Practical Guidelines for Diagnosing and Treating Mania and Bipolar Disorder in the Elderly

William M. McDonald, MD, Charles B. Nemeroff, MD, PhD


Medscape Psychiatry & Mental Health eJournal. 1998;3(2) 

In This Article

Abstract & Introduction

The treatment of manic symptoms in the elderly is confounded by comorbid medical conditions, medication intolerance, and inadequate medication response, which complicate treatment with traditional antimanic agents such as lithium and neuroleptic medication. The challenge to physicians in treating elderly patients with manic symptoms is to recognize the comorbid conditions and determine the most effective medication in order to maximize treatment response and minimize potential side effects. Using a case study format, we will review the differential diagnosis of manic symptoms in elders, common comorbid medical diagnoses, and the available data on alternatives to lithium therapy, including the anticonvulsants, atypical neuroleptics, and calcium-channel blocking agents. These medications provide viable alternatives that are both safe and effective in treating the geriatric patient with mania. Future research is needed to determine if these new agents are effective in the prophylaxis of manic symptoms and the treatment of the depressed phase of bipolar disorder.

There are no reliable estimates of the prevalence of bipolar disorder with predominant mania symptoms in the geriatric population.[1,2] Estimates of the prevalence of mania in the elderly range from 5% to 19%; however, these figures are often based on data from treatment centers, rather than community surveys. Unfortunately, more recent community-based studies have methodological problems that have led researchers to question their validity.[1]

The incidence of mania varies widely between studies. Some researchers have found a gender difference, with women exhibiting a bimodal distribution and peaks in the incidence of mania before 30 years and after 40 years.[3] In contrast, men exhibit a gradual increase in the onset of mania with age, peaking in the eighth and ninth decades.[4,5] More commonly, there is a decline in the incidence of mania with increasing age.[6,7,8,9] This variance is related to methodological differences among these studies, such as the specific criteria used to diagnose mania, the exclusion of organic illness, and adjustment of incidence rates to account for differences in survival between males and females (ie, more females than males survive to age 80).

The primary reason for the wide variability in estimating the incidence of mania is the difficulty in recognizing this condition in the geriatric population. In formulating this patient's differential diagnosis, the clinician needs to understand the importance of the patient's age. If the patient were in his twenties, the differential diagnosis would include schizophrenia, bipolar disorder, psychotic depression, and substance abuse. However, in a patient older than age 70 years with a Mini-Mental State Examination (MMSE) score of 14/30,[10] the primary diagnoses considered should be dementia, delirium, and agitated depression.

The difficulties noted in these studies are the same as those faced by the clinician attempting to diagnose and treat an elderly patient with manic symptoms. The clinical presentation of elderly manic patients overlaps considerably with common geriatric disorders, including dementia, delirium, and agitated depression. In this review, we will discuss practical clinical guidelines in differentiating mania from other common geriatric syndromes and outline the acute and maintenance pharmacologic treatment of elders with mania.


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