An Older Woman with Bipolar Disorder
Ms. W is an 83-year-old unmarried white woman who is brought to the emergency room by members of her church. She has been hospitalized more than six times in the past two years due to episodes of mania. Her friends explain that Ms. W has been disruptive during church services, singing hymns during prayers and the minister’s sermon. They have tried to help encourage her to take her medications, but she insists that she is fine. Ms. W attends the church-affiliated senior center daily, where she eats meals and socializes. She is well liked, although often thought of as odd and strange. She lives in an apartment in a senior housing building and has a friend who pays her bills for her.
Ms. W becomes very agitated in the emergency room, trying to kiss other patients and give them a religious blessing. She opens her purse and starts giving patients varying amounts of dollar bills and coins, stating that God told her to give away her worldly possessions. Ms. W displays loud pressured speech, intrusive behavior, and hyperactivity. After much coaxing she allows her vital signs to be taken. Her blood pressure is 180/110 mm Hg, and her pulse is 100 bpm. Her friends have brought her prescription medications, which include nearly full bottles of metoprolol 50 mg twice daily, lisinopril 10 mg once daily, and olanzapine 15 mg once daily.
Her friends report that Ms. W has a long history of bipolar disorder. While she was hospitalized many times throughout her life, Ms. W was able to support herself, working for many years at the Department of Motor Vehicles and retiring at age 68. She is often noncompliant with medications and has no formal home care or housekeeping services. Her friends report that Ms. W is hard of hearing and also wears glasses, but she did not have her hearing aids or eyeglasses with her.
Ms. W becomes increasingly agitated in the emergency room, touching other patients in her desire to “bless them” and refuses to take any medication. After trying to kiss several staff members she is given olanzapine 10 mg by intramuscular injection, and later takes her blood pressure medications. She is admitted to the inpatient psychiatric unit on an involuntary basis.
Bipolar disorder is a chronic illness marked by exacerbations and remissions. The age of onset of bipolar disorder is typically in early adulthood, but up to 10% of patients present for the first time after age 50 years.1
Bipolar disorder in older adults accounts for 10% to 25% of admissions to inpatient psychiatric units.2,3 The community prevalence of bipolar disorder in older adults is 0.4%. Among elderly patients treated in mental health settings, up to 30% of older adults have symptoms that fall within the spectrum of bipolar disorder. Compared with older adults who suffer from depression, those with bipolar disorder use more than four times the amount of mental health services and are far more likely to require acute inpatient hospitalization.3,4
Bipolar disorder is an illness characterized by periods of mania, depression, or mixed states. Psychotic features may accompany each episode. A manic episode is characterized by a period of at least one week of a persistently elevated, expansive, or irritable mood with pressured speech, racing thoughts, decreased need for sleep, grandiosity, and hyperactivity.1-3 A mixed episode includes features of both mania and depression. A depressive episode typically includes the features of depressed mood and loss of interest in activities, and may be mistaken for an episode of major depressive disorder if the patient’s history is unavailable or not addressed.1,4
Bipolar disorder is often misdiagnosed in older adults and mistaken for anxiety, psychotic disorders, or dementia.5 Mania in an older adult is less likely to present as euphoria and more likely to be associated with irritability, anger, and behavioral disturbances1-5 (Table I). Older adults are likely to present with an irritable mood in all phases of bipolar disorder, making the diagnosis more difficult to identify and often requiring careful review of symptoms and history. Executive dysfunction with poor impulse control is common. The clinician often has a great deal of difficulty obtaining a history from the patient. Use of informants is extremely valuable in determining the course of the illness.5,6
Older adults with bipolar disorder are at high risk for self-harm due to impulsivity, hyperactivity, and suicidal ideation.1,4 They may engage in behaviors such as gambling, excessive spending, or may give away possessions or large amounts of money. They are vulnerable to exploitation by others who may take advantage of their illness to engage them in financial schemes.1,3
An important aspect of the differential diagnosis of an older adult who presents with mania is the entity of a mood disorder due to a general medical condition or related to a medication or substance.1,5,6 This is often referred to as secondary mania, and should always be considered when an older adult with no prior psychiatric history presents with manic symptoms. Common causes of secondary mania include neurologic disorders, endocrine disorders, autoimmune disorders, vitamin deficiencies, and medications4-6 (Table II).
Medications that are FDA-approved for the treatment of bipolar disorder include the mood stabilizers lithium carbonate, valproate, lamotrigine, and extended-release carbamazepine. The antipsychotic agents olanzapine, risperidone, quetiapine, aripiprazole, and ziprasidone are approved for the treatment of mania.7 Treatment of manic or mixed episodes often requires the use of a mood stabilizer and an antipsychotic agent.7,8 Treatment of depressive episodes may best be managed with increasing doses of mood stabilizers. Judicious use of antidepressant agents is required, as drug-induced mania is a frequent occurrence.9 Electroconvulsive therapy is an option for the treatment of depressive or manic episodes. It may be particularly useful for patients who have not responded to medications or who suffer intolerable side effects.7-9
Psychotherapy is an important adjunctive therapy to medication management in the treatment of bipolar disorder.7 Cognitive behavioral therapy has been successfully utilized, as well as supportive therapy and family therapies. Family support and education regarding the disorder is also very helpful.7,8 Compliance with medication and treatment is vital to maintain stability. Patients who suffer from bipolar disorder are often very sensitive to medication side effects such as sedation and will often discontinue therapy. It is important to openly discuss the patients’ concerns about quality of life, relapse prevention, and activity level to promote compliance and gain a therapeutic alliance.7-9
Information regarding bipolar disorder for patients, family, and friends may be downloaded from the Depression and Bipolar Support Alliance at www.dbsalliance.org, Mental Health America at www.nmha.org, MedHelp at www.medhelp.org, and the National Institute of Mental Health at www.nimh.nih.gov/.
Outcome of the Case Patient
Ms. W was admitted to the acute inpatient psychiatric unit. She continued to display intrusive behavior, irritable mood, and poor impulse control. Ms. W slept very little at night and often tried to awaken other patients. She required close observation for several days due to her intrusive behavior and impulsivity. She initially refused medications but became compliant after her church pastor visited and provided encouragement to engage in treatment. She was treated with olanzapine 10 mg daily and valproate 1000 mg daily. After 10 days of therapy her valproate level was 74 mcg/mL (therapeutic range 40-120 mcg/mL). Her thinking became more organized with an improvement in disruptive behavior.
Ms. W was referred to a local case management program and was assigned a supportive case manager to help promote compliance with outpatient treatment and linkage to community services. She was discharged from the hospital after 20 days. Ms. W returned to her apartment and attended her church senior center daily. Her case manager arranged for her medications to be prepared weekly by a visiting nurse. She was continued on stable doses of olanzapine 10 mg once daily and valproate 1000 mg daily.
Ms. W’s strong spiritual beliefs and ties to her church were respected and promoted as a means of support. Prior to her discharge, a team meeting was held that included her church pastor and a neighbor to help plan for her transition back to the community. Her church pastor met with her frequently and encouraged her to keep her psychiatric follow-up visits. She was seen monthly by her psychiatrist for medication management and supportive psychotherapy. At a six-month follow-up visit Ms. W remained stable, and established a positive relationship with her case manager. She has weekly housekeeping services to assist her at home with cleaning and shopping. She is able to socialize with her friends and participates in many church social programs.
The author reports no relevant financial relationships.
1. American Psychiatric Association. Mood disorders. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Text Revision. Washington, DC: American Psychiatric Association; 2000:345-428.
2. Gunning-Dixon FM, Murphy CF, Alexopoulos GS, et al. Executive dysfunction in elderly bipolar manic patients. Am J Geriatr Psychiatry 2008;16(6):506-512.
3. Bartels SJ, Forester B, Miles KM, Joyce T. Mental health service use by elderly patients with bipolar disorder and unipolar depression. Am J Geriatr Psychiatry 2000;8(2):160-166.
4. Gildengers AG, Whyte EM, Drayer RA, et al. Medical burden in late-life bipolar and major depressive disorders. Am J Geriatr Psychiatry 2008;16(3):194-200.
5. Arciniegas DB. New-onset bipolar disorder in late life: A case of mistaken identity. Am J Psychiatry 2006;163(2):198-203.
6. Depp CA, Davis CE, Mittal D, et al. Health-related quality of life and functioning of middle-aged and elderly adults with bipolar disorder. J Clin Psychiatry 2006;67(2):215-221.
7. Aziz R, Lorberg B, Tampi RR. Treatments for late-life bipolar disorder. Am J Geriatr Pharmacother 2006;4(4):347-364.
8. Dennehy EB, Bauer MS, Perlis RH, et al. Concordance with treatment guidelines for bipolar disorder: Data from the systematic treatment enhancement program for bipolar disorder. Psychopharmacol Bull 2007;40(3):72-84.
9. Thase ME. STEP-BD and bipolar depression: What have we learned? Curr Psychiatry Rep 2007;9(6):497-503.
Dr. Lantz is Chief of Geriatric Psychiatry, Beth Israel Medical Center, First Ave @ 16th Street #6K40, New York, NY 10003; (212) 420-2457; fax: (212) 844-7659; e-mail: email@example.com.