Late-life bipolar disorder — assessment and management (MEQ)

(i) Formulation and differential. This is early-onset bipolar I disorder continuing into late life with a current manic episode (first illness at 28, not late-onset first mania). Differentials still include lithium toxicity or subtoxicity contributing to confusion/inattention; delirium from medical causes; substance effects; and less likely a new primary secondary mania because of the established bipolar history — but always re-check drugs and medical drivers that can worsen mania.[1][8] Reduced MoCA with inattention may reflect manic distractibility, sleep deprivation, early toxicity, or delirium — clarify with serial attention testing and medical work-up.[1]

(ii) Acute risk and medical priorities. Financial vulnerability and grandiosity with remortgage plans; firearm access; poor sleep; possible impaired capacity. Urgent lithium level and renal function now: ibuprofen (NSAID) plus thiazide plus age/reduced eGFR is a classic toxicity cocktail even if she is not yet floridly toxic.[3][4] Hold NSAID; review thiazide with physician; hydrate as appropriate; ECG, basic labs, consider infection screen. Collateral and capacity assessment for finances/treatment.[6]

(iii) Acute mania management. Hospitalisation threshold is high given risk, sleep collapse, and medical complexity — least-restrictive but safe setting. If lithium level is therapeutic and not toxic, may continue carefully with dose adjustment for eGFR; if toxic or high-normal with symptoms, hold lithium and treat toxicity first.[4] Antimanic options guided by GERI-BD: lithium and divalproex are both efficacious in older mania with careful dosing; add a low-start atypical antipsychotic (e.g. quetiapine 25–50 mg orally, titrate) for behavioural control and sleep if needed.[2][6] Example divalproex start if lithium held: 125–250 mg orally two to three times daily with LFT/platelets/level monitoring. Reassess mania daily; protect sleep; reduce stimulation.[2]

(iv) Suicide/means and disposition. Even with denied ideation, older adults have high suicide lethality — ask fully about depression history, hopelessness, and plans as the pole can switch; secure the firearm same day with family/police pathways as appropriate under local law.[5] Intensity of care: likely inpatient voluntary if capacitous and agreeable, involuntary if risk and incapacity require (jurisdiction-specific). Do not discharge to an empty safety plan with firearm access.[5][6]

(v) Long-term lithium plan. After stabilisation, plan maintenance with age-attuned lithium targets (often roughly 0.4–0.8 mmol/L maintenance, individualised), more frequent level/eGFR/TSH/calcium checks, sick-day rules, interaction list (no OTC NSAIDs), and carer education. BALANCE supports lithium-centred prophylaxis; do not abandon lithium solely for age if benefits outweigh monitored risks.[3][7] Coordinate GP shared care and old-age CMHT follow-up.[6]