CASE REPORT

Aripiprazole for acute mania in an elderly person

A BSTR A CT
Balaji Bharadwaj, New‑onset bipolar disorder is rare in the elderly. Symptom profile is similar to that
in young adults but the elderly are more likely to have neurological co‑morbidities.
Shivanand Kattimani,
There are no case reports of elderly mania being treated with aripiprazole, an atypical
Anuriddha Mukherjee antipsychotic. A 78‑year‑old gentleman presented to us with symptoms suggestive of
Department of Psychiatry, mania of 1 month’s duration. He had similar history 3 years ago and a family history of
JIPMER, Puducherry, India postpartum psychosis in his mother. There were no neurological signs on examination
and work‑up for an organic etiology was negative except for age‑related cerebral
atrophy. He improved with aripiprazole and tolerated the medications well. The use
Address for correspondence: of psychotropic medications in the elderly is associated with side‑effects of sedation,
Dr. Balaji Bharadwaj, increased cardiovascular risk, and greater risk of extra‑pyramidal side‑effects. The use
Department of of partial dopaminergic antagonists like aripiprazole may be useful in the balancing of
Psychiatry, JIPMER, effects and side‑effects.
Puducherry‑ 605 006, India.
E‑mail: bharadwaj.balaji@gmail. Keywords: Aged, aripiprazole, bipolar disorder, mania
com

M ania commonly affects young adults during their most

productive period of life. The age at onset of mania
may vary from as young as 5 years to 50 years or older,
becoming rarer with advancing age; with the mean age at
onset being 30 years.[1] Of all the new‑onset bipolar disorders,
only 6–8% occurs in those above 60 years.[2] When it occurs
in the elderly, secondary causes like silent cerebral infarcts are
often found.[3] The elderly mania patient also shows more
neurological signs than usually seen in young adults.[4] In
treatment of mania in the elderly, choosing an appropriate
psychotropic is important due to poor tolerability of drugs in
this group. There are no clear guidelines for the management
of bipolar disorder in the elderly because most of the trials
comparing aripiprazole with lithium[5] or haloperidol[6]
involved young adults. This case report describes an unusually
late onset of bipolar disorder in an elderly man and discusses
the differential diagnosis and treatment aspects in this case.
CASE REPORT
A 78‑year‑old person, retired as school teacher with no
history of any substance abuse or medical history. He
had been suffering from bilateral knee pain diagnosed
as osteoarthritis for the last 20 years and was not on any
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DOI: 10.4103/0972-6748.102532
steroids. He presented with 1‑month duration of altered
behavior characterized by excessive psychomotor activity,
emotional lability, increased self‑confidence, excessive
talkativeness, decreased need for sleep, and increased
sense of energy level. There were a few occasions when
he misrecognised his daughter as his wife who had passed
away 6 months ago. On examination, he was an elderly
obese person weighing 92 kg with BMI >27. His vitals were
stable and no focal deficits could be found on neurological
examination. Mental status examination revealed increased
irritability, increased psychomotor activity, and increased
self‑confidence and authoritativeness. No cognitive
impairment could be detected except for inattention
and distractibility. His Mini Mental Status Examination
score was 28/30. No abnormal involuntary movements
were noticed. Neurological examination did not reveal
rigidity or other extra‑pyramidal symptoms. There were
no frontal release reflexes. He did not have any perceptual
abnormalities or delusions. He had impaired personal
judgment and lacked insight.
He had similar behavior 3 years ago, diagnosed and treated
as mania in the same hospital. There was positive family
history in the form of his mother having had symptoms
suggestive of postpartum psychosis. Investigations
including HIV, VDRL, serum vitamin B12 level, TFT,
EEG, routine hemogram, serum electrolytes, blood urea,
and serum creatinine were normal. ECG revealed no
abnormalities, except for a prolonged corrected QT interval
(QTc) of 486 msec. His CT brain [Figure 1] showed cortical
atrophy, especially pronounced in the temporal and frontal
areas. The periventricular regions in the frontal lobe showed

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 Bharadwaj, et al.: Aripiprazole for acute mania in elderly
Figure 1: CT brain shows frontal cortical atrophy (top left), with frontal
subcortical white matter hypodensities (top right). Widened Sylvian
fissures suggestive of temporal pole atrophy and basal ganglia
calcifications are also seen (bottom left). Widening of temporal horns
of lateral ventricles (bottom right) is further evidence of temporal lobe
atrophy
mild hypodensity suggestive of small vessel ischemic
disease. There was bilateral basal ganglia calcification. There
were no infarcts in any region. He didn’t fulfill international
consensus criteria for behavioral variant of Frontotemporal
Dementia (FTD).[7]
He was initiated with aripiprazole 5 mg/day because of his
QTc being 486 msec. Given his age, we chose aripiprazole
as it is less sedating and has lower chances of producing
postural hypotension. He also required intravenous
lorazepam 2 mg sos for his agitated behavior for the first
2 days. Aripiprazole was gradually increased to 15 mg, and
by the end of 3 weeks he showed complete remission of his
manic symptoms. At the time of admission in psychiatry
ward, he scored 27 on mania severity on Young’s mania
rating scale (YMRS)[8] and it came down to 4 at the end
of 3 weeks.
DISCUSSION
Occurrence of first episode of mania in the elderly (after
60 years age) warrants a high index of suspicion for
organic causes. Co‑morbid medical or neurological illness
is common in such persons.[4] Sometimes, infarcts are
evident only in imaging without clinical manifestations.[3]
On evaluation, we did not find any obvious etiology for
his mental illness, except for frontal and temporal atrophy
and possible frontal sub‑cortical white matter involvement.
One possibility considered was that of FTD, but this was
ruled out as he did not fulfill criteria for dementia and
behavioral component of FTD. Bipolar disorder increases
risk of dementia in the elderly.[9] It is possible that the
Industrial Psychiatry Journal 
manic episodes were the initial manifestations of FTD in
this patient and this will be tested only in the follow‑up.
There was family history of postpartum psychosis in his
mother, which is associated with a family history of bipolar
disorder[10] and the index case had been diagnosed as mania
3 years ago with complete remission in the interval period.
These two points and absence of any abnormalities in
laboratory and clinical examination favored diagnosis of
mania.
Aripiprazole has relatively high affinity for both 5‑HT2A
and D2 receptors similar to other atypical antipsychotics
but differs from them due to its partial agonist activity at D2
and 5‑HT1A receptors. Its long half‑life (75 hours) allows
single daily dosing.[11] Therapeutic dose range of aripiprazole
advised for mania is 10–30 mg/day. It has a more favorable
side‑effect profile compared to typical and even atypical
antipsychotics. Aripiprazole has lesser propensity to cause
extra‑pyramidal symptoms, an important factor in the
elderly.[11] Other desirable properties are lesser chance for
causing side‑effects like dyslipidemia, glucose intolerance,
hyperprolactinemia, postural hypotension, sedation, QT
prolongation, and weight gain. Its efficacy has been proven
as monotherapy in treating acute mania and in prophylaxis
of bipolar disorder.[5,6] Hence, we chose aripiprazole for
our patient in view of his already prolonged QTc interval
and age of 78 years.
CONCLUSIONS
This case is unusual in that age of onset of mania is very
late (75 years) and during the current second episode
we could not find any organic etiology. Moreover, his
condition responded well with least side‑effects to
aripiprazole. Hence, aripiprazole may be a safe and effective
antipsychotic medication for the control of mania in the
elderly.
REFERENCES
1. Sadock BJ, Sadock AV. In: Sadock BJ, Sadock SV, editors.
Kaplan & Sadock’s Synopsis of Psychiatry: Behavioral
Sciences/Clinical Psychiatry. 10th ed. New York: Lippincott
Williams & Wilkins; 2007.
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. Fujikawa T, Yamawaki S, Touhouda Y. Silent cerebral
infarctions in patients with late‑onset mania. Stroke
1995;26:946‑9.
4. Tohen M, Shulman KI, Satlin A. First‑episode mania in late
life. Am J Psychiatry 1994;151:130‑2.
5. Keck PE, Orsulak PJ, Cutler AJ, Sanchez R, Torbeyns A,
Marcus RN, et al. Aripiprazole monotherapy in the treatment
of acute bipolar I mania: A randomized, double‑blind,
placebo‑ and lithium‑controlled study. J Affect Disord
2009;112:36‑49.
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Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv
without the copyright holder's express written permission. However, users may print,
download, or email articles for individual use.