Introduction

Mania in the elderly, also known as "late-onset mania”,¹ is a psychiatric condition characterised by elevated mood, hyperactivity, and a range of other symptoms that significantly impact daily functioning. These symptoms can be more challenging to detect in older adults. This is because the symptoms may be attributed to comorbid medical conditions or other age-related issues such as cognitive decline, age-related changes, or chronic medical conditions. As such, mania in older adults can present unique challenges and complexities in its diagnosis and management.²

According to currently accepted definitions:

• The onset of mania in an adult that is >50 years old is considered “late-onset mania”.
• The onset of mania in an adult that is >60 years old is considered “very late-onset mania.”³

Diagnostic Challenges

Comorbid Medical Conditions

Older adults are more likely to have multiple comorbid medical conditions, such as cardiovascular disease, diabetes, and arthritis, which can complicate the diagnosis and management of mania. The presence of these conditions can mask or mimic manic symptoms, making it challenging to distinguish between psychiatric and medical issues. Additionally, medications used to treat these comorbid conditions can interact with psychiatric drugs, requiring careful management.²

Cognitive Decline

Cognitive decline, ranging from mild cognitive impairment to dementia, is common in older populations and it can complicate the clinical presentation of mania. Symptoms of cognitive decline, such as memory loss, disorientation, and impaired judgement, overlap with manic symptoms, making the accurate diagnosis of mania more challenging. Moreover, cognitive deficits can hinder the patient's ability to adhere to treatment plans and manage their condition effectively.⁴

Age-related Changes in Pharmacokinetics and Pharmacodynamics

Age-related changes in the body's ability to absorb, distribute, metabolise, and excrete medications (pharmacokinetics) and changes in drug sensitivity (pharmacodynamics) are significant considerations when treating mania in the elderly. Older adults often have reduced hepatic (liver) and renal (kidney) function, leading to altered drug metabolism and increased risk of adverse effects. These changes require careful dosing and monitoring of psychiatric medications to avoid toxicity and ensure therapeutic efficacy.⁵

Differences in Clinical Presentation and Diagnosis

Mania in elderly patients often manifests with the following symptoms:⁶

• Elevated or Irritable Mood: Prolonged periods of excessively high or irritable mood.
• Increased Activity or Energy: Those with mania may experience a marked increase in goal-directed activities or physical restlessness.
• Grandiosity: Inflated self-esteem or grandiose ideas - an example of a grandiose idea would be someone thinking that they could solve world hunger or find the cure for cancer.
• Decreased Need for Sleep: Feeling rested after only a few hours of sleep.
• Talkativeness: Pressured speech or an increased urge to talk.
• Racing Thoughts: Subjective experience of thoughts racing or flight of ideas (i.e. jumping from topic to topic with no apparent connection between them).
• Distractibility: Easily distracted by irrelevant external stimuli.
• Impulsivity: Engaging in high-risk behaviours (e.g. unprotected sex, excessive spending beyond their means) with a disregard for potential painful consequences.

Whilst these symptoms are similar to younger people presenting with mania, diagnosing mania in the elderly can be difficult due to overlapping symptoms with other geriatric syndromes, such as delirium or dementia. 

Elderly individuals are more likely to exhibit irritability and aggression rather than the classic euphoria seen in younger patients; this can lead to a misdiagnosis as a behavioural issue or another psychiatric condition, like anxiety. 

Additionally, symptoms such as memory loss, disorientation, and executive dysfunction are common in elderly patients with mania, complicating the differentiation from cognitive disorders like Alzheimer's disease​ or delirium, which is often secondary to infection.

As such, the differential diagnosis for mania in the elderly are broad and include, but are not limited to:

• Delirium
• Dementia
• Schizophrenia 
• Schizoaffective disorder
• Drug intoxication
• Mood disorders

Causes of Mania

Krauthammer and Klerman⁷ state that late-onset mania can be triggered by various causes, broadly categorised into neurological, infectious, endocrinological, and iatrogenic (i.e., medical conditions caused by medical treatment) causes. The elderly population is particularly vulnerable to these triggers due to their more fragile health status and age-related changes. 

• Neurological Causes
  • Dementia - Increases the risk of developing mania significantly compared to the general population.
  • Head injury - Trauma to the brain can trigger manic episodes, particularly in the elderly, where recovery and neuroplasticity are diminished.
  • Central Nervous System Tumours - tumours can cause various neuropsychiatric symptoms, including mania.
  • Multiple Sclerosis - This demyelinating disease can also present with psychiatric symptoms.
  • Stroke - Post-stroke mania is more prevalent in the elderly.
  • Epilepsy 
  • Wilson’s Disease - Though rare, this metabolic disorder can cause neuropsychiatric symptoms including mania.
• Infectious Causes
  • Syphilis - Tertiary syphilis can cause neuropsychiatric symptoms. 
  • AIDS-related illness - opportunistic infections can affect the brain.
  • Lyme Disease - known to have neuropsychiatric manifestations.
  • Viral encephalitis - infection and inflammation of the brain can trigger psychiatric symptoms.
• Vitamin B12 deficiency - can cause neuropsychiatric symptoms if severe and prolonged. 
• Endocrinological Causes
  • Thyroid disease - hyperthyroidism can present with manic-like symptoms.
  • Hypercortisolemia - high levels of cortisol can trigger manic symptoms.
• Iatrogenic Causes
  • Medications such as corticosteroids, amphetamines and other sympathomimetics, Levodopa.

Management of Mania in the Elderly

Pharmacological Management

Managing mania in elderly patients requires a tailored pharmacological approach due to the high frequency of comorbid conditions and pharmacokinetic and pharmacodynamic changes that occur as we age. These factors, combined, increase the risk of adverse events and drug interactions.⁸

• Lithium is highly effective in controlling manic episodes, but its use in older people requires close monitoring due to a narrow therapeutic index and potential for toxicity. During any lithium treatment, lithium levels and kidney function, which often declines with age, must be regularly assessed to avoid lithium accumulation and possible toxicity. Common side effects of lithium treatment include tremors, weight gain, and thyroid dysfunction​. 
• Valproate is another effective mood stabiliser. In the elderly, valproate is often better tolerated than lithium. It is beneficial in patients with mixed affective states or rapidly cycling bipolar disorder. However, valproate also must be monitored closely, as it can cause liver toxicity, gastrointestinal disturbances, and impair cognitive function.⁹
• Atypical antipsychotics, such as olanzapine, risperidone, and quetiapine, are also commonly used in managing mania. These medications are beneficial in patients with psychotic features or severe agitation. They are generally better tolerated than older antipsychotics, but they still pose risks such as increasing rates of metabolic syndrome, falls, and sedation.¹⁰

Non-Pharmacological Management

Non-pharmacological strategies are equally important in managing mania in elderly patients. They can provide complementary benefits that address psychosocial and environmental factors.

• Psychosocial Interventions: Engaging patients in structured psychosocial interventions can help stabilise their mood and improve overall well-being. Support groups, family therapy, and psychoeducation are valuable tools to help patients and their families understand the condition and develop coping strategies​.
• Cognitive-Behavioural Therapy (CBT): CBT can be particularly effective in managing symptoms of mania by helping patients identify and modify negative thought patterns and behaviours. It also helps develop healthier coping mechanisms and enhance problem-solving skills.
• Stable and Structured Environment: Ensuring a stable daily routine and reducing environmental stressors can significantly mitigate manic symptoms. Regular sleep patterns, balanced nutrition, and consistent daily activities help maintain a sense of normalcy and minimise agitation​.¹¹

Summary

Mania in the elderly, or late-onset mania, is a complex condition that requires a careful consideration of comorbid medical conditions, cognitive decline, and age-related changes in pharmacokinetics and pharmacodynamics. Accurate diagnosis and effective management require a thorough and multidisciplinary approach to address the unique challenges presented by mania in this population. With appropriate treatment and support, older adults with mania can achieve improved outcomes and a better quality of life. Understanding the various causes and triggers of the disorder is crucial in developing effective prevention and treatment strategies for this vulnerable population.