Psych · Old age psychiatry — mood disorders
Late-life bipolar disorder
Also known as Older-age bipolar disorder · OABD · Geriatric bipolar disorder · Late-onset bipolar disorder · Late-onset mania · Secondary mania in older adults
Exam-exhaustive fellowship reference on late-life bipolar disorder — early-onset vs late-onset bipolarity, secondary/organic mania, lithium in the elderly (targets, interactions, toxicity), medical comorbidity, suicide risk and lethality, GERI-BD, maintenance (BALANCE), bipolar depression without antidepressant monotherapy, ECT, RANZCP/CANMAT/BAP. FRANZCP-primary, globally tagged.
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Target exams
Red flags
- First manic or hypomanic episode after age 50–60 — treat as secondary/organic until reasonably excluded (neuroimaging, drugs, medical causes)
- Active suicidal ideation, plan, or lethal means in bipolar depression or mixed states — same-day senior review and means restriction
- Lithium toxicity signs (vomiting, coarse tremor, ataxia, confusion, seizures) — stop lithium, urgent level, fluids, consider dialysis
- Acute fluctuating inattention — delirium first; do not label as pure mania until medical drivers addressed
- New neurological signs, stepwise cognitive decline, or fever with psychiatric change — urgent medical/neuro work-up
- Antidepressant monotherapy in known or suspected bipolar depression — high switch/mixed risk
Meet the patient
A 71-year-old man with a 40-year history of bipolar I disorder arrives manic: he has not slept for four nights, is spending his grandchildren's inheritance on shares, and is hostile to the ward staff. His creatinine has climbed 30 per cent this year, he takes lisinopril and a thiazide, and last week he had diarrhoea for three days.[1][9]
Across the bay is a 68-year-old woman with no psychiatric history who became elevated for the first time two weeks after a right-hemisphere stroke and a course of high-dose prednisolone.[8]
Two patients, one word — mania — and the examiner's first question is the same for both: "Is this primary bipolar, or is something driving it?" Everything below answers that.[1][8]
References18ShowHide
- [1]Depp CA, Jeste DV Bipolar disorder in older adults: a critical review Bipolar Disord, 2004.PMID 15383127
- [2]Young RC, Gyulai L, Mulsant BH, Flint A, et al. Pharmacotherapy of bipolar disorder in old age: review and recommendations Am J Geriatr Psychiatry, 2004.PMID 15249272
- [3]Sajatovic M, Madhusoodanan S, Coconcea N Managing bipolar disorder in the elderly: defining the role of the newer agents Drugs Aging, 2005.PMID 15663348
- [4]Lala SV, Sajatovic M Medical and psychiatric comorbidities among elderly individuals with bipolar disorder: a literature review J Geriatr Psychiatry Neurol, 2012.PMID 22467842
- [5]Sajatovic M, Forester BP, Gildengers A, Mulsant BH Aging changes and medical complexity in late-life bipolar disorder: emerging research findings that may help advance care Neuropsychiatry (London), 2013.PMID 24999372
- [6]Young RC, Mulsant BH, Sajatovic M, Gildengers AG, et al. GERI-BD: A Randomized Double-Blind Controlled Trial of Lithium and Divalproex in the Treatment of Mania in Older Patients With Bipolar Disorder Am J Psychiatry, 2017.PMID 29088928
- [7]Shulman KI, Almeida OP, Herrmann N, Schaffer A, et al. Delphi survey of maintenance lithium treatment in older adults with bipolar disorder: An ISBD task force report Bipolar Disord, 2019.PMID 30375703
- [8]Krauthammer C, Klerman GL Secondary mania: manic syndromes associated with antecedent physical illness or drugs Arch Gen Psychiatry, 1978.PMID 757997
- [9]McKnight RF, Adida M, Budge K, Stockton S, et al. Lithium toxicity profile: a systematic review and meta-analysis Lancet, 2012.PMID 22265699
- [10]Cipriani A, Hawton K, Stockton S, Geddes JR Lithium in the prevention of suicide in mood disorders: updated systematic review and meta-analysis BMJ, 2013.PMID 23814104
- [11]Geddes JR, Goodwin GM, Rendell J, et al. Lithium plus valproate combination therapy versus monotherapy for relapse prevention in bipolar I disorder (BALANCE): a randomised open-label trial Lancet, 2010.PMID 20092882
- [12]Yatham LN, Kennedy SH, Parikh SV, et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) 2018 guidelines for the management of patients with bipolar disorder Bipolar Disord, 2018.PMID 29536616
- [13]Malhi GS, Bell E, Bassett D, et al. The 2020 Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders Aust N Z J Psychiatry, 2021.PMID 33353391
- [14]Conwell Y, Van Orden K, Caine ED Suicide in older adults Psychiatr Clin North Am, 2011.PMID 21536168
- [15]Grande I, Berk M, Birmaher B, Vieta E Bipolar disorder Lancet, 2016.PMID 26388529
- [16]Goodwin GM, Haddad PM, Ferrier IN, et al. Evidence-based guidelines for treating bipolar disorder: Revised third edition recommendations from the British Association for Psychopharmacology J Psychopharmacol, 2016.PMID 26979387
- [17]Sachs GS, Nierenberg AA, Calabrese JR, et al. Effectiveness of adjunctive antidepressant treatment for bipolar depression N Engl J Med, 2007.PMID 17392295
- [18]UK ECT Review Group Efficacy and safety of electroconvulsive therapy in depressive disorders: a systematic review and meta-analysis Lancet, 2003.PMID 12642045