Mania after administration of cholinesterase inhibitors in patients with dementia and comorbid bipolar disorder: two case reports

Bipolar Disorder and Manic-Like Symptoms in Alzheimer's, Vascular and Frontotemporal Dementia: A Systematic Review

BACKGROUND

An increased risk of manic episodes has been reported in patients with neurodegenerative disorders, but the clinical features of bipolar disorder (BD) in different subtypes of dementia have not been thoroughly investigated.

OBJECTIVES

The main aim of this study is to systematically review clinical and therapeutic evidence about manic syndromes in patients with Alzheimer's disease (AD), vascular dementia (VaD), and frontotemporal dementia (FTD). Since manic-mixed episodes have been associated to negative outcomes in patients with dementia and often require medical intervention, we also critically summarized selected studies with relevance for the treatment of mania in patients with cognitive decline.

METHODS

A systematic review of the literature was conducted according to PRISMA guidelines. PubMed, Scopus, and Web of Science databases were searched up to February 2022. Sixty-one articles on patients with AD, VaD, or FTD and BD or (hypo) mania have been included.

RESULTS

Manic symptoms seem to be associated to disease progression in AD, have a greatly variable temporal relationship with cognitive decline in VaD, and frequently coincide with or precede cognitive impairment in FTD. Overall, mood stabilizers, and electroconvulsive therapy may be the most effective treatments, while the benefits of short-term treatment with antipsychotic agents must be balanced with the associated risks. Importantly, low-dose lithium salts may exert neuroprotective activity in patients with AD.

CONCLUSION

Prevalence, course, and characteristics of manic syndromes in patients with dementia may be differentially affected by the nature of the underlying neurodegenerative conditions.

Acetylcholinesterase Inhibitors in the Treatment of Neurodegenerative Diseases and the Role of Acetylcholinesterase in their Pathogenesis

Acetylcholinesterase (AChE) plays an important role in the pathogenesis of neurodegenerative diseases by influencing the inflammatory response, apoptosis, oxidative stress and aggregation of pathological proteins. There is a search for new compounds that can prevent the occurrence of neurodegenerative diseases and slow down their course. The aim of this review is to present the role of AChE in the pathomechanism of neurodegenerative diseases. In addition, this review aims to reveal the benefits of using AChE inhibitors to treat these diseases. The selected new AChE inhibitors were also assessed in terms of their potential use in the described disease entities. Designing and searching for new drugs targeting AChE may in the future allow the discovery of therapies that will be effective in the treatment of neurodegenerative diseases.

Frontotemporal Dementia and Late-Onset Bipolar Disorder: The Many Directions of a Busy Road

It is a common pathway for patients with the behavioral variant of frontotemporal dementia (bvFTD) to be first misdiagnosed with a primary psychiatric disorder, a considerable proportion of them being diagnosed with bipolar disorder (BD). Conversely, not rarely patients presenting in late life with a first episode of mania or atypically severe depression are initially considered to have dementia before the diagnosis of late-onset BD is reached. Beyond some shared features that make these conditions particularly prone to confusion, especially in the elderly, the relationship between bvFTD and BD is far from simple. Patients with BD often have cognitive complaints as part of their psychiatric disorder but are at an increased risk of developing dementia, including FTD. Likewise, apathy and disinhibition, common features of depression and mania, respectively, are among the core features of the bvFTD syndrome, not to mention that depression may coexist with dementia. In this article, we take advantage of the current knowledge on the neurobiology of these two nosologic entities to review their historical and conceptual interplay, highlighting the clinical, genetic and neuroimaging features that may be shared by both disorders or unique to each of them.

Cognitive impairment in bipolar disorder Neuroprogression or behavioral variant frontotemporal dementia?

Patients with Bipolar Disorder (BD) usually display cognitive deficits with aging. However, the correlation between BD and dementia syndromes is inconclusive, despite the similarity with behavioral variant frontotemporal dementia. We report a 78-year-old female patient who had bipolar type 1 disorder since adolescence. Her symptoms ranged from apathy to psychotic mania. She had had three hospitalizations, and since her last stay 10 years ago, her symptoms had remained stable. However, in the past 2 years, she displayed different symptoms, such as irritability manifested as verbal and physical aggression, cognitive impairment, repetitive pattern of behavior, perambulation, persecutory delusions, disorientation, and hyporexia. Treatment with anticholinesterases or mood stabilizers promoted no improvement. She scored 17/30 points on the Mini-Mental State Examination. Neuropsychological assessment suggested deficits in executive function, attention, and memory. Neuroimaging tests revealed frontotemporal degeneration and hypoperfusion. Diagnostic and therapeutic approaches for this type of patient represent a significant challenge for clinicians.

Donepezil-associated manic episode with psychotic features: a case report and review of the literature

OBJECTIVE

Reports of manic episodes associated with the use of cholinesterase inhibitors (including donepezil) are limited. Despite the previous notion of procholinergic drugs potentially inducing depression, the contemporary evidence for cholinesterase inhibitors appears to also indicate a trend for elevated mood (in patients with or without a history of depressive disorder).

METHOD

Case report.

RESULTS

The authors report a case of a manic episode with psychotic features associated with the up-titration of donepezil in a patient with Alzheimer's disease and a distant history of major depression but without a preexisting bipolar disorder.

CONCLUSION

Pathophysiology of donepezil-induced mania appears to contradict the traditional cholinergic-adrenergic hypothesis. Donepezil-associated mania should be suspected after donepezil initiation/dose up-titration when correlated to new onset of mania. Donepezil should be used more cautiously in patients with current or previous mood episodes or in those who are otherwise at high risk for manic episodes (e.g., cerebrovascular disease). Although this requires further investigation in different patient populations, there may be subtypes of older patients with neurocognitive disorders who are particularly vulnerable to activation effects of cholinesterase inhibitors.

Donepezil-induced mania

OBJECTIVE

To report a case of mania associated with the titration of donepezil in an elderly patient.

SETTING

A 400-bed academic acute care psychiatric facility.

CASE SUMMARY

A 70-year-old male with a history of paranoid schizophrenia, alcohol dependence, and mild cognitive impairment was admitted after concerns that he was responding to internal stimuli and exhibited increased disorganization. The patient was initiated on quetiapine, titrated to 500 mg at bedtime, to address disorganization, hallucinations, and poor sleep. After improvement of psychotic symptoms and assessment of cognitive function, donepezil 5 mg daily was initiated and titrated to 10 mg daily after two weeks. Days following the increase of donepezil to 10 mg daily, the patient exhibited symptoms of mania and became hyperverbal with elevated mood and agitation. A decreased need for sleep with an increase in cleaning activities throughout the day was noted. Donepezil was suspected to have induced the new symptoms and was discontinued. Following discontinuation, the manic symptoms completely resolved over a two-week period.

CONCLUSION

The titration of donepezil was associated with the onset of mania. Previous trials involving off-label donepezil use in patients with bipolar disorder, but not schizophrenia, have reported the development of manic symptoms. Although rare, there is mounting evidence that donepezil is associated with the emergence of mania. Clinicians should be aware of this potential side effect in all patients treated with donepezil.

A rivastigmine-precipitated manic episode in a patient with Alzheimer-type dementia

The occurrence of mania in the geriatric population is rare. Furthermore, there were only six case reports of elderly patients with secondary mania resulting from treatment with cholinesterase inhibitors. In all cases, patients had a prior psychiatric history. We report the case of an elderly patient with no prior history of psychiatric or other organic disorders who experienced first episode mania following treatment with rivastigmine. We discuss the possible mechanism of mania in this patient.

Bipolar disorder: clinical perspectives and implications with cognitive dysfunction and dementia

Introduction. Cognitive dysfunction as a core feature in the course of bipolar affective disorder (BPD) is a current subject of debate and represents an important source of psychosocial and functional burden. Objectives. To stand out the connection and clinical implications between cognitive dysfunction, dementia, and BPD. Methods. A nonsystematic review of all English language PubMed articles published between 1995 and 2011 using the terms "bipolar disorder," "cognitive dysfunction," and "dementia". Discussion. As a manifestation of an affective trait or stage, both in the acute phases and in remission, the domains affected include attention, executive function, and verbal memory. The likely evolution or overlap with the behavioural symptoms of an organic dementia allows it to be considered as a dementia specific to BPD. This is named by some authors, as BPD type VI, but others consider it a form of frontotemporal dementia. It is still not known if this process is neurodevelopmental or neurodegenerative in nature, or both simultaneously. The assessment should consider the iatrogenic effects of medication, the affective symptoms, and a neurocognitive evaluation. Conclusion. More specific neuropsychological tests and functional imaging studies are needed and will assume an important role in the near future for diagnosis and treatment.