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Case Report 


Nawal Tarahib Alotaibi et al, 2020;4(3):763–765.

International Journal of Medicine in Developing Countries

A case report: bipolar disorder

Nawal Tarahib Alotaibi1, Mohammed Abdulaziz Abdulrahman Al-Shamekh2, Dyna Khaled Mohammed Al-Hajri3, Muath Saud Alyasi4*, Haifa Khalaf Al-Shammari5, Al-Batool Fahad Ali Al-Mousa5

Correspondence to: Muath Saud Alyasi

*Medical Intern, Faculty of Medicine, University of Tabuk, Tabuk, Saudi Arabia.

Email: Moad1416 [at] gmail.com

Full list of author information is available at the end of the article.

Received: 19 January 2020 | Accepted: 23 January 2020


ABSTRACT

Background:

Bipolar disorder (BD) is considered as one of the most common chronic diseases among populations that are always conjugated by depression; however, in chronic cases, it might increase the risk of death.


Case presentation:

A 65-year-old Saudi male presented to the Emergency Department due to irritation and agitation symptoms. He had a history of hypertension but with no previous history of strokes, seizures, any other psychotic or depressive symptoms, and substance use. The patient was admitted in psychiatry, where a lot of investigations were performed, and thus, he underwent computed tomography and magnetic resonance imaging. The patient was started on valproic acid 500 mg and olanzapine 5 mg for 15 days. The patient’s results were all within the normal range, and the imaging showed no significant findings. The symptoms gradually improved with an improved mental state. The patient was finally discharged on valproic acid 1,000 mg/day and olanzapine 10 mg/day.


Conclusion:

This case ensured that the late onset of BD should be considered even though bipolar affective disorder typically presents in the younger populations. Valproic acid and olanzapine drugs helped in the enhancement of the mental state of the patient.


Keywords:

Bipolar disorder, depression, manic episode, chronic disorders.


Introduction

Bipolar disorder (BD) is considered as one of the chronic diseases of abnormal mood characterized by a manic episode or depression. The onset age of BD varies approximately between 20 and 30 years. About 90% of bipolar patients start to have symptoms before the fifth decade of their lives [1]. Although it is a multifactorial illness with uncertain etiology, geriatric new onset manic episodes are highly associated with secondary organic causes [2]. The presented case demonstrates the importance of considering the late onset of BD when approaching elderly patients.


Case Presentation

A case of a 65-year-old Saudi male, who was a retired teacher, presented to the Emergency Department (ER) with irritation and agitation state. On his arrival, the patient was loudly expressing the desire to leave the hospital disturbing other patients in ER; therefore, the patient was given haloperidol 5 mg/IM and midazolam 3 mg/IV, and as a result, he underwent chemical restraint during the initial interview.

The patient was in a complete healthy state until 2 weeks before presenting to the ER when he started to become overly talkative and hyperactive, he was overspending his money, had a decreased need of sleep, and was spending the night relentlessly fixing things around his house. The patient started to become uncharacteristically aggressive both verbally and physically; as a result of an altercation, his neighbor reported him to the police. The patient had also been driving recklessly, complaining that there was a camera installed to watch him, as well as he mentioned that he heard a voice advising him to do certain things. These symptoms increased in intensity over the week before admission.

Almost, 11 months ago, the patient was seen in a different hospital in the emergency department for the same symptoms and was discharged on olanzapine 5 mg and valproic acid 500 mg. He used these medications for 3 months, during which he noted a marked improvement regarding his mood and sleep and returned to his baseline. The patient had a history of hypertension with no record of previous strokes or seizures. The patient had no other psychotic or depressive symptoms and no history of substance use. The patient and the family denied any history of psychiatric illnesses in the family. The patient was then admitted for inpatient psychiatric hospitalization with the plan to rule out any possible organic cause for a late onset mood disorder.

The initial investigations were performed, which included complete blood count with differential, electrolytes, renal function test, liver function tests, thyroid function test, lipid profile, Vitamin D, Vitamin B12, fasting glucose level, HbA1c, and syphilis and brucella screening, as well as added endocrinology laboratories that were requested by the consulted endocrinology team. The patient also underwent computed tomography (CT) of the brain as well as magnetic resonance imaging (MRI) of the brain and spinal cord. The patient’s results were all within the normal range, and the imaging showed no significant findings.

The patient was started on valproic acid 500 mg and olanzapine 5 mg, and he was still talkative, overfamiliar, and overdemanding. The symptoms gradually improved during admission. Approximately, 15 days later, he went out on pass for 2 days and returned with good feedback from his family. However, they mentioned that he thought one of his acquaintances which had cast black magic on him, so olanzapine was gradually increased to 10 mg over 1 week. He was then discharged with an improved mental state, with his delusions being shakable on the 24th day of admission along with the establishment of the diagnosis of late onset BD with no safety concerns. The patient was discharged on valproic acid 1,000 mg/day and olanzapine 10 mg/day.


Discussion

It was reported that BD had a definite impact on the quality of the patient’s life and increased the risk of death [3]. It had difficulty in diagnosis, especially in its initial time [4]. The presented case had a severe manic episode in his later life at the age of 65 years. This was agreed with Van Gerpen et al. [5], whereas in contrast to the case described by Kessler et al. [6] who reported that BD is always ranged between the late time of adolescence and early period of adulthood. The patient underwent many investigations and performed radiological imaging to rule out neurological events such as a CNS infection, epilepsy, stroke and head injury in addition to any space-occupying lesions, vitamin deficiencies, endocrine disorders, dementia, and medication-acquired side effects. After a detailed history and full physical examination, initial laboratory workup, CT, and MRI were performed to exclude brain insults, considering that a neurovascular event could be a cause of a manic episode. However, brain CT and MRI revealed no evidence of ischemic or hemorrhagic strokes or small vessel infarctions. Although antidepressant-induced mania was also considered as a differential diagnosis, it was excluded due to the patient and his family who denied any selective serotonin reuptake inhibitor intake. Regarding the management of geriatric mania, the patient was started on olanzapine and valproic acid as they have been recommended as the first-line medications but with lower starting doses and a slower rate of uptitration [7]. This was in agreement with Chou et al. [8], whose case was a 59-year old and treated approximately with the same medications (olanzapine, lithium, and valproate) as first-line medications. Although the present patient’s symptoms and his mental state started to improved gradually, olanzapine was gradually increased from 5 to 10 mg over 1 week, because according to his family, one of his acquaintances cast black magic on him. This was similar to the case that was diagnosed by Gómez-Durán et al. [9] who reported that his case was very aggressive due to the domination of her neighbors who controlled his will through black magic. Furthermore, Samuel et al. [10] proved that olanzapine at 10 mg/day improved the mental state of his patient in 1–2 days. In the case study of Mudigubba et al. [11], it was found that olanzapine was more effective in the treatment of mania with psychotic features because olanzapine is considered as the only antipsychotic drug that has the approval of the Food and Drug Administration for bipolar maintenance therapy. In addition to other literature [12,13] in a double-blind trial, it was confirmed that a combination of valproate and olanzapine showed a greater efficacy in the treatment of acute mania and depression, in the presence or absence of psychotic features. This case ensured that the late onset of BD is considered although bipolar affective disorder typically presents in the younger populations.


Conclusion

BD is an uncommon mental disease that has definite symptoms arising among the population, and the onset of this disease is not only restricted to young adulthood but also in elderly adults. The diagnosis is to be taken as a differential diagnosis while following the process of excluding organic etiologies when new-onset manic symptoms among elderly patients could be faced. Furthermore, a drastic improvement in the initiation of treatment had been observed in the presented patient. Therefore, it was aimed to enforce the guidelines in the management of such cases and to avoid its possible misdiagnosis.


List of Abbreviations

BD Bipolar disorder
CT Computed tomography
ER Emergency Department
MRI Magnetic resonance imaging

Conflict of interest

The authors declared that there is no conflict of interest regarding the publication of this case report.


Funding

None.


Consent of publication

Informed consent was obtained from all the participants.


Ethical approval

Ethical approval was obtained from the Institutional Research and Ethics Board.


Author details

Nawal Tarahib Alotaibi1, Mohammed Abdulaziz Abdulrahman Al-Shamekh2, Dyna Khaled Mohammed Al-Hajri3, Muath Saud Alyasi4, Haifa Khalaf Al-Shammari5, Al-Batool Fahad Ali Al-Mousa5

  1. Consultant Psychiatrist, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
  2. Resident Psychiatry, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
  3. Senior house officer, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
  4. Medical Intern, Faculty of Medicine, University of Tabuk, Tabuk, Saudi Arabia
  5. Medical Intern, Faculty of Medicine, University of Qassim, Saudi Arabia

References

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  2. Rowland TA, Marwaha S. Epidemiology and risk factors for bipolar disorder. Ther Adv Psychopharmacol. 2018;8:251–69. https://doi.org/10.1177/2045125318769235
  3. Montes JM, Saiz J, de Dios C, Ezquiaga E, García A, Argudo I, et al. Perfi l de los pacientes ambulatorios con trastorno bipolar: un estudio transversal en la Comunidad de Madrid. Actas Esp Psiquiatr. 2008;36:277–84.
  4. López Castromán J, Baca García E, Botillo Martín C, Quintero Gutiérrez del Álamo J, Navarro Jiménez R, Negueruela López M, et al. Errores de diagnóstico y estabilidad temporal en el trastorno bipolar. Actas Esp Psiquiatr. 2008;36:205–9.
  5. Van Gerpen MW, Johnson JE, Winstead DK. Mania in the geriatric population: a review of the literature. Am J Geriatr Psychiatry. 1999;7:188–202. Comment in: American Journal of Geriatric Psychiatry. 2001;9:180. https://doi.org/10.1097/00019442-199908000-00002
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  11. Mudigubba M, Gowthami B, Dinesh R, Karthik M, Bharathi, Yogananda R. Co-morbidity in bipolar affective disorder: a case report. J Drug Deliv Ther. 2013;3:141–2. https://doi.org/10.22270/jddt.v3i3.532
  12. Perlis RH, Welge JA, Vornik LA, Hirschfeld RM, Keck PE. A typical antipsychotics in the treatment of mania: a meta-analysis of randomized, placebo-controlled trials. J Clin Psychiatry. 2006;67:509–16. https://doi.org/10.4088/JCP.v67n0401
  13. Brambilla P, Barale F, Soares JC. A typical antipsychotics and mood stabilization in bipolar disorder. Psychopharmacology. 2003;166:315–32. https://doi.org/10.1007/s00213-002-1322-9


How to Cite this Article
Pubmed Style

Alotaibi NT, Al-Shamekh MAA, Al-Hajri DKM, Alyasi MS, Al-Shammari HK, Al-Mousa AFA. A case report: bipolar disorder. IJMDC. 2020; 4(3): 763-765. doi:10.24911/IJMDC.51-1579426852


Web Style

Alotaibi NT, Al-Shamekh MAA, Al-Hajri DKM, Alyasi MS, Al-Shammari HK, Al-Mousa AFA. A case report: bipolar disorder. http://www.ijmdc.com/?mno=82622 [Access: March 29, 2020]. doi:10.24911/IJMDC.51-1579426852


AMA (American Medical Association) Style

Alotaibi NT, Al-Shamekh MAA, Al-Hajri DKM, Alyasi MS, Al-Shammari HK, Al-Mousa AFA. A case report: bipolar disorder. IJMDC. 2020; 4(3): 763-765. doi:10.24911/IJMDC.51-1579426852



Vancouver/ICMJE Style

Alotaibi NT, Al-Shamekh MAA, Al-Hajri DKM, Alyasi MS, Al-Shammari HK, Al-Mousa AFA. A case report: bipolar disorder. IJMDC. (2020), [cited March 29, 2020]; 4(3): 763-765. doi:10.24911/IJMDC.51-1579426852



Harvard Style

Alotaibi, N. T., Al-Shamekh, . M. A. A., Al-Hajri, . D. K. M., Alyasi, . M. S., Al-Shammari, . H. K. & Al-Mousa, . A. F. A. (2020) A case report: bipolar disorder. IJMDC, 4 (3), 763-765. doi:10.24911/IJMDC.51-1579426852



Turabian Style

Alotaibi, Nawal Tarahib, Mohammed Abdulaziz Abdulrahman Al-Shamekh, Dyna Khaled Mohammed Al-Hajri, Muath Saud Alyasi, Haifa Khalaf Al-Shammari, and Al-Batool Fahad Ali Al-Mousa. 2020. A case report: bipolar disorder. International Journal of Medicine in Developing Countries, 4 (3), 763-765. doi:10.24911/IJMDC.51-1579426852



Chicago Style

Alotaibi, Nawal Tarahib, Mohammed Abdulaziz Abdulrahman Al-Shamekh, Dyna Khaled Mohammed Al-Hajri, Muath Saud Alyasi, Haifa Khalaf Al-Shammari, and Al-Batool Fahad Ali Al-Mousa. "A case report: bipolar disorder." International Journal of Medicine in Developing Countries 4 (2020), 763-765. doi:10.24911/IJMDC.51-1579426852



MLA (The Modern Language Association) Style

Alotaibi, Nawal Tarahib, Mohammed Abdulaziz Abdulrahman Al-Shamekh, Dyna Khaled Mohammed Al-Hajri, Muath Saud Alyasi, Haifa Khalaf Al-Shammari, and Al-Batool Fahad Ali Al-Mousa. "A case report: bipolar disorder." International Journal of Medicine in Developing Countries 4.3 (2020), 763-765. Print. doi:10.24911/IJMDC.51-1579426852



APA (American Psychological Association) Style

Alotaibi, N. T., Al-Shamekh, . M. A. A., Al-Hajri, . D. K. M., Alyasi, . M. S., Al-Shammari, . H. K. & Al-Mousa, . A. F. A. (2020) A case report: bipolar disorder. International Journal of Medicine in Developing Countries, 4 (3), 763-765. doi:10.24911/IJMDC.51-1579426852