As with younger patients, the mainstays of acute treatment are neuroleptics and lithium, with anticonvulsants or ECT reserved for refractory cases. Some general points to consider are given below.

1. The greater inter-individual variability in drug metabolism makes predicting the therapeutic dose difficult. Rapid tranquillization with haloperidol 5 to 10 mg (often with 1-2 mg of lorazepam) can be used, but haloperidol has a long half-life and may lead to sudden immobility after a few days.

2. There is an increased risk of falls in the elderly when trying to balance the treatment of overactivity with sedating tranquillizers.

3. There is an increased risk of confusion and delirium if anticholinergic drugs are given to counteract side-effects.

4. Although lithium is seen as a 'kinder' treatment of milder mania, the risk of side-effects and toxicity is much increased in the elderly. (50)

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