Download Clinical Charactheristics of Late Onset Mania

Original Paper / Araştırma
DOI: 10.5455/jmood.20141011043638
Clinical Charactheristics of Late Onset Mania
Derya Ipekcioglu1, Ozlem Cetinkaya1, Deniz Eker2, Fulya Maner3, Mehmet Cem Ilnem3,
Numan Konuk4
ÖZET:
ABS­TRACT:
Geç başlangıçlı maninin klinik karakteristikleri
Clinical charactheristics of late onset mania
Amaç: Bu çalışmada erken ve geç başlangıçlı iki uçlu
bozukluk tip I manik dönem tanısı almış hastaların,
demografik ve klinik özelliklerinin retrospektif olarak karşılaştırılması amaçlandı.
Yöntem: Yatarak tedavi gören iki uçlu bozukluk tip I manik
dönem tanısı almış 24 yaşlı hasta (≥65 yaş), kendi içlerinde
50 yaş sınır kabul edilerek erken ve geç başlangıçlı olarak
iki gruba ayrılmış ve 29 genç hasta (19-55 yaş) ile sosyodemografik özellikler, aile hikayesi, profilaktik tedavi,
fiziksel hastalık, klinik belirtiler, hastanede kalış süresi,
uygulanan tedavi ve klinik düzelme halleri açısından retrospektif olarak karşılaştırıldı.
Bulgular: Gençlerde ve erken başlangıç yaşlı hastalarda
daha yüksek aile öyküsü bulunmaktadır. Geç başlangıç
yaşlı grupta fiziksel hastalık oranı daha fazla bulunmuştur.
Eğitim süresi ile hastalık süresi arasında pozitif bir korelasyon vardır. Fikir uçuşması ve basınçlı konuşmaya genç ve
erken başlangıçlı yaşlı hastalarda daha yüksek oranda rastlanmıştır. Gençlerde daha çok erotomanik tipte, yaşlılarda
ise perseküsyon tipinde hezeyanlara daha sık rastlanmıştır.
Tedavide yaşlı hastalarda daha çok valproat tercih edilmiş
ve geç başlangıçlı yaşlılarda erken başlangıçlı yaşlılara
göre daha fazla antipsikotik kullanılmıştır. Hastanede kalış
süresi yaşlı hasta grubunda daha uzundu.
Sonuç: Bulgularımız geç başlangıçlı maninin klinik görünüm, semptom profili, aile öyküsü, eşlik eden fiziksel
hastalık oranı, hastanede kalış süresi ve tedaviye yanıt
gibi özellikler açısından, erken başlangıçlı maniye göre
farklılıkları olduğunu göstermektedir. Fakat geç başlangıçlı
mani alanında yapılan çalışmalarda göz önüne alındığında,
bu tablonun farklı bir klinik alt tip olduğuna dair net bir
sonuca ulaşmanın şu an için mümkün olmadığı gözükmektedir. Yeterli vaka sayısına sahip, daha ileri çalışmalara
ihtiyaç vardır.
Anahtar sözcükler: geç başlangıçlı, erken başlangıçlı,
mani, yaşlı, iki uçlu mizaç bozukluğu
Journal of Mood Disorders 2015;5(2):53-61
Objective: Our aim is to compare demographic and
clinical characteristics of patients with early and late-onset
diagnosed as bipolar disorder type I (BPD-I) manic episode
retrospectively.
Method: A total of 24 elderly (≥65 years old) hospitalized
patients with bipolar disorder were divided into 2 groups
as those with early-onset and late-onset disorder,
according to a threshold of 50 years of age, and were
retrospectively compared with 29 young patients (19-55
years old) in terms of sociodemographic characteristics,
clinical symptoms, family history, prophylactic treatment,
co-existing medical conditions, duration of hospitalization,
psychiatric treatment, and clinical improvement.
Results: A positive family history was also more prevalent
in young patients and patients with early-onset disease.
Co-existing medical conditions were more common in
patients with late-onset disease. A positive correlation was
found between the duration of education and duration
of illness. Flight of ideas and pressured speech were
more commonly observed in young patients and patients
with early-onset disease. While delusions of erotomanic
type were more frequent in young patients, persecution
delusions were more common in elderly patients. In terms
of treatment, valproate was preferred in the elderly patients
and antipsychotic medications were more frequently used
in late-onset elderly patients when compared to earlyonset elderly patients. The duration of hospitalization was
longer in elderly patients than younger ones.
Conclusion: Our findings show that late-onset mania has
different characteristics compared to early-onset mania
in terms of clinical characteristics, symptom profile,
family history, co-existing medical diseases, duration of
hospitalization, and response to treatment. However, it
is hard to conclude that it as a different clinical subgroup
when previous studies about late-onset mania are taken
into consideration. Further studies with adequate sample
sizes are needed.
Key words: late-onset, early-onset, mania, elderly, bipolar
disorder
Journal of Mood Disorders 2015;5(2):53-61
Journal of Mood Disorders Volume: 5, Number: 2, 2015 - www.jmood.org
1
MD, Bakirkoy Prof. Dr. Mazhar Osman
Training and Research Hospital for Psychiatry,
Neurosurgery and Neurological Diseases,
Istanbul-Turkey
2
MD, Crozer Chester Medical Center Psychiatry
Department, USA
3
MD, Associate Professor of Psychiatry,
Bakirkoy Prof. Dr. Mazhar Osman Training and
Research Hospital for Psychiatry,
Neurosurgery and Neurological Diseases,
Istanbul-Turkey
4
MD, Professor of Psychiatry, Istanbul
University, Cerrahpasa Medical Faculty,
Psychiatry Department, Istanbul-Turkey
Ya­zış­ma Ad­re­si / Add­ress rep­rint re­qu­ests to:
Derya Ipekcioglu,
Bakirkoy Prof. Dr. Mazhar Osman Training and
Research Hospital for Psychiatry,
Neurosurgery and Neurological Diseases,
Istanbul-Turkey
Elekt­ro­nik pos­ta ad­re­si / E-ma­il add­ress:
[email protected]
Ka­bul ta­ri­hi / Da­te of ac­cep­tan­ce:
11 Ekim 2014 / October 11, 2014
Bağıntı beyanı:
D.I., O.C., D.E., F.M., M.C.I., N.K.: Yazarlar bu
makale ile ilgili olarak herhangi bir çıkar
çatışması bildirmemişlerdir.
Declaration of interest:
D.I., O.C., D.E., F.M., M.C.I., N.K.: The authors
reported no conflict of interest related to this
article.
53
Clinical charactheristics of late onset mania
INTRODUCTION
patients with geriatric mania. The euphoria in elderly manic
detailed, but more frequently stereotyped and repetitive.
A period of hypomania or major depression should be
patients is not contagious. Speech and ideation is not typically
present at, before or after mania for a diagnosis of Bipolar I
Hostility is more prominent in this patient group (5-7).
Disorder, according to DSM-5, which was published by the
American Association of Psychiatry in 2013. A diagnosis of
functions of patients during a manic episode. This
Bipolar II Disorder requires presence of a current or past
derangement shows a partial or complete recovery as the
period of hypomania and current or past episode of major
clinical disease recedes. It was reported that the risk of
depression (1).
dementia may increase in patients with geriatric mania.
There is no specific description of mania in the elderly in the
There is no consensus on whether late-onset manic
Severe derangement may be detected in the cognitive
episodes represent a different entity or they should or should
current classification systems (5,8-13).
not be considered differently for treatment. One of the main
reasons of this controversy is lack of conclusive studies. Data
clinical differences between young and elderly manic
obtained from limited number of studies is not adequate to
patients. Thus, prospective studies of the initial phases
clarify this issue.
underline the importance of the association between age
and psychopathology (5).
The higher rate of secondary mania in elderly population
Processes related with ageing are important in the
and the consequent higher mortality rates of mania in the
elderly, as well as the relationship between affective disorders
and late-onset mania. The first one is the presence of a higher
and dementia and differences in treatment approaches are
rate of positive family history in early-onset mania, in
the main reasons why a detailed evaluation of the concept of
comparison with late-onset mania. The second difference is
mania is necessary.
the higher rate of an association between late-onset mania
There is difficulty in determining the frequency of manic
and cerebral organic disorder and neurological comorbidities,
episodes in the elderly. The most important reason is lack of
in comparison with early-onset disease. The third main
a clear definition of the geriatric population in terms of age
difference is the higher rate of secondary mania in geriatric
limits. Different age groups older than 50 years of age were
patients (10,12-16).
arbitrarily selected in various studies. According to a
currently accepted definition, cases over 50 years of age are
differences with late onset mania in a review. According to
considered as “late-onset”, and cases over 60 years of age are
the epidemiological data, clinical features and treatment,
considered as “very late-onset” manic disorders (2).
five main issues could be identified as: late-onset bipolar
Mania may run atypical course in the elderly and may
illness as secondary disorder, expression of a lower
cause diagnostic difficulties. One of the major confused
vulnerability to the disease, subform of pseudodementia,
diagnoses is delirium. There are more confessional symptoms
risk factor for developing dementia, and bipolar type VI
in mania with a very acute onset. Late-onset bipolar disorder
(bipolarity in the context of dementia – like processes). The
is associated with more severe cognitive impairment than
question as to whether some forms of bipolar type VI could
early–onset bipolar disorder. These symptoms can disappear
constitute a special risk factor for developing dementia
in few days and the underlying manic symptoms become
deserves further investigation (17).
prominent. Sometimes paranoid ideation can supervene the
manic picture in the elderly, and a clinical picture of delusional
adult patients, they had higher rates and longer duration of
mania may be seen. One of the features of elderly manic
hospitalization and showed a slower improvement. Another
patients without past history of mania is talking on a topic
point in geriatric patients with mania is the rate of
without really entering deeper into it, in contrast to a real
institutionalization. The rate of institutionalization in this
flight of ideas In this case; it is hard to detect the clinical
group of patients in 3-10 years was reported as 20% - 28.5%.
picture of mania in an elderly patient (3,4).
Again, the presence of a neurological disorder was reported
as a cause of increase in the rate of institutionalization
Depressive symptoms are more frequent, typical flight of
There are 3 main differences between the early-onset
On the other hand, Azorin et al. reported five main
When older manic patients are compared with young
ideas is rare and inconsistent with the patient’s mood, and
(2,5,7,10,12-15).
persecution ideation is considerably more frequent in
54
Epidemiological researches into late–onset mania are
Journal of Mood Disorders Volume: 5, Number: 2, 2015 - www.jmood.org
D. Ipekcioglu, O. Cetinkaya, D. Eker, F. Maner, M. C. Ilnem, N. Konuk
limited, according to a review by Van Lammeren et al. It was
year, physical illness, migration, divorce, and family
stated that in older patients it was important to identify-or
problems. Prophylactic therapy was assessed according to
rule out –somatic causes (secondary mania, dementia,
the presence or absence of mood stabilizer use at the time of
delirium), and symptomatic treatment is mostly similar to
hospitalization. Also, the patients were classified in two
the treatment of mania in young adults. It was also underlined
groups according to the presence or absence of a physical
that maintenance treatment may not always be necessary in
illness, which included hypertension, diabetes mellitus,
secondary mania, but it should be considered in the presence
heart failure, dysfunction of liver or kidney, rheumatologic
of risk factors for bipolar disorder (15).
disease, peptic ulcer, and chronic obstructive pulmonary
METHOD
disease. Another two groups were constituted according to
the presence or absence of a psychiatric illness (except
dementia) in their family history.
Patients with a diagnosis of bipolar disorder were
The patients were evaluated in terms of psychiatric
detected with a retrospective chart review of all patients
symptoms and these were compared across groups. The
hospitalized at the Geriatric Psychiatry Ward of the
delusions were classified under the headings of grandiose,
Department of Psychiatry of Istanbul University Cerrahpaşa
persecutory, erotomanic, somatic, mystic, jealous, magical,
School of Medicine in the last 10 years, and then among
reference and discovery. The groups were compared
them only those with a diagnosis of manic episode were
according to the delusion types. Speech was classified as
selected. These patients were divided in two groups and
logorrhea, coprolalia, pressured speech, detailed speech,
included in the study. Elderly patients who were younger
and flight of ideas, and evaluated under these headings.
than 50 years of age at their first episode constituted the first
Mood was assessed under the headings of dysphoria,
group, and elderly patients who were older than 50 years of
euphoria, irritable, elevated, anxious, angry, and labile, in the
age at their first episode constituted the second group. There
corresponding patient groups.
were 11 patients in the first group, and 13 in the second
group, making a total of 24.
and Fisher’s exact test were used for the comparison of
categorical variables. Descriptive properties only were given
The third group was composed of 29 young patients (19-
55 years of age) with a diagnosis of bipolar disorder–manic
episode who were hospitalized at the Department of
Psychiatry of Istanbul University Cerrahpaşa School of
All of the data were evaluated statistically. Chi square test
for the doses of medicine and duration of illness.
RESULTS
Medicine. For the recruitment of the third group 321 patients
were reviewed on their charts retrospectively in the last 10
• Group 1: Early–onset elderly manic patients (elderly
years. The patients were selected at random beginning from
patients experiencing the first episode before 50 years of
the lowest protocol number and detecting one out of ten
age). Total number of patients in this groups was 11.
consecutive cases. The sociodemographic characteristics
• Group 2: Late–onset elderly manic patients (elderly
(gender, duration of education, marital status), presence of a
patients experiencing first episode after 50 years of age).
Total number of patients in this group was 13.
psychosocial stressor in the first episode, prophylactic
treatment, physical illness, family history, symptoms (speech,
•
Group 3: Young manic patients. Total number of patients
in this group was 29.
mood, affect), treatment (mood stabilizers and neuroleptics),
duration of stay at the hospital, and clinical improvements
were determined from the charts, and these variables were
sample are given in Table 1.
compared to those of first and second groups in the study.
Gender: There was no statistically significant difference
between the groups. There were female dominance in all
The jobs of the patients were classified under the items:
Sociodemographic and clinical characteristics of the
unemployed, housewives, workers, civil servants, students,
groups (p=0.362).
self-employed, and retired individuals. Marital status was
classified in three groups: bachelors, married, widows (by
significantly longer in Group 3 when compared to Group 2.
divorce and death). The presence of a psychosocial stressor
was sought according to the loss of a beloved one in the last
differences between the groups (p=0.036).
Journal of Mood Disorders Volume: 5, Number: 2, 2015 - www.jmood.org
Duration of education: The duration of education was
Marital status: There were statistically significant
55
Clinical charactheristics of late onset mania
Psychosocial stressor in the first episode: No
significant differences could be found between the groups.
Prophylactic treatment: The proportion of patients not
taking prophylactic drugs were less than 17% of all patients
in each group.
Physical Disorder: In the comparison of Group 1 and 2;
taking prophylactic medications was high, without a
physical disorders were significantly more prevalent in
significant difference between the groups (p=0.813). Those
Group 2 (p=0.040).
Tab­le 1: Sociodemographic and clinical characteristics
Gender
Women
Men
Duration of education
Median education duration (year)
Marital status
Bachelor
Married
Widow
Psychosocial stressor in the first episode
Yes
No
Prophylactic treatment
Yes
No
Physical illness
Yes
No
Family history
Yes
No
Group 1 (n:11)
Group 2 (n:13)
Group 3 (n:29)
p
8 (%72.7)
3 (%27.3)
9 (%69.2)
4 (%30.8)
15 (%51.7)
14 (%48.3)
0.362
10.75
7.71
9.67
2 (%18.2)
6 (%54.5)
3 (%27.3)
0(%0.0)
8 (%61.5)
5 (%38.5)
13 (%44.8)
12 (%41.4)
4 (%13.8)
*0.036
6 (%54)
5 (%46)
4 (%30)
9 (%70)
10 (%34)
19 (%66)
0.423
1 (%9.1)
10 (%90.9)
2 (%15.4)
11 (%84.6)
5 (%17.2)
24 (%82.8)
0.813
5 (%45.5)
6 (%54.5)
11 (%84.6)
2 (%15.4)
6 (%20.7)
23 (%79.3)
*0.040
4 (%36.4)
7 (%63.6)
0 (%0.0)
13 (%100)
12 (%41.4)
17 (%58.6)
*0.07
Group 1 (n:11)
Group 2 (n:13)
Group 3 (n:29)
p
3 (%27.3)
8 (%72.7)
8 (%61.5)
5 (%38.5)
12 (%41.4)
17 (%58.6)
0.089
1 (%9.1)
10 (%90.9)
0 (%0.0)
13 (%100)
5 (%17.2)
24 (%82.8)
*0.046
3 (%27.3)
8 (%72.7)
0 (%0.0)
13 (%100)
4 (%13.8)
25 (%86.2)
0.076
*0.023
3 (%27.3)
8 (%72.7)
0 (%0.0)
13 (%100)
3 (%10.3)
26 (%89.7)
*0.023
4 (%36.4)
7 (%63.6)
0 (%0.0)
13 (%100)
3 (%10.3)
26 (%89.7)
0.070
0.066
2 (%18.2)
9 (%81.8)
0 (%0.0)
13 (%100)
7 (%24.1)
22 (%75.9)
0.068
*0.016
0 (%0.0)
11 (%100)
4 (%30.8)
9 (%69.2)
3 (%10.3)
26 (%89.7)
*0.018
0 (%0.0)
11 (%100)
0 (%0.0)
13 (%100)
5 (%17.2)
24 (%82.8)
0.062
p<0.05 statistical significant
Tab­le 2: Comparison of clinical symptom profiles across study groups
Persecutory Delusion
Yes
No
Erotomanic Delusion
Yes
No
Flight Of Ideas
Yes
No
Pressured Speech
Yes
No
Detailed Speech
Yes
No
Anger
Yes
No
Anxiety
Yes
No
Dysphoria
Yes
No
p<0.05 statistical significant
56
Journal of Mood Disorders Volume: 5, Number: 2, 2015 - www.jmood.org
D. Ipekcioglu, O. Cetinkaya, D. Eker, F. Maner, M. C. Ilnem, N. Konuk
Family History: In the comparison of Group 1 and 2,
a marginally significant difference (p=0.070).
more patients had a positive family history in Group 1. The
statistical significance was marginal (p=0.07). In the
patients in Group 1 with this symptom, with a marginally
comparison of Group 2 and 3, there were significantly more
significant difference (P=0.066)
patients with a positive family history in Group 3 (p=0.07)
In the comparison of Group 1 and 3, there were more
Anger: In the comparison of Group 1 and 2, there were
more patients with this symptom in Group 1, with a
The symptoms of the sample are given in Table 2.
marginally significant difference (p=0.068).
Persecutory Delusion: In comparison of Group 1 and 2,
In the comparison of Group 2 and 3, there were
there were more patients with this symptom in Group 2, with
significantly more patients with this symptom in Group 3
marginal significance of the difference (p=0.089).
(p=0.016).
Erotomanic Delusion: In the comparison of Group 2
Anxiety: In the comparison of Group 1 and 2, there were
and 3, there were significantly more patients with erotomanic
significantly more patients with this symptom in Group 2
delusions in Group 3 (p=0.046).
(p=0.018).
Flight Of Ideas: In the comparison of Group 2 and 3,
Dysphoria: In the comparison of Group 1 and 3, there
there were more patients with this symptom in Group 3, with
were more patients with this symptom in Group 3, with a
a marginally significant difference (p=0.076).
marginally significant difference (p=0.062).
In the comparison of Group 1 and 2, there were
Treatment: The most frequently preferred mood
significantly more patients with this symptom in Group 1
(p=0.023).
stabilizer was valproate in the geriatric patient population.
Pressured Speech: In the comparison of Group 1 and 2,
The doses of valproate and lithium were lower than those
there were significantly more patients with this symptom in
used in younger patients (Table 3).
Group 1 (p=0.023)
Haloperidol, which is one of the typical neuroleptic drugs
Detailed Speech: In the comparison of Group 1 and 2,
was not used in early-onset elderly patients, while it was
there were more patients in Group 1 with this symptom, with
used in 7 of the 13 late–onset elderly patients at a mean daily
Tab­le 3: Comparison of treatments across study groups
Lithium
Group 1
Group 2
Group 3
Carbamazepine
Group 1
Group 2
Group 3
Valproate
Group 1
Group 2
Group 3
Haloperidole
Group 1
Group 2
Group 3
Median
S.D.
Min. (mg/day)
Max. (mg/day)
500
750
1140
346.41
212.13
340.58
300
600
600
900
900
1800
0
0
750
0
0
100
0
0
600
0
0
800
983
780
1166
355
303
250
400
400
1000
1500
1000
1500
0
6.85
16.94
0
6.46
8.59
0
1
5
0
20
40
S.D.
Min. (day)
Max. (day)
10.78
24.33
16
20
10
8
47
96
73
Tab­le 4: Comparison of the duration of stay at hospital between study groups
Median
Duration of stay at the hospital
Group 1
Group 2
Group 3
34
30.69
28
Journal of Mood Disorders Volume: 5, Number: 2, 2015 - www.jmood.org
57
Clinical charactheristics of late onset mania
Tab­le 5: Comparison of clinical improvement between study groups
Clinical improvement
Partial
Marked
Group 1 (n:11)
Group 2 (n:13)
Group 3 (n:29)
P
6 (%54.5)
5 (%45.5)
9 (%69.2)
4 (%30.8)
20 (%69)
9 (%31)
0.664
p<0.05 statistical significant
dose of 6.8 mg. As expected, the dose of haloperidol in young
(20). There are also other studies reporting a stronger
patients was higher, with a mean dose of 16.9 mg/day.
association between the first manic episode and stressors, in
comparison with following episodes (22).
A total of 6 patients received treatment with atypical
neuroleptics, 2 patients from the late – onset group with
risperidone and 1 patient from this group with olanzapine,
patients than younger ones and this is an expected finding.
and 2 patients from the young group with olanzapine and 1
In the comparison of two elderly groups, physical disorders
patient with risperidone.
were significantly more prevalent in late–onset elderly
Physical disorders are more prevalent among elderly
patients. This may be related with their closer relationship
Duration of stay at the hospital: The duration of stay at
the hospital was longer in the elderly groups (Table 4).
with healthcare institutions beginning from an earlier stage
in life due to their psychiatric condition. Also, the high
Clinical improvement: Especially a partial
prevalence of physical disorders in late–onset patients may
improvement was observed in the young and late-onset
have an association with more frequent occurrence of
groups, while partial and pronounced improvements were
secondary mania.
observed in similar proportions in the early–onset group
(p=0.664) (Table 5).
literature, positive family history was significantly more
DISCUSSION
In accordance with other studies reported in the medical
frequent in the early-onset elderly and young patient groups
than the late–onset group. In the present study, no patient in
the late–onset mania had a positive family history.
We found an increase in the frequency of manic episodes
Etiologically, these findings reflect the high rate of genetic
in advanced age in favor of females, although the difference
heritage in early–onset patients, and rare family history
was not significant in our study. This is in accordance with
positivity in late–onset patients. Rare family history positivity
other reports from the medical literature showing an
in late–onset mania and more frequent organic causes in the
increased frequency of mood disorders in women. Manic
etiology were underlined in the literature (2,8,10,23-25). Our
clinical presentation was reported to be 1.5 – 2.3 times more
findings are in accordance with those data.
prevalent in women in the elderly group of patients (10,18-
21).
erotomanic delusion were more frequent in the young group,
In the comparison of these 3 groups in terms of delusions,
In the comparison of the duration of education of the
while persecutory delusions were more frequent in elderly
groups, it was significantly longer in young manic patients
patients. Although the number of patients is small, this is in
than late–onset elderly patients. This was attributed to the
parallel with reports of a decrease in sexual interest with
increase in the education level in Turkey in recent years.
ageing. In the comparison of early-onset and late–onset
There were no significant differences between the groups
elderly patients in terms of persecutory delusions, a
in terms of the presence of psychosocial stressors in the year
marginally significant increase was found in the late–onset
before the first manic episode. Psychosocial stressors were
elderly patient group. This underscores the importance of
present in the first episode in 54% of patients with early–
the differential diagnosis of late–onset manic episodes from
onset patients, in 30% of patients with late–onset and 34% in
schizophrenia and other psychotic disorders (2,13,26,27).
young patients. Yassa et al have drawn attention towards the
high rate of devastating life events that they had found in
incongruent with mood in patients with geriatric mania in
their study on hospitalized geriatric patients with mania
comparison with young patients (5). Hostility and hatred
58
Post detected a much higher rate of persecutory ideas
Journal of Mood Disorders Volume: 5, Number: 2, 2015 - www.jmood.org
D. Ipekcioglu, O. Cetinkaya, D. Eker, F. Maner, M. C. Ilnem, N. Konuk
were reported to be prominent in geriatric patients (6).
population. Valproate is more effective than lithium in those
Young et al have found non-significant negative relationships
conditions. The doses of valproate and lithium were lower
in age–sexual attention compartments in their study on 40
than those used in younger patients. This is in accordance
manic hospitalized patients in different age groups (7). We
with data suggesting that lower doses should be considered
found erotomanic delusions more prevalent in young manic
in elderly patients, due to a decrease in the pharmacokinetics
patients, and persecutory delusions more prevalent in
of medications in parallel with the slowing in body functions
elderly manic patients in the present study.
in ageing (2,18,25,28).
In a comparison of early–onset elderly group and late–
Haloperidol, which is among the typical neuroleptics
onset elderly group, flight of ideation and pressured speech
was not used in any of the early–onset elderly patients,
were significantly more prevalent in the early–onset group.
whereas it was used by 7 of 13 late–onset patients at a mean
In the comparison of late–onset elderly group and young
daily dose of 6.8 mg. Haloperidol is used in low doses
patients, a marginally significant increase of flight of ideas
especially treatment of acute conditions such as agitation,
was found in the young group.
behavioral disturbances, and psychosis in the geriatric group
Slater and Roth reported that speech was not typically
(2,15). Addition of antipsychotics to treatment in late–onset
detailed in the elderly manic patients, but more frequently
elderly patients may be related to more frequent occurrence
stereotyped and repetitive. Post also found that typical flight
of psychotic symptoms such as persecutory delusions.
of ideation was less prevalent in elderly manic patients (5,6).
Haloperidol was used by young patients at a mean daily dose
In the present study, rarer typical flight of ideas in late–onset
of 16.9 mg, which is high and expected in this age group.
elderly manic patients and more frequent occurrence of it in
especially the young manic patients is in accordance with
their side effect profile. In the present study, a total of 6
other reports in medical literature.
patients used atypical neuroleptics: one patient used
In a comparison of late–onset elderly patients with young
olanzapine and 2 patients used risperidone in the late–onset
patient group, an angry mood was significantly more
group, and 2 patients used olanzapine and one patient used
prevalent in young patients, and in the comparison of late–
risperidone in the young manic patient group. In a review by
onset and early–onset elderly patients, anxiety was
Aziz et al, the data on treatment of late-life bipolar disorder
significantly more prevalent in the late–onset patient group.
were reported to be limited, but the available evidence
In the comparison of the young patient group with both
showed efficacy for some commonly used treatments.
elderly groups, dysphoric mood was more prevalent in the
Lithium, divalproex sodium, carbamazepine, lamotrigine,
young group, with a marginally significant difference with
atypical antipsychotics, and antidepressants have all been
early–onset, and significant difference with the late–onset
found to be beneficial in the treatment of elderly patients
group. There are studies in the literature reporting higher
with bipolar disorder. Although there are no specific
rates of dysphoric mood, irritability and negativism
guidelines for the treatment of these patients, monotherapy
symptoms in geriatric manic patients in comparison with
followed by combination therapy of the various classes of
young manic patients (2,5,13).
drugs may help with the resolution of symptoms. ECT and
Atypical neuroleptics are reported to be safer in terms of
We detected higher rates of dysphoric and angry mood in
psychotherapy may be useful in the treatment of refractory
young patients, and higher rates of anxiety in late–onset
conditions. More controlled studies are required in this age
elderly patients in the present study.
group before definitive treatment strategies can be developed
(29).
The treatments of patients were evaluated especially in
terms of mood stabilizers and haloperidol, which were used
by an adequate number of patients for statistical
were longer, which is in accordance with the data reporting
comparisons. Valproate was the most frequently used
slower response to treatment in elderly patient population
medication in the geriatric patient population. This was
and higher prevalence of physical disorders that may
attributed to the safer use of valproate in geriatric patients in
necessitate longer hospitalizations.
comparison with lithium, and its better tolerance, in
accordance with the data in the literature. Organic causes are
partial improvement was obtained in young patients and
important in the etiology of mania in the geriatric patient
late–onset elderly patients, and partial and pronounced
Journal of Mood Disorders Volume: 5, Number: 2, 2015 - www.jmood.org
The duration of hospitalization of the elderly patients
In the evaluation of clinical improvement, especially a
59
Clinical charactheristics of late onset mania
improvement were obtained in early–onset group in similar
suggest that there are three groups of age at onset but early
rates. There is data in the literature reporting a weaker
and intermediate groups are similar in regarding their
response to treatment in the elderly patient population, with
clinical variables. The late-onset group includes almost a
a higher rate of residual psychopathology at the end of
quartile of patients and seemed to have a different clinical
treatment. We observed a higher frequency of partial
profile (31).
improvement in young patients.
Our findings show that late–onset mania has differences
In a study by Montes et al, geriatric bipolar disorder was
in terms of clinical presentation, symptom profile, family
found to have similar clinical characteristics as young
history, rate of accompanying physical disorders, duration
patients, without a great difference in subtype or age of onset
of hospital stay, and clinical response. On the other hand,
(30).
the fact that attending psychiatrists were different, and
In the study of Pinto et al conducted on 169 patients with
clinical improvements were decided upon the observations
bipolar I disorder; the early- onset group (18.2±2 years)
of these different observers, absence of standardized scales
included 34% of the patients. The second group (26.1±5.5
(such as Mania Rating Scale; MRS) and inadequate sample
years) included 44% of the patients. The third group (50.9±9.1
size limit achieving a firm conclusion. Taking into
years) included 22% of the patients. Early and intermediate
consideration the other studies about late–onset mania, it
onset groups were not significantly different, and had more
may be concluded that it may not be yet possible to reach a
family history of affective disorders, more psychotic
definite answer to the question if this clinical picture is a
symptoms, more history of suicide attempts and more
different sub-type. Further studies with adequate sample
history of drug abuse than the late-onset group. These results
sizes are needed.
References:
1. American Psychiatric Association. Diagnostic and Statistical
Manual of Mental Disorders, fifth edition, (DSM V), Washington
DC, American Psychiatric Association 2013.
11. Samame C, Martino DJ, Strejilevich SA. A quantitative review of
neurocognition in euthymic late-life bipolar disorder. Bipolar
Disord. 2013;15:633-44.
2. Van Gerpen MW, Johnson JE, Winstead DK. Mania in the Geriatric
Patient Population: A review of the Literature. Am J Geriatr
Psychiatry. 1999;7:188-202.
12.Aprahamian I, Nunes PV, Forlenza OV. Cognitive impairment
and dementia in late-life bipolar disorder. Curr Opin Psychiatry.
2013;26:120-3.
3. Schouws SN, Comijs HC, Stek ML, Dekker J, Oostervink F, Naarding
P, van der Velde I, Beekman AT. Cognitive impairment in early and
late bipolar disorder. Am J Geriatr Psychiatry. 2009;17:508-15.
13. Schouws SN, Comijs HC, Stek ML, Dekker J, Oostervink F, Naarding
P, van der Velde I, Beekman AT. Cognitive impairment in early and
late bipolar disorder. Am J Geriatr Psychiatry. 2009;17:508-15.
4. Banga A, Gyurmey T, Matuskey D, Connor DF, Kaplan RF, Steffens
DC. Late-life onset bipolar disorder presenting as a case of
pseudo-dementia: a case discussion and review of literature. Yale
J Biol Med. 2013;13;86:235-44.
14. Martino DJ, Strejilevich SA, Manes F. Neurocognitive functioning
in early-onset and late-onset older patients with euthymic bipolar
disorder. Int J Geriatr Psychiatry. 2013;28:142-8.
5. Post F. Affective Disorders; The Clinical psychiatry of date life;
Pergamon Press. 1965;77-82.
6. Slater E, Roth M. Clinical Psychiatry, 3rd ed: Baltimore, Williams &
Wilkins. 1977;571-2.
7. Young RC, Falk JR. Age, Manic Psychopathology and treatmant
response. Int J Geriatr Psychiatry. 1989;4:73-8.
8. Chen ST, Altshuler LL, Spar JE. Bipolar disorder in late life: A
Review. J Geriatr Psychiatry Neurol. 1998;11:29-35.
15. Van Lammeren A, Dols A, van Gerven H, Kupka RW, Stek ML.
Mania in late life: bipolar disorder as diagnosis by exclusion.
Tijdschr Psychiatr. 2011;53:813-23.
16.Besga A, Martinez-Cengotitabengoa M, González-Ortega I,
Gutierrez M, Barbeito S, Gonzalez-Pinto A. The role of white matter
damage in late onset bipolar disorder. Maturitas. 2011;70:160-3.
17. Azorin JM, Kaladjian A, Adida M, Fakra E. Late-onset bipolar illness:
the geriatric bipolar type VI. CNS Neurosci Ther. 2012;18:208-13.
18. Kaplan HI, Sadock BJ. Mood Disonders, Comprehensive Textbook
of Psychiatry; 7th ed. 2001;1286-431.
9. Ertan T. Can mania in the elderly lead the clinician to the
misdiagnosis of dementia? A review. Turk Psikiyatri Derg.
1998;9:43-7.
19. Eastham JH, Jeste DV, Young RC. Assessment and Treatment of
Bipolar Disorder in the Elderly. Drugs Aging. 1988;12:205-24
10. Dols A, Kupka RW, van Lammeren A, Beekman AT, Sajatovic
M, Stek ML. The prevalence of late-life mania: a review. Bipolar
Disord. 2014;16:113-8.
20. Yassa R, Nair V, Nastase C, Camille Y, Belzile L. Prevalence of
bipolar disorder in a psychogeriatric population. J Affect Disord.
1988;14:197-201.
60
Journal of Mood Disorders Volume: 5, Number: 2, 2015 - www.jmood.org
D. Ipekcioglu, O. Cetinkaya, D. Eker, F. Maner, M. C. Ilnem, N. Konuk
21. Snowdon J. A retrospective case-note study of bipolar disorder in
old age. Br J Psychiatry. 1991;158: 485-90.
27. Mirchandani IC, Young RO. Management of mania in the elderly:
an update. Ann Clin Psychiatry. 1993;5;67-77.
22. Hays JC, Krishnan KR, Blazer DG. Age of first onset of bipolar
disorder: Demografic, family history and psychosocial correlates.
Depress Anxiety. 1998;7;76-82.
28.Kaplan HI, Sadock BJ. Lithium. Comprehensive Textbook ok
Psychiatry 7th ed. 2001; 2377-9.
23. Krauthammer C, Klerman GL. Secondary mania: manic syndromes
associated with antecedent physical illness or drugs. Arch Gen
Psychiatry. 1978;35:1333-9.
24. Shulman Kİ. Neurologic Comorbidity and Mania in Old Age. Clin
Neurosci. 1997;37-40.
25. Shulman KI, Herrmann N. Bipolar disorder in old age. Can Fam
Physician. 1999;45:1229-37.
26. Mc Donald WM, Nemeroff CB. The diagnosis and treatment of
mania in the elderly. Bull Menninger Clin. 1996;60: 174-96.
Journal of Mood Disorders Volume: 5, Number: 2, 2015 - www.jmood.org
29.Aziz R, Lorberg B, Tampi RR. Treatments for late-life bipolar
disorder. Am J Geriatr Pharmacother. 2006;4:347-64.
30.Montes JM, Alegria A, Garcia-Lopez A, Ezquiaga E, BalanzaMartínez V, Sierra P, Toledo F, Alcaraz C, Perez J, de Dios C.
Understanding bipolar disorder in late life: clinical and treatment
correlates of a sample of elderly outpatients. J Nerv Ment Dis.
2013;201:674-9.
31. Gonzalez Pinto A, Barbeito S, Jose Díaz F, Vega P, Mosquera F,
López P, Alberich S, Ruiz de Azua S, Ugarte A, Martin M, de Leon
J. Age at onset in bipolar I disorder: two may be better than three
subgroups. Rev Psiquiatr Salud Ment. 2009;2:29-34.
61