ABSTRACT

There are three broad groups of older bipolar patients. The first group is comprised of patients whose illness began early in life and persisted into old age. The second group is made up of individuals with earlier onset of depression and then a long latency before mania becomes manifest. Finally is the important group of late onset mania (secondary mania) (1). Studies of elderly inpatient bipolars reveal a high prevalence of comorbidity, particularly neurological disorders. This has served to cloud issues of diagnosis and nosology (2) and hence management. The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) (3) describes ‘‘a mood disorder due to a general medical condition’’ (293.83) but how can we be sure that ‘‘the disturbance is the direct physiologic consequence of a general medical condition?’’ The concept of secondary mania implies that cerebral organic factors are primarily responsible for the emerging manic syndrome (4). Similarly, neurologists tend to use the term ‘‘disinhibition syndromes’’ to describe a condition that is virtually identical to that of secondary mania. Because of the high prevalence of neurologic comorbidity, this scenario is very common in old age (5), and diagnostic clarity is still wanting in this murky area.