Cases That Test Your Skills

‘Killer trolls’: One older man’s battle

Current Psychiatry. 2007 March;6(3):91-105

References

1. Depp C, Jeste D. Bipolar disorder in older adults: a critical review. Bipolar Disord 2004;6:343-67.

2. Sajatovic M, Blow FC, Ignacio RV, Kales HC. New-onset bipolar disorder in later life. Am J Geriatr Psychiatry 2005;13:282-9.

3. Arciniegas DB. New-onset bipolar disorder in late life: a case of mistaken identity. Am J Psychiatry 2006;163:198-203.

4. Young RC. Bipolar disorder in older persons: perspectives and new findings. Am J Geriatr Psychiatry 2005;13:265-7.

5. Young RC. Evidence-based pharmacological treatment of geriatric bipolar disorder. Psychiatr Clin North Am 2005;28:837-69.

6. Diagnostic and statistical manual of mental disorders, 4 ed, text rev. Washington, DC; American Psychiatric Association; 2000.

7. Blumberg HP, Stern E, Ricketts S, et al. Rostral and orbital prefrontal cortex dysfunction in the manic state of bipolar disorder. Am J Psychiatry 1999;156:1986-8.

8. Gitlin M. Treatment-resistant bipolar disorder. Mol Psychiatry 2006;11:227-40.

9. Dubovsky SL. Treatment of bipolar depression. Psychiatr Clin N Am 2005;28:349-70.

10. Kroenke K. A 75-year-old man with depression. JAMA 2002;287:1568-76.

11. Shanmugham B, Karp J, Drayer R, et al. Evidence-based pharmacological interventions for geriatric depression. Psychiatr Clin N Am 2005;28:821-35.

12. Alexopoulos GS. In: Sadavoy J, Jarvik LF, Grossberg GT, Meyers BS, eds. Comprehensive textbook of geriatric psychiatry, 3 ed. New York: WW Norton and Co.; 2002:609-53.

13. Sneed JR, Roose SP, Sackeim HA. Vascular depression: a distinct diagnostic subtype? Biol Psychiatry 2006;60:1295-8.

14. Higgins N, Regan C. A systematic review of the effectiveness of interventions to help older people adhere to medication regimes. Age Ageing 2004;33:224-9.

15. Ownby RL, Hertzog C, Crocco E, Duara R. Factors related to medication adherence in memory disorder clinic patients. Aging & Mental Health 2006;10:378-85.

16. Sajatovic M, Madhusoodanan S, Coconcea N. Managing bipolar disorder in the elderly: defining the role of the newer agents. Drugs Aging 2005;22:39-54.

17. Cavanagh J, Smyth R, Goodwin GM. Relapse into mania or depression following lithium discontinuation: a 7-year follow up. Acta Psychiatr Scand 2004;109:91-5.

18. Dunner DL. Atypical antipsychotics: efficacy across bipolar disorder subpopulations. J Clin Psychiatry 2005;66(suppl 3):20-7.

19. American Diabetes Association, American Psychiatric Association, American Association of Clinical Endocrinologists, North American Association for the Study of Obesity. Consensus development conference on antipsychotic drugs and obesity and diabetes. Diabetes Care 2004;27:596-601.

20. Leverich GS, Altshuler LL, Frye MA, et al. Risk of switch in mood polarity to hypomania or mania in patient with bipolar depression during acute and continuation trials of venlafaxine, sertraline, and bupropion as adjuncts to mood stabilizers. Am J Psychiatry 2006;163:232-9.

Lithium can cause dull affect, cognitive slowing, and depersonalization. Titrating to the lowest effective dosage might minimize these effects.

Dementia. Cognitive deficits that accompany mania in older adults could suggest dementia, which usually develops over years and is preceded by cognitive changes without manic-type symptoms. By contrast, bipolar mania emerges more abruptly and is accompanied by affective symptoms. Agitation and psychosis—both symptoms of late-stage dementia—can be early signs of geriatric BPD.²

Delirium. Restlessness, irritability, aggression, and changes in affect can accompany delirium, especially the hyperactive or hyperalert types. Symptoms of anxiety, depression, fear, and loose or tangential thinking also are common.

Mania shares some of these features but typically presents with an abnormally and persistently elevated or irritable mood lasting ≥1 week, usually without prominent cognitive impairment.⁶ Mania can also include:

grandiosity
decreased need for sleep
flight of ideas
distractibility
pressured or increased rate of speech
psychomotor agitation
potentially harmful activities
increased goal-directed activities.⁶

By contrast, delirium is marked by waxing and waning consciousness and changes in cognition, such as disorientation and confusion.⁶

Frontal lobe lesions. Decreased prefrontal executive control could underlie mania’s cognitive and emotional symptoms. Decreased right rostral and orbital prefrontal cortex activation has been associated with impaired planning, judgment, and insight, as well as inappropriate conduct.⁷

Table

Clinical features of geriatric bipolar disorder (BPD)

Psychotic features (delusions, hallucinations)
Mean prevalence of 64% (range 20% to 85%) is similar to that of mixed-age groups; paranoia might be more prevalent
Family history
High rates of psychiatric disorders (“affective disorder” in most studies) reported in 10 studies
Compared with younger adults with BPD, older patients:
show longer latency from first depression to mania onset might be more likely to relapse into depression after mania might have less-intense mania are hospitalized longer, possibly because of greater medical comorbidity have less comorbid substance abuse and more-prominent age-associated morphologic abnormalities on neuroimaging²
Compared with late-life schizophrenia, late-life BPD patients show:
more depressive symptoms fewer positive and negative symptoms greater community living and relationship skills, with similar activities of daily living
Source: References 1,2

Continued treatment: depression emerges

Several months later, Mr. B presents with severe depression and continued medication nonadherence. He complains of hypersomnia, poor appetite, anhedonia, amotivation, and a leaden-like paresis in his hands and feet.

We readmit Mr. B to the psychiatric unit. He avoids contact with others, has lost 18 lbs over 6 weeks, and suffers hypotension caused by poor hydration before admission. Three weeks later, he complains that ants are crawling around his room and into his mouth.

Noncontrast brain CT shows no abnormalities. Laboratory tests performed at admission show a subtherapeutic lithium level (0.03 mEq/L), unremarkable thyroid panel, and normal B12 and folate, so we begin to rule out a medical cause for his psychiatric symptoms.

The authors’ observations

Check for these and other possible causes of depressive symptoms in older patients with a history of BPD. Mr. B’s depression likely resulted from multiple causes, including medical disease, functional impairment, loss of social and family contacts, and substance abuse—all late-life predictors of depression. BPD also predisposed him to depression.

Bipolar depression. Despite its profound morbidity and mortality, bipolar depression remains a mystery, especially in the elderly. Mr. B’s depression emerged after he was free of depressive symptoms for more than 20 years.

Some researchers believe that compared with other depressions, bipolar depression has a more acute onset, marked psychomotor retardation, and lessened response to antidepressants.^6,8 Kraepelin associated bipolar depression with lethargy, mental slowing, and hypersomnia, whereas agitation and insomnia signal unipolar depression.⁹

To differentiate bipolar from unipolar or secondary depression in older patients, watch for:

suicide risk, which is heightened during BPD’s depressive phase⁹
secondary manias, for which underlying causes must be determined and treated if possible.

Medication-induced depression. Medications can cause depressive symptoms (see Related resources), but identifying an offending agent without an obvious chronologic relationship can be difficult, especially in older patients who are taking numerous medications.⁹

Depression caused by medication might be limited to somatic complaints such as fatigue or tiredness,⁹ and often lacks features seen with mood disorders such as depressed mood, anhedonia, guilt, and diminished interest in activities. Mr. B’s anhedonia and amotivation suggest his depression was not medication-induced.¹⁰

Disease-induced depression. Medical comorbidities are common among older persons with mood disorders and can complicate treatment response and outcome. Physical disease can cause or worsen depression:¹¹

Endocrine and immunologic diseases might cause depression or mania.
Cardiovascular and cerebrovascular diseases; CNS disorders such as dementia, Parkinson’s disease, and multiple sclerosis; cancer; and connective tissue disease increase risk for comorbid depression.

Mr. B’s hypertension, diabetes, or coronary artery disease could have contributed to his depression or complicated the course.