a 78-year - old person , retired as school teacher with no history of any substance abuse or medical history .
he had been suffering from bilateral knee pain diagnosed as osteoarthritis for the last 20 years and was not on any steroids .
he presented with 1-month duration of altered behavior characterized by excessive psychomotor activity , emotional lability , increased self - confidence , excessive talkativeness , decreased need for sleep , and increased sense of energy level .
there were a few occasions when he misrecognised his daughter as his wife who had passed away 6 months ago . on examination , he was an elderly obese person weighing 92 kg with bmi > 27 .
mental status examination revealed increased irritability , increased psychomotor activity , and increased self - confidence and authoritativeness .
he had similar behavior 3 years ago , diagnosed and treated as mania in the same hospital .
there was positive family history in the form of his mother having had symptoms suggestive of postpartum psychosis .
investigations including hiv , vdrl , serum vitamin b12 level , tft , eeg , routine hemogram , serum electrolytes , blood urea , and serum creatinine were normal .
ecg revealed no abnormalities , except for a prolonged corrected qt interval ( qtc ) of 486 msec .
his ct brain [ figure 1 ] showed cortical atrophy , especially pronounced in the temporal and frontal areas .
the periventricular regions in the frontal lobe showed mild hypodensity suggestive of small vessel ischemic disease .
he didnt fulfill international consensus criteria for behavioral variant of frontotemporal dementia ( ftd ) .
ct brain shows frontal cortical atrophy ( top left ) , with frontal subcortical white matter hypodensities ( top right )
. widened sylvian fissures suggestive of temporal pole atrophy and basal ganglia calcifications are also seen ( bottom left ) .
widening of temporal horns of lateral ventricles ( bottom right ) is further evidence of temporal lobe atrophy he was initiated with aripiprazole 5 mg / day because of his qtc being 486 msec . given his age , we chose aripiprazole as it is less sedating and has lower chances of producing postural hypotension .
he also required intravenous lorazepam 2 mg sos for his agitated behavior for the first 2 days .
aripiprazole was gradually increased to 15 mg , and by the end of 3 weeks he showed complete remission of his manic symptoms . at the time of admission in psychiatry ward
, he scored 27 on mania severity on young 's mania rating scale ( ymrs ) and it came down to 4 at the end of 3 weeks .
occurrence of first episode of mania in the elderly ( after 60 years age ) warrants a high index of suspicion for organic causes .
, we did not find any obvious etiology for his mental illness , except for frontal and temporal atrophy and possible frontal sub - cortical white matter involvement .
one possibility considered was that of ftd , but this was ruled out as he did not fulfill criteria for dementia and behavioral component of ftd .
it is possible that the manic episodes were the initial manifestations of ftd in this patient and this will be tested only in the follow - up .
there was family history of postpartum psychosis in his mother , which is associated with a family history of bipolar disorder and the index case had been diagnosed as mania 3 years ago with complete remission in the interval period .
these two points and absence of any abnormalities in laboratory and clinical examination favored diagnosis of mania .
aripiprazole has relatively high affinity for both 5-ht2a and d2 receptors similar to other atypical antipsychotics but differs from them due to its partial agonist activity at d2 and 5-ht1a receptors .
it has a more favorable side - effect profile compared to typical and even atypical antipsychotics .
aripiprazole has lesser propensity to cause extra - pyramidal symptoms , an important factor in the elderly .
other desirable properties are lesser chance for causing side - effects like dyslipidemia , glucose intolerance , hyperprolactinemia , postural hypotension , sedation , qt prolongation , and weight gain .
its efficacy has been proven as monotherapy in treating acute mania and in prophylaxis of bipolar disorder .
hence , we chose aripiprazole for our patient in view of his already prolonged qtc interval and age of 78 years .
this case is unusual in that age of onset of mania is very late ( 75 years ) and during the current second episode we could not find any organic etiology .
hence , aripiprazole may be a safe and effective antipsychotic medication for the control of mania in the elderly .
 new - onset bipolar disorder is rare in the elderly . 
 symptom profile is similar to that in young adults but the elderly are more likely to have neurological co - morbidities . 
 there are no case reports of elderly mania being treated with aripiprazole , an atypical antipsychotic . a 78-year - old gentleman presented to us with symptoms suggestive of mania of 1 month 's duration . 
 he had similar history 3 years ago and a family history of postpartum psychosis in his mother . 
 there were no neurological signs on examination and work - up for an organic etiology was negative except for age - related cerebral atrophy . 
 he improved with aripiprazole and tolerated the medications well . 
 the use of psychotropic medications in the elderly is associated with side - effects of sedation , increased cardiovascular risk , and greater risk of extra - pyramidal side - effects . the use of partial dopaminergic antagonists like aripiprazole may be useful in the balancing of effects and side - effects . 