What is the management approach for a 60-year-old female patient presenting with mania and Intellectual Developmental Disorder (IDD)?

Management of Mania in a 60-Year-Old Female with Intellectual Developmental Disorder

The management should begin with mood stabilizers or antipsychotics approved for acute mania in adults, with lithium, valproate, or atypical antipsychotics (aripiprazole, risperidone, quetiapine, olanzapine) as first-line agents, while simultaneously conducting a comprehensive assessment to identify and address contributing medical, environmental, and behavioral factors specific to individuals with IDD. 1

Initial Pharmacological Management

First-Line Medication Options

• Start with FDA-approved agents for bipolar disorder in adults, recognizing that lithium is the only agent with FDA approval down to age 12 years for acute mania and maintenance therapy 1
• Alternative first-line options include: aripiprazole, valproate, olanzapine, risperidone, quetiapine, or ziprasidone, all approved for acute mania in adults 1
• Antipsychotics are commonly used in IDD populations, with 32% of psychiatric outpatients with IDD receiving antipsychotics and 28% receiving mood stabilizers 2

Medication Selection Considerations

• Consider family history of treatment response, as parental response may predict offspring response 1
• Avoid unnecessary polypharmacy, though multiple agents are often required in practice 1
• Monitor for atypical side effects, as medications including antiepileptics and calcium channel blockers carry high risk of psychiatric or behavioral side effects in IDD populations 1

Critical Assessment of Contributing Factors

Medical and Pain-Related Causes

Before attributing symptoms solely to mania, systematically rule out medical contributors that commonly present as behavioral changes in IDD:

• Assess for common sources of pain: ear infections, headaches, menstrual issues, injuries, constipation, gastroesophageal reflux, and dental problems, as individuals with limited language may express physical discomfort through behavioral changes 1
• Evaluate for seizure disorders, particularly post-ictal symptoms including dysphoria and irritability, as individuals with IDD have increased seizure risk 1
• Review all current medications for psychiatric or behavioral side effects, especially stimulants, muscle relaxants, antiepileptics, and centrally acting antiemetics 1

Environmental and Psychosocial Triggers

Individuals with IDD are highly sensitive to environmental changes that can precipitate or exacerbate manic symptoms:

• Identify recent life stressors: moves to new residence, problems with family/friends/caregivers, changes in routine, staff turnover, trauma/abuse, or sleep disturbance (2.8 times more likely in IDD) 1
• Assess living environment and support adequacy, as demands exceeding cognitive abilities can trigger psychiatric symptoms 1
• Evaluate for trauma history, recognizing that individuals with IDD have higher rates of substantiated maltreatment (11.3% in one study) 1, 3

Behavioral Function Analysis

• Conduct functional behavioral assessment to understand whether manic-appearing behaviors serve specific functions (escape/avoidance, attention-seeking, access to preferred items, or self-stimulation) 1
• Consult with psychologist or behavior analyst trained in applied behavioral analysis (ABA) to identify setting events, antecedents, and consequences maintaining behaviors 1, 4

Diagnostic Considerations Specific to IDD

Avoid Diagnostic Overshadowing

• Do not attribute all behavioral symptoms to IDD itself—psychiatric disorders occur at least three times more often in individuals with IDD than in typically developing individuals 1, 3
• Recognize atypical presentations: psychiatric illness may present differently in IDD, with mania potentially manifesting through aggression, self-injurious behavior, or physical complaints rather than classic mood symptoms 2
• Depression commonly co-occurs and was the most frequent diagnostic class even in IDD populations presenting with behavioral disturbance 2

Differential Diagnosis

• Rule out delirium, particularly in older adults, as delirious mania can present with features of mania, delirium, psychosis, and catatonia 5
• Assess for dementia in this 60-year-old patient, as adults with IDD face destabilizing life events with aging (declining health, loss of caregivers/loved ones) that can mimic or trigger psychiatric symptoms 1
• Evaluate for comorbid ADHD, anxiety disorders, and ODD, which show particularly high rates in IDD and frequently underlie or co-occur with mood symptoms 3

Multimodal Treatment Approach

Non-Pharmacological Interventions

• Implement positive behavioral support planning and functional communication training, which are capable of mitigating severe behavioral impairment in IDD 4
• Ensure adequate communication system across all settings, as limited communication ability can frustrate individuals and exacerbate psychiatric symptoms 1
• Optimize environmental demands to match cognitive abilities (demand-ability matching) through consultation with occupational therapy, speech-language pathology, and social work 1

Monitoring and Follow-Up

• Track response using standardized measures that can be repeated over time to document changes from baseline 1
• Obtain collateral information from caregivers and multiple sources, as early recognition of mental health conditions in IDD requires input beyond patient self-report 6
• Reassess safety and support needs proactively, as manic episodes may require increased supervision and environmental modifications 1

Common Pitfalls to Avoid

• Do not assume behavioral symptoms are "just the IDD"—this diagnostic overshadowing delays appropriate psychiatric treatment 3, 6
• Do not overlook medical causes of behavioral change, particularly pain, which may be the primary driver in non-verbal or minimally verbal individuals 1
• Do not use antidepressants as monotherapy for bipolar disorder, as they may destabilize mood or precipitate mania; always combine with mood stabilizer if treating depressive symptoms 1
• Do not neglect trauma-informed care principles, given the elevated trauma exposure in this population 6, 4