IS IT MANIA, DELIRIUM, OR CATATONIA? A CASE SERIES ON DELIRIOUS MANIA IN OLDER ADULTS

Abstract

Introduction Delirium can be thought of as acute brain failure and is characterized by a disturbance in attention and awareness as well as cognition which develops over a short period of time. It is a serious condition that is associated with high morbidity and mortality, particularly in critically ill patients. Although delirium has been described for thousands of years, it is frequently overlooked and the pathophysiology remains poorly understood. Our understanding of the different presentations of delirium continues to evolve. Delirious mania was studied in 1849 by Bell, with a 75% mortality in the cohort investigated. Although there has been over a century and a half since that description, there continue to be limited diagnostic criteria and treatment guidelines for delirious mania. Methods Case series, systematic literature review Results Case Identification: Cases of delirious mania have been identified and described in the literature. Delirious mania is characterized with the typical disturbances in attention, awareness, and cognition along with mania and psychosis. In one of the first attempts to define the condition, Bell proposed that there was no association with prior mental or systemic disorder. Multiple case studies since then have described an acute onset of a delirious and manic state in the absence of a history of bipolar or depressive disorder. Past history of a personal or family history of psychiatric conditions such as bipolar illness or a depressive disorder may provide diagnostic guidance and help identify a primary psychiatric disturbance. In older adults with mania or psychosis, delirium must be considered in the differential as they often have compromised reserve capacities and are prone to developing delirium from conditions that may not be deliriogenic in younger adults. We describe two cases that we believe reflect delirious mania in patients that were previously diagnosed with mania stemming from a psychiatric disorder. Treatment: A case series (with patients aged 50-67) by Karmacharya et al. (2008) put forth electroconvulsive therapy (ECT) as the definitive treatment for delirious mania. They also found that clozapine, quetiapine, lithium, and valproate which may otherwise have been prescribed in a manic episode were not first line treatments. The medications, even when helpful, took an unacceptably long time to work. Curiously, high dose benzodiazepines have also been found to be effective which has led to the association with catatonia. . One of the cases illustrates prolonged recovery while on clozapine, but did not require a high dose of benzodiazepines for rapid improvement despite being in a similar age range. Much like previous case reports, our cases also help to illustrate the overlap of the symptoms of hyperactive delirium with mania and catatonia, particularly in older adults. Conclusions The cases described illustrate characteristics of delirious mania in patients with a previously diagnosed psychiatric history. They highlight the importance of comparing the patient's current episode to previous psychiatric presentations. Both cases were originally thought to be due to mania, hence warranting admission to psychiatric units. However, they were found to have a large and complicated medical component to their illness. The initial admission to psychiatric units delayed treatment of their serious medical illnesses and may have contributed to a prolonged hospital stay. The argument can be made to manage these patients on a medical floor with psychiatric services given the critical nature of the medical presentation and more immediate access to life supporting interventions. These cases reiterate the need for formal diagnostic criteria to aid in the early diagnosis of delirious mania. This research was funded by Non-applicable