A case report on very late onset mania

Diagnosing primary psychiatric disorder in elderly is a challenge considering the high prevalence of neurological and other medical diseases presenting with psychiatric manifestation. The first episode of mania occurring after the age of 80 years is extremely rare. We report a case of an 88-year-old married Hindu male educated up to fifth standard from rural background and lower socioeconomic status presenting with first episode mania, diagnosed using the tenth revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10) criteria. Secondary causes were ruled out and successfully treated with low dose olanzapine.


Introduction
Th e manic episode in elderly is a serious clinical problem which requires careful evaluation and management.Unfortunately, the clinical data and research in this area are inadequate.Th is is especially signifi cant considering the fact the elderly population is on a steady rise with increasing life expectancy and improved healthcare facilities.Th e incidence of mania in the population aged more than 75 years is around two per 100000.[1] Th e main challenge in late-onset cases of mania is to exclude secondary causes like vascular mania, multiple sclerosis, Parkinson's disease, temporal lobe epilepsy, acquired immunodefi ciency syndrome (AIDS), dementia, and traumatic brain injury [2] before considering primary psychiatric diagnosis like unipolar mania.A number of studies have consistently reported that the prevalence of bipolar disorder has an inverse relationship with age, with a decline in prevalence with increasing age.[3] We report a case of an 88-year-old man who was diagnosed with the fi rst episode of mania aft er detailed evaluation.

Case report
An 88-year-old married male presented to the Geriatric Mental Health outpatient department (OPD), with three months' history of unduly cheerful mood, over-talkativeness, increased activity level-doing excessive worship of God, restlessness, and decreased need for sleep.No signifi cant past or family history of any medical or psychiatric illness was present.Onset of illness was acute with no treatment received for current illness.No history of substance use, head trauma, cognitive decline, or altered consciousness was obtained.He was well-adjusted pre-morbidly.
Mental status examination at the time of presentation in OPD revealed a playful elderly male with preserved higher mental functions, increased psychomotor activity, elated aff ect, ideas of grandiosity, and insight Grade I/V.Physical examination was within normal limits except bilateral cataract (immature).His Young Mania Rating Scale (YMRS) score was 23 and Mini Mental Status Examination (MMSE) score was 27/30.Th e possibility of a manic episode was kept and the patient was admitted in Department of Geriatric Mental Health for further evaluation and management.In view of late onset of symptoms, his detailed systemic examination was carried out 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, serum electrolytes, thyroid function tests, the Venereal Disease Research Laboratory (VDRL) test, Elisa for human immunodefi ciency virus (HIV), and serum vitamin B12 were done and were all normal.Magnetic resonance imaging (MRI) of the brain showed mild atrophy consistent with his age.Aft er considering the laboratory results and normal imaging results, the diagnosis was set as the fi rst manic episode as per the tenth revision of the International Statistical Classifi cation of Diseases and Related Health Problems (ICD-10) criteria and the patient was started with olanzapine 5 mg per day along with sustained release zolpidem 6.25 mg for sleep.Th e dosage of olanzapine was increased to 7.5 mg and sustained release zolpidem to 12.5 mg aft er two days.Th e patient initially showed improvement in his sleep followed by other symptoms over a period of next seven days and his YMRS score reduced to eight, and was subsequently discharged.He had been followed up in OPD aft er two weeks and was maintaining well on same medications (tab olanzapine 7.5 mg, tab zolpidem 12.5 mg per day).

Discussion
Our patient presented with symptoms suggestive of a manic episode but considering the very late onset of illness and lack previous episodes in the past it is imperative to rule out the possible secondary causes before confi rming the diagnosis of mania.His extensive evaluation failed to reveal any secondary causes and his symptoms responded positively to treatment.And patient was diagnosed mania without psychotic symptoms using the ICD-10 diagnostic criteria.
Th ere are signifi cant variations in the reported incidence of bipolar disorder in the elderly and no clear consensus on mania/hypomania.A one-year incidence rate of 0.1% among adults over 65 years which is lower compared to younger age groups.[4] Th ere are a few studies in late-onset manic episodes which suggest an average age of onset be around 56 years.[4] Our patient had an age of onset of mania at 88 years which is much higher than reported by any studies.Th is case signifi es the very fact that it is not extremely uncommon to have cases of fi rst episode of mania even at a late age.It also underlines the importance of ruling out secondary causes by detailed evaluation and investigations before confi rming the diagnosis.
Our case shows that the drug dosage requirement in controlling manic symptoms in elderly is much lesser compared to younger age and as far as possible the general principle of geriatric psychopharmacology should be followed giving minimum medications at minimum eff ective concentration.[5]

Conclusion
Th is case highlights the fact that primary psychiatric disorder can actually occur at any age but requires a detailed evaluation to rule out secondary causes before fi nalising the diagnosis.Once confi rmed the patient can be managed in the same lines that of the younger population but psychotropic dosage should be kept at minimum eff ective dosage.Scientifi c and systematic research in this area is highly required to formulate eff ective management strategy in elderly population.