2013 John Wiley & Sons A/S

Published by John Wiley & Sons Ltd.

Bipolar Disorders 2014: 16: 113118

BIPOLAR DISORDERS

Review Article

The prevalence of late-life mania: a review

Dols A, Kupka RW, van Lammeren A, Beekman AT, Sajatovic M,
Stek ML. The prevalence of late-life mania: a review.
Bipolar Disord 2014: 16: 113118. 2013 John Wiley & Sons A/S.
Published by John Wiley & Sons Ltd.

Annemiek Dolsa, Ralph W Kupkab,

Anouk van Lammerena, Aartjan T
Beekmanb, Martha Sajatovicc and
Max L Steka
a

Objectives: Since there is a worldwide steady increase in the number of

individuals living longer and an expected increase in the number of older
adults who will be diagnosed with bipolar disorder, there is a growing
need to better understand late-life mania. We provide in this review a
report of published studies focusing on the prevalence of late-life mania
in the community and in senior psychiatric care facilities.
Methods: We conducted a search of PubMed and Psychinfo databases
using combinations of the keywords bipolar, manic/a, manic depression,
elderly, and older including English-language reports presenting
quantitative data on the prevalence of mania in adults over the age of
50 years.
Results: Eighteen out of 188 potentially eligible studies met our inclusion
criteria, with most studies focusing on psychiatric inpatient samples. The
overall prevalence of late-life mania was estimated to be 6.0% in the
reported 1,519 older psychiatric inpatients. In elderly inpatients with
bipolar disorder, the mean prevalence of late-onset mania was 44.2%.
For other relevant care facilities, no rm conclusions could be drawn.
Conclusions: Late-life mania is not rare in older psychiatric inpatients
and late-onset mania is associated with increased somatic comorbidity in
patients aged 50 years and older. Several hypotheses regarding the
relationship between somatic illness and late-life mania in the elderly
have been proposed and studies on this relationship and the prevalence
of late-life mania in dierent senior psychiatric care facilities deserve
specic attention in future research projects.

Two peaks in age for a rst manic episode have

been identied: one early in adult life and the second in the fth decade (1, 2). The majority of rst
manic episodes occur early in life, but mania can
rst present at any age, with de novo manic symptoms described in patients in their eighth and ninth
decades (35). Potential dierences between earlyand late-onset bipolar disorder have been the subject of many studies (6). Much less investigated is
the topic of late-life mania, which has a heterogeneous origin, such as late-onset bipolar disorder,
pre-existing depressive disorder converting to bipolar disorder, or secondary mania caused by somatic
illness or medication. Additionally, symptoms
accompanying late-life neuropsychiatric conditions
such as dementia and delirium can mimic mania in
late life (7).

Department of Old Age Psychiatry,

Department of Psychiatry, GGZ inGeest,
VU University Medical Center, Amsterdam,
The Netherlands, cUniversity Hospitals Case
Medical Center, Cleveland, OH, USA
b

doi: 10.1111/bdi.12104
Key words: bipolar delirium dementia
elderly geriatric mania hypomania late
life mania manic episode secondary
mania
Received 7 April 2012, revised and accepted for
publication 1 May 2013
Corresponding author:
Annemiek Dols, M.D., Ph.D.
Department of Old Age Psychiatry
GGZ inGeest
VU University Medical Center
Valeriusplein 14
Amsterdam 1075BH
The Netherlands
Fax: 317885577
E-mail: a.dols@ggzingeest.nl

Whereas strong evidence indicates that the prevalence of bipolar disorder decreases with age,
from 1.4% in individuals aged 1844 years to 0.1
0.4% in those aged 65 years and over (8), data on
the prevalence of late-life mania are sparse. The
aim of this analysis was to review the prevalence of
mania in published studies that focused specically
on adults aged 50 years and older. We identied
the proportions of elderly individuals with mania
in published samples from inpatient, outpatient,
emergency room (ER), nursing home, and community settings and determined both the overall prevalence and the prevalence of late-onset mania
when this information was available. On the basis
of the results of our review, we identied gaps and
discuss potential directions for future research on
late-life mania.

113

Dols et al.
Methods

We conducted an electronic search of the Medline,

Psychinfo, and Cochrane databases for published
studies using the search terms bipolar, manic/a,
manic depression, elderly, and older. Databases
were searched until December 2011. Articles were
also found by cross-referencing identied articles,
and searching the reference lists in geriatric psychiatry textbooks. Titles and abstracts from the
obtained articles were reviewed and all retrieved
papers were screened to meet the following inclusion criteria: (i) studies reporting on the prevalence
of mania; (ii) studies including patients aged
50 years and over; (iii) studies with participants of
any age, only if separate data were reported for the
patients aged 50 years and over; (iv) a sample size
of at least 10 patients; and (v) a clear denition of
mania consistent with diagnostic criteria of DSMIII, DSM-IV, ICD-9, or ICD-10.
We chose a minimum age of 50 years in accordance with a previously published review on
elderly people with bipolar disorder (9), and to be
as inclusive of published papers as possible. Two
of the authors (AD and AvL) separately reviewed
the abstracts of all of the studies and in any case of
disagreement consensus was reached during conferences to discuss the articles and determine
whether they met inclusion or exclusion criteria.
Sample weighted averages with 95% condence
intervals (CIs) were calculated for the psychiatric
and bipolar disorder inpatients.
Results

The data search by keywords yielded 186 potentially eligible articles and another three studies
were found by cross-referencing. A total of 171
studies were excluded, resulting in 18 studies meeting inclusion criteria. Reasons for exclusion were
no data on the prevalence of mania in 163 studies
and no data specic to patients above the age of 50
years in reports involving mixed-age bipolar disorder samples in eight studies. The characteristics of
the included studies are listed in Table 1.

persons were small sample sizes, retrospective

methods, lack of standardized measures, overemphasis on inpatients, and lack of longitudinal data.
These limitations are in line with those mentioned
in a previously published review on late-life bipolar
disorder (9). In addition, studies reported prevalences in dierent age samples and with dierent
age cutos, and few studies were designed to identify the prevalence of mania in elderly people or,
more precisely, the prevalence of late-onset mania.
We dened late-onset mania as rst life-time mania
in patients above age 50 years; this is in accordance with a previously published review on
elderly people with bipolar disorder with an age of
50 years as the cuto for late-onset bipolar disorder. We excluded one study that reported on manic
patients aged 40 years or older.
Overall sample

The 18 published reports provided information on

22,333 patients, of whom 1,766 were inpatients,
with a total sample mean age of 69.8 years (standard deviation = 4.7 years, range: 50103 years).
Only one study included patients aged 5060 years
(10). In our review, the group of patients aged
90 years and over is under-represented. Most studies included slightly more women, except for the
largest study in an outpatient population receiving
veteran services. Only three studies reported the
ethnicity of the total sample, but it is assumed that,
apart from the two studies in Asia, the vast majority of patients included in the studies were Caucasian. The sample size ranged from 48 to 16,330
individuals.
Prevalence of late-life mania in clinical settings and in
the community

Elderly patients, especially those with physical

comorbidity and physical, psychological, or psychosocial impairment, were treated in a variety of
clinical care facilities, including inpatient and outpatient settings, ERs, and nursing homes. We
examined the presence of late-life mania in each of
these care settings and in the community.

Types of study

Half of the studies were published in the last 10

years. Nine studies were conducted in the USA,
three in Canada, three in Europe, one in Australia,
one in Japan, and one in India. With only a single
exception, the methodology of the studies was retrospective record review or database analysis. All
studies were cross-sectional. Methodological problems in the published studies on mania in elderly

114

Inpatient setting

Six studies reported the relative proportion of

older adults with mania in inpatient psychiatric
settings (1116). All studies were retrospective
chart reviews. The sample of inpatients in psychiatric settings was 1,519, aged 60 to 96 years. The
mean prevalence of late-life mania in our study
was 6.0% (95% CI: 4.87.2%). One study

Late-life mania: a review

Table 1. Prevalence of mania in the community and in care facilities relevant to older psychiatric patients

Study
Inpatients
Takeshima and
Kurata 2010 (15)
Benedetti et al.
2008 (11)
Moak 1990 (13)

Sample
size

364

Psychiatric emergency ward in Japan

284

University psychiatric ward in Italy

78

Psychogeriatric long-stay service in a

state mental hospital in the USA
Admission to a psychogeriatric unit in
Canada
Consecutive admissions to an acute
psychogeriatric unit in the USA
Psychiatric hospital in the USA

Yassa et al.
217
1988 (16)
Mei-Tal and
112
Meyers 1985 (12)
Roth 1955 (14)
464
Inpatients with bipolar disorder
Sajatovic et al.
48
2005 (10)
Young et al.
2003 (21)

57

Tohen et al.
1994 (20) Shulman and
Tohen 1994 (17)
Shulman et al. 1992 (18)
Stone 1989 (19)

50

92

Outpatients
Prakash et al.
522
2009 (23)
Outpatients with bipolar disorder
Sajatovic et al.
16,330
2005 (22)
Almeida and
Fenner 2002 (24)
Community
Preville et al.
2008 (27)

Mean age (years) (SD)

[range]

Sample setting

492

2,798

Nursing homes
Cravello et al.
252
2011 (25)
Psychiatric emergency room
Shulman et al.
173
1996 (26)

Consecutive discharges of a university

acute care geropsychiatric inpatient
unit in the USA
Consecutive admissions to a
university geropsychiatric
inpatient service in the USA
Consecutive admissions to a university
psychiatric ward in the USA

67
>60
74
[6588]
71.4 (10)

Prevalence of
mania (%)

11.3

Prevalence of
first mania (%)

1.8

>65

4.7

72.5
[6096]
>60

50

67.3 (10.4)
>50
70.4 (7.4)
[6092]

43.9

68.8 (4.2)
>65

28

Admissions to two university

psychiatric hospitals in the UK

70.3
[6582]

53

Tertiary care setting in India

68.5 (5.8)
[6080]

5.7

US Veterans Administration database

analysis of patients with psychosis or
bipolar disorder
Administrative database analysis of
patients with bipolar disorder in
Western Australia

70.2 (7.1)
>60

4.3

>65

Cross-sectional survey of a communitydwelling older adult sample in

Quebec, Canada

73.8 (6.1)
>65

0.6

Nursing-home register of 95 residential

facilities across Italy

81.2 (7.0)
[65103]

1.6

Community hospital emergency room

referrals to psychiatry in Toronto,
Canada

71.2 (8.4)
>60

All analyses were retrospective cross-sectional chart reviews except for the two database analyses by Sajatovic et al. (22) and Almeida
and Fenner (24).

specically identied a prevalence of 1.8% for lateonset mania (11). In another study (12), three of
nine manic patients were diagnosed with somatic
comorbidity that may have triggered mania. The
clinical picture of mania is, when described, with
classical symptoms and in 3075% of cases accompanied by delusions and hallucinations (16). Data
on family history of mood disorders are sparse;
one study mentioned that a positive family history

was rare (11), and another study reported an

absence of a positive family history for mania (16).
In identifying the prevalence of mania in elderly
inpatients with bipolar disorder, a total of six studies reporting on 247 individuals were reviewed (10,
1721). Only one study reported on the prevalence
of late-life mania (50%) in elderly inpatients with
bipolar disorder (22). The percentage of patients
with bipolar disorder with late-onset mania ranged

115

Dols et al.
from 28% (20) to 43.9% (21) and 53% (19). The
mean prevalence of late-onset mania in patients
with bipolar disorder was 44.2% (95% CI: 37.3
51.1%). The numbers of converters from unipolar
depression to bipolar disorder (32%) were mentioned in only one study (19).
Two studies reported the medical comorbidity of
hospitalized patients with mania (10, 19). Sajatovic
et al. (10) found a mean of 3.7 comorbid medical
conditions in patients over the age of 50 years, and
Stone (19) reported a percentage of 24% for neurological comorbidity. This suggests that medical
comorbidity is frequent and possibly related the
onset of mania.
In the six studies reviewed, the patients with
bipolar disorder with late-life mania were predominantly female. Conicting results were obtained in
these samples for the relationship between index
age and a family history of mood disorder, with
one study reporting no relationship (21), another
reporting a positive family history in 37.5% of
patients with late-life mania (20), and another
reporting a signicantly earlier age of onset in
patients with a positive family history (19). One
study reported that 42.9% of patients with late-life
mania showed psychotic features (20).
Outpatient setting

Only one study reported on the prevalence of

mania among patients aged 50 years and over
attending an outpatient psychiatric clinic. In Bangalore, India, 5.7% of the 522 outpatients were
diagnosed with mania (23). This was a retrospective chart review in elderly outpatients in a tertiary
care setting. Half of the patients had psychotic
symptoms, and 23.3% had a positive family history for mood disorders.
Two studies reported the prevalence of (hypo)
mania among older patients with bipolar disorder
attending an outpatient clinic. In a large retrospective study of 16,330 patients with bipolar disorder
aged 60 years or older receiving Veterans Health
Administration Services, 82.5% had an earlier
onset of bipolar disorder, 6.1% of the patients
were diagnosed with late-onset bipolar disorder,
and 3% switched diagnosis from (unipolar) depression to bipolar disorder (22). Manic symptoms
requiring admission occurred in 4.3% of elderly
patients with bipolar disorder in that year. A study
of rst-contact diagnosis of bipolar disorder in an
outpatient sample found that 8% of patients with
bipolar disorder aged 65 years or older presented
with de novo manic symptoms (24).
More than half of the patients were female.
These studies show that, similar to the situation in

116

younger adults, in older outpatients with bipolar

disorder manic symptoms are not as frequent as
depressive symptoms, but still approximately 5%
of elderly patients with bipolar disorder experience
mania or hypomania each year.
Nursing homes

In a study investigating neuropsychiatric syndromes in 252 non-demented elderly people living

in residential facilities, 1.6% had euphoria and disinhibition as manic symptoms (25). Manic symptoms may not be common in nursing homes,
although we found no literature reporting specically the occurrence of mania as dened by
DSM-III or DSM-IV.
Psychiatric ER

Although manic symptoms often warrant acute

treatment, there was only one study reporting on
the prevalence of manic symptoms in elderly persons visiting the ER. A chart review of 173 individuals aged 60 years and over who presented to a
psychiatric ER indicated that 30 patients were
diagnosed with bipolar disorder (17%), and that
two of them were experiencing their rst manic episode (26). This indicates that late-life and lateonset mania may not be rare in the ER.
The community

Only one study was designed to investigate the

prevalence of mania in elderly people living in the
community; all other studies just reported on bipolar disorder. Using a diagnostic interview based on
DSM-IV criteria, Preville et al. (27) found that
0.6% of 2,798 respondents aged 65 years and over
reported a manic episode with symptoms impairing
at least one area of social functioning and lasting
at least one week during the previous 12 months.
Discussion

Late-life mania has a heterogeneous origin, including early-onset or late-onset bipolar disorder, preexisting depressive disorder converting to bipolar
disorder, secondary mania caused by somatic
illness or medication, and late-life neuropsychiatric
conditions such as dementia and delirium. Most of
the studies reviewed here report on mania as part
of bipolar disorder.
The prevalence of late-life mania in inpatient settings is approximately 6.0% for patients aged
50 years and older, including both early-onset and
late-onset bipolar disorder. This is congruent with

Late-life mania: a review

a conservative estimate that 810% of psychiatric
inpatients over age 5560 years are diagnosed with
bipolar disorder, since many of those patients will
present with depression and mania caused by disorders other than bipolar disorder may play a role
(9). About one-third of elderly patients with mania
are experiencing their rst manic episode (i.e., lateonset mania), either with or without preceding
depressive episodes. This suggests that late-onset
mania is a frequent condition in clinical settings.
Overall, the mean percentages in our review translate to a number of six manic patients in every 100
admissions to a psychogeriatric unit, of whom two
to three patients are experiencing a rst manic
episode.
Among elderly psychiatric outpatients, the only
available study reported a prevalence of (hypo)
mania of 5.7% (23). In a previous review, the rate
of bipolar disorder among elderly outpatients was
estimated to be 6.1% (9). Thus, the suggestion of
these authors, that their estimate may be too low
since bipolar depression is often misdiagnosed as
(unipolar) depressive disorder, is conrmed by
these recent ndings. The prevalence of late-onset
mania among older outpatients with bipolar disorder ranged from 8% to 9.1%.
Long-term care institutions are common settings
for older adults with chronic mental illnesses, with
a reported prevalence of bipolar disorder ranging
from 3% to 9.7% (28, 29). We found a low percentage of 1.6% for (hypo)mania in the only study
on this topic (25). Clearly, larger studies are needed
to conrm the prevalence of psychiatric symptoms
in non-demented people living in residential facilities where psychiatric care is often scarce.
The ER may be a very important component of
health care provision for elderly people with psychiatric illness. In the study of Shulman et al.,
17% of psychiatric patients aged 60 years and over
attending the ER were diagnosed with bipolar disorder (26). Two of these 29 patients were experiencing their rst manic episode. This high
percentage of elderly people turning to the ER for
late-onset mania warrants future study.
Most studies in the community focus on the incidence rather than prevalence of mania. We found
only one study on the prevalence of mania in the
community, which reported a 12-month prevalence
of manic symptoms of 0.6% (27). In large epidemiologic studies, the prevalence of bipolar disorder in
individuals older than 65 years ranged from 0.1%
to 0.4% (7). Comparing these results suggests that
manic symptoms in community samples are not
exclusively related to bipolar disorder.
In our search we found a limited number of published reports that specically evaluated the

prevalence of mania in people aged 50 years and

older, with only nine papers published in the last
decade. The literature is further limited in that all
but one of the available reports were based upon
retrospective analyses. Our review included information on 22,333 individuals, of whom the large
majority (77.8%) were outpatients. These data
were derived from only three out of 18 studies,
with a major contribution of 16,630 patients with
bipolar disorder aged 60 years or older receiving
Veterans Health Administration services (22). The
large majority of studies came from western countries, especially the USA. Moreover, most studies
were performed in centers that are specialized in
caring for psychiatric elderly patients or even
elderly patients with bipolar disorder, further limiting generalizability. Given the large proportion of
studies on inpatients, ndings based on this clinical
sample are likely more representative of elderly inpatients with mania than elderly patients with
mania in other clinical settings.
Our review of elderly manic inpatients also
revealed extensive medical comorbidity. Dierent
hypotheses regarding the relationship between
somatic illness and mania in elderly patients have
been proposed. Somatic factors may be a true
cause of mania (secondary mania), or merely triggering mania as a rst manifestation of bipolar disorder in a person with a latent vulnerability, and
with or without a previous history of depressive
episodes. Somatic comorbidity may also be a coincidental nding without any causal relationship to
mania. The list of medications, metabolic disturbances, and neurological conditions that can cause
secondary mania is extensive (30). Our search
strategy did not detect studies reporting the prevalence of mania in non-psychiatric settings, but
mania may present in medical units and neurological wards. Late-life mania may occur not infrequently in patients with (non-symptomatic)
vascular brain damage. Steens and Krishnan (31)
proposed criteria for vascular mania and depression subtype speciers, and their concept of vascular mania appears to have some overlap with the
neurological disinhibition syndrome. In this
respect, secondary mania is comparable to delirium that can be caused by many somatic conditions, especially in elderly people and patients with
a vulnerable brain (32).
There are limited data on manic symptomatology that is not directly related to a specic diagnosis. Most available studies use the DSM or ICD
criteria focusing on classication and diagnoses of
disorders rather than on the syndromal and symptomatic levels. The fact that mania in older adults
is more common than previously assumed

117

Dols et al.
emphasizes the need for research targeting the nature of manic symptoms in this specic population.
There is still insucient knowledge about the specic symptom prole, the long-term history of
aective symptoms that precede a manic presentation, the role of family history, and the precise
eects of somatic comorbidity. Understanding the
typical clinical presentation, complexities related
to comorbidity, and eventually biological determinants could help to gain insight into the eects of
the aging brain on the development of late-life
mania within the broad spectrum of bipolar disorders. Moreover, it could improve timely identication and inform treatment recommendations for
geriatric mania. Clinical trials specically focused
on geriatric mania are essential to enable formulation of evidence-based treatment guidelines. Given
the growing number and proportion of elderly
people worldwide, there is a clear need for research
on identication, assessment, and treatment of
geriatric mania.
Disclosures
The authors of this paper do not have any conicts of interest
in connection with this manuscript.

References
1. Goodwin FK, Jamison KR. Manic-Depressive Illness.
Bipolar Disorders and Recurrent Depression, 2nd edn.
Oxford: Oxford University Press, 2007.
2. Kennedy N, Everitt B, Boydell J, Van Os J, Jones PB,
Murray RM. Incidence and distribution of rst-episode
mania by age: results from a 35-year study. Psychol Med
2005; 35: 855863.
3. Kellner MB, Neher F. A rst episode of mania after age
80. Can J Psychiatry 1991; 36: 607608.
4. Summers WK. Mania with onset in the eighth decade: two
cases and a review. J Clin Psychiatry 1983; 44: 141143.
5. Walter-Ryan WG. Mania with onset in the ninth decade.
J Clin Psychiatry 1983; 44: 430431.
6. Leboyer M, Henry C, Paillere-Martinot ML, Bellivier F.
Age at onset in bipolar aective disorders: a review. Bipolar Disord 2005; 7: 111118.
7. Sajatovic M, Blow FC. Bipolar Disorder in Later Life. Baltimore, MD: The Johns Hopkins University Press, 2007.
8. Brieger P, Marneros A. Bipolar disorders in late life. In:
Kasper S, Hirschfeld RMA eds. Handbook of Bipolar Disorder: Diagnosis and Therapeutic Approaches. Boca
Raton, FL: Taylor & Francis Group, LLC., 2005: 8393.
9. Depp CA, Jeste DV. Bipolar disorder in older adults: a
critical review. Bipolar Disord 2004; 6: 343367.
10. Sajatovic M, Bingham CR, Campbell EA, Fletcher DF.
Bipolar disorder in older adult inpatients. J Nerv Ment Dis
2005; 193: 417419.
11. Benedetti A, Scarpellini P, Casamassima F et al. Bipolar
disorder in late life: clinical characteristics in a sample of
older adults admitted for manic episode. Clin Pract
Epidemiol Ment Health 2008; 4: 22.

118

12. Mei-Tal V, Meyers BS. Empirical study on an inpatient

psychogeriatric unit: diagnostic complexities. Int J Psychiatry Med 1985; 15: 91109.
13. Moak GS. Discharge and retention of psychogeriatric
long-stay patients in a state mental hospital. Hosp Community Psychiatry 1990; 41: 445447.
14. Roth M. The natural history of mental disorder in old age.
J Ment Sci 1955; 101: 281301.
15. Takeshima M, Kurata K. Late-life bipolar depression due
to the soft form of bipolar disorder compared to unipolar
depression: an inpatient chart review study. J Aect Disord 2010; 123: 6470.
16. Yassa R, Nair V, Nastase C, Camille Y, Belzile L. Prevalence of bipolar disorder in a psychogeriatric population.
J Aect Disord 1988; 14: 197201.
17. Shulman KI, Tohen M. Unipolar mania reconsidered: evidence from an elderly cohort. Br J Psychiatry 1994; 164:
547549.
18. Shulman KI, Tohen M, Satlin A, Mallya G, Kalunian D.
Mania compared with unipolar depression in old age. Am
J Psychiatry 1992; 149: 341345.
19. Stone K. Mania in the elderly. Br J Psychiatry 1989; 155:
220224.
20. Tohen M, Shulman KI, Satlin A. First-episode mania in
late life. Am J Psychiatry 1994; 151: 130132.
21. Young RC, Jain H, Kiosses DN, Meyers BS. Antidepressant-associated mania in late life. Int J Geriatr Psychiatry
2003; 18: 421424.
22. Sajatovic M, Blow FC, Ignacio RV, Kales HC. New-onset
bipolar disorder in later life. Am J Geriatr Psychiatry
2005; 13: 282289.
23. Prakash O, Kumar CN, Shivakumar PT, Bharath S, Varghese M. Clinical presentation of mania compared with
depression: data from a geriatric clinic in India. Int Psychogeriatr 2009; 21: 764767.
24. Almeida OP, Fenner S. Bipolar disorder: similarities and
dierences between patients with illness onset before
and after 65 years of age. Int Psychogeriatr 2002; 14:
311322.
25. Cravello L, Palmer K, de Girolamo G, Caltagirone C,
Spalletta G. Neuropsychiatric symptoms and syndromes
in institutionalized elderly people without dementia. Int
Psychogeriatr 2011; 23: 425434.
26. Shulman RW, Marton P, Fisher A, Cohen C. Characteristics of psychogeriatric patient visits to a general
hospital emergency room. Can J Psychiatry 1996; 41:
175180.
27. Preville M, Boyer R, Grenier S et al. The epidemiology of
psychiatric disorders in Quebecs older adult population.
Can J Psychiatry 2008; 53: 822832.
28. Koenig HG, Blazer DG. Epidemiology of geriatric aective disorders. Clin Geriatr Med 1992; 8: 235251.
29. Tariot PN, Podgorski CA, Blazina L, Leibovici A. Mental
disorders in the nursing home: another perspective. Am J
Psychiatry 1993; 150: 10631069.
30. Van Gerpen MW, Johnson JE, Winstead DK. Mania in
the geriatric patient population: a review of the literature.
Am J Geriatr Psychiatry 1999; 7: 188202.
31. Steens DC, Krishnan KR. Structural neuroimaging and
mood disorders: recent ndings, implications for classication, and future directions. Biol Psychiatry 1998; 43: 705
712.
32. Shulman KI. Disinhibition syndromes, secondary mania
and bipolar disorder in old age. J Aect Disord 1997; 46:
175182.