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Abstract or Description

A female, age 78, with generalized anxiety disorder (GAD), history of major depression, and hypothyroidism presents for mood and anxiety concerns. Her mood is depressed, and sleep, appetite, energy, and concentration are poor. She recently saw a geriatric psychiatrist and described no past manic episodes, psychotic symptoms, or family history for bipolar disorder. No one has concerns about her cognition. She began levothyroxine 150 mcg 3 weeks ago for newly diagnosed hypothyroidism. On exam, she is talkative, overinclusive, has almost pressured speech, labile mood, and lid lag. Neuropsychology testing, CBC, and CMP are normal. TSH is 0.173. She is diagnosed with GAD exacerbated by hyperthyroidism due to over-replaced thyroid hormone causing a hypomanic syndrome. Possibly she was hyperthyroid prior to burnout and recent hypothyroid state, explaining the temporality of her manic symptoms. She reports feeling better at follow-up after medication adjustment. Late-onset mania is a (hypo)manic syndrome in a person 50 or older without a previous history of mania3. 5-10% of patients are 50+ years when they experience their first manic episode of bipolar disorder2. However, (hypo)manic syndromes can also be due to vascular etiology, dementia, medications, renal failure, and thyroid derangement. One study reports a 2.8% prevalence of organic cause of mania in those >65 compared to 1.2% prevalence in those

  1. Almeida, O. P., & Fenner, S. (2002). Bipolar disorder: similarities and differences between patients with illness onset before and after 65 years of age. International psychogeriatrics, 14(3), 311–322.
  2. Arnold, I., Dehning, J., Grunze, A., & Hausmann, A. (2021). Old Age Bipolar Disorder-Epidemiology, Aetiology and Treatment. Medicina, 57(6), 587.
  3. Sami, M., Khan, H., & Nilforooshan, R. (2015). Late onset mania as an organic syndrome: A review of case reports in the literature. Journal of affective disorders, 188, 226–231.

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late-onset mania, thyroid derangement, geriatric assessment clinic


Medical Education

Importance of complete assessment in the work-up of late onset mania