Delusional and aggressive, while playing the lottery

CASE Delusional and aggressive
Mr. P, age 78, of Filipino heritage, is brought to the psychiatric hospital because he has been verbally aggressive toward his wife for sev­eral weeks. He has no history of a psychiatric diagnosis or inpatient psychiatric hospitaliza­tion, and no history of taking any psychotropic medications.

According to his wife, Mr. P has been rumi­nating about his father, who died in World War II, saying that “the Japanese never gave his body back” to him. Also, his wife describes 3 weeks of physically aggressive behavior, such as throwing punches; the last episode was 2 days before admission.

Mr. P is not bathing, eating, taking his medi­cations, and attending to his activities of daily living. He sleeps for only 1 to 2 hours a night; is irritable and easily distractible; and experi­ences flight of ideas. Mr. P has been buying lottery tickets, telling his daughter that he will become a millionaire and then buy a house in the Philippines.

Mr. P reports depressed mood, but no other depressive symptoms are present. He reports no suicidal or homicidal ideations, auditory or visual hallucinations, or anxiety symptoms. He has no history of substance abuse.

What diagnosis would you give Mr. P?
   a) late-onset bipolar disorder
   b) Alzheimer’s disease
   c) major depressive disorder
   d) frontotemporal dementia

The authors’ observations
Bipolar disorder in later life is a complex and confounding neuropsychiatric syn­drome with diagnostic and therapeutic challenges. The disorder can affect people of all ages and is not uncommon among geriatric patients, with a 1-year prevalence in United States of 0.4%.¹ In one study, 10% of new bipolar disorder cases were found to occur after age 50.² As the American population grows older, the number of bipolar disorder cases among seniors is expected to increase.³

It was once thought that symptoms of bipolar disorder disappear with age; newer research has disproved this theory, and proposes that untreated bipolar dis­order worsens over time.⁴ Persons who are given the diagnosis later in life could have had bipolar disorder for decades, but symptoms became more noticeable and problematic with age.⁵

Common symptoms in geriatric patients can differ from what we might expect in younger patients: agitation, hyperactivity, irritability, confusion, and psychosis.⁶ When the disorder presents in patients age >60, it can be severe, with significant changes in cognitive function, including difficulties with memory, perception, judgment, and problem-solving.^7,8

HISTORY Medical comorbidities
Mr. P emigrated from the Philippines 20 years ago, is married, and lives with his wife. He has 3 brothers; his parents were divorced, and his mother remarried. Mr. P completed high school.

Mr. P has an extensive medical history: diabetes mellitus, hypertension, dyslipid­emia, and recent double coronary artery bypass grafting. He is taking several medi­cations: sitagliptin, 25 mg/d; pantoprazole, 5 mg/d; metformin, 1,000 mg/d; rivaroxaban, 20 mg/d; amiodarone, 200 mg/d; metoprolol, 12.5 mg/d; olmesartan medoxomil, 40 mg/d; aspirin, 81 mg/d; simvastatin, 10 mg/d; eszopi­clone, 3 mg at bedtime; and amlodipine, 5 mg at bedtime.

Mr. P was following up with his primary care physician for his medical conditions and was adherent with treatment until 1 week before he was admitted to our facility.

The authors’ observations
Always rule out medical causes in a case of new-onset mania, which is particu­larly important in geriatric patients. Older patients with new-onset mania are more than twice as likely to have a comorbid neurologic disorder.⁹ Neurologic causes of late-onset mania include:
   • stroke
   • tumor
   • epilepsy
   • Huntington’s disease and other movement disorders
   • multiple sclerosis and other white-matter diseases
   • head trauma
   • infection (such as neurosyphilis)
   • Creutzfeldt-Jakob disease
   • frontotemporal dementia.¹⁰

Mr. P’s presentation of psychomotor agitation, impaired functioning, decreased need for sleep, increased energy, hyperver­bal speech, and complex paranoid delu­sions meets DSM-5 criteria for bipolar disorder, manic phase. In addition, older manic patients frequently present with confusion, disorientation, and distract­ibility. Younger patients with mania often present with euphoric moods and gran­diosity; in contrast, geriatric patients are more likely to show a mixture of depressed affect and manic symptoms (pressured speech and a decreased need for sleep).^11-15

We considered an emerging neurode­generative process, because dementia can present early with disinhibition, lability, and other behavioral disturbances, includ­ing classic manic syndromes.¹⁶ Although we could not fully rule out a neurode­generative process in the initial phase of treatment, Mr. P’s longitudinal course demonstrated no change in baseline cog­nitive function and no evidence of subse­quent decline, making dementia unlikely.¹⁷

Patients with frontotemporal demen­tia are more likely to present initially to a psychiatrist than to a neurologist.¹⁸

Frontotemporal dementia is a progressive neurodegenerative disease that affects the frontal and temporal cortices; it is a com­mon cause of dementia in patients age <65.¹⁹ Frontotemporal dementia is char­acterized by insidious behavioral and personality changes; often, the initial pre­sentation lacks any clear neurologic signs or symptoms. Key features include apa­thy, disinhibition, loss of sympathy and empathy, repetitive motor behaviors, and overeating.²⁰

 

Mr. P’s symptoms stabilized with dival­proex sprinkles and risperidone. There was no evidence of decline in memory, social interaction, or behavior.

EVALUATION Paranoia
On mental status exam, Mr. P has an appropri­ate appearance; he is clean and shaven, with good eye contact. Muscular tone and gait are within normal limits. Level of activity is increased; he exhibits psychomotor agitation. Speech is rapid, over-productive, and loud; thought process shows flight of ideas, and thought associations are circumstantial.

Mr. P has paranoid delusions about the staff trying to hurt him. His judgment is poor, evidenced by an inability to take care of him­self. Insight is minimal, as seen by noncompli­ance with treatment. Mr. P is oriented only to person and place. His mood is anxious; affect is labile.

Complete blood count, comprehensive met­abolic profile, blood alcohol level, urine analy­sis, urine toxicology, electrocardiogram, and CT scan of the head are within normal limits.

Mr. P is given a diagnosis of mood disorder due to general medical condition, psychotic disorder due to general medical condition. The team rules out acute delirium, bipolar I disor­der, and neurodegenerative disorders such as frontotemporal dementia.

Mr. P is maintained on pre-admission medi­cations for his medical conditions. A mood sta­bilizer, divalproex sprinkles, 250 mg/d, is added.

Once on the unit, Mr. P is re-evaluated. Divalproex is increased to 500 mg/d; risperi­done, 0.5 mg/d, is added to address paranoia. Mr. P also receives group and individual psy­chotherapy. He does not participate in neuro­psychological testing, and no single-photon emission CT analysis is done. Mr. P remains in the hospital for 2 weeks. After a family meeting, his daughter says she feels comfortable taking Mr. P home. He follows up in the outpatient clinic and is doing well.

The authors’ observations
Treating geriatric patients with bipolar disorder requires attention to several fac­tors (Table). Older patients might tolerate or metabolize medications differently than younger adults, and therefore may need a different dosage. Older patients are more likely to have comorbid medical conditions and to be taking medications for those ail­ments. Treatment is much more compli­cated for this age group because physicians need to account for possible drug-drug interactions.²¹

A number of medications can be helpful in treating older patients who have bipolar disorder.¹¹ Ongoing research compares lith­ium with anticonvulsants in older bipolar disorder patients to determine which drug has the greatest benefit with the lowest risk of side effects.

Psychotherapy can be a valuable addition to pharmacotherapy in older adults. Some psychotherapy programs are specifically geared to older bipolar disorder patients.^22,23

Use of divalproex sodium in older patients
First, perform baseline laboratory tests: complete blood count, liver function, and electrocardiogram. Initiate divalproex sodium, 250 mg at bedtime, increasing the dosage every 3 to 5 days by 250 mg, with a target dose of 500 to 2,000 mg/d (divided into 2 or 3 doses). Monitor serum levels; levels of 29 to 100 μg/mL are effective and well tolerated. Common side effects include excess sedation, ataxia, tremor, nausea, and, rarely, hepatotoxicity, leuko­penia, and thrombocytopenia.²⁴

Use of lithium in geriatric patients
First, perform baseline laboratory tests: electrolytes, creatinine, blood urea nitro­gen, urine, thyroid stimulating hormone, and electrocardiogram. Starting dosage is 300 mg at bedtime (150 mg for frail cachec­tic patients). Monitor serum levels 12 hours after last dose, adjusting dosage every 5 days until a target serum level of 0.5 to 0.8 mEq/L is reached. Common dosages for geriatric patients are 300 to 600 mg/d, which often can be given as a single bed­time dose. Cautions: When using lithium with a thiazide diuretic or nonsteroidal anti-inflammatory drug, watch for dehy­dration, vomiting, and diarrhea, which will elevate the serum lithium level. Side effects include ataxia, tremor, urinary frequency, thirst, nausea, diarrhea, hypothyroidism, and exacerbation of psoriasis. Once sta­bilized, monitor the serum lithium level, thyroid-stimulating hormone, and kidney function every 3 to 6 months.²⁴

Bottom Line
In geriatric patients, bipolar disorder can present with agitation, irritability, confusion, and psychosis, rather than euphoric mood and grandiosity. When you suspect bipolar disorder in an older patient, first rule out medical causes of symptoms. When selecting treatment, consider comorbid medical conditions and possible drug-drug interactions.

 

Disclosures
The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

CASE Delusional and aggressive
Mr. P, age 78, of Filipino heritage, is brought to the psychiatric hospital because he has been verbally aggressive toward his wife for sev­eral weeks. He has no history of a psychiatric diagnosis or inpatient psychiatric hospitaliza­tion, and no history of taking any psychotropic medications.

According to his wife, Mr. P has been rumi­nating about his father, who died in World War II, saying that “the Japanese never gave his body back” to him. Also, his wife describes 3 weeks of physically aggressive behavior, such as throwing punches; the last episode was 2 days before admission.

Mr. P is not bathing, eating, taking his medi­cations, and attending to his activities of daily living. He sleeps for only 1 to 2 hours a night; is irritable and easily distractible; and experi­ences flight of ideas. Mr. P has been buying lottery tickets, telling his daughter that he will become a millionaire and then buy a house in the Philippines.

Mr. P reports depressed mood, but no other depressive symptoms are present. He reports no suicidal or homicidal ideations, auditory or visual hallucinations, or anxiety symptoms. He has no history of substance abuse.

What diagnosis would you give Mr. P?
   a) late-onset bipolar disorder
   b) Alzheimer’s disease
   c) major depressive disorder
   d) frontotemporal dementia

The authors’ observations
Bipolar disorder in later life is a complex and confounding neuropsychiatric syn­drome with diagnostic and therapeutic challenges. The disorder can affect people of all ages and is not uncommon among geriatric patients, with a 1-year prevalence in United States of 0.4%.¹ In one study, 10% of new bipolar disorder cases were found to occur after age 50.² As the American population grows older, the number of bipolar disorder cases among seniors is expected to increase.³

It was once thought that symptoms of bipolar disorder disappear with age; newer research has disproved this theory, and proposes that untreated bipolar dis­order worsens over time.⁴ Persons who are given the diagnosis later in life could have had bipolar disorder for decades, but symptoms became more noticeable and problematic with age.⁵

Common symptoms in geriatric patients can differ from what we might expect in younger patients: agitation, hyperactivity, irritability, confusion, and psychosis.⁶ When the disorder presents in patients age >60, it can be severe, with significant changes in cognitive function, including difficulties with memory, perception, judgment, and problem-solving.^7,8

HISTORY Medical comorbidities
Mr. P emigrated from the Philippines 20 years ago, is married, and lives with his wife. He has 3 brothers; his parents were divorced, and his mother remarried. Mr. P completed high school.

Mr. P has an extensive medical history: diabetes mellitus, hypertension, dyslipid­emia, and recent double coronary artery bypass grafting. He is taking several medi­cations: sitagliptin, 25 mg/d; pantoprazole, 5 mg/d; metformin, 1,000 mg/d; rivaroxaban, 20 mg/d; amiodarone, 200 mg/d; metoprolol, 12.5 mg/d; olmesartan medoxomil, 40 mg/d; aspirin, 81 mg/d; simvastatin, 10 mg/d; eszopi­clone, 3 mg at bedtime; and amlodipine, 5 mg at bedtime.

Mr. P was following up with his primary care physician for his medical conditions and was adherent with treatment until 1 week before he was admitted to our facility.

The authors’ observations
Always rule out medical causes in a case of new-onset mania, which is particu­larly important in geriatric patients. Older patients with new-onset mania are more than twice as likely to have a comorbid neurologic disorder.⁹ Neurologic causes of late-onset mania include:
   • stroke
   • tumor
   • epilepsy
   • Huntington’s disease and other movement disorders
   • multiple sclerosis and other white-matter diseases
   • head trauma
   • infection (such as neurosyphilis)
   • Creutzfeldt-Jakob disease
   • frontotemporal dementia.¹⁰

Mr. P’s presentation of psychomotor agitation, impaired functioning, decreased need for sleep, increased energy, hyperver­bal speech, and complex paranoid delu­sions meets DSM-5 criteria for bipolar disorder, manic phase. In addition, older manic patients frequently present with confusion, disorientation, and distract­ibility. Younger patients with mania often present with euphoric moods and gran­diosity; in contrast, geriatric patients are more likely to show a mixture of depressed affect and manic symptoms (pressured speech and a decreased need for sleep).^11-15

We considered an emerging neurode­generative process, because dementia can present early with disinhibition, lability, and other behavioral disturbances, includ­ing classic manic syndromes.¹⁶ Although we could not fully rule out a neurode­generative process in the initial phase of treatment, Mr. P’s longitudinal course demonstrated no change in baseline cog­nitive function and no evidence of subse­quent decline, making dementia unlikely.¹⁷

Patients with frontotemporal demen­tia are more likely to present initially to a psychiatrist than to a neurologist.¹⁸

Frontotemporal dementia is a progressive neurodegenerative disease that affects the frontal and temporal cortices; it is a com­mon cause of dementia in patients age <65.¹⁹ Frontotemporal dementia is char­acterized by insidious behavioral and personality changes; often, the initial pre­sentation lacks any clear neurologic signs or symptoms. Key features include apa­thy, disinhibition, loss of sympathy and empathy, repetitive motor behaviors, and overeating.²⁰

 

Mr. P’s symptoms stabilized with dival­proex sprinkles and risperidone. There was no evidence of decline in memory, social interaction, or behavior.

EVALUATION Paranoia
On mental status exam, Mr. P has an appropri­ate appearance; he is clean and shaven, with good eye contact. Muscular tone and gait are within normal limits. Level of activity is increased; he exhibits psychomotor agitation. Speech is rapid, over-productive, and loud; thought process shows flight of ideas, and thought associations are circumstantial.

Mr. P has paranoid delusions about the staff trying to hurt him. His judgment is poor, evidenced by an inability to take care of him­self. Insight is minimal, as seen by noncompli­ance with treatment. Mr. P is oriented only to person and place. His mood is anxious; affect is labile.

Complete blood count, comprehensive met­abolic profile, blood alcohol level, urine analy­sis, urine toxicology, electrocardiogram, and CT scan of the head are within normal limits.

Mr. P is given a diagnosis of mood disorder due to general medical condition, psychotic disorder due to general medical condition. The team rules out acute delirium, bipolar I disor­der, and neurodegenerative disorders such as frontotemporal dementia.

Mr. P is maintained on pre-admission medi­cations for his medical conditions. A mood sta­bilizer, divalproex sprinkles, 250 mg/d, is added.

Once on the unit, Mr. P is re-evaluated. Divalproex is increased to 500 mg/d; risperi­done, 0.5 mg/d, is added to address paranoia. Mr. P also receives group and individual psy­chotherapy. He does not participate in neuro­psychological testing, and no single-photon emission CT analysis is done. Mr. P remains in the hospital for 2 weeks. After a family meeting, his daughter says she feels comfortable taking Mr. P home. He follows up in the outpatient clinic and is doing well.

The authors’ observations
Treating geriatric patients with bipolar disorder requires attention to several fac­tors (Table). Older patients might tolerate or metabolize medications differently than younger adults, and therefore may need a different dosage. Older patients are more likely to have comorbid medical conditions and to be taking medications for those ail­ments. Treatment is much more compli­cated for this age group because physicians need to account for possible drug-drug interactions.²¹

A number of medications can be helpful in treating older patients who have bipolar disorder.¹¹ Ongoing research compares lith­ium with anticonvulsants in older bipolar disorder patients to determine which drug has the greatest benefit with the lowest risk of side effects.

Psychotherapy can be a valuable addition to pharmacotherapy in older adults. Some psychotherapy programs are specifically geared to older bipolar disorder patients.^22,23

Use of divalproex sodium in older patients
First, perform baseline laboratory tests: complete blood count, liver function, and electrocardiogram. Initiate divalproex sodium, 250 mg at bedtime, increasing the dosage every 3 to 5 days by 250 mg, with a target dose of 500 to 2,000 mg/d (divided into 2 or 3 doses). Monitor serum levels; levels of 29 to 100 μg/mL are effective and well tolerated. Common side effects include excess sedation, ataxia, tremor, nausea, and, rarely, hepatotoxicity, leuko­penia, and thrombocytopenia.²⁴

Use of lithium in geriatric patients
First, perform baseline laboratory tests: electrolytes, creatinine, blood urea nitro­gen, urine, thyroid stimulating hormone, and electrocardiogram. Starting dosage is 300 mg at bedtime (150 mg for frail cachec­tic patients). Monitor serum levels 12 hours after last dose, adjusting dosage every 5 days until a target serum level of 0.5 to 0.8 mEq/L is reached. Common dosages for geriatric patients are 300 to 600 mg/d, which often can be given as a single bed­time dose. Cautions: When using lithium with a thiazide diuretic or nonsteroidal anti-inflammatory drug, watch for dehy­dration, vomiting, and diarrhea, which will elevate the serum lithium level. Side effects include ataxia, tremor, urinary frequency, thirst, nausea, diarrhea, hypothyroidism, and exacerbation of psoriasis. Once sta­bilized, monitor the serum lithium level, thyroid-stimulating hormone, and kidney function every 3 to 6 months.²⁴

Bottom Line
In geriatric patients, bipolar disorder can present with agitation, irritability, confusion, and psychosis, rather than euphoric mood and grandiosity. When you suspect bipolar disorder in an older patient, first rule out medical causes of symptoms. When selecting treatment, consider comorbid medical conditions and possible drug-drug interactions.

 

Disclosures
The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

CASE Delusional and aggressive
Mr. P, age 78, of Filipino heritage, is brought to the psychiatric hospital because he has been verbally aggressive toward his wife for sev­eral weeks. He has no history of a psychiatric diagnosis or inpatient psychiatric hospitaliza­tion, and no history of taking any psychotropic medications.

According to his wife, Mr. P has been rumi­nating about his father, who died in World War II, saying that “the Japanese never gave his body back” to him. Also, his wife describes 3 weeks of physically aggressive behavior, such as throwing punches; the last episode was 2 days before admission.

Mr. P is not bathing, eating, taking his medi­cations, and attending to his activities of daily living. He sleeps for only 1 to 2 hours a night; is irritable and easily distractible; and experi­ences flight of ideas. Mr. P has been buying lottery tickets, telling his daughter that he will become a millionaire and then buy a house in the Philippines.

Mr. P reports depressed mood, but no other depressive symptoms are present. He reports no suicidal or homicidal ideations, auditory or visual hallucinations, or anxiety symptoms. He has no history of substance abuse.

What diagnosis would you give Mr. P?
   a) late-onset bipolar disorder
   b) Alzheimer’s disease
   c) major depressive disorder
   d) frontotemporal dementia

The authors’ observations
Bipolar disorder in later life is a complex and confounding neuropsychiatric syn­drome with diagnostic and therapeutic challenges. The disorder can affect people of all ages and is not uncommon among geriatric patients, with a 1-year prevalence in United States of 0.4%.¹ In one study, 10% of new bipolar disorder cases were found to occur after age 50.² As the American population grows older, the number of bipolar disorder cases among seniors is expected to increase.³

It was once thought that symptoms of bipolar disorder disappear with age; newer research has disproved this theory, and proposes that untreated bipolar dis­order worsens over time.⁴ Persons who are given the diagnosis later in life could have had bipolar disorder for decades, but symptoms became more noticeable and problematic with age.⁵

Common symptoms in geriatric patients can differ from what we might expect in younger patients: agitation, hyperactivity, irritability, confusion, and psychosis.⁶ When the disorder presents in patients age >60, it can be severe, with significant changes in cognitive function, including difficulties with memory, perception, judgment, and problem-solving.^7,8

HISTORY Medical comorbidities
Mr. P emigrated from the Philippines 20 years ago, is married, and lives with his wife. He has 3 brothers; his parents were divorced, and his mother remarried. Mr. P completed high school.

Mr. P has an extensive medical history: diabetes mellitus, hypertension, dyslipid­emia, and recent double coronary artery bypass grafting. He is taking several medi­cations: sitagliptin, 25 mg/d; pantoprazole, 5 mg/d; metformin, 1,000 mg/d; rivaroxaban, 20 mg/d; amiodarone, 200 mg/d; metoprolol, 12.5 mg/d; olmesartan medoxomil, 40 mg/d; aspirin, 81 mg/d; simvastatin, 10 mg/d; eszopi­clone, 3 mg at bedtime; and amlodipine, 5 mg at bedtime.

Mr. P was following up with his primary care physician for his medical conditions and was adherent with treatment until 1 week before he was admitted to our facility.

The authors’ observations
Always rule out medical causes in a case of new-onset mania, which is particu­larly important in geriatric patients. Older patients with new-onset mania are more than twice as likely to have a comorbid neurologic disorder.⁹ Neurologic causes of late-onset mania include:
   • stroke
   • tumor
   • epilepsy
   • Huntington’s disease and other movement disorders
   • multiple sclerosis and other white-matter diseases
   • head trauma
   • infection (such as neurosyphilis)
   • Creutzfeldt-Jakob disease
   • frontotemporal dementia.¹⁰

Mr. P’s presentation of psychomotor agitation, impaired functioning, decreased need for sleep, increased energy, hyperver­bal speech, and complex paranoid delu­sions meets DSM-5 criteria for bipolar disorder, manic phase. In addition, older manic patients frequently present with confusion, disorientation, and distract­ibility. Younger patients with mania often present with euphoric moods and gran­diosity; in contrast, geriatric patients are more likely to show a mixture of depressed affect and manic symptoms (pressured speech and a decreased need for sleep).^11-15

We considered an emerging neurode­generative process, because dementia can present early with disinhibition, lability, and other behavioral disturbances, includ­ing classic manic syndromes.¹⁶ Although we could not fully rule out a neurode­generative process in the initial phase of treatment, Mr. P’s longitudinal course demonstrated no change in baseline cog­nitive function and no evidence of subse­quent decline, making dementia unlikely.¹⁷

Patients with frontotemporal demen­tia are more likely to present initially to a psychiatrist than to a neurologist.¹⁸

Frontotemporal dementia is a progressive neurodegenerative disease that affects the frontal and temporal cortices; it is a com­mon cause of dementia in patients age <65.¹⁹ Frontotemporal dementia is char­acterized by insidious behavioral and personality changes; often, the initial pre­sentation lacks any clear neurologic signs or symptoms. Key features include apa­thy, disinhibition, loss of sympathy and empathy, repetitive motor behaviors, and overeating.²⁰

 

Mr. P’s symptoms stabilized with dival­proex sprinkles and risperidone. There was no evidence of decline in memory, social interaction, or behavior.

EVALUATION Paranoia
On mental status exam, Mr. P has an appropri­ate appearance; he is clean and shaven, with good eye contact. Muscular tone and gait are within normal limits. Level of activity is increased; he exhibits psychomotor agitation. Speech is rapid, over-productive, and loud; thought process shows flight of ideas, and thought associations are circumstantial.

Mr. P has paranoid delusions about the staff trying to hurt him. His judgment is poor, evidenced by an inability to take care of him­self. Insight is minimal, as seen by noncompli­ance with treatment. Mr. P is oriented only to person and place. His mood is anxious; affect is labile.

Complete blood count, comprehensive met­abolic profile, blood alcohol level, urine analy­sis, urine toxicology, electrocardiogram, and CT scan of the head are within normal limits.

Mr. P is given a diagnosis of mood disorder due to general medical condition, psychotic disorder due to general medical condition. The team rules out acute delirium, bipolar I disor­der, and neurodegenerative disorders such as frontotemporal dementia.

Mr. P is maintained on pre-admission medi­cations for his medical conditions. A mood sta­bilizer, divalproex sprinkles, 250 mg/d, is added.

Once on the unit, Mr. P is re-evaluated. Divalproex is increased to 500 mg/d; risperi­done, 0.5 mg/d, is added to address paranoia. Mr. P also receives group and individual psy­chotherapy. He does not participate in neuro­psychological testing, and no single-photon emission CT analysis is done. Mr. P remains in the hospital for 2 weeks. After a family meeting, his daughter says she feels comfortable taking Mr. P home. He follows up in the outpatient clinic and is doing well.

The authors’ observations
Treating geriatric patients with bipolar disorder requires attention to several fac­tors (Table). Older patients might tolerate or metabolize medications differently than younger adults, and therefore may need a different dosage. Older patients are more likely to have comorbid medical conditions and to be taking medications for those ail­ments. Treatment is much more compli­cated for this age group because physicians need to account for possible drug-drug interactions.²¹

A number of medications can be helpful in treating older patients who have bipolar disorder.¹¹ Ongoing research compares lith­ium with anticonvulsants in older bipolar disorder patients to determine which drug has the greatest benefit with the lowest risk of side effects.

Psychotherapy can be a valuable addition to pharmacotherapy in older adults. Some psychotherapy programs are specifically geared to older bipolar disorder patients.^22,23

Use of divalproex sodium in older patients
First, perform baseline laboratory tests: complete blood count, liver function, and electrocardiogram. Initiate divalproex sodium, 250 mg at bedtime, increasing the dosage every 3 to 5 days by 250 mg, with a target dose of 500 to 2,000 mg/d (divided into 2 or 3 doses). Monitor serum levels; levels of 29 to 100 μg/mL are effective and well tolerated. Common side effects include excess sedation, ataxia, tremor, nausea, and, rarely, hepatotoxicity, leuko­penia, and thrombocytopenia.²⁴

Use of lithium in geriatric patients
First, perform baseline laboratory tests: electrolytes, creatinine, blood urea nitro­gen, urine, thyroid stimulating hormone, and electrocardiogram. Starting dosage is 300 mg at bedtime (150 mg for frail cachec­tic patients). Monitor serum levels 12 hours after last dose, adjusting dosage every 5 days until a target serum level of 0.5 to 0.8 mEq/L is reached. Common dosages for geriatric patients are 300 to 600 mg/d, which often can be given as a single bed­time dose. Cautions: When using lithium with a thiazide diuretic or nonsteroidal anti-inflammatory drug, watch for dehy­dration, vomiting, and diarrhea, which will elevate the serum lithium level. Side effects include ataxia, tremor, urinary frequency, thirst, nausea, diarrhea, hypothyroidism, and exacerbation of psoriasis. Once sta­bilized, monitor the serum lithium level, thyroid-stimulating hormone, and kidney function every 3 to 6 months.²⁴

Bottom Line
In geriatric patients, bipolar disorder can present with agitation, irritability, confusion, and psychosis, rather than euphoric mood and grandiosity. When you suspect bipolar disorder in an older patient, first rule out medical causes of symptoms. When selecting treatment, consider comorbid medical conditions and possible drug-drug interactions.

 

Disclosures
The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.