CASE Delusional and aggressive
Mr. P, age 78, of Filipino heritage, is brought to the psychiatric hospital because he has been verbally aggressive toward his wife for several weeks. He has no history of a psychiatric diagnosis or inpatient psychiatric hospitalization, and no history of taking any psychotropic medications.
According to his wife, Mr. P has been ruminating about his father, who died in World War II, saying that “the Japanese never gave his body back” to him. Also, his wife describes 3 weeks of physically aggressive behavior, such as throwing punches; the last episode was 2 days before admission.
Mr. P is not bathing, eating, taking his medications, and attending to his activities of daily living. He sleeps for only 1 to 2 hours a night; is irritable and easily distractible; and experiences flight of ideas. Mr. P has been buying lottery tickets, telling his daughter that he will become a millionaire and then buy a house in the Philippines.
Mr. P reports depressed mood, but no other depressive symptoms are present. He reports no suicidal or homicidal ideations, auditory or visual hallucinations, or anxiety symptoms. He has no history of substance abuse.
What diagnosis would you give Mr. P?
a) late-onset bipolar disorder
b) Alzheimer’s disease
c) major depressive disorder
d) frontotemporal dementia
The authors’ observations
Bipolar disorder in later life is a complex and confounding neuropsychiatric syndrome with diagnostic and therapeutic challenges. The disorder can affect people of all ages and is not uncommon among geriatric patients, with a 1-year prevalence in United States of 0.4%.1 In one study, 10% of new bipolar disorder cases were found to occur after age 50.2 As the American population grows older, the number of bipolar disorder cases among seniors is expected to increase.3
It was once thought that symptoms of bipolar disorder disappear with age; newer research has disproved this theory, and proposes that untreated bipolar disorder worsens over time.4 Persons who are given the diagnosis later in life could have had bipolar disorder for decades, but symptoms became more noticeable and problematic with age.5
Common symptoms in geriatric patients can differ from what we might expect in younger patients: agitation, hyperactivity, irritability, confusion, and psychosis.6 When the disorder presents in patients age >60, it can be severe, with significant changes in cognitive function, including difficulties with memory, perception, judgment, and problem-solving.7,8
HISTORY Medical comorbidities
Mr. P emigrated from the Philippines 20 years ago, is married, and lives with his wife. He has 3 brothers; his parents were divorced, and his mother remarried. Mr. P completed high school.
Mr. P has an extensive medical history: diabetes mellitus, hypertension, dyslipidemia, and recent double coronary artery bypass grafting. He is taking several medications: sitagliptin, 25 mg/d; pantoprazole, 5 mg/d; metformin, 1,000 mg/d; rivaroxaban, 20 mg/d; amiodarone, 200 mg/d; metoprolol, 12.5 mg/d; olmesartan medoxomil, 40 mg/d; aspirin, 81 mg/d; simvastatin, 10 mg/d; eszopiclone, 3 mg at bedtime; and amlodipine, 5 mg at bedtime.
Mr. P was following up with his primary care physician for his medical conditions and was adherent with treatment until 1 week before he was admitted to our facility.
The authors’ observations
Always rule out medical causes in a case of new-onset mania, which is particularly important in geriatric patients. Older patients with new-onset mania are more than twice as likely to have a comorbid neurologic disorder.9 Neurologic causes of late-onset mania include:
• stroke
• tumor
• epilepsy
• Huntington’s disease and other movement disorders
• multiple sclerosis and other white-matter diseases
• head trauma
• infection (such as neurosyphilis)
• Creutzfeldt-Jakob disease
• frontotemporal dementia.10
Mr. P’s presentation of psychomotor agitation, impaired functioning, decreased need for sleep, increased energy, hyperverbal speech, and complex paranoid delusions meets DSM-5 criteria for bipolar disorder, manic phase. In addition, older manic patients frequently present with confusion, disorientation, and distractibility. Younger patients with mania often present with euphoric moods and grandiosity; in contrast, geriatric patients are more likely to show a mixture of depressed affect and manic symptoms (pressured speech and a decreased need for sleep).11-15
We considered an emerging neurodegenerative process, because dementia can present early with disinhibition, lability, and other behavioral disturbances, including classic manic syndromes.16 Although we could not fully rule out a neurodegenerative process in the initial phase of treatment, Mr. P’s longitudinal course demonstrated no change in baseline cognitive function and no evidence of subsequent decline, making dementia unlikely.17
Patients with frontotemporal dementia are more likely to present initially to a psychiatrist than to a neurologist.18
Frontotemporal dementia is a progressive neurodegenerative disease that affects the frontal and temporal cortices; it is a common cause of dementia in patients age <65.19 Frontotemporal dementia is characterized by insidious behavioral and personality changes; often, the initial presentation lacks any clear neurologic signs or symptoms. Key features include apathy, disinhibition, loss of sympathy and empathy, repetitive motor behaviors, and overeating.20