Late Life mania

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