Mohammed T. Abou-Saleh

478 PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRYpsychiatric history, and a definable medical or neurologicaletiology. While it is true that organic factors may precipitatemania in some elderly patients, these cases appear to be in theminority. Manic episodes can be caused by such widely prescribedmedications as levodopa, procyclidine, pergolide, selegiline andbromocriptine 17 . A variety of steroids have been reported toproduce manic syndromes, as have thyroid supplements, andthere have been case reports of mania associated with H2-antagonists, antiarrhythmics, estrogen and antitubercularagents 18 . In addition, mania can occur in association with systemicinfections, such as influenza, Q fever and St Louis type Aencephalitis. Cases of mania secondary to space-occupyinglesions, such as meningiomas, subarachnoid hemorrhages andmetastases (usually in the non-dominant hemisphere), have alsobeen reported 6 . In these cases, mania usually resolves withremoval of the offending pharmacologic agent or treatment ofthe underlying disorder.More commonly, mania has been reported in elderly patientswith cerebrovascular and neurological disorders. One prospectivestudy found that 20% of patients with mania over the age of 60had a first manic episode closely temporally related to a cerebralorganic disorder 11 . Another prospective study of 20 manicpatients with onset over age 50 found that 65% developedbipolar disorder after a silent cerebral infarction 19 . In particular,injury to the right hemisphere appears to be strongly associatedwith the development of mania. There have been reports ofsecondary mania in patients with ischemic injury to right-sidedbasal ganglia, orbitofrontal cortex, and right basotemporalcortex 20 . It has been hypothesized that these brain areas may besignificant because of their connections to the limbic system andthe modulation of emotion. Overall, however, mania followingstroke is much less common than depression after a stroke. In onelarge study of 700 stroke victims only three developed manicsyndromes 21 . There have been two case reports of maniasecondary to infarctions in the thalamic and perithalamicareas 22 . Starkstein et al. 23 studied 11 patients who developedmania after stroke and found that eight had lesions involvinglimbic areas and nine had right hemispheric involvement. Thesepatients also had significantly larger bifrontal and third ventricularbrain ratios than matched control patients, indicating preexistinganterior subcortical atrophy. Moreover, almost half ofthe patients had a family history of affective disorder in a firstdegreerelative. Taken together, the current literature on mania inpatients with neurologic and cerebrovascular disorders underscoresthat genetic loading is also a factor contributing to thedevelopment of mania in these patients as well. Furthermore,while up to a quarter of elderly manic patients in various studieshave been found to have some evidence of concurrent cerebraldisease, it is still unclear to what extent these impairments play anetiological role in the development of mania. If cases in whichsubjects with a known previous history of affective disorder areexcluded, few cases of clear secondary mania are found 6,11,12 .Anexception to this is Shulman et al. 13 , who felt that 36% of elderlypatients they studied who were hospitalized with mania had truesecondary mania associated temporally with clearly documentedneurological disorders.Mania can occur in the setting of dementia. In a chart review of134 patients with Alzheimer’s disease, 2% were found to have hadmania 24 , although others have reported higher rates 25 . Broadheadand Jacoby 11 found that 32% of elderly manic patients studiedscored in the demented range on cognitive testing, even thoughthey had no history of progressive cognitive decline. Furthermore,more extensive cortical atrophy on head CT correlated withpoorer test scores, but there was no significant difference betweenearly- and late-onset manic patients with respect to CT findings orcognitive changes. It is unknown at this time whether thesepatients have progressed to develop true dementia. In oneretrospective study of 92 elderly patients with mania, only threewent on to develop documented dementia over a 10 year followupperiod 12 . To date, there does not appear to be an increased riskfor elderly manic patients to develop dementia compared to therest of the population.As in younger patients, stressful life events have been felt bysome investigators to precipitate mania in elderly patients. Onestudy that reported on 10 elderly manic patients found that 70%had major changes in lifestyle in the 6 months preceding onset ofmania. Stresses included marital discord and disruption of livingarrangements 5 .REFERENCES1. Regier DA, Boyd JH, Burke JD Jr. et al. 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