Geriatric patients presenting in an inpatient or outpatient setting.
Identify, evaluate and initiate treatment in elderly patients with mania.
Definition of Mania:
Geriatric patients presenting with an episode of mania most often have an earlier onset and history of primary bipolar disorder.
DSM-5 criteria define a manic episode as:
- A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy, lasting at least 1 week and present most of the day, nearly every day (or any duration if hospitalization is necessary).
- During the period of mood disturbance and increased energy or activity, three (or more) of the following symptoms (four if the mood is only irritable) are present to a significant degree and represent a noticeable change from usual behavior:
- Inflated self-esteem or grandiosity.
- Decreased need for sleep (e.g., feels rested after only 3 hours of sleep).
- More talkative than usual or pressure to keep talking.
- Flight of ideas or subjective experience that thoughts are racing.
- Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed.
- Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation (i.e., purposeless non-goal-directed activity).
- Excessive involvement in activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments).
- The mood disturbance is sufficiently severe to cause marked impairment in social or occupational functioning or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.
- The episode is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, other treatment) or another medical condition.
Treatment of Mania
Initial treatment approach should begin by addressing any contributing causes to the symptoms and then considering possible pharmacologic treatments. First, discontinue antidepressants as these may increase manic symptoms in some patients. Next consider a trial of medication:
- Lithium exhibits some anti-suicidal benefits distinct from its mood stabilizing properties and appears to have possible neuroprotective effects. Based on a recent controlled geriatric trial (Young 2017), lithium can be started at 300 mg/day with a target serum level of 0.70-0.99. Trough lithium levels can be measured 5 days after any dose change. Side effects may include polyuria, polydipsia, nausea, diarrhea, and tremor and can generally be managed (Gitlin 2016). More problematic side effects include weight gain, cognitive slowing and possible longer-term effects of hypothyroidism, increased parathyroid hormone and calcium, and renal impairment. Medication interactions (e.g., diuretics, ACE inhibitors, and NSAIDs) may require decreased lithium dosing. Monitoring of renal, thyroid function, and lithium levels should be done at least every 6 months.
- Divalproex is an anticonvulsant with good efficacy data for treatment of manic episodes. It is generally well tolerated in the geriatric population. It can be started at 500 mg/day with target serum concentrations of 70-99 µg/ml. (Young 2017). Common side effects include nausea, sedation, weight gain, and benign tremor. Divalproex has rarely been associated with liver failure and pancreatitis. Monitoring of weight, complete blood count, and liver function tests should be done every 3 months for the first year, then annually.
- Atypical antipsychotics can be used as an adjunct medication for partial response to lithium or divalproex or as monotherapy for patients unable to tolerate lithium or divalproex. There are no prospective controlled trials of atypical antipsychotics in the geriatric bipolar population. There is post hoc evidence in controlled trials for geriatric bipolar patients using quetiapine (Sajatovic 2008) and olanzapine (Bayer 2001). Side effects vary depending on the medication but may include sedation, weight gain, increased blood glucose and hyperlipidemia. Check weight monthly, labs every 3 months then annually, and EKG and prolactin as clinically indicated. The Abnormal Involuntary Movement Scale (AIMS) used annually may detect tardive dyskinesia in patients taking antipsychotics, though the risk is lower for atypical antipsychotics compared with typical antipsychotics.
In a recent double blind controlled trial of lithium and divalproex for the treatment of mania in older patients (Young RC 2017), both medications were effective and adequately tolerated. Lithium was associated with a greater reduction in mania scores overall. Treatment guidelines for older persons with bipolar disorder emphasize lithium (effective, may prevent suicide, and is neuroprotective) and de-emphasize antipsychotics (metabolic side effects of diabetes, weight gain, hyperlipidemia). More double- blinded studies need to be done to better establish efficacy and tolerability of treatments in bipolar disorder in geriatric patients.
Offer treatment strategies for Bipolar Geriatric patients experiencing a manic episode.
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- Bayer JL, Siegal A, Kennedy JS. “Olanzapine, divalproex and placebo treatment, non-head to head comparisons of older adult acute mania. 10th Congress of Intl. Psychogeriatric Association; Nice France. 2001.
- Beyer JL. “Bipolar and Related Disorders,” in Textbook of Geriatric Psychiatry, Steffens DC, Blazer DG, Thakur ME, Eds. APA Publishing, Washington DC 2015: 283-307.
- Chen P et al. “Update on the epidemiology, diagnosis, and treatment of mania in older-age bipolar disorder.” Curr Psychiatry Rep 2017; 19: 46.
- Gitlin M. “Lithium side effects and toxicity: prevalence and management strategies.” Int J Bipolar Disorder 2016; 4(27): 1-10.
- Lala SV, Sajatovic M. “Medical and psychiatric comorbidities among elderly individuals with bipolar disorder: a literature review.” J Geriatric Psych Neurol. . 2012 Mar;25(1):20-5.
- Ng F et al. “The International Society for Bipolar Disorders (ISBD) consensus guidelines for the safety monitoring of bipolar disorder treatments.” Bipolar Disord 2009; 11: 559–595.
- Young RC, Biggs JT, Ziegler VE, Meyer DA. “A rating scale for mania: reliability, validity, and sensitivity.” Br J Psych; 133: 429-435.
- Young RC et al. “GERI-BD: A randomized double-blind controlled trial of lithium and divalproex in the treatment of mania in older patients with bipolar disorder.” 2017; Am J Psych 174:1086-1093.