Late onset mania is a kind of Psychiatric illness in which Manic symptoms develops for the first time after the age of 60 years or the continuation of recurrent bipolar illness.

1. Late onset Mania
DR. RAVI SONI
DM SR III
DEPT. OF GERIATRIC MENTAL HEALTH
KGMU, LKO
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2. 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
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3. 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.
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4. 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. 5
Kennedy GJ, 2008

6. 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)
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7. 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

8. 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

9. 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

10. 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
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11. 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
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12. 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
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13. 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
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14. 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
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15.  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
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16. 16

17. Kennedy GJ, 2008
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18. 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

19. 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.

20. King George’s Medical University UP, LucknowKing George’s Medical University UP, Lucknow
INDIAINDIA 20