Delirious mania in the elderly

A factor analytical study report on mania from Nepal

BACKGROUND AND OBJECTIVES

Phenomenological studies on mood disorder are rare in Nepal which prompted us to undertake the current factor analytical study of mania.

MATERIALS AND METHODS

It was a cross-sectional descriptive study for which we did purposive sampling technique according to certain inclusion and exclusion criteria. The study sample consists of fifty patients, who fulfilled the International Classification of Diseases, Tenth Edition (ICD-10) diagnostic criteria for Manic Episode and/or Bipolar Affective Disorder-current episode mania. Tools used were ICD-10 Diagnostic Criteria for Research, Young's Mania Rating Scale (YMRS), and Brief Psychiatric Rating Scale (BPRS). Principal component factor analysis was applied to the 35 symptoms taken from YMRS and BPRS.

RESULTS

Factor analysis revealed the presence of four main factors, which explained 51.082% of the total variance. These are "pure mania" which isolated 11 manic symptoms, "dysphoric mania" which isolated five depressive symptoms, "hostile mania" which isolated six symptoms, and the fourth factor, we called it "delirious mania," isolated four symptoms.

CONCLUSION

The identified factors and subtypes are a useful conceptualization of atypical features among patients with acute mania. Further validation studies are required to determine whether the identified subtypes are of clinical and theoretical importance.

Delirium and depression: inter-relationship and clinical overlap in elderly people

Delirium and depression are complex neuropsychiatric syndromes common in the elderly and are associated with poor health-care outcomes. Accurate diagnosis is essential to the provision of optimum health care for individuals with these conditions but is complicated by substantial clinical overlap in symptoms and comorbidities. A careful assessment of the patient's symptoms, including their context and time course, is needed for accurate diagnosis. Previous depression is common in patients with delirium and depressive illness is a recognised sequelae of delirium. The two syndromes seem to be caused by similar pathophysiological mechanisms, involving disturbances in stress and inflammatory responses, monoaminergic and melatonergic signalling, which point to new avenues for therapeutic intervention. Improved methods to assess delirium and depression in populations at high risk by virtue of their age, diminished cognitive reserve and physical frailty is a key target to achieve improved health-care outcomes in elderly individuals.

Is the concept of delirious mania valid in the elderly? A case report and a review of the literature

Delirious mania has been well recognized in the published literature and in the clinic. Over the years there has been refinement of understanding of its clinical features, course, and treatment. The literature suggests that delirious mania should be considered in individuals who present with a constellation of sudden onset delirium, mania, and psychosis. However, delirious mania is not recognized under a formal classification system nor are there any formal guidelines for its treatment. We, as such, question if the concept of delirious mania in the elderly is valid. We present a case of an elderly man with marked features of delirium with minimal manic or psychotic features who had a previous diagnosis of bipolar I disorder. On thorough clinical assessments no identifiable cause of his delirium was found. We therefore considered his presentation to be more likely due to delirious mania. Electroconvulsive therapy was considered and offered to which he responded very well. We invite the reader to consider whether delirious mania is a valid concept in the elderly, where features of delirium may be more prominent than manic or psychotic features.

Rediscovering catatonia: the biography of a treatable syndrome

OBJECTIVE

Catatonia, a disorder of movement and mood, was described and named in 1874. Other observers quickly made the same recognition. By the turn of the century, however, catatonia was incorporated as a type within a conjured syndrome of schizophrenia. There, catatonia has lain in the psychiatric classification for more than a century.

METHOD

We review the history of catatonia and its present status. In the 1970s, the tie was questioned when catatonia was recognized among those with mood disorders. The recognition of catatonia within the neuroleptic malignant syndrome offered effective treatments of high doses of benzodiazepines and electroconvulsive therapy (ECT), again questioning the tie. A verifying test for catatonia (the lorazepam sedation test) was developed. Soon the syndromes of delirious mania, toxic serotonin syndrome, and the repetitive behaviors in adolescents with autism were recognized as treatable variations of catatonia.

RESULTS

Ongoing studies now recognize catatonia among patients labeled as suffering from the Gilles de la Tourette's syndrome, anti-NMDAR encephalitis, obsessive-compulsive disease, and various mutisms.

CONCLUSION

Applying the treatments for catatonia to patients with these syndromes offers opportunities for clinical relief. Catatonia is a recognizable and effectively treatable neuropsychiatric syndrome. It has many faces. It warrants recognition outside schizophrenia in the psychiatric disease classification.

Delirious mania: can we get away with this concept? A case report and review of the literature

Background. Delirious mania (DM) as a clinical entity is well described, yet is often unrecognized in clinical practice. While most often misdiagnosed as acute psychotic episodes of organic delirium, these patients meet the criteria for mania with attendant delirium and pose therapeutic challenges. In addition to the case presentation, this paper also discusses the available literature on DM. Case Presentation. A 29-year-old man with DM was treated with a combination of electroconvulsive therapy (ECT), divalproex 2000 mg/day, loxapine 100 mg/day, and lorazepam 4 mg/day. He demonstrated clinically significant improvement by day 10, which persisted through the twelve-month follow-up period. Conclusions. DM is a severe psychiatric syndrome which should be accurately diagnosed. Patients with DM should be treated aggressively, especially with ECT. Lack of recognition of DM can lead to serious morbidity or fatal outcomes. Though the concept of DM is well established, recent psychiatric literature does not make a mention of this life threatening yet treatable condition. We propose that there is a dire need to keep this concept alive.

Clinical features of delirious mania: a series of five cases and a brief literature review

BACKGROUND

Little is known about the cause and psychopathology of delirious mania, a type of disorder where delirium and mania occur at the same time. This condition still has no formal diagnostic classification. To provide more information about this potentially life-threatening condition, we studied five patients with delirious mania.

METHODS

We describe the cases of five patients with delirious mania admitted to an acute inpatient psychiatric unit between January 2005 and January 2007, and discuss the cases in the context of a selective review of the clinical literature describing the clinical features and treatment of delirious mania.

RESULTS

Two patients had two episodes of delirious mania. Delirium usually resolved faster than mania though not always the case. Delirious mania remitted within seven sessions of the electroconvulsive therapy (ECT).

CONCLUSIONS

Delirious mania is a potentially life-threatening but under-recognized neuropsychiatric syndrome. Delirious mania that is ineffectively treated may induce a new-onset manic episode or worsen an ongoing manic episode, and the patient will need prolonged hospitalization. Delirious mania also has a close relationship with catatonia. Early recognition and aggressive treatment, especially with electroconvulsive therapy, can significantly reduce morbidity and mortality.

Treatments for late-life bipolar disorder

BACKGROUND

Bipolar affective disorder is not uncommon in the elderly; prevalence rates in the United States range from 0.1% to 0.4%. However, it accounts for 10% to 25% of all geriatric patients with mood disorders and 5% of patients admitted to geropsychiatric inpatient units. These patients often present a tremendous treatment challenge to clinicians. They frequently have differing treatment needs compared with their younger counterparts because of substantial medical comorbidity and age-related variations in response to therapy. Unfortunately, the management of geriatric bipolar disorder has been relatively neglected compared with the younger population. There continues to be a scarcity of published, controlled trials in the elderly, and no treatment algorithms specific to bipolar disorder in the elderly have been devised.

OBJECTIVE

The goal of this article was to review the current literature on both the pharmacologic and nonpharmacologic management of late-life bipolar disorder.

METHODS

English-language articles written on the treatment of bipolar disorder in the elderly were identified. The first step in data collection involved a search for evidence-based clinical practice guidelines in the Cochrane Database of Systematic Reviews (up until the third quarter of 2006). Systematic reviews were then located in the following databases: MEDLINE (1966-September 2006), EMBASE (1980-2006 [week 36]), and PsycINFO (1967-September 2006 [week 1]). Additional use was made of these 3 databases in searching for single randomized controlled trials, meta-analyses, cohort studies, case-control studies, case series, and case reports. "Elderly," used synonymously with "geriatric," was defined as individuals aged > or =60 years. However, to take into account ambiguity in the nomenclature, the key words aged, geriatric, elderly, and older were combined with words indicating pharmacologic treatments such as pharmacotherapy; classes of medications (eg, lithium, antidepressants, antipsychotics, anticonvulsants, benzodiazepines); and names of selected individual medications (eg, lithium, valproic acid, lamotrigine, carbamazepine, oxcarbazepine, topiramate, gabapentin, zonisamide, clozapine, risperidone, olanzapine, quetiapine, ziprasidone, aripiprazole). These terms were then combined with the diagnostic terms bipolar disorder, mania, hypomania, depression, or bipolar depression. Finally, the terms ECT and psychotherapy were also queried in combination with indicators for age and diagnosis. A few articles on "older adults," usually defined as individuals aged 50 to 55 years, were also included. They may allow for possible extrapolation of data to the geriatric population. Additionally, several mixed-age studies were included for similar considerations. Case reports and case series were described for their potential heuristic value.

RESULTS

Unfortunately, there is a considerable dearth of literature involving evidence-based clinical practice guidelines and even randomized controlled trials in elderly individuals with bipolar disorder. Available options for the treatment of bipolar disorder (including those for mania, hypomania, depression, or maintenance) in the elderly include lithium, antiepileptics, antipsychotics, benzodiazepines, antidepressants, electroconvulsive therapy (ECT), and psychotherapy.

CONCLUSIONS

The data for the treatment of late-life bipolar disorder are limited, but the available evidence shows efficacy for some commonly used treatments. Lithium, divalproex sodium, carbamazepine, lamotrigine, atypical antipsychotics, and antidepressants have all been found to be beneficial in the treatment of elderly patients with bipolar disorder. Although there are no specific guidelines for the treatment of these patients, monotherapy followed by combination therapy of the various classes of drugs may help with the resolution of symptoms. ECT and psychotherapy may be useful in the treatment of refractory disease. There is a need for more controlled studies in this age group before definitive treatment strategies can be enumerated.

Diffusion-weighted magnetic resonance imaging of white matter in bipolar disorder: a pilot study

OBJECTIVE

Diffusion-weighted magnetic resonance imaging (MRI) has shown increased sensitivity in detecting brain white matter disease compared to traditional T2-weighted MRI. Diffusion-weighted imaging (DWI) can quantitatively assess the microstructural integrity of white matter using the average apparent diffusion coefficient (ADC(av)), a measure of the extent to which water molecules move freely within tissue. On the basis of numerous studies suggesting white matter disease in bipolar patients, particularly patients with more severe illness, this study aimed to test the utility of DWI in assessing the white matter integrity of bipolar patients with severe illness.

METHODS

The existing MRI scans of eight bipolar patients and eight age-matched controls with neurological illness were examined retrospectively. ADC(av) values for pixels within white matter regions of interest (ROIs) were calculated and used to plot ADC(av) frequency histograms for each ROI. Mean ADC(av) values for the two groups were then compared by ANCOVA.

RESULTS

The bipolar mean ADC(av) (0.855 +/- 0.051 x 10(-3) mm2/s) for combined white matter ROIs significantly exceeded that of controls (0.799 +/- 0.046 x 10(-3) mm2/s), while covarying for age (F = 4.47, df = 3, p = 0.025).

CONCLUSIONS

This is the first report of an elevated ADC(av) in the white matter of a group of patients with bipolar disorder. In this group of patients with severe illness, increased white matter ADC(av) suggests microstructural changes consistent with decreased white matter integrity. DWI may be an additional, useful tool to assess white matter abnormalities in bipolar disorder.

Bipolar disorder in older adults: a critical review

OBJECTIVES

The goal of this article is to provide a comprehensive critical review of studies reporting the prevalence, features, age of onset, course, comorbidity, and neuropsychology of, as well as service utilization, in bipolar disorder in older age.

METHODS

We searched the Medline, Pubmed, and PsycINFO databases using combinations of the keywords 'Bipolar', 'Manic/a', 'Manic Depression', 'Elderly', and 'Older'. We included English-language reports presenting quantitative data on the prevalence and/or any descriptive information about adults with bipolar disorder over age 50. Findings from similar studies were pooled when possible. A total of 61 studies met our broad criteria.

RESULTS

Common methodological problems in the published studies included small sample sizes, retrospective chart review, lack of standardized measures, overemphasis on inpatients, and dearth of longitudinal data. Strong evidence indicates that bipolar disorder becomes less common with age, accounts for 8-10% of late life psychiatric admissions, is associated with neurologic factors in late-onset groups, and is a heterogeneous life-long illness. Weak or inconsistent evidence was found for a higher prevalence of mixed episodes in older adults, a lower treatment response, and the association with lower family history in late-onset groups. Minimal information is available on bipolar depression in late life.

CONCLUSIONS

Bipolar disorder in old age is a growing public health problem. Greater research on bipolar disorder in older people will assist in enhancing services to this group as well as inform research on bipolar disorder across the life span.

Aging-related issues in bipolar disorder: a health services perspective

Among the elderly, bipolar disorder is a significant public health problem, often leading to functional impairment and substantial use of health care resources. There has been a growing awareness regarding the manifestations of bipolar disorder among older adults owing to both changes in national demographics and developing sophistication in the treatment of bipolar illness. Bipolar disorder accounts for 5% to 19% of mood disorder presentations in the elderly, although a clear picture of the exact prevalence of bipolar disorder among older adults in the community is still lacking. Data from treatment centers give a somewhat unreliable picture of the true prevalence and manifestations of bipolar disorder in the general population as elderly patients tend to underuse mental health systems, under-report psychiatric symptoms, and are often treated in nonhospital/clinic settings, such as nursing homes. Factors of particular relevance in late-life bipolar disorder include age of onset, symptom presentation/recognition, secondary mania, psychiatric and medical comorbidity, and response to treatment. Future mental health services research must further explore these issues to optimize care for older adults with bipolar disorder.