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Clinical Atlas Prestige · Evidence-first

Psych VivasOld age psychiatry — mood disorders

Psych Vivas · Old age psychiatry — mood disorders

Late-life bipolar disorder — structured clinical viva

Fellowship viva covering secondary mania, organic work-up, GERI-BD, geriatric lithium targets, medical comorbidity, and suicide lethality.

clinical
On this page & tools

Target exams

FRANZCPMRCPsychABPNMD-DNB

Target exams

FRANZCPMRCPsychABPNMD-DNB
Prompt
You are the old-age psychiatry registrar. A 69-year-old man with no prior psychiatric contact presents with a first manic episode. Vascular risk factors are present; he started high-dose prednisolone three weeks ago for COPD exacerbation. Discuss formulation (late-onset vs secondary mania), work-up, acute management including whether lithium is reasonable (GERI-BD), suicide risk in older adults, and how you would counsel about long-term lithium if primary bipolar is later confirmed.

Interpretation

Reveal interpretation

Formulate as first late-life manic syndrome with strong secondary mania likelihood (steroid temporal link, vascular risk, no prior bipolar history). Secondary mania teaching (Krauthammer and Klerman) prioritises identifying antecedent illness or drugs; still manage the manic syndrome and risk while tapering steroids with medical team if feasible and completing organic work-up (labs, ECG, neuroimaging threshold high for late first mania).[1][2]

Acute treatment can include carefully dosed lithium or divalproex — GERI-BD supports efficacy of both in older mania — plus low-start antipsychotic if needed, sleep restoration, and legal/risk management.[3][7] Suicide risk remains relevant across poles and after the storm; older adults have high lethality — ask and restrict means.[5] If a primary bipolar diagnosis consolidates over time, counsel that maintenance lithium remains evidence-supported in older adults with lower targets and strict monitoring (ISBD Delphi), and lithium has anti-suicide meta-analytic support in mood disorders.[4][6]

Key points

Late first mania is organic-first

Steroids, stroke, and other medical drivers outrank assuming lifelong primary bipolar on day one.

GERI-BD keeps lithium on the table

Lithium and divalproex both work in older mania with careful dosing — age alone is not an absolute lithium ban.

Maintenance lithium is age-attuned

Lower targets, renal/thyroid/calcium monitoring, and interaction vigilance — not reflexive deprescribing.
[1] [3] [4]

References

  1. [1]Krauthammer C, Klerman GL Secondary mania: manic syndromes associated with antecedent physical illness or drugs Arch Gen Psychiatry, 1978.PMID 757997
  2. [2]Depp CA, Jeste DV Bipolar disorder in older adults: a critical review Bipolar Disord, 2004.PMID 15383127
  3. [3]Young RC, Mulsant BH, Sajatovic M, et al. GERI-BD: A Randomized Double-Blind Controlled Trial of Lithium and Divalproex in the Treatment of Mania in Older Patients With Bipolar Disorder Am J Psychiatry, 2017.PMID 29088928
  4. [4]Shulman KI, Almeida OP, Herrmann N, et al. Delphi survey of maintenance lithium treatment in older adults with bipolar disorder: An ISBD task force report Bipolar Disord, 2019.PMID 30375703
  5. [5]Conwell Y, Van Orden K, Caine ED Suicide in older adults Psychiatr Clin North Am, 2011.PMID 21536168
  6. [6]Cipriani A, Hawton K, Stockton S, Geddes JR Lithium in the prevention of suicide in mood disorders: updated systematic review and meta-analysis BMJ, 2013.PMID 23814104
  7. [7]Malhi GS, Bell E, Bassett D, et al. The 2020 Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders Aust N Z J Psychiatry, 2021.PMID 33353391