There is a relative lack of evidence relating to specific etiology and management of late-onset bipolar illness and first episode mania in the elderly. This is despite a significant number of older patients presenting with this condition and a potential increase in prevalence with steady growth of the elderly population all over the world. There are also several distinct features of late-life mania that distinguish it from the adult onset manic presentation. Also, clinical diagnosis of late life mania may be difficult to establish at times due to the presence of several comorbidities and the potential overlap of symptomotology with other common disorders such as delirium and dementia. This review attempts to summarize the current knowledge of bipolar affective disorder, specifically late onset mania in the elderly and consider important factors that need to be accounted for its diagnosis, investigation, and management.

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The population of elderly substance users is gradually increasing over the years in India due to the aging population and changing demographics. Hence, clinicians are likely to encounter a larger proportion of elderly substance users with time. This narrative review aims to provide an overview of the substance use disorders in the elderly with a focus on the Indian population. The epidemiology of substance use disorders in the elderly is discussed, as is the unique features of specific substances of use in this population. The overlay of medical comorbidities in the elderly substance users is highlighted. This is followed by the discussion of the key issues in the assessment and management of elderly substance users. The directions of future research in this field are subsequently highlighted.

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Frontal lobe epilepsy (FLE) manifests with brief, nocturnal seizures arising in the frontal lobe along with unusual behavioral symptoms or postures, frequently misdiagnosed as a psychogenic nonepileptic seizure (PNES) or a sleep disorder. Ancient literature has rarely mentioned the antiepileptic effect of opium or different opioids. Here we are presenting a case with FLE, though initially diagnosed PNES, who had significant relief in his symptoms on using opium, and this led to opium dependence. Index case further emphasizes concern and caution as misdiagnosis of FLE may lead to substance dependenc.

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Progressive supranuclear palsy (PSP) is a rare neurodegenerative disease, which tends to be progressive, causing weakness of the structures in the brain stem that controls eye movements. PSP falls under the rubric of Parkinsonism plus syndromes that are a group of heterogeneous degenerative neurological disorders that differ from the classical idiopathic Parkinson's disease. PSP is often underreported, making it important for clinicians to be aware of this disorder. Here we report a case of PSP, which presented primarily with speech disturbances and recurrent falls due to postural instability. On investigating, the magnetic resonance imaging (MRI) revealed a classical sign diagnostic of PSP.

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Dementia has been declared by the World Health Organization as a significant public health problem around the world. Frontotemporal dementia (FTD) is a lesser known, yet the second most common type of dementia among older adults under the age of 65 years. Age of onset in FTD is around late fifties, which is not typical for a diagnosis of dementia. In dementia, it is common to see psychiatric symptoms such as hallucinations or delusions as initial presentations. However, FTD may mimic mood disorders. Unfortunately, there are no definitive treatments or ways to prevent FTD. Additionally, challenges such as an earlier age of onset, delay in diagnosis, and difficulties with placement in nursing homes may be encountered while treating FTD patients. Here, we explore FTD through the case of a 61-year-old Caucasian female who initially presented with suicidal ideations.

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Delirious mania is a rare psychiatric syndrome characterized by the presence of delirious and manic symptoms at the same time in a patient with history of bipolar disorder. After its first description in 1832, delirious mania in the literature exists only in the form of case reports and case series. Among the elderly, its occurrence is still rarer. However, an unsuspecting clinician may come across this rare entity and may misdiagnose it for delirium, which needs to be managed aggressively. Hence, we preferred to describe a case of an elderly male here, who presented to us with delirious mania and responded well to olanzapine.

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Background: Electroconvulsive therapy (ECT) is the one of the oldest and effective treatments in psychiatry today. It has been used in a wide variety of psychiatric disorders in both young and old patients. Aims of the study: The present study is a retrospective chart review of geriatric patients receiving ECT as a treatment option in a tertiary care general hospital psychiatry setting. Methodology: The study evaluated ECT records over a 5-year period between the years 2010 and 2014, and it was observed that 23 elderly patients (aged ≥60 years) had received ECT. Results: The patients received modified bitemporal ECT using a brief pulse ECT machine and had no major complications. A total of 184 ECT treatments were administered at an average of 8 treatments per case. The major diagnoses of patients were schizophrenia and major depression. The main indications of ECT were intolerance to medication, suicidal behavior and aggression. Out of the 23 elderly patients, 18 (78.26%) showed a good response to ECT. The only complication noted was memory loss and confusion in 3 cases. Patients with medical illnesses like hypertension, diabetes and both together received ECT without any complications. Conclusions: This study adds to the scarce database on the use of ECT in elderly patients in India and adds evidence to the fact that ECT is a safe and effective treatment in the elderly.

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Background: Elderly patients presenting with cognitive and depressive symptoms often create a diagnostic challenge between depression and the dementing process. Various screening and diagnostic instruments have been developed for differentiating the two, one of which is Addenbrooke's cognitive examination (ACE). However, results have not been consistent across various studies, and not much data is available in the Indian context. Aims and Objectives: To study cognition in elderly patients presenting with both cognitive and depressive symptoms at the baseline and at 3 months follow-up after starting antidepressants, and to compare the two profiles. Materials and Methods: It was a follow-up study with 70 participants who had presented with both depressive and cognitive symptoms. Tablet escitalopram was given and ACE was performed at the baseline and at 3 months after starting antidepressants. Improvement on ACE was present in 37 participants and absent in 33 participants. The cognitive profile of these two groups was subjected to statistical analysis. Wilcoxon signed-rank test was used to study the difference between the full and domain ACE scores between the preintervention phase and postintervention phase within each group. Results: There is a significant difference between preintervention and postintervention full ACE scores and different domain scores in the depression group unlike in the MCI group. Conclusion: Diagnostic tools such as ACE can be utilized for differentiating mood disorder with an actual dementing process. It also reveals the need for periodic assessments of such patients.

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Introduction: Despite a plethora of prevalence studies, research on the course and outcome of late-life depression (LLD) have received little attention in India. Thus, the present study was undertaken to explore the course and outcome of LLD. Materials and Methods: A retrospective case note review of outpatient clinic was undertaken. Only those patients having completed the baseline Mini-Mental State Examination (MMSE) and Hamilton Rating Scale for Depression (HAMD) on the first visit were included in the study. Other relevant information was collected from the case notes. Results: Forty-eight patients fulfilled the selection criteria. The mean age of the sample was 67.3 years, with male preponderance (72%). There was no significant difference in demographic variables between genders, urban/rural domicile, and early/late onset depression (EOD/LOD). The EOD and LOD cases (cut-off age 60 years for the groups) were similar except that the former had more severe illness and longer duration of untreated illness at the baseline. Sixty-five percent patients (n = 31) attended at least one follow-up visit. The mean intervals of the first, second, and third follow-up visits were 3.7 ± 5.1 weeks, 5.1 ± 4.5 weeks, and 8.4 ± 5.7 weeks, and >50% improvement on HAMD was noted in 19%, 21% and 21% patients respectively. However, those who responded at earlier times either dropped out or showed recrudescence of symptoms. While those who responded at later times maintained the benefit. Conclusions: This is the first study to look at short-term outcome of LLD in India. The response rates were low and patients showed a fluctuating degree of improvement.

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Aim: To compare the symptom profile of patients with delirium without preexisting cognitive deficits and those experiencing delirium in the background of preexisting cognitive deficits. Materials and Methods: A total of 107 patients aged ≥60 years with diagnosis of delirium as per the Diagnostic and Statistical Manual, IV text revision criteria were evaluated on Short Informant Questionnaire on Cognitive Decline in the Elderly (Short IQCODE), Delirium Rating Scale Revised 98 version (DRS-R98), amended delirium motor symptom scale, and delirium etiology checklist and risk factor checklist. On the basis of short IQCODE score, the study sample was divided into those with (≥3.5) and without cognitive deficits and were compared for the symptom profile, motor subtype, risk factors, and etiologies. Results: Based on the short IQCODE scores, the patients were divided into those with (≥3.5) and without cognitive deficits (<3.5). Those with cognitive deficits (n = 20) were significantly older and more often had delirium prior to getting admitted to the hospital. The groups did not differ in terms of frequency and severity of various symptoms of delirium, DRS-R98 total score, DRS-R98 severity score, DRS-R98 cognitive domain score, DRS-R98 noncognitive domain score, motor subtypes, various risk factors, various associated etiologies, mean number of risk factors for delirium, and mean number of associated etiologies. There was no association between mean IQCODE score and severity scores for each symptom of delirium as per DRS-R98, DRS-R98 total score, DRS-R98 severity score, DRS-R98 cognitive domain score, and DRS-R98 noncognitive domain score. Conclusion: There is no difference in the symptom profile of those with and without preexisting cognitive deficits.

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