|Year : 2015 | Volume
| Issue : 2 | Page : 112-114
Delirious mania in geriatric age: A rare presentation
Ravi Mukundkumar Soni, Hitesh Khurana, Sarvada C Tiwari
Department of Geriatric Mental Health, King George's Medical University, Lucknow, Uttar Pradesh, India
|Date of Web Publication||18-Jan-2016|
Ravi Mukundkumar Soni
Department of Geriatric Mental Health, King George's Medical University, Lucknow - 226 003, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Delirious mania is a rare psychiatric syndrome characterized by the presence of delirious and manic symptoms at the same time in a patient with history of bipolar disorder. After its first description in 1832, delirious mania in the literature exists only in the form of case reports and case series. Among the elderly, its occurrence is still rarer. However, an unsuspecting clinician may come across this rare entity and may misdiagnose it for delirium, which needs to be managed aggressively. Hence, we preferred to describe a case of an elderly male here, who presented to us with delirious mania and responded well to olanzapine.
Keywords: Bipolar disorder, delirious mania, delirium, elderly, mania
|How to cite this article:|
Soni RM, Khurana H, Tiwari SC. Delirious mania in geriatric age: A rare presentation. J Geriatr Ment Health 2015;2:112-4
| Introduction|| |
Delirious mania is a rare psychiatric syndrome characterized by acute onset, manic or hypomanic symptoms with signs or symptoms of delirium, past and family histories of affective disorder, and responsivity to treatment for mania.  The syndrome was first identified by Calmeil in 1832.  Bell in 1849 had described it as a separate clinical entity and hence, it is also known as Bell's mania.  Afterward, it was differentiated from acute mania and hypomania by Kraepelin in 1921 and he described it as a most severe form of mania.  Since then, it has been reported only in case reports and case series as secondary to some underlying physical cause.  It is still rarer in elderly patients. 
Reports of delirious mania in the elderly are very few. To our knowledge, Weintraub and Lippmann reported two cases of elderly individuals with mania who initially presented with delirium.  Rosenzweig et al. reported a case of an elderly retired teacher with no previous history of psychiatric illness who developed delirium and manic symptoms in close association with a cycle of carboplatin and paclitaxel chemotherapy.  Lee et al. reported five cases of delirious mania, out of which one patient was elderly who presented with florid manic symptoms and later on developed delirium.  Maldeniya and Vasudev reported a case of an elderly man with features of delirium with little or no manic symptoms, who had past history of bipolar I disorder. They also questioned the concept of delirious mania in the elderly. 
Keeping in view the rarity of this diagnosis, responsiveness to antipsychotic medication, and questioning over the concept of delirious mania in the elderly, we here report a case of an elderly male who had presented to us with delirious mania as primary presentation of bipolar affective disorder.
| Case Report|| |
Mr. R.B was a 70-year-old illiterate male farmer of rural origin who attended the outdoor geriatric mental health services in February 2015. He presented to us with decreased sleep, irritability, grandiose talks, talkativeness, increased energy level, and confusion for 8 days. He was diagnosed as a case of bipolar affective disorder with the current episode of mania according to the International Classification of Diseases (ICD) 10 while he also had confusion, inattentiveness, and daytime naps.
Further enquiry revealed that he had three manic episodes with the first episode at age of 35 years, second episode at the age of 40 years, and third episode at the age of 63 years. After that, he was maintained on mood stabilizers until before 1 year when he developed side effects from carbamazepine after which he had an episode of depression for which, he was on quetiapine (100 mg), lorazepam (2 mg), nitrazepam (10 mg), and fluoxetine (20 mg). The patient had intolerance to divalproex sodium and developed side effects with low dose in the past. He was also taking antitubercular drugs for pulmonary tuberculosis but they were stopped 1 month before admission because the treatment regimen was completed. Mr. R.B did not have any history of substance use, so the possibility of substance withdrawal or intoxication delirium was ruled out. Mr. R.B was a farmer by occupation and was well-functioning before illness. The family members did not notice any difficulty with his memory. His activity of daily living was not affected at all. There had been no family history of mental illness.
On hospitalization, all the routine blood and urine investigations were within normal range. A possibility of antidepressant-induced mania was entertained. Fluoxetine, nitrazepam, and lorazepam were stopped and he was started on divalproex sodium 500 mg at night considering his manic symptoms. However, he became more confused and disorganized. He was found singing songs and more talkative at times and sometimes was very irritable. He also developed urinary incontinence in the next 10 days or so. We considered side effects of divalproex sodium because the patient had a history of intolerance to even a low dose of the same. There are research evidences, which support the development of cognitive decline, delirium, and drug-induced Parkinsonism More Details with valproic acid. ,, He scored 19 on the 30-item Hindi Mental Status Examination (HMSE).  He demonstrated deficits in the domains of orientation, attention and calculation, recall, language, and copying; a possibility of delirium was considered and divalproex sodium was stopped. We did medical workup again for identifying a cause of confusion. Metabolic abnormalities and other possible causes of delirium were ruled out on the basis of normal blood cell count, blood sugar, and electrolytes. Electrocardiogram (ECG), chest x-ray, viral markers, and venereal disease research laboratory (VDRL) were within the normal range too. Levels of vitamin B 12 and folate were found to be within the normal range. An electroencephalogram (EEG) was performed, which showed generalized slowing with athe bsence of any seizure activity. Computerized tomography imaging of the brain showed diffuse cerebral cortical atrophy with ischemic demyelination in the periventricular region, which was not contributing to the clinical state according to neurology experts. Mr. R.B continued to be in a state of confusion and showed manic symptoms for next 5 days. No physical cause of the symptoms could be identified. Ultimately, a possibility of delirious mania was entertained. He was put on olanzapine 5 mg at night. Within 3 days, Mr. R.B started showing improvement in the delirious symptoms. He came out of confusion and became oriented to place and time within 7 days. He started showing improvement in goal-directed activity, grandiose talks, and sleep pattern. Olanzapine dose was increased to 10 mg after 10 days. He showed gradual improvement on olanzapine and was stabilized with HMSE score of 25 on the 15th day of starting olanzapine. Attendants reported that his condition had improved up to a premorbid level and then he was discharged on the same dose of olanzapine after 1 month.
| Discussion|| |
Delirious mania as the primary presentation of bipolar disorder is a rare condition. It needs to be managed on the lines of mania as laid down in the diagnostic criteria by Bond. If the treating clinician does not suspect delirious mania and considers it as a case of delirium, it will complicate the management of the patient. Hence, identification of delirious mania and its differentiation from delirium is essential in clinical situations.
The presentation of this patient as delirious mania has been very typical as described by Bond. The patient had acute onset of manic and delirious symptoms with past and family histories of bipolar disorder, which responded well to olanzapine.  Olanzapine is very commonly used for the treatment of acute episode of manic symptoms.
In this case the cognitive symptoms evolved gradually over the preexisting manic symptoms, which is quite similar to other cases of delirious mania in the elderly as described in the past. , Hence, our case very easily fits into the diagnosis of delirious mania.
There is a possibility that our patient developed delirious symptoms due to underlying medical illness and these delirious symptoms getting superimposed on the ongoing manic symptoms due to fluoxetine induced manic switch but this possibility seems unlikely in our case. Though the patient had been on antitubercular treatment, it did not seem to contribute to delirium because it was stopped 1 month before admission to our department. The routine investigations that included blood cell counts, serum electrolytes assessment, and urinary examination did not point to any pathology. Another possibility is of a cerebrovascular phenomenon manifesting as confusion and mania.  However, the absence of neurological signs and negative brain imaging study ruled out this possibility too. Swartz et al. cautioned that "the recognition of DM is critical once an 'organic aetiology' has been excluded. Not treating such patients effectively and incorrect attribution to drugs can be dangerous." 
This is quite likely that old age predisposed our patient to delirious symptoms. Old age is considered as an independent risk factor for developing delirium in the elderly.  Mania is usually not considered a diagnosis in elderly patients who present with confusion and they are treated as a case of delirium. Thorough physical assessment with current and past psychiatric histories is very important in the identification and treatment of delirious mania.
| Conclusion|| |
Our case shows that classic delirious mania can present in the elderly. Though delirious mania has not found any place in the modern classification of psychiatric illnesses, the concept of delirious mania is still valid in old age psychiatry as elderly people can have atypical presentation of psychiatric syndromes. Though a single case report does not make a good evidence base, in relation to rare presentations case reports it still can guide clinical practice.
On the basis of our experience with this case, we recommend that delirious mania be considered as a differential diagnosis in an elderly patient with history of affective disorder, who presents with delirious symptoms in the absence of acute medical condition.
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Conflicts of interest
There are no conflicts of interest.
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