Clinical Geriatrics

Case Presentation
Ms. W is an 83-year-old unmarried white woman who is brought to the emergency room by members of her church. She has been hospitalized more than six times in the past two years due to episodes of mania. Her friends explain that Ms. W has been disruptive during church services, singing hymns during prayers and the minister’s sermon. They have tried to help encourage her to take her medications, but she insists that she is fine. Ms. W attends the church-affiliated senior center daily, where she eats meals and socializes. She is well liked, although often thought of as odd and strange. She lives in an apartment in a senior housing building and has a friend who pays her bills for her.

Ms. W becomes very agitated in the emergency room, trying to kiss other patients and give them a religious blessing. She opens her purse and starts giving patients varying amounts of dollar bills and coins, stating that God told her to give away her worldly possessions. Ms. W displays loud pressured speech, intrusive behavior, and hyperactivity. After much coaxing she allows her vital signs to be taken. Her blood pressure is 180/110 mm Hg, and her pulse is 100 bpm. Her friends have brought her prescription medications, which include nearly full bottles of metoprolol 50 mg twice daily, lisinopril 10 mg once daily, and olanzapine 15 mg once daily.

Her friends report that Ms. W has a long history of bipolar disorder. While she was hospitalized many times throughout her life, Ms. W was able to support herself, working for many years at the Department of Motor Vehicles and retiring at age 68. She is often noncompliant with medications and has no formal home care or housekeeping services. Her friends report that Ms. W is hard of hearing and also wears glasses, but she did not have her hearing aids or eyeglasses with her.

Ms. W becomes increasingly agitated in the emergency room, touching other patients in her desire to “bless them” and refuses to take any medication. After trying to kiss several staff members she is given olanzapine 10 mg by intramuscular injection, and later takes her blood pressure medications. She is admitted to the inpatient psychiatric unit on an involuntary basis.

Discussion
Bipolar disorder is a chronic illness marked by exacerbations and remissions. The age of onset of bipolar disorder is typically in early adulthood, but up to 10% of patients present for the first time after age 50 years.1

Bipolar disorder in older adults accounts for 10% to 25% of admissions to inpatient psychiatric units.2,3 The community prevalence of bipolar disorder in older adults is 0.4%. Among elderly patients treated in mental health settings, up to 30% of older adults have symptoms that fall within the spectrum of bipolar disorder. Compared with older adults who suffer from depression, those with bipolar disorder use more than four times the amount of mental health services and are far more likely to require acute inpatient hospitalization.3,4 

Bipolar disorder is an illness characterized by periods of mania, depression, or mixed states. Psychotic features may accompany each episode. A manic episode is characterized by a period of at least one week of a persistently elevated, expansive, or irritable mood with pressured speech, racing thoughts, decreased need for sleep, grandiosity, and hyperactivity.1-3 A mixed episode includes features of both mania and depression. A depressive episode typically includes the features of depressed mood and loss of interest in activities, and may be mistaken for an episode of major depressive disorder if the patient’s history is unavailable or not addressed.1,4