resolution of Acute Episode: Some studies have suggested an association between greater age at onset and greater duration of episode and/or chronicity. However these studies do not differentiate between age at onset and age alone.
6. Relapse: MacDonald has noted an association between greater age and shorter intervals between episodes in pt.s with bipolar. Stone has reported an increase in frequency of readmission, over 1-month to 10-yr follow up, for those with histories of previous affective episodes than for those without such history.
7. Mortality: Observed mortality rate for elderly bipolar pt.s appears to be greater than the base rate for this age group in the community. Neither Dhingra and Rabins nor Shulman et al. detected a difference in mortality between geriatric patients with late onset of illness and patients of the same age with early onset of illness.
8. Cognitive Dysfunction/Dementia: Dhingra and Rabins could not detect differences in cognitive impairment, as assesses by MMSE score, between patients with late-onset mania and geriatric patients with early-onset mania at 5 and 7 yr follow ups.
9. Treatment: Differences in treatment in regards of age have not been explored however consideration must be given to factors that influence drug pharmokinetics and pharmacodynamics.
10. Pharmacokinetics: Reduced lithium clearance can be associated with increased age. The volume of distribution, because of increased fat/lean body mass ratio, may also be reduced. Lower doses of lithium might be needed to achieve equivalent plasma levels.
11. Efficacy of Acute Pharmacotherapy: Schaffer and Garvey suggest that lithium levels below 1.0 meq/liter can be effective in some elderly patients. Broadhead and Jacoby did not note differences in therapeutic response in relation to age at onset.

Conclusion: late-life illness may be more heterogenous. It appears less genetically determined. Older adults seem to be more susceptible to iatrogenic mania. Late life onset of bipolar may reflect vulnerability acquired through brain changes and disorders associated with aging. There is not a tremendous amount of information regarding late-onset bipolar.

Presented by Joeseph Sharpe, MD