Mania is different in the elderly, and today we look at the medical causes to watch out for.
KELLIE NEWSOME: Bipolar disorder is different in the elderly. Today we look at the medical causes to watch out for.
CHRIS AIKEN: Welcome to the Carlat Psychiatry Podcast, keeping psychiatry honest since 2003. I’m Chris Aiken, the editor in chief of the Carlat Report. And I’m Kellie Newsome, a psychiatric NP and a dedicated reader of every issue.
KELLIE NEWSOME: This year, we did something new at the Carlat Report. We tallied up the clicks in the online journals, broke down the paywall, and made the top 15 articles free online. To read them, check the link in the show notes or Google “Top 15 Carlat Psychiatry Articles of 2023.” The list inspired us to turn the greatest hits into podcasts, with updates from the latest research. Today is #6: Mania in Older Adults by Julia Cromwell from the Geropsychiatry Report. Why start with #6? Because #5 is a closely related piece on Mood Stabilizers in Older Adults, which we’ll cover next week.
CHRIS AIKEN: Let’s start with a case. Alice is an 81-year-old woman who has no history of psychiatric problems, but she’s brought to your office by her children who say she’s had a personality change. She is euphoric, hyper, talkative, and tells you – through many tangents – about a talk show host who communicates with her late at night. All signs point to a first episode of mania, but mania usually starts in the teenage years. Why is it coming out now?
KELLIE NEWSOME: Bipolar disorder typically starts around age 15-25. So when you see it start in later life, especially in someone with no history of mood problems, you have to wonder if something else is causing it.
CHRIS AIKEN: In older adults, mania is much more likely to have a physical cause, especially if it’s a new onset, but even when the patient has a long history of bipolar disorder a new medical problem can still be the culprit. Here’s what to look for: a medical or neurologic disorder, a medication side effect, and substance use. When one of these causes is present, we call it secondary mania.
KELLIE NEWSOME: Generally the symptoms of mania are the same in older adults as they are in those of less seasoned age. You know, DSM stuff like euphoric or irritable mood, increased energy and goal-directed activity; grandiosity; decreased sleep; pressured speech; flight of ideas; and distractibility. Here’s one difference: Older patients are more likely to have irritability or confusion as part of their mania. You’re also more likely to see mixed states – where mania and depression overlap – in older adults. In my own practice, I rarely see euphoric mania unless it’s in someone under 30. One symptom that may tip you off to secondary mania – to a medical cause – is cognitive. When the brain is shaken up by a physical cause, you’re likely to see cognitive impairment along with the mania. In fact, the list of physical causes of secondary mania is pretty similar to the ones that cause cognitive impairment, delirium, and dementia. And all of these can occur together – in other words, you may be dealing with a patient who has full mania on top of delirium or dementia. Hagop Akiskal wrote up a case series of secondary mania in patients who were in a nursing home for dementia – in his experience most of them had a family history of bipolar, so we saw it as a bipolar condition that was unmasked by dementia, perhaps by the shrinking of the frontal lobes. Maybe so, but either way it reminds us that frontotemporal dementia is a type that is particularly likely to present with behavioral symptoms that mimic mania.
CHRIS AIKEN: In dementia, the mania will overlap with a picture of progressive cognitive decline. Their memory and cognitive abiltiies just steadily get worse. If delirium is the cause, the manic symptoms will overlap with waxing and waning consciousness. The patient has hours of clarity, and times of confusion where they are not as responsive or aware and oriented to their surroundings. Delirium has many medical causes, like infection and electrolyte imbalance, and the best approach is to treat that underlying cause. Of course, delirium can occur on top of dementia, so you could see a patient who has both – and mania on top of them.
KELLIE NEWSOME: Let’s pause for a preview of the CME quiz
1. Which medication treats mania, but is also associated with causing mania in rare cases?
A. Valproate (Depakote)
B. Carbamazepine (Equetro)
C. Atypical antipsychotics
Think you know the answer? If you don’t, just keep listening it’s up ahead. And when you’re ready, find the full set of two questions through the link in the show notesCHRIS AIKEN: Patients with mania are not the best historians. They tend to get caught up in the moment and might give a muddled history of past mood episodes. So how do you know if the mania really came out of nowhere? Talk to the family.
But even if the family recounts a long history of bipolar disorder, physical causes may still be contributing to the current episode. Cerebrovascular disease, for example, is much more common in bipolar disorder than it is in the general public – stroke is the leading cause of death in bipolar.
KELLIE NEWSOME: To look for physical causes, start with the medication list. Here are some stand out meds that can trigger manic symptoms:
- Antibiotics like clarithromycin
- Antidepressants, especially the norepinephrine ones - tricyclics and SNRIs like venlafaxine
- Another source of that noradrenergic rush is over the counter nasal decongestants containing ephedrine and pseudoephedrine, or sympathomimetics like epinephrine
- Blood pressure medications
- Dopaminergic agents such as levodopa, pramipexole, and bromocriptine
- Herbal or dietary supplements like SAMe, St John’s Wort, or the popular hormone DHEA
- Steroids or bronchodilators
CHRIS AIKEN: Here’s a paradoxical one. Some atypical antipsychotics have been associated with mania in case reports, even ones that are approved to treat mania like aripiprazole, olanzapine, quetiapine, and ziprasidone. These are complex meds with lots of pharmacodynamics properties, some like ziprasidone and quetiapine have antidepressant properties that resemble SSRIs and SNRIs. Others like aripiprazole, brexpiprazole and cariprazine increase dopamine D3 transmission. After medications, look for substance use. Just about any recreational drug can cause mania, even caffeine. I remember in the 1990’s when Starbuck’s was just starting its global climb I admitted a man with new onset mania who had recently developed a liking for the coffeehouse. He was drinking 10 large lattes a day.
KELLIE NEWSOME: Next, look for medical causes. Here’s a brief list: Endocrine disorders, Electrolyte abnormalities, infectious disease that affect the brain, like encephalitis, HIV/AIDS, and neurosyphilis; Vitamin B12 deficiency; Systemic Lupus. From the neurologic text we think about traumatic brain injuries, strokes; tumors, epilepsy, multiple sclerosis, and recent neurosurgical procedures. For stroke, it’s the right frontal strokes that tend to cause mania. The left frontal strokes tend to cause depression.
CHRIS AIKEN: To uncover these problems, you may need to order some tests. Start with a neurological exam. If you find any abnormalities, consider further testing, like a CT or MRI of the head, EEG to rule out seizures, an autoimmune panel for autoimmune disease or a CSF analysis to look for infection.
KELLIE NEWSOME: To treat secondary mania, you start by treating the underlying cause. Meanwhile, you’ll probably need a mood stabilizer or antipsychotic to control the symptoms, at least for the short term. The choice will depend on the patient – their health problems and which side effects they are most vulnerable to. So avoid quetiapine if they have a problem with orthostatic falls; avoid lithium if they’ve had a recent heart attack; and don’t use carbamazepine if they have hyponatremia. One difference with secondary mania is that you can usually taper off the mood stabilizer once the underlying cause is treated and the patient is stable. If the underlying cause is not treatable – lke a TBI or a stroke – they may need to stay on it. Check out the online article for more details including tables on medical causes and the medical work up of secondary mania. It’s by Julia Cromwell, who is an inpatient geriatric psychiatrist at Mass General Brigham Salem Hospital, and who has no conflicts of interest to disclose. We’ll be back with more greatest hits from the printed journal, next time: How to Choose a Mood Stabilizer in Older Adults. Meanwhile, get daily research updates on Dr. Aiken’s social media feeds – search for ChrisAikenMD on twitter, linkedin, facebook, and that new one – Threads. Thank you for making us the #1 downloaded psychiatry podcast in 2023.