First episode mania at 75 years of age.

Late onset psychiatric disorders are often associated with organic factors, either medical or neurological. Mania occurring for the first time in the elderly population is rarely reported. We hereby report a patient with first episode mania who was investigated in detail, but no organic factors were found. He was diagnosed as first episode mania and was managed with divalproex and olanzapine.

INTRODUCTION

Late onset psychiatric disorders often represent a challenge for the psychiatrists as far as the diagnosis and management issues are concerned. The elderly patients have generally been reported to have associated medical, especially neurological illnesses and are also prone to side effects of various psychotropic medications. Late onset mood disorders, including mania, have generally been reported to be associated with vascular risk factors.[1] Depression has been more commonly reported than mania as a mood disorder in the elderly population. The incidence of mania at age >75 years has been reported to be around only 2 per 100000 persons.[2] Because of the scares reports of first onset of manic episode at the age of 75 years, we hereby report a case of a 75-years-old male who was diagnosed to be having first manic episode at this age.

CASE REPORT

A 75-year-old married Hindu male, farmer by occupation, presented to us with history of five days duration with complaints of unduly cheerful mood, over-talkativeness, big talks, aggressive behavior and decreased sleep. There was no past or family history of any medical or psychiatric illness. There was no history of any substance abuse/dependence or any history of drug use. There was no associated history of any loss of consciousness, forgetfulness, head injury, or urinary / fecal incontinence. He was well adjusted premorbidly. Mental status examination at the time of presentation revealed an authoritative elderly male with adequate grooming and hygiene, increased psychomotor activity, elated affect, ideas of grandiosity and insight Grade I/V. His mini mental status examination revealed a score of 26/30. Possibility of first manic episode was kept and patient was admitted for investigations and management. In view of late onset of symptoms, his detailed systemic examination, including neurological examination, was done and was found to be normal. His fundus examination was also normal. His investigations, including complete blood counts, kidney function tests, liver function tests, blood sugar, S. electrolytes, thyroid function tests, Elisa for HIV, and serum vitamin B12 were done and were all normal. Magnetic resonance imaging of the brain and electroencephalography were also done and were found be normal. In view of normal investigations and clinical presentation, a diagnosis of first manic episode was made and the patient was started on divalproex 500 mg per day along with lorazepam 2 mg per day and olanzapine 7.5 mg per day. Divalproex was increased to 750 mg per day subsequently over a period of next next days. The patient showed improvement in his symptoms over a period of next 10 days and was subsequently discharged. He has been followed up in the out patient department for the next six months and has been maintaining well in remission on sodium valproate 750 mg per day. His other medications including olanzapine and lorazepam were tapered and stopped over a period of two months after discharge.

DISCUSSION

Our patient fulfilled the criteria for manic episode as per ICD 10. Detailed examination and investigations failed to establish any organic etiology for the symptoms. There was no history of any cardiac illness or any other systemic illness like diabetes mellitus. His brain MRI was also normal with no evidence for any sub cortical hyper-intensities or any old infarcts. His mini mental status score was also within normal limits.

A critical review on bipolar disorders in the elderly reported that the age of onset of mania to be around 56.4 years (SD=7.3; range 38–70).[3] A study on clinical presentation of mood disorders in a geriatric clinic in India reported the mean age of patients suffering from mania at index visit to be 68.5 years with SD=5.75.[4]

Our case had age of onset of mania at 75 years which is rare and our patient was elder than other studies that have reported the age at onset of mania.

Our case highlights the fact that one should take detailed history and do a detailed examination in patients with late onset psychiatric disorders. One should also look for indicators like perplexed affect, marked aggression/irritability, cognitive impairments, marked disinhibition, emotional incontinence and other symptoms suggestive of organicity in patients with mania. It might be prudent not to investigate extensively elderly patients presenting with typical symptoms suggestive of psychiatric disorder with no findings suggestive of organicity in history or examination.

Our case was subsequently started on divalproex along with olanzapine and lorazepam and he recovered well with treatment. Our case highlights the fact that primary psychiatric illnesses can occur at late age and should be managed as they are being manageable in young patients, though these patients may require less dosage of psychotropic medications. More systematic research on late onset mood disorders, especially mania, is warranted to better understand the phenomenology and other factors in this sub group of patients.