Is the Concept of Delirious Mania Valid in the Elderly? A Case Report and a Review of the Literature

Delirious mania has been well recognized in the published literature and in the clinic. Over the years there has been refinement of understanding of its clinical features, course, and treatment. The literature suggests that delirious mania should be considered in individuals who present with a constellation of sudden onset delirium, mania, and psychosis. However, delirious mania is not recognized under a formal classification system nor are there any formal guidelines for its treatment. We, as such, question if the concept of delirious mania in the elderly is valid. We present a case of an elderly man with marked features of delirium with minimal manic or psychotic features who had a previous diagnosis of bipolar I disorder. On thorough clinical assessments no identifiable cause of his delirium was found. We therefore considered his presentation to be more likely due to delirious mania. Electroconvulsive therapy was considered and offered to which he responded very well. We invite the reader to consider whether delirious mania is a valid concept in the elderly, where features of delirium may be more prominent than manic or psychotic features. 1. Introduction Delirious mania has been described as a clinical syndrome since 1832 by Calmeil [1]. The literature has recognized this concept in the form of clinical reports, but delirious mania has not been formally captured in a classification system such as the Diagnostic and Statistical Manual of Mental Disorders [2]. A reasonable definition of delirious mania is concurrence of rapid onset delirium, mania, and psychosis without association with a physical illness, prior toxicity, or another mental disorder [3]. Bell in 1849 identified that out of 1700 patients seen in McLean Asylum, USA, 40 patients presented with a “disease resembling some advanced stages of mania, and fever” [4]. He described features including a sudden onset of clouding of consciousness, delusions, hallucinations, overactivity, and sleeplessness. The term delirious mania was first coined by Kraepelin [5] in 1921. Kraepelin had categorized mania into three subtypes: delirious mania, acute mania and hypomania. He felt that there was a continuum from the mildest form, hypomania, to acute mania and finally delirious mania as the most severe form of mania [5]. Other definitions include those of Klerman who tried to expand the characterization of mania into 5 stages: normal, neurotic, hypomanic, manic, and delirious stages [6]. Carson and Goodwin [7] noted that six patients out of a series of twenty manic cases, besides having manic symptoms,