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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. 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