Pharmacologic treatment of geriatric mania

Abstract

The prevalence of geriatric mania is uncertain. Although there are high rates of mania in clinical and residential facilities, community based epidemiologic studies are limited. Given the difficulty in making an accurate diagnosis, geriatric mania appears to be underreported. Although the commonly held opinion is that onset and prevalence of mania decreases with age, there is contradictory evidence that, particularly in men, the incidence of new onset mania increases with age. Clinically, the diagnosis and treatment of geriatric mania is challenging, because these patients present with comorbid medical, neurologic, and dementing illnesses. This paper reviews presentations of mania in the elderly and updates the pharmacologic treatment of mania in the elderly. Although few of the studies target the elderly, the published data in younger patients on the use of the atypical antipsychotics, as well as the advent of newer anticonvulsants, have demonstrated promise in the treatment of older patients.

Treatment of bipolar disorder in older adults

“…However, the use of lithium in older adults, particularly individuals over the age of 70 may be complicated by the presence of side effects (Tueth et al, 1998;McDonald, 2000). Lithium pharmacokinetics are significantly altered by aging.…”

“…Prior to initiation of lithium therapy in the elderly, preliminary medical work-up should include assessment of renal function, electrolytes, ECG, thyroid function and fasting blood glucose (McDonald, 2000). Typical starting doses are 150-300 mg/day with gradual titration toward maintenance blood levels made at longer time intervals (5-7 days) because of the increased time required for the elderly to reach steady state kinetics (Foster, 1992).…”

“…Valproate and carbamazepine are the most widely prescribed compounds in the older adults with bipolar illness (McDonald, 2000). Valproate in particular has been shown to be an effective and well-tolerated medication in the elderly (Evans et al, 1995;McFarland et al, 1990) although there is still a lack of controlled, rigorous trials involving use of valproate among older adults with bipolar disorder (Chen et al, 1999).…”

“…In the elderly, carbamazepine is initiated at 100 mg once or twice daily, and with gradual increases (100-200 mg every 3-5 days) to a typical dosing range of 400-800 mg/daily (McDonald, 2000). Targeted serum levels are generally 6-12 mg/l, although some elderly patients will not tolerate the higher dosing ranges.…”

“…While bilateral electrode placement may be more effective in mania (Small et al, 1985), unilateral placement may be associated with less acute cognitive disturbance (Black et al, 1987;Mukherjee et al, 1994). McDonald (2000) has recently recommended that suprathreshold stimulus (150%-400% over the stimulus threshold) using the unilateral D'Elia placements is as effective as bilateral treatments. In addition, it has been reported that among elderly patients with resistant depression, 6 months of maintenance ECT is more effective than prophylactic medication and is more cost-effective than pharmacotherapy .…”