Secondary Mania in Older Adults
Case 1
Past History
Ms. A, a 67-year-old married African American woman with no previous psychiatric history, was seen for an acute manic episode with psychotic symptoms. She had been in her usual state of health until 3 days before admission, when she developed an abnormally elated mood accompanied by delusions and racing thoughts.The patient’s medical history was remarkable for a history of well-controlled hypertension, a resection of a left parieto-occipital meningioma, and a three-vessel coronary bypass graft for angina 4 years earlier. She reported two episodes of transient slurred speech, one just before the meningioma resection and the other 4 months before she was seen for the manic episode. Her usual medications included extended-release nifedipine (60 mg/day), ticlopidine (250 mg t.i.d.), and benazepril (20 mg/day).
Present Illness
Approximately 3 weeks before her hospital admission, Ms. A reported that she had contracted an upper respiratory tract infection with a cough and had begun treatment with intermittent doses of pseudoephedrine, 60 mg, plus hydrocodone, 5 mg. Her infectious symptoms were not improving, so clarithromycin was added. After 7 days of clarithromycin therapy, Ms. A arose from her bed earlier than usual and announced to her daughter, “I feel free! I feel alive!” These statements were accompanied by an elated mood and an unprecedented interest in the Bible. The family reported this was a marked change, as Ms. A was typically rather quiet and reserved.Over the next 2 days, Ms. A became increasingly hyperverbal and would quote scripture while she ran through the house with her hands up in the air. She began frantically writing a lengthy and disorganized missive to God in which she apologized for past sins and transgressions. Her manic symptoms persisted and escalated to include emotional effusiveness, overfamiliarity, sleeplessness, and the development of delusions and auditory hallucinations. She asserted that she was receiving messages from Bob Hope through the television, appeared suspicious of family members when they expressed concern, and was unwilling to undergo an outpatient magnetic resonance imaging (MRI) scan because she thought she was under arrest. She described hearing voices of individuals from previous “waking” dreams. There was no history of confusion, disorientation, stereotyped motor activity, or changes in level of consciousness.Ms. A was first admitted to the neurology service for evaluation and management, and she was subsequently transferred to the inpatient psychiatry service. There were no remarkable physical or neurological findings. During the mental status examination Ms. A was noted to be an attentive, cooperative woman who appeared her stated age and had a lively, engaging demeanor and normal motor activity. Her speech was mildly pressured and tangential, requiring redirection to guide her back to the question. She described herself as “better than ever—excellent,” and her affect was congruent with her mood. She described ideas of reference in that characters on television shows were making special references to her recent religious enlightenment. She denied further auditory hallucinations or paranoid delusions. Notably, her cognitive abilities were not impaired, and she scored 28 out of 30 on the Mini-Mental State Examination (MMSE) (4), although she exhibited some errors on confrontation naming, e.g., “tie” for a “tassel.”Ms. A’s serum chemistry, cerebrospinal fluid and cultures, urinalysis, blood cultures, and chest X-ray were unremarkable. The hematology profile was notable for a mild normocytic anemia with a hematocrit of 33.0 ml/dl. Her erythrocyte sedimentation rate was slightly elevated at 48 mm/hour. Her level of thyroid-stimulating hormone was low at 0.23 μU/ml (normal=0.39–0.45) with a normal free T4 level. A brain computed tomography (CT) scan showed evidence only of her past meningioma resection. A brain MRI revealed encephalomalacia related to the previous surgery as well as abnormal hyperintensities in the brain stem, periventricular matter, and deep white matter. These hyperintensities most likely represented chronic ischemic changes. An electroencephalogram (EEG) showed slow sharp waves in the area of the surgical resection but no epileptiform activity or other abnormal patterns.Low-dose haloperidol was administered from the beginning of Ms. A’s stay in the psychiatry unit and was tapered off by the time of discharge. Throughout her hospital stay, her manic and psychotic symptoms gradually dissipated. At the time of discharge, Ms. A was taking clonazepam, 0.5 mg b.i.d., which was tapered and discontinued after discharge. Her family members reported that her disposition at the time of discharge was somewhat brighter than her baseline but not remarkably so.
Discussion
Case 2
Past History
Mr. B, a 60-year-old man with no past psychiatric history, was involuntarily admitted after being seen in a clinic with insomnia, increased energy level, pressured speech, tangential thinking, and grandiose delusions. He had been married and divorced twice, with no children, and was living alone in his own home. He was employed as a freelance sports journalist. Although he claimed to have unusually close relationships with several women, there was no evidence so support this claim; he did not meet criteria for a diagnosis of erotomania. On a recent business trip he spent several hundred dollars on clothing to “catch the ladies’ eyes” and had his eyebrow and tongue pierced as he thought this would make him more attractive.Mr. B had been diagnosed with hypertension but was untreated. He acknowledged episodes of depression in the past, but none had required hospitalization. He denied abuse of alcohol or illicit substances in the past, and the only remarkable aspect of his family psychiatric history was that his brother was diagnosed with panic disorder.
Present Illness
Mr. B was admitted to the inpatient psychiatry service, where he continued to display manic symptoms for approximately 4 days while his medication doses were being titrated, all the while requesting a “decongestant for the brain.” His speech was pressured with some clanging, and his affect was superficial, dysphoric, and tearful at times. Mr. B felt he possessed special powers; he claimed that he was a “sounder,” which he described as a person who can see into the future, and that he had the ability to “run the United Nations.” He stated that his powers “make quantum leaps look like picnics.” His rapid thought processes led him to feel that the rest of the world was slow, to the point that he felt telephones dialed too slowly. At times Mr. B experienced auditory hallucinations of music and television commercials.The results of serum chemistries, a complete blood count, liver function tests, and thyroid function tests were all within normal limits. The results of a fluorescent treponema antibody absorption test and a urine drug screen were negative.During a workup for his manic episode, a CT scan revealed a right-sided heterogenous, partially cystic, and calcified mass in the medial aspect of the right temporal lobe. Differential diagnosis included a giant aneurysm dermoid/epidermoid lesion, a glioma, and a nerve sheath tumor, such as a meningioma or an atypical schwannoma. An MRI with gadolinium performed 2 days later revealed a well-circumscribed extra-axial mass 3.4 cm (anterior-posterior) by 3.0 cm (transverse) by 3.0 cm (craniocaudal), which extended into the right foramen ovale, medial to the right temporal lobe (Figure 1). The neurosurgery service was consulted and opted to debulk the tumor in approximately 2 months.
Mr. B’s drug doses were titrated to 20 mg/day of olanzapine and 1500 mg b.i.d. of divalproex sodium. By the ninth day of his hospitalization he insisted on being discharged to his own home with outpatient follow-up. His mental status examination was markedly improved with euthymic mood, no abnormal movements, and logical and goal-directed thought processes, without psychosis or thoughts of harming himself or others.
Follow-Up
Mr. B underwent a right pterional craniotomy, and the mass was resected. The psychiatry consultation service followed him closely during his hospital stay. Postoperatively his recovery was complicated by pneumonia and some dysphagia. He was treated with several antibiotics and transferred to the rehabilitation medicine service, where his mental status continued to improve.
Discussion
Treatment Considerations
Conclusions
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