Delirious Mania: Recognition and Successful Treatment with Donepezil in the Context of Historical and Contemporary Investigations of Delirium and Delirious Mania

Aims: Presentation of a case of severe delirious mania with resolution of delirium after treatment with
donepezil.
Presentation of Case: KA was a 44 y/o Australian female with a history of bipolar affective disorder
with psychotic manic episodes. Two weeks prior to her psychiatric admission she was admitted to a
medical ward after an overdose (OD) of acetaminophen. On review, it appeared that this OD may
have been the beginning of an unrecognized delirious mania. The patient was sent home and
returned 2 weeks later for a prolonged psychiatric admission with multiple medical comorbidities.
Psychiatric management and medical care were provided in intensive settings and despite adequate
treatment and improvement in mood symptoms, her delirium did not resolve. Immediately upon
institution of donepezil, her delirium resolved. After a period of stability, donepezil was stopped. Her
delirium returned and donepezil was reinstituted with resolution of normal cognitive function.
Discussion: The DSM 5 criteria for Delirium and some inherent difficulties using these criteria are
discussed. A review of the literature of delirious mania is presented which shows unresolved
controversies but an evolving recognition of this disorder. A Cochrane Review shows no benefit in the
use of acetylcholinesterases in the treatment of delirium. However, the multiple etiologies and
pathological processes involved in delirium may require unique and individual recognition and
management.
Conclusion: This case suggests that the use of donepezil is strongly recommended in the treatment
of delirious mania. Further study is required to clarify in this challenging disorder.