Textbook Bipolar Disorder in Older Age Patients 1St Edition Susan W Lehmann Ebook All Chapter PDF

Bipolar Disorder in Older Age Patients
1st Edition Susan W. Lehmann

Visit to download the full and correct content document:
https://textbookfull.com/product/bipolar-disorder-in-older-age-patients-1st-edition-susa
n-w-lehmann/
More products digital (pdf, epub, mobi) instant
download maybe you interests ...
Acetabular Fractures in Older Patients Assessment and

Management Theodore T. Manson
https://textbookfull.com/product/acetabular-fractures-in-older-
patients-assessment-and-management-theodore-t-manson/
The Treatment of Bipolar Disorder : Integrative

Clinical Strategies and Future Directions 1st Edition
Andre F. Carvalho
https://textbookfull.com/product/the-treatment-of-bipolar-
disorder-integrative-clinical-strategies-and-future-
directions-1st-edition-andre-f-carvalho/
Urban Regeneration: A Manifesto for transforming UK

Cities in the Age of Climate Change Steffen Lehmann
https://textbookfull.com/product/urban-regeneration-a-manifesto-
for-transforming-uk-cities-in-the-age-of-climate-change-steffen-
lehmann/
Communication and Learning in an Age of Digital

Transformation 1st Edition Susan Mancino
https://textbookfull.com/product/communication-and-learning-in-
an-age-of-digital-transformation-1st-edition-susan-mancino/
Enlightenment in an Age of Destruction: Intellectuals,
World Disorder, and the Politics of Empire 1st Edition
Christopher Britt
https://textbookfull.com/product/enlightenment-in-an-age-of-
destruction-intellectuals-world-disorder-and-the-politics-of-
empire-1st-edition-christopher-britt/
Aeromedical Evacuation Management of Acute and

Stabilized Patients William W. Hurd
https://textbookfull.com/product/aeromedical-evacuation-
management-of-acute-and-stabilized-patients-william-w-hurd/
Destination China Angela Lehmann
https://textbookfull.com/product/destination-china-angela-
lehmann/
Fit at Any Age It s Never Too Late 1st Edition Susan

Niebergall
https://textbookfull.com/product/fit-at-any-age-it-s-never-too-
late-1st-edition-susan-niebergall/
Project business management 1 Edition Edition Lehmann
https://textbookfull.com/product/project-business-
management-1-edition-edition-lehmann/
Bipolar Disorder in
Older Age Patients
Susan W. Lehmann
Brent P. Forester
Editors
123
Bipolar Disorder in Older Age Patients
Susan W. Lehmann Brent P. Forester
•
Editors
Bipolar Disorder in Older

Age Patients
123
Editors
Susan W. Lehmann Brent P. Forester
Department of Psychiatry and Behavioral Division of Geriatric Psychiatry
Sciences, Division of Geriatric Psychiatry McLean Hospital
and Neuropsychiatry Belmont, MA
The Johns Hopkins University School USA
of Medicine
Baltimore, MD and
USA
Behavioral Health, Population Health
Management
Partners Healthcare
Boston, MA
USA
and
Harvard Medical School

Boston, MA
USA
ISBN 978-3-319-48910-0 ISBN 978-3-319-48912-4 (eBook)

DOI 10.1007/978-3-319-48912-4
Library of Congress Control Number: 2016955929
© Springer International Publishing AG 2017

This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part
of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations,
recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission
or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar
methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this
publication does not imply, even in the absence of a specific statement, that such names are exempt from
the relevant protective laws and regulations and therefore free for general use.
The publisher, the authors and the editors are safe to assume that the advice and information in this
book are believed to be true and accurate at the date of publication. Neither the publisher nor the
authors or the editors give a warranty, express or implied, with respect to the material contained herein or
for any errors or omissions that may have been made.
Printed on acid-free paper
This Springer imprint is published by Springer Nature

The registered company is Springer International Publishing AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
We dedicate this book to our patients and
their families who have inspired us and
taught us countless lessons about the impact
of bipolar disorder on their lives.
Susan W. Lehmann, MD
Brent P. Forester, MD, M.Sc.
Preface
Over sixty years ago, Sir Martin Roth described a case series of patients over the
age of 60 who were hospitalized for a psychiatric condition. He observed that
patients with mania, who constituted 6% of all individuals with affective disorder,
tended to have a worse outcome than other patients with depressive disorders and
were discharged less often [1]. Roth was the first to distinguish a different clinical
course and prognosis of elders with affective disorders compared to elders with
dementia or paranoid disorders.
During the past six decades since Roth first published his findings, older age
bipolar disorder has been relatively understudied compared with unipolar depres-
sion. Yet, older individuals with bipolar disorder continue to present clinical chal-
lenges. Over the next 20 years, the population of individuals over age 60 is expected
to increase dramatically, due to the combined effects of increase in life expectancy
and longevity as a result of advances in general health care, and the demographic
influx of the baby boomer generation into older age brackets. Along with the rapid
aging of the population are projections for significantly increased numbers of older
individuals with mental health needs, including bipolar disorder [2].
Bipolar disorder occurs in individuals across the lifespan, from childhood
through old age. At all ages, bipolar disorder can be difficult to diagnose and to
treat. While depressive disorders are frequently managed by non-psychiatric
healthcare clinicians, bipolar disorder—with its complexities of clinical presenta-
tion, comorbid substance use disorders, and varying affective states—often requires
the specific expertise of a psychiatrist. In older age, issues of diagnosis and clinical
management are compounded by the presence of comorbid medical disorders
commonly occurring with aging. Changes in physiology (especially renal, hepatic,
and cardiac function), concomitant medications, and concerns about cognitive
impairment further complicate clinical decision-making for the psychiatrist caring
for the older patient with bipolar disorder. Moreover, older age bipolar disorder
causes significant psychiatric and social morbidity, including high use of outpatient
and inpatient psychiatric resources [3]. Effective care of the older patient with
bipolar disorder must also include advanced knowledge about best practices
regarding optimum modes of psychotherapy, psychosocial support, and treatment
care settings.
vii
viii Preface
Fortunately, in recent years, there has been increased interest in understanding

the clinical features, biological underpinnings, and best approaches to management
for individuals with older age bipolar disorder. This book brings together experts in
older age bipolar disorder, presenting current knowledge in these areas and high-
lighting future research directions. The scope of the book is broad, encompassing
epidemiology, the clinical assessment and diagnosis of the older patient who may
have bipolar disorder, the neurobiology of older age bipolar disorder, and the
principles of clinical management. In addition, there are chapters on substance use
disorders and cognitive impairment in bipolar disorder. Other chapters focus on
lithium, neuromodulation, psychotherapy, complementary and alternative medicine
and its relevance for older age bipolar disorder, and a review of treatment care
settings. Each chapter includes at least one clinical patient “Vignette” with
“Learning Points,” which illustrates principles described in the chapter, and each
chapter concludes with a summary list of “Clinical Pearls” for the clinician.
This book is aimed for the general psychiatrist caring for older adults with
bipolar disorder. Throughout the book, we highlight aspects which are especially
unique or important to the care of the older patient with bipolar disorder. As our
co-authors frequently note, there still is much more to learn about older age bipolar
disorder. Additional research is needed to better understand the neurobiology of the
disorder, the relationship between older age bipolar disorder, cognitive impairment
and risk for major neurocognitive disorder, optimum pharmacotherapy, and best
practices for older patients with both bipolar disorder and substance use disorders.
Collaboration across research centers will be required to collect consistent neuro-
biological and clinical data that will lead to a better understanding of the trajectory
of bipolar disorder into older age and relevant neurobiological and psychosocial
markers to guide the development of more specific and effective interventions.
We have benefited greatly from the collaboration and support of wonderful
colleagues who are leaders in the field of old-age psychiatry and older age bipolar
disorder and who have contributed so generously of their expertise and time to this
book. We are especially indebted to the excellent editing guidance provided by
Elizabeth Corra from Springer. We believe that this book will help the general and
geriatric psychiatrist more effectively provide evidence-based and thoughtful psy-
chiatric care to improve the quality of life and daily functioning of older adults with
bipolar disorder.
Finally, we are indebted to our families. Brent thanks his wife, Kim, son Rylan,
and daughter Sasha, for their endless support, patience, and good humor. Susan
thanks her husband, Richard, for his unflagging support and encouragement, which
make all things possible.
Baltimore, MD, USA Susan W. Lehmann

Belmont, MA, USA; Boston, MA, USA Brent P. Forester
Preface ix
References
1. Roth M. The natural history of mental disorder in old age. J Ment Sci. 1955;101:281–91.
2. Bartels SJ, Naslund JA. The underside of the silver tsunami—older adults and mental health
care. NEJM. 2013;368:493–6.
3. Bartels SJ, Forester B, Miles KM, Joyce T. Mental health service use by elderly patients with
bipolar disorder and unipolar major depression. Am J Geriatr Psychiatry. 2000 Spring;8
(2):160–6.
Contents
1 Epidemiology of Older Age Bipolar Disorder . . . . . . . . . . . . . . . . . . 1

Nicole Leistikow and Susan W. Lehmann
2 Clinical Assessment of Older Adults with Bipolar Disorder . . . . . . . 21
Annemiek Dols, Peijun Chen, Rayan K. Al Jurdi
and Martha Sajatovic
3 Neurobiology of Older Age Bipolar Disorder . . . . . . . . . . . . . . . . . . 43
Eulogio Eclarinal and Olusola Ajilore
4 Clinical Management of Older Age Bipolar Disorder . . . . . . . . . . . . 57
Annemiek Dols, Megan Y.S. Chan and Kenneth Shulman
5 Older Age Bipolar Disorder and Substance Use . . . . . . . . . . . . . . . . 83
Chaya Bhuvaneswaran, Rita Hargrave and E. Sherwood Brown
6 Cognitive Impairment and Older Age Bipolar Disorder . . . . . . . . . 107
Sara Weisenbach and Danielle Carns
7 Lithium in Older Age Bipolar Disorder . . . . . . . . . . . . . . . . . . . . . . . 127
Soham Rej
8 Neuromodulation Therapies and Ketamine in Older
Age Bipolar Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
Adriana P. Hermida and Oliver M. Glass
9 Psychotherapy and Psychosocial Interventions, Family
Psychoeducation, and Support for Older Age Bipolar Disorder . . . 169
Dimitris N. Kiosses, Lindsey C. Wright and Robert C. Young
10 Complementary and Integrative Therapies for Older Age Bipolar
Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191
Maria Cristina Poscablo-Stein and Adriana P. Hermida
11 Treatment Settings for Older Age Bipolar Disorder: Inpatient,
Partial Hospitalization, Outpatient, Models of Integrated Care . . . . 213
Colin Depp and Rachel C. Edelman
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231
xi
Contributors
Olusola Ajilore Psychiatric Institute, University of Illinois at Chicago, Chicago,

IL, USA
Rayan K. Al Jurdi Department of Psychiatry and Behavioral Sciences, Baylon
College of Medicine, Houston, TX, USA
Chaya Bhuvaneswaran West Newton, MA, USA
Danielle Carns Adler School of Professional Psychology, Chicago, IL, USA
Megan Y.S. Chan Department of Psychological Medicine, Tan Tock Seng
Hospital, Singapore, Singapore
Peijun Chen Department of Psychiatry, Louis Stokes Cleveland VA Medical
Center, Cleveland, OH, USA
Colin Depp Department of Psychiatry, University of California at San Diego, La
Jolla, CA, USA
Annemiek Dols Department of Old Age Psychiatry, VU Medical Center,
GGZinGeest, Amsterdam, The Netherlands
Eulogio Eclarinal Ambulatory Clinic, Neuropsychiatric Institute, University of
Illinois at Chicago, Chicago, IL, USA
Rachel C. Edelman Department of Psychiatry, University of California at San
Diego, La Jolla, CA, USA; Santa Monica, CA, USA
Oliver M. Glass Department of Psychiatry and Behavioral Medicine, East Car-
olina University, Greenville, NC, USA
Rita Hargrave Oakland, CA, USA
Adriana P. Hermida Department of Psychiatry and Behavioral Sciences, Emory
University School of Medicine, Atlanta, GA, USA
Dimitris N. Kiosses Westchester Division, Department of Psychiatry, New York
Presbyterian Hospital-Weill Cornell Medicine, White Plains, NY, USA
xiii
xiv Contributors
Susan W. Lehmann Department of Psychiatry and Behavioral Sciences, Johns

Hopkins University School of Medicine, Baltimore, MD, USA
Nicole Leistikow Department of Psychiatry and Behavioral Sciences, Johns
Hopkins University School of Medicine, Baltimore, MD, USA
Maria Cristina Poscablo-Stein Department of Psychiatry and Behavioral Sci-
ences, Emory University School of Medicine, Atlanta, GA, USA
Soham Rej Division of Geriatric Psychiatry, Department of Psychiatry, Institute
for Community and Family Psychiatry, Jewish General Hospital, Montreal, QC,
Canada
Martha Sajatovic Department of Psychiatry, School of Medicine, Case Western
Reserve University, Cleveland, OH, USA
E. Sherwood Brown Department of Psychiatry, The University of Texas South-
western Medical Center, Dallas, TX, USA
Kenneth Shulman Department of Psychiatry, Sunnybrook Health Sciences Cen-
tre, Toronto, ON, Canada
Sara Weisenbach Department of Psychiatry, University of Utah School of
Medicine, Salt Lake City, UT, USA
Lindsey C. Wright New York, NY, USA
Robert C. Young Westchester Division, Department of Psychiatry, New York
Presbyterian Hospital-Weill Cornell Medicine, White Plains, NY, USA
Epidemiology of Older Age Bipolar
Disorder 1
Nicole Leistikow and Susan W. Lehmann
1.1 Introduction
Worldwide population reports project significant increases in the population of

older adults over the next 40 years [1]. Greater numbers of older adults and their
longer life expectancy due to healthcare advances will result in greater numbers of
older adults living with bipolar disorder. Older adults with bipolar disorder (OABD)
utilize more healthcare services than similar-aged healthy peers, yet remain less
well-studied than younger age groups [2–4]. Consequently, the identification of and
care for elders with bipolar disorder represent a growing public health need [5],
giving greater urgency to understanding the prevalence, clinical presentation, and
course of OABD.
1.2 Definition
Researchers have defined OABD in different ways, contributing to methodological

complexity. While there is no clear consensus regarding when “older age” begins,
most studies have defined OABD as starting between age 50 and 60 [1, 4, 6–8].
However, it is important to recognize that older adults with OABD may comprise 3
or even 4 distinct groups of individuals: (1) persons living longer with bipolar
N. Leistikow (&) S.W. Lehmann

Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School
of Medicine, 600 North Wolfe Street, Meyer 4-181, Baltimore, MD 21287, USA
e-mail: leistikow@jhmi.edu
S.W. Lehmann
e-mail: slehman@jhmi.edu
© Springer International Publishing AG 2017 1

S.W. Lehmann and B.P. Forester (eds.), Bipolar Disorder in Older Age Patients,
DOI 10.1007/978-3-319-48912-4_1
2 N. Leistikow and S.W. Lehmann
Table 1.1 Defining older age bipolar disorder

An Early-onset bipolar disorder = Older age
adult >age Early-onset depressive disorder with new-onset mania bipolar
50 with disorder
New-onset mania in individual with no prior mood
illness (in the absence of a specific medical trigger, but
may be associated with brain injury, silent stroke or
cerebrovascular risk factors)
Secondary mania (temporally and directly linked to a
specific medical trigger) followed by symptoms
consistent with bipolar disorder
disorder that began in the first half of their life, (2) those with a preexisting
depressive disorder that started early in adulthood and converts to bipolar disorder
in later life, (3) those without previous episodes of depressive illness who present
with new-onset mania in later life, and (4) those individuals with “secondary
mania” who acquire bipolar disorder, or a psychiatric condition appearing similar to
bipolar disorder, as a direct result of other medical causes (Table 1.1). The defi-
nitions of early- versus late-onset and secondary bipolar illnesses will be discussed
below in the next section.
1.3 Limitations
One of the major challenges in studying bipolar disorder in older age is that it is less
common in older than in younger individuals. An important limitation to the
majority of studies to date is small sample size. The largest research samples of
individuals with bipolar disorder have had populations in the low thousands [9, 10],
with the majority of studies looking at sample sizes in the low hundreds or less [5].
Because searching within inpatient populations is a convenient way to locate sub-
jects with a relatively rare disorder, the majority of studies on late-life bipolar illness
focus on this group. However, this approach skews samples toward those individuals
with more severe illness, and thus, findings may not be relevant for individuals with
milder symptoms and those who require only outpatient care [5, 11]. Additionally,
there is a lack of longitudinal studies in this area, resulting in a paucity of information
about the long-term course of older age bipolar disorder. Further, retrospective
collection of historical details, such as an individual’s age of onset and clinical
presentation, is subject to recall bias or error. Lack of prospective data may also
contribute to a selection bias of individuals who survive into later life.
In general, the studies we cite are from US samples unless indicated. Different
countries have varying demographic proportions between old and young, different
medical and mental health systems in place, and different social services available
which may affect age of onset proportions and prevalence rates in inpatient versus
outpatient populations as well as health services utilization.
1 Epidemiology of Older Age Bipolar Disorder 3
1.4 Prevalence in the Community
Overall, the prevalence rates of individuals living in the community with bipolar
illness decrease with age [1, 12, 13]. Whereas bipolar disorder is present in 1.4 % of
individuals aged 18–44, prevalence rates decrease to 0.1–0.5 % in people aged 65 and
older [11, 14]. When individuals with both bipolar type 1 and bipolar type 2 disorders
are considered, prevalence of OABD has been reported to be 1 % of individuals over
the age of 60 [15]. It remains unclear whether this is a historic effect, related to
diagnosis and identification of older patients, a cohort effect related to a lower level of
disease among adults born earlier, a result of increased mortality among individuals
with early-onset bipolar disorder (EOBD), or a combination of factors [16].
1.5 Prevalence in Treatment Settings
However, in contradistinction to low prevalence rates among older people living

independently in the community, late-life bipolar disorder is more common in
treatment settings. Since the landmark Epidemiologic Catchment Area study
(ECA) in the 1980s, which found bipolar illness in 9.7 % of chronically institu-
tionalized adults in prisons or nursing homes, researchers have recognized that the
illness is overrepresented in care settings, and this discrepancy increases as people
age [14, 17, 18]. For instance, a recent survey of 2600 New York City senior living
facility residents found a bipolar disorder prevalence rate of 7.8 % [19]. In addition,
a large study of all veterans in a national database found that fully one-quarter of
those receiving either outpatient or inpatient treatment through the Veterans
Administration for a bipolar diagnosis were aged 60 or older [20].
On inpatient psychiatric units, there seems to be relatively equal rates of younger
and older adults with bipolar illness, close to 10 % for each, despite the declining
prevalence of bipolar disorder in older age [5, 12, 15]. An early study of patients
with late-onset bipolar disorder (LOBD) found that they accounted for 9.3 % of
geriatric affective disorder admissions over a 2-year period [21]. One recent review
article calculated the prevalence of mania in adults over the age of 50 who were
being treated in a hospital for any mental illness to be 6.0 %, with one-third of those
having first-time late-onset mania [11]. Rates of bipolar illness among those pre-
senting to psychiatric emergency rooms are higher than in inpatient settings.
A study of 2419 adult visitors to a Seattle psychiatric crisis unit found that 14 % of
these patients had bipolar disorder [22]. Another study that focused on psychiatric
emergency department visitors older than age 60 found that 17 % had bipolar
disorder [23].
Therefore, although the prevalence of bipolar disorder decreases with advancing
age, individuals with OABD represent a sizable proportion of the bipolar commu-
nity, with a need for acute psychiatric services as well as day hospital treatment and
case management that is equal to or greater than their younger cohort [2, 5, 13, 20].
1.6 Age of Onset
The clinical heterogeneity of older individuals with bipolar disorder is an ongoing

area of research. As a group, older adults with bipolar illness share qualities of
aging, including greater medical comorbidity, increased risk for polypharmacy, and
physiologic reduction in renal function. However, research over many years has
identified two distinct types of bipolar disorder among older adults, each with
varying courses: EOBD and LOBD.
When this phenomenon was initially observed, there was interest in distin-
guishing between these two groups. However, it has been challenging to assemble
large sample populations, and most studies have had modest numbers and incon-
sistent findings, making conclusions hard to draw. Some trends have been observed
but with uncertain clinical significance. Over the past decade, researchers have
placed less emphasis on distinguishing between early- and late-onset illnesses. It
remains to be seen whether larger studies may reveal important clinical distinctions
between these two groups. However, generalizing about the nature of bipolar dis-
order in later life, without taking into account these possible subtypes, runs the risk
of conflating age-related versus disease-specific effects.
1.6.1 Bimodal Distribution
Defining the age at onset of bipolar disorder has posed significant challenges for
researchers and there continues to be no clear consensus about how this should be
done. Does one use the age at first mental health contact, the age at first psychiatric
hospitalization, or the first time the patient experienced significant mood symptoms
causing impairment in functioning? Does onset of bipolar disorder begin at the first
depression or the first mania? If manias present first, the task of determining age of
onset is relatively straightforward. However, for as many as 25 % of individuals
who eventually meet DSM 5 diagnostic criteria for bipolar disorder, the first psy-
chiatric treatment or hospitalization for any mood disorder will be for major
depression, sometimes years to decades prior to the emergence of mania, delaying a
correct diagnosis [7, 13, 24–27].
Despite these challenges, multiple studies of bipolar disorder have found a
bimodal distribution of age of onset, with two major groups: a larger group
experiencing onset of manic symptoms before age 30 and a smaller group with
onset after age 40 [1, 7, 10, 24, 25, 28–32]. Some studies have defined an additional
group with early onset in childhood or adolescence [33–36]. For the most part, two
groups of individuals have been described: those with early-onset and late-onset
disease.
1.6.2 Cutpoints and Proportionality of Early- Versus

Late-Onset Bipolar Disorder in the Treatment
Population
It is important to recognize that although an estimated 90 % of patients who will

develop bipolar illness over their life span are diagnosed by the age of 50, first
mental health contact occurs after age 60 for a significant minority of 8–9 % [24,
25, 28]. Although the findings are not unequivocal, research suggests that those
who experience bipolar disease onset later in life may have different demographic
profiles, risk factors, clinical presentation, and disease course. Future research may
delineate whether they have distinct etiologies.
Various studies not only differ in the definition of “age of onset” for their
subject population, but also use different cutpoints to distinguish early- and
late-onset groups, challenging comparisons across studies. Researchers have uti-
lized different approaches to determine which age cutpoint to use. Some studies
have attempted to calculate a mathematically likely age dividing line based on the
statistical distribution of their sample, while other studies have used arbitrary or
convenience cutpoints. Using a cutpoint at age 40, one study found the proportion
of early- and late-onset bipolar patients in a community sample in England to be 78
and 22 %, respectively [25]. Using a cutpoint at age 50, a study looking at both
inpatients and outpatients diagnosed with bipolar I disorder, found that of those
over 60, about one-third had experienced late onset of their illness [37]. Using a
later cutpoint at age 60, a large Veterans Administration study of both inpatients
and outpatients found that at least 9 % of individuals over 60 with bipolar disorder
had just been diagnosed with that disorder in the prior year [20]. Using a lower
cutpoint at age 45, a small study of inpatients hospitalized with mania found the
proportion of patients with late versus early onset to be roughly equal [7]. Using a
cutpoint at age 47 based on first psychiatric hospitalization, a midsize retrospective
study of inpatients with bipolar disorder found that only 6.3 % had LOBD [29].
There remains a wide variation in the proportion of OABD that current studies
ascribe to early- versus late-onset disease. The International Society for Bipolar
Disorders Task Force on Older Age Bipolar Disorder noted that while age 50 may
be a reasonable cutpoint to distinguish EOBD from LOBD, this is an area requiring
further study, and a lower cutpoint of age 40 may be warranted if supported by
future research [1].
1.7 Demographic Distinctions
Individuals who present with bipolar illness at a later age tend to be skewed
demographically in three ways. One distinction is that while male to female gender
ratios are fairly even among younger adults with EOBD, women predominate in
many late-onset bipolar samples [9, 21, 25, 27, 35, 38]. It remains unclear whether
this indicates a survival cohort, a bias in users of medical services, or a correlation
between female gender and vulnerability to late-onset disease. A large study of both
inpatients and outpatients in Denmark saw no statistically significant gender dif-
ference among older patients with bipolar disorder [10], similar to results from an
inpatient study in Scotland that took population gender rates into account [39] and a
small study of outpatients in England [30]. One finding that has been consistent
across studies is that individuals presenting with bipolar illness later in life are
less likely than early-onset patients to have a family history of bipolar illness
[21, 24–26, 31], raising the question of alternative pathways to disease.
Finally, bipolar illness impacts close relationships [40]. Two studies found that
those with later onset of illness were more likely to be married or living with
someone in their older age than those with earlier onset of disease [32, 35]. One of
the few prospective examinations of age of onset in bipolar illness found that 52 %
of those who first became ill after age 30 were married at the time of the study
compared to 27 % of those who experienced illness before age 21 and 40 % of
those first ill before age 30 [33]. Another small study found that those with later
onset reported more social support and perceived their social support to be more
adequate compared with those who had earlier onset of bipolar disease [26]. These
results suggest that social support may be a casualty of the disease striking before or
during the age when people often find and consolidate partnerships and also has
ramifications for prognosis and service utilization as patients age.
1.8 Heterogeneous Etiologies—Including Cerebrovascular

Risk Factors and Secondary Mania
The bimodal distribution of age of onset, demographic differences, and possible

distinctions in natural course of disease all beg the question, “Could LOBD be
secondary to or exacerbated by cerebrovascular disease or any other focal neuro-
biological insult?” There seems to be clear evidence that cerebrovascular disease is
frequently associated with LOBD, but not through one definitive pathway, and little
characterization of predisposing factors. Furthermore, there is evidence for both
new-onset mania in the setting of cerebrovascular risk and secondary mania trig-
gered by a proximate medical cause.
The hypothesis that cerebrovascular insult may initiate onset of bipolar disorder
later in life comes from rare observations of new-onset mania following brain
injury. Mania-inducing strokes represent <1 % of all strokes but seem to pre-
dominate in the right frontal or temporal region [41–45]. There are no prospective
studies following these patients over the long term; what evidence there is suggests
that a proportion have resolution of their manic symptoms after one episode of
mania and others go on to have bipolar disorder with recurring episodes of mood
disturbance [44].
In addition to strokes causing mania, there is a growing literature suggesting a

role for silent cerebral infarctions in late-onset bipolar illness. These are brain
lesions seen on imaging but not known to be linked temporally to symptoms. An
early small study found that 65 % of patients with LOBD had silent brain infarcts
compared to 25 % of patients with early onset of either depression or bipolar
disorder [46]. A more recent small study found that 92 % of patients with LOBD
(compared to 53 % of those with EOBD) had visible brain infarctions on imaging,
the majority of which, 62 %, were silent [47]. A small study of patients with their
first episode of mania after age 65 found that 71 % had a comorbid neurologic
disorder, twice as many compared to their age cohort with earlier onset bipolar
illness [48].
More broadly, the link between LOBD and general cerebrovascular risk has been
examined by many studies, with inconclusive results. An early study found that
elderly patients with bipolar illness had significantly more cortical atrophy and
poorer scores on cognitive tests than age-matched controls but did not find dif-
ferences between those with early- versus late-onset illness [24]. However, a later
study found that those with LOBD had significantly more cerebrovascular abnor-
malities [32]. Another small study that rigorously matched late-onset and
early-onset patients by race, sex, and age found that the late-onset group had
significantly more vascular risk factors and disease than those who were their same
age but had disease onset earlier in life [29]. A small study in England found that
among an older group of outpatients, those whose bipolar disorder occurred later
had a significantly higher stroke risk compared to those who had earlier onset [30].
A large prospective Danish registry study of more than 200,000 patients found that
having dementia, a disease of diverse etiologies but always related to structural
brain disease, significantly increased the risk of developing mania or bipolar dis-
order [49].
In fact, the relationship between brain ischemia and bipolar illness may be more
complex. Cerebrovascular disease may be a cause of LOBD, but early-onset bipolar
illness itself, or its treatment, may predispose to conditions causing strokes such as
inflammation, metabolic derangements, and obesity. The small study mentioned
above found a higher incidence of silent cerebral infarcts in individuals with
late-onset bipolar illness. This study also demonstrated that 47 % of patients in their
60s with early-onset bipolar illness had silent infarcts on brain imaging compared to
20 % of healthy people the same age [47], suggesting ischemia as both a trigger for
and a consequence of bipolar illness.
The hypothesis that vascular injury to the brain may contribute to the onset of
bipolar illness in a subset of individuals is particularly intriguing because it suggests
that screening for and treating vascular risk factors could potentially delay or
prevent onset of mania, and is an important question for future research. In addition,
the increased risk for vascular disease in those with EOBD needs to be factored into
treatment.
In addition to the possibility that symptomatic or silent cerebrovascular injury
can cause new-onset mania in later life, the phenomenon of mania secondary to
medication, somatic illness, delirium, or dementia is well established (Fig. 1.1) [11,
Fig. 1.1 Possible causes of late-life mania
50, 51]. In some cases, when the offending agent or illness is removed or suc-
cessfully treated, mania resolves and does not recur. However, other patients may
recover from the inciting factor but go on to develop repeating patterns of mania
and depression best characterized as bipolar disorder, that we may think of as
having been unmasked or triggered by the event. Others still may have chronic
illnesses which cause a manic-like syndrome best thought of as a mood disorder
secondary to a medical condition. Medications implicated are numerous and include
corticosteroids, isoniazid, dopaminergic agents, and antidepressants [50]. Drugs of
abuse including alcohol, cocaine, stimulants, and hallucinogens can also incite
mania [52]. Illnesses-causing mania are likewise numerous and include Cushing’s
disease, influenza, HIV, neurosyphilis, multiple sclerosis, hyperthyroidism, brain
tumors, and seizure disorders among others [52]. Delirium is an acute state of
global confusion that can present with manic symptoms but should be resolved
before diagnosis of ongoing mania is made. Dementias, especially frontal-temporal
dementia, can present with manic-like syndromes and have cerebrovascular injury
as an overlapping risk factor (Fig. 1.1).
Clinical Vignette 1.1

Ms. S is a 70-year-old married African American woman who was diagnosed
with bipolar disorder in her 60s after experiencing a steroid-induced
psychosis.
Her family history was notable for dementia in her mother. Her personal
history was notable for an unremarkable birth and development; she suc-
cessfully completed college and worked as a nurse until retirement in her 50s,
and was married with one child. Her medical history was significant for giant
cell arteritis requiring treatment with steroids.
Her psychiatric history was notable for the absence of mental illness until
her 60s, when Ms. S was brought to the emergency department by her
husband for talking fast and not making sense. A psychiatric consult attrib-
uted her abnormal behavior to high-dose prednisone she was taking at the
time. This was tapered off and she returned to baseline. Six years later, she
began having increased energy, with problems falling asleep, and increased
cleaning at night while again on steroid medication. She was hospitalized on a
medical service, diagnosed with steroid-induced psychosis, treated with
low-dose neuroleptic medication, and discharged on a lower dose of steroids.
Two months later, Ms. S presented with her first episode of depression
marked by low mood, low appetite with weight loss, low energy, sadness,
loss of confidence, isolation, and poor concentration. She was diagnosed with
major depression and started on nortriptyline and after two months had res-
olution of depression but then began to experience decreased sleep and
increased energy. Lithium was added to her regimen and her diagnosis was
changed to bipolar disorder. Eventually, nortriptyline was tapered and dis-
continued and her mood remained stable on lithium alone for years with no
further episodes of mania or depression.
Learning Points
• Steroids are an example of a medication that can trigger manic episodes
which respond to antipsychotic treatment.
• Some patients will go on to develop recurrent mood episodes which may
be managed with usual treatments for bipolar disorder such as mood
stabilizers.
1.9 Bipolar 1 Disorder Versus Bipolar 2 Disorder
The majority of studies of OABD do not distinguish between bipolar 1 and bipolar
2 disorders, and the use of mania as a convenient defining feature of bipolar
disorder naturally skews samples toward those with bipolar 1 disease. Bipolar
spectrum disorders are a relatively recent area of interest post-dating many studies
and will not be discussed here.
There have been relatively few studies looking specifically at older age or
late-onset bipolar 2 disorder. One study of 525 outpatients in Italy noted a statis-
tically significant reduced prevalence of late-life (defined as age 50) bipolar 2
disorder similar to the reduced prevalence of bipolar 1 disorder found elsewhere [6].
An additional observation was that features of atypical depression (defined in
DSM-IV as hypersomnia, increased appetite or weight gain, leaden paralysis, and
rejection sensitivity), which were seen more frequently in younger patients with
bipolar 2 illness, seemed to diminish as patients aged.
1.10 Natural History and Course of Illness
1.10.1 Initial Presentation
As previously discussed, mania, the hallmark of bipolar illness, can occur for the
first time at any age, with elders in their 90s experiencing new-onset mania [39, 53–
55]. When the first manic episode arises in the context of a lifetime of unipolar
depression, the clinical diagnosis is changed to bipolar illness. However, there is
disagreement about whether to define bipolar disorder onset as occurring at the time
of first depression, decades prior, or whether to consider the later onset of mania as
initiating bipolar disorder, representing a change or evolution in illness course.
There may be important differences in the way older and younger patients first
present with mania. An older study that defined late-onset bipolar illness as
occurring after age 40 found the late-onset group to present less acutely, with less
violence, irritability, and psychosis, but with more visual, olfactory, and somatic
hallucinations [25]. A population-wide Danish study of 1719 inpatients and out-
patients found that of those diagnosed with bipolar disorder by the end of their first
hospital admission, those with late-onset bipolar illness (defined as beginning after
age 50) presented with more psychosis related to depressions and less psychosis
related to manias when compared to other inpatients with early onset disease [10].
However, these are relative differences between those with EOBD and LOBD
and should not give the impression that those with LOBD do not frequently present
with manias or that these manias do not feature psychotic symptoms. Notably, the
same study, one of the few looking at a large group of older outpatients, found no
differences in initial presentation for outpatients with late-onset compared with
early-onset bipolar illness, suggesting that differences between the two groups may
be less prominent among individuals with milder disease.

Mr. J is a 74-year-old Caucasian widowed man who presented with his first
episode of mania at the age of 73.
His family history was notable only for later life dementia in his mother. He
had an unremarkable birth and development, did well in school, graduated from
college, and had a career as a college professor with a successful marriage and
two children. Mr. J had no history of substance abuse and his medical history was
notable only for hypertension. When he was in his late 60s, his wife died sud-
denly of an aneurysm and he started seeing a counselor for difficulty coping with
this loss. He was started on citalopram after a one-time visit with a psychiatrist
and was then continued on this medication subsequently by his primary care
physician. His intense feelings of sadness were not accompanied by changes in
sleep, appetite, concentration, or self-attitude, and his depressed mood remitted
after 1 year. He continued to take citalopram over the next five years.
Five years later, Mr. J experienced a number of difficult events over the
course of several months: His brother died, his daughter-in-law was diagnosed
with cancer, and he himself had a knee surgery with slow recovery. He began
having trouble sleeping with increased energy, late-night reading, and began
sending 3 a.m. emails to family members. His primary care doctor continued
citalopram and started trazodone to help with sleep. The patient felt
over-caffeinated and stimulated. He had an elevated self-attitude, became more
talkative than normal, and began having conversations out loud when others
were not present. Normally frugal, he started purchasing expensive items for
himself and began considering investing in new business propositions.
Mr. J was diagnosed with bipolar 1 disorder. Citalopram and trazodone
were stopped, and he was treated with lithium and olanzapine during an
outpatient partial hospitalization. Over the course of a month, he became less
pressured in speech, began sleeping 7–8 hours regularly, and was able to curb
his spending. He experienced increased fatigue for which his olanzapine was
decreased and he was discharged to outpatient care. He remains on medi-
cations and has had no further episodes of either depression or hypomania.
Learning Points
• Bipolar illness should be considered in elders of any age presenting with
manic or hypomanic behavior even in the absence of prior mental illness.
• Antidepressants may contribute to flares of bipolar illness even years after
their initiation.
1.10.2 Natural Course
It is clear that for many individuals with bipolar disorder, “the illness does not ‘burn
out’ or attenuate over time” [2, 7]. Even among outpatient samples, which tend to
have individuals with less severe illness, up to 5 % per year of older patients with
diagnosed bipolar illness flare into mania or hypomania [11].
One recent large study of 2257 outpatients with bipolar I disorder that compared
patients younger and older than 60 found no statistically significant difference in
acute symptoms of depression or elevated mood, beyond younger people having
more distractibility [8]. However, this study did not categorize patients by the age
of bipolar disease onset and focused on outpatients with insurance, who may have
been a healthier cohort. A recent midsize study of almost 600 outpatients found that
those individuals over 65 years of age with bipolar 1 or 2 disorder had more
depressive and catatonic episodes than hypomanic/manic episodes compared with
their younger counterparts [56].
In general, in older age, bipolar disorder is likely to feature more frequent
episodes of illness and decreasing time spent at baseline [12, 40]. One small
prospective study found that older patients had a more “fragile recovery” with a
significantly greater proportion who had been hospitalized for mania relapsing into
depression prior to discharge [24].
The European Mania in Bipolar Longitudinal Evaluation of Medication

(EMBLEM) study, one of the few large prospective studies comparing both older
and younger adults being treated for mania, found that adults over 60 were less
likely to present with psychosis, were more likely to have experienced rapid cycling
of a least 4 episodes in the last year, and were more likely to have been treated with
antidepressants [38]. The same study found that by 3 months after an acute mania,
late-onset patients, while having equally severe mania scores at the outset (though
less severe than younger patients), recovered faster and were discharged more
frequently than early-onset older patients. After 2 years of psychiatric follow-up,
significantly more older patients had recurrence of illness than younger patients and
recurred in fewer days [37]. Older patients who had early onset of their illness fared
the worst: Compared with younger patients, fewer recovered and of those that did,
more relapsed into illness [37]. An earlier study found that, similar to younger
populations, medication non-adherence remains a common trigger of relapse or
rehospitalization for this older age group [7].
Frequent recurrence of illness with briefer remissions may partly explain the
greater healthcare use among older adults with bipolar illness. One study comparing
patients over the age of 60 with either unipolar or bipolar depression found that
those with bipolar illness used almost 4 times the total amount of mental health
services and were three times more likely to have been hospitalized in the 6 months
prior to the study than those with unipolar depression [2]. Additionally, although
the mechanisms remain unclear, some research suggests that bipolar disorder is a
neuroprogressive disease, in which episodes of illness leave a lasting legacy on the
brain, contributing to medical comorbidities, cognitive and functional decline, and
poor response to treatment [1, 3].

Ms. M is a 69-year-old divorced Caucasian woman who was diagnosed with
bipolar 1 disorder in her mid-30s, who with advancing age has become
increasingly challenging to effectively treat, with longer periods of illness
duration and only brief periods of illness remission.
Her family history was notable for bipolar disorder and dementia in her
father and bipolar disorder in a half-sister. Ms. M had an uneventful birth and
development, graduated high school, worked in clerical jobs, later was on
disability for her bipolar disorder, was married and divorced 2 times, and had
4 adult children, one with whom she lived. She had no history of alcohol or
illicit substance abuse but was a lifelong cigarette smoker. Her medical his-
tory was notable for high blood pressure, diabetes type II, and osteoarthritis.
After her diagnosis with bipolar 1 disorder in her late 30s, she had numerous
hospitalizations for manic episodes marked by increased energy, paranoia,
delusional thinking, and aggressive behavior toward family members alter-
nating with hospitalizations for severe depressive episodes. Lithium was a
mainstay of her psychiatric treatment along with antipsychotic or antide-
pressant medications during episodes of illness.
When younger, Ms. M returned to her baseline with independent func-

tioning after each mood episode. In her 60s, she experienced more functional
and cognitive decline with longer psychiatric hospitalizations when ill. In
addition, she required more day-to-day supervision from family members
when at home, and also started attending an adult day care.
Ms. M presented for acute psychiatric care after vigorous paranoid com-
plaints about her day care facility and her family, accusing them of
mistreating her and stealing her money. She was guarded, fearful, and felt
guilty and was experiencing auditory hallucinations of dead relatives. She
was thought initially to be in a mixed state and started on olanzapine, but later
switched to risperidone due to drug-induced Parkinsonism. Her standing
treatment with lithium was temporarily discontinued due to concerns that a
high serum level had caused ataxia and confusion. Over the course of a
4-month hospitalization, she developed catatonia with minimal verbal
responses, thought due to depression. Sertraline was added to her regimen.
After several weeks, Ms. M became more active and engaged but then
became agitated with reduced sleep and aggressive behavior toward staff with
paranoid accusations and yelling and was diagnosed with mania. Sertraline
was stopped and lithium was restarted along with multiple trials of different
antipsychotic medications, including aripiprazole and ziprasidone. Valproic
acid had previously resulted in neutropenia and, therefore, was not a thera-
peutic option during this hospitalization. Her family, already under significant
stress unrelated to the patient, was not able to support the frequent blood
draws and other measures necessary for a clozapine trial at the time.
After several months, her mood and sleep normalized and she was suc-
cessfully discharged home, with scheduled outpatient follow-up, under the
care of her family on a medication regimen of lithium, quetiapine, and
low-dose haloperidol. Ms. M relapsed, however, within 12 months and
returned to the emergency room due to severe paranoid delusions.
Learning Points
• With advancing age, bipolar illness can present with fewer periods of
euthymia as well as functional decline.
• Older adults are more likely to experience adverse effects of medication
and doses should be titrated cautiously.
1.10.3 Increased Morbidity and Mortality
Bipolar disorder in older age significantly increases the risk of functional decline.
One study of community-dwelling adults over the age of 45 found that those with
bipolar disorder had health care-related quality-of-life scores similar to or worse
than individuals with schizophrenia, and greater medical comorbidity and preva-
lence of alcohol use disorder than control subjects with similar education and
occupational achievements [57]. Although younger adults with bipolar disorder
have a relatively better overall prognosis than those with schizophrenia, bipolar
disorder in advancing age is associated with increasing functional impairment,
attenuating these earlier distinctions.
A large study of more than 54,000 patients hospitalized for depression or bipolar
disorder in Sweden compared mortality rates and causes of death with the general
population and found that those with bipolar disorder had more deaths than
expected or “excess mortality” even over those with unipolar depression, with
standardized mortality ratios of 2.5 in men and 2.7 in women for all causes [58].
Notably, compared to individuals with unipolar depression, those with bipolar
disorder had more deaths from natural causes and less from suicide, suggesting that
either bipolar disorder, the behaviors associated with it, or its treatment shortens life
span [58]. This premature mortality may partly account for the decreased preva-
lence of bipolar disorder in later life and samples of older adults with early-onset
bipolar disorder may be considered a survivor cohort [1].
Other studies have shown similarly increased mortality likely due to bipolar
illness [16, 59]. A 26-year follow-up analysis of the original five-center Epidemi-
ologic Catchment Area (ECA) study found that those with any bipolar spectrum
illness had 1.42 greater odds of having died in the follow-up period when compared
to those with no bipolar illness after adjusting for age [60]. The association between
bipolar illness and increased mortality remained statistically significant even after
adjusting for increased depressive episodes and drug and alcohol abuse in the group
with bipolar illness. However, when stratified by age and adjusted for drug and
alcohol abuse, the association for those age 30–44 rose above the threshold for
statistical significance, suggesting that if drug and alcohol use can be reduced or
prevented in this younger population, some excess mortality may decline.
1.10.4 Medical Comorbidity
In later life, comorbid medical conditions are common in older adults with bipolar
disorder, including an increased prevalence of hypertension, diabetes, cardiac dis-
ease, and dementia [3]. Despite a similar degree of medical comorbidity, including
cardiovascular disease, those with bipolar illness, compared with unipolar major
depression, have a greater prevalence of endocrine and metabolic disorders,
specifically, hypothyroidism, diabetes, and obesity [61]. It remains unclear how
much of this difference can be attributed to use of medications, such as lithium and
antipsychotics, versus the contribution of factors related to bipolar illness itself.
1.10.5 Psychiatric Comorbidity
Results from the five-center ECA study found that individuals of any age with
bipolar I disorder have a substantially higher risk of drug and alcohol use—with a
substance abuse prevalence rate of 61 % and a lifetime prevalence of drug and

alcohol dependence double that of those with major depression [62]. Another
community sample demonstrated that those living with bipolar disorder in later life
continue to report more alcohol use disorder, dysthymia, generalized anxiety dis-
order, and panic disorder than their age cohort without bipolar disorder. Although
screening elders for psychiatric and substance use disorder comorbidity is recom-
mended, the prevalence of lifetime and 12-month alcohol use disorder, dysthymia,
and panic disorder in this group was less than in those under 65 with bipolar
disorder [63]. One study that divided age of onset into three groups found that those
who developed bipolar disorder before age 21 showed a greater prevalence of drug
use disorders than those with later onset disease [33].
1.11 Summary
Although the prevalence of bipolar illness decreases with age, the need for mental
health services among elderly patients with bipolar illness rises. Older patients may
have more frequent recurrences of depressions and hypomanias or manias with
briefer remissions when compared to younger patients. They also have dispropor-
tionately high rates of healthcare utilization when compared to older patients with
unipolar depression. Clinical management of older age bipolar disorder will be
discussed in Chap. 4, but is frequently complicated by medical comorbidity, psy-
chiatric comorbidity, functional and cognitive decline, loss of social supports, and
age-related physiologic changes in renal and liver function affecting drug phar-
macokinetics and pharmacodynamics. Research has identified EOBD and LOBD as
groups with likely different etiologies of bipolar disorder, but the significance for
prognosis and treatment remains unclear. Perhaps to a degree greater than for any
other mood disorder, the clinical complexity of OABD requires thoughtful and
consistent psychiatric care.
Clinical Pearls
• The numbers of older adults with bipolar disorder are expected to increase
in the future.
• While prevalence rates of older age bipolar disorder are low in community
samples, older adults with bipolar disorder are frequently seen in clinical
treatment settings and have high rates of psychiatric service utilization.
• OABD represents a heterogeneous group of individuals and includes
adults with EOBD and LOBD, who may differ in terms of clinical course
as well as illness pathogenesis.
• Individuals with late-onset bipolar illness are more likely to be women,
less likely to have a family history of bipolar disorder, and more likely to
have cerebrovascular risk factors or disease.
• Bipolar disorder does not “burn out” with advancing age. Rather, older
adults with bipolar disorder may experience more frequent periods of
illness with less time spent euthymic and at baseline levels of functioning.
• Individuals with OABD frequently have medical and psychiatric comor-
bidities which complicate treatment.
References
1. Sajatovic M, Strejilevich SA, Gildengers AG, Dols A, Al Jurdi RK, Forester BP, et al.
A report on older-age bipolar disorder from the International Society for Bipolar Disorders
Task Force. Bipolar Disord. 2015;17(7):689–704.
2. Bartels SJ, Forester B, Miles KM, Joyce T. Mental health service use by elderly patients with
bipolar disorder and unipolar major depression. Am J Geriatr Psychiatry. 2000;8(2):160–6.
3. Sajatovic M, Forester BP, Gildengers A, Mulsant BH. Aging changes and medical complexity
in late-life bipolar disorder: emerging research findings that may help advance care.
Neuropsychiatry (London). 2013;3(6):621–33.
4. Forester BP, Ajilore O, Spino C, Lehmann SW. Clinical characteristics of patients with late
life bipolar disorder in the community: data from the NNDC registry. Am J Geriatr
Psychiatry. 2015;23(9):977–84.
5. Depp CA, Jeste DV. Bipolar disorder in older adults: a critical review. Bipolar Disord. 2004;6
(5):343–67.
6. Benazzi F. Bipolar II depression in late life: prevalence and clinical features in 525 depressed
outpatients. J Affect Disord. 2001;66(1):13–8.
7. Lehmann SW, Rabins PV. Factors related to hospitalization in elderly manic patients with
early and late-onset bipolar disorder. Int J Geriatr Psychiatry. 2006;21(11):1060–4.
8. Al Jurdi RK, Nguyen QX, Petersen NJ, Pilgrim P, Gyulai L, Sajatovic M. Acute bipolar I
affective episode presentation across life span. J Geriatr Psychiatry Neurol. 2012;25(1):6–14.
9. Kessing LV. Gender differences in subtypes of late-onset depression and mania. Int
Psychogeriatr. 2006;18(4):727–38.
10. Kessing LV. Diagnostic subtypes of bipolar disorder in older versus younger adults. Bipolar
Disord. 2006;8(1):56–64.
11. Dols A, Kupka RW, van Lammeren A, Beekman AT, Sajatovic M, Stek ML. The prevalence
of late-life mania: a review. Bipolar Disord. 2014;16(2):113–8.
12. Chen ST, Altshuler LL, Spar JE. Bipolar disorder in late life: a review. J Geriatr Psychiatry
Neurol. 1998;11(1):29–35.
13. Sajatovic M, Chen P. Geriatric bipolar disorder. Psychiatr Clin North Am. 2011;34(2):
319–33.
14. Weissman MM, Leaf PJ, Tischler GL, Blazer DG, Karno M, Bruce ML, et al. Affective
disorders in five United States communities. Psychol Med. 1988;18(1):141–53.
15. Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE. Lifetime prevalence
and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey
Replication. Arch Gen Psychiatry. 2005;62(6):593–602.
16. Miller C, Bauer MS. Excess mortality in bipolar disorders. Curr Psychiatry Rep. 2014;
16(11):499-014-0499-z.
17. Koenig HG, Blazer DG. Epidemiology of geriatric affective disorders. Clin Geriatr Med.
1992;8(2):235–51.
18. Merikangas KR, Akiskal HS, Angst J, Greenberg PE, Hirschfeld RM, Petukhova M, et al.
Lifetime and 12-month prevalence of bipolar spectrum disorder in the National Comorbidity
Survey replication. Arch Gen Psychiatry. 2007;64(5):543–52.
19. Sheeran T, Greenberg RL, Davan LA, Dealy JA, Young RC, Bruce ML. A descriptive study
of older bipolar disorder residents living in New York City’s adult congregate facilities.
Bipolar Disord. 2012;14(7):756–63.
20. Sajatovic M, Blow FC, Ignacio RV, Kales HC. New-onset bipolar disorder in later life. Am J
Geriatr Psychiatry. 2005;13(4):282–9.
21. Yassa R, Nair V, Nastase C, Camille Y, Belzile L. Prevalence of bipolar disorder in a
psychogeriatric population. J Affect Disord. 1988;14(3):197–201.
22. Wingerson D, Russo J, Ries R, Dagadakis C, Roy-Byrne P. Use of psychiatric emergency
services and enrollment status in a public managed mental health care plan. Psychiatr Serv.
2001;52(11):1494–501.
23. Shulman RW, Marton P, Fisher A, Cohen C. Characteristics of psychogeriatric patient visits
to a general hospital emergency room. Can J Psychiatry. 1996;41(3):175–80.
24. Broadhead J, Jacoby R. Mania in old age: a First Prospective Study. Int J Geriatr Psychiatry.
1990;5(4):215–22.
25. Kennedy N, Everitt B, Boydell J, Van Os J, Jones PB, Murray RM. Incidence and distribution
of first-episode mania by age: results from a 35-year study. Psychol Med. 2005;35(6):855–63.
26. Hays JC, Krishnan KR, George LK, Blazer DG. Age of first onset of bipolar disorder:
demographic, family history, and psychosocial correlates. Depress Anxiety. 1998;7(2):76–82.
27. Shulman K, Post F. Bipolar affective disorder in old age. Br J Psychiatry. 1980;136:26–32.
28. Almeida OP, Fenner S. Bipolar disorder: similarities and differences between patients with
illness onset before and after 65 years of age. Int Psychogeriatr. 2002;14(3):311–22.
29. Cassidy F, Carroll BJ. Vascular risk factors in late onset mania. Psychol Med. 2002;
32(2):359–62.
30. Subramaniam H, Dennis MS, Byrne EJ. The role of vascular risk factors in late onset bipolar
disorder. Int J Geriatr Psychiatry. 2007;22(8):733–7.
31. Schurhoff F, Bellivier F, Jouvent R, Mouren-Simeoni MC, Bouvard M, Allilaire JF, et al.
Early and late onset bipolar disorders: two different forms of manic-depressive illness? J
Affect Disord. 2000;58(3):215–21.
32. Wylie ME, Mulsant BH, Pollock BG, Sweet RA, Zubenko GS, Begley AE, et al. Age at onset
in geriatric bipolar disorder. Effects on clinical presentation and treatment outcomes in an
inpatient sample. Am J Geriatr Psychiatry. 1999;7(1):77–83.
33. Coryell W, Fiedorowicz J, Leon AC, Endicott J, Keller MB. Age of onset and the
prospectively observed course of illness in bipolar disorder. J Affect Disord. 2013;
146(1):34–8.
34. Bellivier F, Golmard JL, Rietschel M, Schulze TG, Malafosse A, Preisig M, et al. Age at
onset in bipolar I affective disorder: further evidence for three subgroups. Am J Psychiatry.
2003;160(5):999–1001.
35. Azorin JM, Bellivier F, Kaladjian A, Adida M, Belzeaux R, Fakra E, et al. Characteristics and
profiles of bipolar I patients according to age-at-onset: findings from an admixture analysis.
J Affect Disord. 2013;150(3):993–1000.
36. Leboyer M, Henry C, Paillere-Martinot ML, Bellivier F. Age at onset in bipolar affective
disorders: a review. Bipolar Disord. 2005;7(2):111–8.
37. Oostervink F, Nolen WA, Kok RM. EMBLEM Advisory Board. Two years’ outcome of acute
mania in bipolar disorder: different effects of age and age of onset. Int J Geriatr Psychiatry.
2015;30(2):201–9.
38. Oostervink F, Boomsma MM, Nolen WA. Bipolar disorder in the elderly; different effects of
age and of age of onset. J Affect Disord. 2009;116(3):176–83.
39. Sibisi CD. Sex differences in the age of onset of bipolar affective illness. Br J Psychiatry.
1990;156:842–5.
40. Goodwin FK, Jamison KR, Ghaemi SN. Manic-depressive illness: bipolar disorders and
recurrent depression. 2nd ed. New York: Oxford University Press; 2007.
41. Celik Y, Erdogan E, Tuglu C, Utku U. Post-stroke mania in late life due to right
temporoparietal infarction. Psychiatry Clin Neurosci. 2004;58(4):446–7.
42. Robinson RG. Mood disorders secondary to stroke. Semin Clin Neuropsychiatry. 1997;
2(4):244–51.
43. Robinson RG, Boston JD, Starkstein SE, Price TR. Comparison of mania and depression after
brain injury: causal factors. Am J Psychiatry. 1988;145(2):172–8.
44. Santos CO, Caeiro L, Ferro JM, Figueira ML. Mania and stroke: a systematic review.
Cerebrovasc Dis. 2011;32(1):11–21.
45. Starkstein SE, Boston JD, Robinson RG. Mechanisms of mania after brain injury. 12 case
reports and review of the literature. J Nerv Ment Dis. 1988;176(2):87–100.
46. Fujikawa T, Yamawaki S, Touhouda Y. Silent cerebral infarctions in patients with late-onset
mania. Stroke. 1995;26(6):946–9.
47. Huang SH, Chung KH, Hsu JL, Wu JY, Huang YL, Tsai SY. The risk factors for elderly
patients with bipolar disorder having cerebral infarction. J Geriatr Psychiatry Neurol. 2012;
25(1):15–9.
48. Tohen M, Shulman KI, Satlin A. First-episode mania in late life. Am J Psychiatry. 1994;
151(1):130–2.
49. Nilsson FM, Kessing LV, Sorensen TM, Andersen PK, Bolwig TG. Enduring increased risk
of developing depression and mania in patients with dementia. J Neurol Neurosurg
Psychiatry. 2002;73(1):40–4.
50. Krauthammer C, Klerman GL. Secondary mania: manic syndromes associated with
antecedent physical illness or drugs. Arch Gen Psychiatry. 1978;35(11):1333–9.
51. Evans DL, Byerly MJ, Greer RA. Secondary mania: diagnosis and treatment. J Clin
Psychiatry. 1995;56(Suppl 3):31–7.
52. Van Gerpen MW, Johnson JE, Winstead DK. Mania in the geriatric patient population: a
review of the literature. Am J Geriatr Psychiatry. 1999;7(3):188–202.
53. Kellner MB, Neher F. A first episode of mania after age 80. Can J Psychiatry. 1991;36
(8):607–8.
54. Summers WK. Mania with onset in the eighth decade: two cases and a review. J Clin
Psychiatry. 1983;44(4):141–3.
55. Walter-Ryan WG. Mania with onset in the ninth decade. J Clin Psychiatry. 1983;44(11):
430–1.
56. Nivoli AM, Murru A, Pacchiarotti I, Valenti M, Rosa AR, Hidalgo D, et al. Bipolar disorder
in the elderly: a cohort study comparing older and younger patients. Acta Psychiatr Scand.
2014;130(5):364–73.
57. Depp CA, Davis CE, Mittal D, Patterson TL, Jeste DV. Health-related quality of life and
functioning of middle-aged and elderly adults with bipolar disorder. J Clin Psychiatry.
2006;67(2):215–21.
58. Osby U, Brandt L, Correia N, Ekbom A, Sparen P. Excess mortality in bipolar and unipolar
disorder in Sweden. Arch Gen Psychiatry. 2001;58(9):844–50.
59. Shulman KI, Tohen M, Satlin A, Mallya G, Kalunian D. Mania compared with unipolar
depression in old age. Am J Psychiatry. 1992;149(3):341–5.
60. Ramsey CM, Spira AP, Mojtabai R, Eaton WW, Roth K, Lee HB. Lifetime manic spectrum
episodes and all-cause mortality: 26-year follow-up of the NIMH Epidemiologic Catchment
Area Study. J Affect Disord. 2013;151(1):337–42.
Another random document with
no related content on Scribd:
previously passed a prohibitory constitutional amendment, in itself
defective, and as no legislation had been enacted to enforce it, those
who wished began to sell as though the right were natural, and in
this way became strong enough to resist taxation or license. The
Legislature of 1882, the majority controlled by the Republicans,
attempted to pass the Pond liquor tax act, and its issue was joined.
The liquor interests organized, secured control of the Democratic
State Convention, nominated a ticket pledged to their interests,
made a platform which pointed to unrestricted sale, and by active
work and the free use of funds, carried the election and reversed the
usual majority. Governor Foster, the boldest of the Republican
leaders, accepted the issue as presented, and stumped in favor of
license and the sanctity of the Sabbath; but the counsels of the
Republican leaders were divided, Ex-Secretary Sherman and others
enacting the role of “confession and avoidance.” The result carried
with it a train of Republican disasters. Congressional candidates
whom the issue could not legitimately touch, fell before it, probably
on the principle that “that which strikes the head injures the entire
body.” The Democratic State and Legislative tickets succeeded, and
the German element, which of all others is most favorable to freedom
in the observance of the Sabbath, transferred its vote almost as an
entirety from the Republican to the Democratic party.
Ohio emboldened the liquor interests, and in their Conventions
and Societies in other States they agreed as a rule to check and, if
possible, defeat the advance of the prohibitory amendment idea. This
started in Kansas in 1880, under the lead of Gov. St. John, an
eloquent temperance advocate. It was passed by an immense
majority, and it was hardly in force before conflicting accounts were
scattered throughout the country as to its effect. Some of the friends
of temperance contended that it improved the public condition; its
enemies all asserted that in the larger towns and cities it produced
free and irresponsible instead of licensed sale. The latter seem to
have had the best of the argument, if the election result is a truthful
witness. Gov. St. John was again the nominee of the Republicans, but
while all of the remainder of the State ticket was elected, he fell
under a majority which must have been produced by a change of
forty thousand votes. Iowa next took up the prohibitory amendment
idea, secured its adoption, but the result was injurious to the
Republicans in the Fall elections, where the discontent struck at
Congressmen, as well as State and Legislative officers.
The same amendment had been proposed in Pennsylvania, a
Republican House in 1881 having passed it by almost a solid vote
(Democrats freely joining in its support), but a Republican Senate
defeated, after it had been loaded down with amendments. New York
was coquetting with the same measure, and as a result the liquor
interests—well organized and with an abundance of money, as a rule
struck at the Republican party in both New York and Pennsylvania,
and thus largely aided the groundswell. The same interests aided the
election of Genl. B. F. Butler of Massachusetts, but from a different
reason. He had, in one of his earlier canvasses, freely advocated the
right of the poor to sell equally with those who could pay heavy
license fees, and had thus won the major sympathy of the interest.
Singularly enough, Massachusetts alone of all the Republican States
meeting with defeat in 1882, fails to show in her result reasons which
harmonize with those enumerated as making up the elements of
discontent. Her people most do favor high tariffs, taxes on liquors
and luxuries, civil service reforms, and were supposed to be more
free from legal and political abuses than any other. Massachusetts
had, theretofore, been considered to be the most advanced of all the
States—in notions, in habit, and in law—yet Butler’s victory was
relatively more pronounced than that of any Democratic candidate,
not excepting that of Cleveland over Folger in New York, the
Democratic majority here approaching two hundred thousand. How
are we to explain the Massachusetts’ result? Gov. Bishop was a high-
toned and able gentleman, the type of every reform contended for.
There is but one explanation. Massachusetts had had too much of
reform; it had come in larger and faster doses than even her
progressive people could stand—and an inconsistent discontent took
new shape there—that of very plain reaction. This view is confirmed
by the subsequent attempt of Gov. Butler to defeat the re-election of
Geo. F. Hoar to the U. S. Senate, by a combination of Democrats with
dissatisfied Republicans. The movement failed, but it came very near
to success, and for days the result was in doubt. Hoar had been a
Senator of advanced views, of broad and comprehensive
statesmanship, but that communistic sentiment which occasionally
crops out in our politics and strikes at all leaders, merely from the
pleasure of asserting the right to tear down, assailed him with a vigor
almost equal to that which struck Windom of Minnesota, a
statesman of twenty-four years’ honorable, able and sometimes
brilliant service. To prejudice the people of his State against him, a
photograph of his Washington residence had been scattered
broadcast. The print in the photograph intended to prejudice being a
coach with a liveried lackey. It might have been the coach and lackey
of a visitor, but the effect was the same where discontent had run
into a fever.
Political discontent gave unmistakable manifestations of its
existence in Ohio, Massachusetts, New York (where Ex-Governor
Cornell’s nomination had been defeated by a forged telegram),
Michigan, Nebraska, Kansas, Iowa, Connecticut, California,
Colorado, Pennsylvania, and Indiana. The Republican position was
well maintained in New Hampshire, Vermont, Rhode Island,
Minnesota, Illinois, and Wisconsin. It was greatly improved in
Virginia, where Mahone’s Republican Readjuster ticket carried the
State by nearly ten thousand, and where a United States’ Senator and
Congressman at large were gained, as well as some of the District
Congressmen. The Republicans also improved the situation in North
Carolina and Tennessee, though they failed to carry either. They also
gained Congressmen in Mississippi and Louisiana, but the
Congressional result throughout the country was a sweeping
Democratic victory, the 48th Congress, beginning March 4, 1883,
showing a Democratic majority of 71 in a total membership of 325.
In Pennsylvania alone of all the Northern States, were the
Republican elements of discontent organized, and here they were as
well organized as possible under the circumstances. Charles S. Wolfe
had the year previous proclaimed what he called his “independence
of the Bosses,” by declaring himself a candidate for State Treasurer,
“nominated in a convention of one.” He secured 49,984 votes, and
this force was used as the nucleus for the better organized
Independent Republican movement of 1882. Through this a State
Convention was called which placed a full ticket in the field, and
which in many districts nominated separate legislative candidates.
The complaints of the Independent Republicans of Pennsylvania
were very much like those of dissatisfied Republicans in other
Northern States where no adverse organizations were set up, and
these can best be understood by giving the official papers and
correspondence connected with the revolt, and the attempts to
conciliate and suppress it by the regular organization. The writer
feels a delicacy in appending this data, inasmuch as he was one of the
principals in the negotiations, but formulated complaints, methods
and principles peculiar to the time can be better understood as
presented by organized and official bodies, than where mere
opinions of cotemporaneous writers and speakers must otherwise be
given. A very careful summary has been made by Col. A. K. McClure,
in the Philadelphia Times Almanac, and from this we quote the data
connected with the—
The Independent Republican Revolt In
Pennsylvania.
The following call was issued by Chairman McKee, of the

committee which conducted the Wolfe campaign in 1881:
Headquarters State Committee,
Citizens’ Republican Association, Girard House,
Philadelphia, December 16, 1881.
To the Independent Republicans of Pennsylvania:

You are earnestly requested to send representatives from each county to a State conference, to be held at Philadelphia,
Thursday, January 12th, 1882, at 10 o’clock A.M., to take into consideration the wisdom of placing in nomination proper
persons for the offices of Governor, Lieutenant-Governor, Secretary of Internal Affairs and Supreme Court Judge, and such
other matters as may come before the conference, looking to the overthrow of “boss rule,” and the elimination of the
pernicious “spoils system,” and its kindred evils, from the administration of public affairs. It is of the utmost importance that
those fifty thousand unshackled voters who supported the independent candidacy of Hon. Charles S. Wolfe for the office of
State Treasurer as a solemn protest against ring domination, together with the scores of thousands of liberty-loving citizens
who are ready to join in the next revolt against “bossism,” shall be worthily represented at this conference.
I. D. McKee, Chairman.
Frank Willing Leach, Secretary.

Pursuant to the above call, two hundred and thirteen delegates, representing thirty-three of the sixty-
six counties, met at the Assembly Building, January 12th, 1882, and organized by the election of John J.
Pinkerton as chairman, together with a suitable list of vice-presidents and secretaries. After a general
interchange of views, a resolution was adopted directing the holding of a State Convention for the
nomination of a State ticket, May 24th. An executive committee, with power to arrange for the election
of delegates from each Senatorial district, was also appointed, consisting of Messrs. I. D. McKee, of
Philadelphia; Wharton Barker, of Montgomery; John J. Pinkerton, of Chester; F. M. Nichols, of Luzerne;
H. S. McNair, of York, and C. W. Miller, of Crawford. Mr. Nichols afterwards declining to act, George E.
Mapes, of Venango, was substituted in his place. Before the time arrived for the meeting of the
convention of May 24th, several futile efforts were made to heal the breach between the two wings of the
Republican party. At a conference of leading Independents held in Philadelphia, April 23d, at which
Senator Mitchell was present, a committee was appointed for the purpose of conferring with a similar
committee from the regular organization, upon the subject of the party differences. The members of the
Peace Conference, on the part of the Independents, were Charles S. Wolfe, I. D. McKee, Francis B.
Reeves, J. W. Lee, and Wharton Barker. The committee on the part of the Stalwarts were M. S. Quay,
John F. Hartranft, C. L. Magee, Howard J. Reeder, and Thomas Cochran. A preliminary meeting was
held at the Continental Hotel, on the evening of April 29th, which adjourned to meet at the same place
on the evening of May 1st; at which meeting the following peace propositions were agreed upon:
Resolved, That we recommend the adoption of the following principles and methods by the
Republican State Convention of May 10th.
First. That we unequivocally condemn the use of patronage to promote personal political ends, and
require that all offices bestowed within the party shall be upon the sole basis of fitness.
Second. That competent and faithful officers should not be removed except for cause.
Third. That the non-elective minor offices should be filled in accordance with rules established by law.
Fourth. That the ascertained popular will shall be faithfully carried out in State and National
Conventions, and by those holding office by the favor of the party.
Fifth. That we condemn compulsory assessments for political purposes, and proscription for failure to
respond either to such assessments or to requests for voluntary contributions, and that any policy of
political proscription is unjust, and calculated to disturb party harmony.
Sixth. That public office constitutes a high trust to be administered solely for the people, whose
interests must be paramount to those of persons or parties, and that it should be invariably conducted
with the same efficiency, economy, and integrity as are expected in the execution of private trusts.
Seventh. That the State ticket should be such as by the impartiality of its constitution and the high
character and acknowledged fitness of the nominees will justly commend itself to the support of the
united Republican party.
Resolved, That we also recommend the adoption of the following permanent rules for the holding of
State Conventions, and the conduct of the party:
First. That delegates to State Conventions shall be chosen in the manner in which candidates for the
General Assembly are nominated, except in Senatorial districts composed of more than one county, in
which conferees for the selection of Senatorial delegates shall be chosen in the manner aforesaid, and
the representation of each county shall be based upon its Republican vote cast at the Presidential
election next preceding the convention.
Second. Hereafter the State Convention of the Republican party shall be held on the second
Wednesday of July, except in the year of the Presidential election, when it shall be held not more than
thirty days previous to the day fixed for the National Convention, and at least sixty days’ notice shall be
given of the date of the State Convention.
Third. That every person who voted the Republican electoral ticket at the last Presidential election
next preceding any State Convention shall be permitted to participate in the election of delegates to State
and National Conventions, and we recommend to the county organizations that in their rules they allow
the largest freedom in the general participation in the primaries consistent with the preservation of the
party organization.
M. S. Quay,
J. F. Hartranft,
Thomas Cochran,
Howard J. Reeder,
C. L. Magee,
On the part of the Republican State Committee, appointed by Chairman Cooper.
Charles S. Wolfe,
I. D. McKee,
Francis B. Reeves,
Wharton Barker,
J. W. Lee,
On the part of Senator Mitchell’s Independent Republican Committee.

The following resolution was adopted by the joint conference:
Resolved, That we disclaim any authority to speak or act for other persons than ourselves, and simply
make these suggestions as in our opinion are essential to the promotion of harmony and unity.
In order, however, that there might be no laying down of arms on the part of the Independents, in the
false belief that the peace propositions had ended the contest, without regard to whether they were
accepted in good faith, and put in practice by the regular convention, the following call was issued by the
Independent Executive Committee:
Executive Committee,
Citizens’ Republican Association of
Pennsylvania, Girard House.
Philadelphia, May 3d, 1882.
To the Independent Republicans of Pennsylvania:

At a conference of Independent Republicans held in Philadelphia, on January 12th, 1882, the following resolution was
adopted, to wit:
Resolved, That a convention be held on the 24th day of May, 1882, for the purpose of placing in nomination a full
Independent Republican ticket for the offices to be filled at the general election next November.
In pursuance and by the authority of the above resolution the undersigned, the State Executive Committee appointed at the
said conference, request the Independent Republicans of each county of the Commonwealth of Pennsylvania to send
delegates to the Independent Convention of May 24th, the basis of representation to be the same as that fixed for Senators
and Representatives of the General Assembly of Pennsylvania.
Should the convention of May 10th fail to nominate as its candidates men who in their character, antecedents and
affiliations are embodiments of the principles of true Republicanism free from the iniquities of bossism, and of an honest
administration of public affairs free from the evils of the spoils system, such nominations, or any such nomination, should be
emphatically repudiated by the Independent Convention of May 24th, and by the Independent Republicans of Pennsylvania
in November next.
The simple adoption by the Harrisburg Convention of May 10th of resolutions of plausible platitudes, while confessing the
existence of the evils which we have strenuously opposed, and admitting the justice of our position in opposing them, will not
satisfy the Independent Republicans of this Commonwealth. We are not battling, for the construction of platforms, but for the
overthrow of bossism, and the evils of the spoils system, which animated a despicable assassin to deprive our loved President
Garfield of his life, and our country of its friend and peacemaker.
The nomination of slated candidates by machine methods, thereby tending to the perpetuation of boss dominion in our
Commonwealth, should never be ratified by the Independent Republicans in convention assembled or at the polls. Upon this
very vital point there should be no mistake in the mind of any citizen of this State. The path of duty in this emergency leads
forward, and not backward, and forward we should go until bossism and machinism and stalwartism—aye, and Cameronism
—are made to give way to pure Republicanism. The people will not submit to temporizing or compromising.
We appeal to the Independent Republicans of Pennsylvania to take immediate steps toward perfecting their organization in
each county, and completing the selection of delegates to the Independent State Convention. Use every exertion to secure the
choice as delegates of representative, courageous men, who will not falter when the time arrives to act—who will not desert
into the ranks of the enemy when the final time of testing comes. Especially see to it that there shall not be chosen as
delegates any Pharisaical Independents, who preach reform, yet blindly follow boss leadership at the crack of the master’s
whip. Act quickly and act discreetly.
A State Campaign Committee of fifty, comprising one member from each Senatorial district, has been formed, and any one
desiring to co-operate with us in this movement against the enemies of the integrity of our State, who shall communicate with
us, will be immediately referred to the committeeman representing the district in which he lives. We urgently invite a
correspondence from the friends of political independence from all sections of the State.
Again we say to the Independent Republicans of Pennsylvania in the interest of justice and the Commonwealth’s honor,
leave no stone unturned to vindicate the rights of the people.
Wharton Barker.
John J. Pinkerton.
Geo. E. Mapes.
H. S. McNair.
Charles W. Miller.
Frank Willing Leach, Secretary.
In pursuance of the above call, the Independent Convention met, May 24th, in Philadelphia, and
deciding that the action of the regular Republican Convention, held at Harrisburg on May 10th, did not
give the guarantee of reform demanded by the Independents, proceeded to nominate a ticket and adopt
a platform setting forth their views.
Although the break between the two wings of the party was thus made final to all appearances, yet all
efforts for a reconciliation were not entirely abandoned. Thos. M. Marshall having declined the
nomination for Congressman at Large on the Republican ticket, the convention was reconvened June
21st, for the purpose of filling the vacancy, and while in session, instructed the State Central Committee
to use all honorable means to secure harmony between the two sections of the party. Accordingly, the
Republican State Committee was called to meet in Philadelphia, July, 13th. At this meeting the following
propositions were submitted to the Independents:
Pursuant to the resolution passed by the Harrisburg Convention of June 21st, and authorizing the
Republican State Committee to use all honorable means to promote harmony in the party, the said
committee, acting in conjunction with the Republican candidates on the State ticket, respectfully submit
to the State Committee and candidates of the Independents the following propositions:
First. The tickets headed by James A. Beaver and John Stewart, respectively, be submitted to a vote of
the Republican electors of the State, at primaries, as hereinafter provided for.
Second. The selection of candidates to be voted for by the Republican party in November to be
submitted as aforesaid, every Republican elector, constitutionally and legally qualified, to be eligible to
nomination.
Third. A State Convention to be held, to be constituted as recommended by the Continental Hotel
Conference, whereof Wharton Barker was chairman and Francis B. Reeves secretary, to select
candidates to be voted for by the Republican party in November, its choice to be limited to the
candidates now in nomination, or unlimited, as the Independent State Committee may prefer.
The primaries or convention referred to in the foregoing propositions to be held on or before the
fourth Wednesday of August next, under regulations or apportionment to be made by Daniel Agnew,
Hampton L. Carson, and Francis B. Reeves, not in conflict, however, with the acts of Assembly
regulating primary elections, and the candidates receiving the highest popular vote, or the votes of a
majority of the members of the convention, to receive the united support of the party.
Resolved, That in the opinion of the Republican State Committee the above propositions fully carry
out, in letter and spirit, the resolution passed by the Harrisburg Convention, June 21st, and that we
hereby pledge the State Committee to carry out in good faith any one of the foregoing propositions
which may be accepted.
Resolved, That the chairman of the Republican State Committee be directed to forward an official
copy of the proceedings of this meeting, together with the foregoing propositions, to the Independent
State Committee and candidates.
Whereupon, General Reeder, of Northampton, moved to amend by adding a further proposition, as
follows.
Fourth. A State Convention, to be constituted as provided for by the new rules adopted by the late
Republican State Convention, to select candidates to be voted for by the Republican party in November,
provided, if such convention be agreed to, said convention shall be held not later than the fourth
Wednesday in August. Which amendment was agreed to, and the preamble and resolutions as amended
were agreed to.
This communication was addressed to the chairman of the Independent State Committee, I. D.
McKee, who called the Independent Committee to meet July 27th, to consider the propositions. In the
meantime the Independent candidates held a conference on the night of July 13th, and four of them
addressed the following propositions to the candidates of the Stalwart wing of the party:
Philadelphia, July 13th, 1882.
To General James A. Beaver, Hon. William T. Davies, Hon. John M. Greer, William Henry Rawle, Esq., and Marriott
Brosius, Esq.
Gentlemen: By a communication received from the Hon. Thomas V. Cooper, addressed to us as candidates of the
Independent Republicans, we are advised of the proceedings of the State Committee, which assembled in this city yesterday.
Without awaiting the action of the Independent State Committee, to which we have referred the communication, and
attempting no discussion of the existing differences, or the several methods proposed by which to secure party unity, we beg
to say that we do not believe that any of the propositions, if accepted, would produce harmony in the party, but on the
contrary, would lead to wider divisions. We therefore suggest that the desired result can be secured by the hearty co-
operation of the respective candidates. We have no authority to speak for the great body of voters now giving their support to
the Independent Republican ticket, nor can we include them by any action we may take. We are perfectly free, however, to act
in our individual capacity, and desire to assure you that we are not only willing, but anxious to co-operate with you in the
endeavor to restore peace and harmony to our party. That this can be accomplished beyond all doubt we feel entirely assured,
if you, gentlemen, are prepared to yield, with us, all personal considerations, and agree to the following propositions:
First. The withdrawal of both tickets.
Second. The several candidates of these tickets to pledge themselves not to accept any subsequent nomination by the
proposed convention.
Under these conditions we will unite with you in urging upon our respective constituencies the adoption of the third
proposition submitted by your committee, and conclude the whole controversy by our final withdrawal as candidates. Such
withdrawal of both tickets would remove from the canvass all personal as well as political antagonisms, and leave the party
united and unembarrassed.
We trust, gentlemen, that your judgment will approve the method we have suggested, and that, appreciating the
importance of concluding the matter with as little delay as possible, you will give us your reply within a week from this date.
Very respectfully, your obedient servants,
John Stewart.
Levi Bird Duff.
George W. Merrick.
George Junkin.
William McMichael, Independent candidate for Congressman at Large, dissented from the
proposition of his colleagues, and addressed the following communication to Chairman Cooper:
Hon. Thomas V. Cooper, Chairman, etc.

Dear Sir: Your letter of July 12th is received, addressed to the chairman of the State Committee of the Independent
Republicans and their candidates, containing certain propositions of your committee. I decline those propositions, because
they involve an abandonment of the cause of the Independent Republicans.
If a new convention, representing all Republicans, had nominated an entirely new ticket, worthy of popular support, and
not containing the name of any candidate on either of the present tickets, and sincerely supporting the principles of the
Independent Republicans, the necessity for a separate Independent Republican movement would not exist. Your proposition,
however, practically proposes to re-nominate General Beaver, and reaffirm the abuse which we oppose.
The convention of Independent Republicans which met in Philadelphia on May 24th, announced principles in which I
believe. It nominated me for Congressman at Large, and I accepted that nomination. It declared boldly against bossism, the
spoils system, and all the evils which impair Republican usefulness, and in favor of popular rule, equal rights of all, national
unity, maintenance of public credit, protection to labor, and all the great principles of true Republicanism. No other ticket
now in the field presents those issues. The people of Pennsylvania can say at the polls, in November, whether they approve of
those principles, and will support the cause which represents them. I will not withdraw or retire unless events hereafter shall
give assurance that necessary reform in the civil service shall be adopted; assessments made upon office-holders returned,
and not hereafter exacted; boss, machine, and spoils methods forever abandoned; and all our public offices, from United
States Senator to the most unimportant officials, shall be filled only by honest and capable men, who will represent the
people, and not attempt to dictate to or control them.
I shall go on with the fight, asking the support of all my fellow-citizens who believe in the principles of the Independent
Republican Convention of May 24th.
Yours truly,
William McMichael.
To these propositions General Beaver and his colleagues replied in the following communication:
Hon. Thomas V. Cooper, Chairman Republican State Committee, Philadelphia, Pa.
Sir: We have the honor to acknowledge the receipt through you of a communication addressed to us by the Hon. John
Stewart, Colonel Levi Bird Duff, Major G. W. Merrick, and George Junkin, Esq.; in response to certain propositions submitted
by the Republican State Committee, representing the Republican party of Pennsylvania, looking to an amicable and
honorable adjustment of whatever differences there may be among the various elements of the party. Without accepting any
of the propositions submitted by your committee, this communication asks us, as a condition precedent to any
recommendation on the part of the writers thereof, to declare that in the event of the calling of a new convention, we will
severally forbid the Republicans of Pennsylvania to call upon us for our services as candidates for the various positions to be
filled by the people at the coming election. To say that in the effort to determine whether or not our nomination was the free
and unbiased choice of the Republican party we must not be candidates, is simply to try the question at issue. We have no
desire to discuss the question in any of its numerous bearings. We have placed ourselves unreservedly in the hands of the
Republicans of Pennsylvania. We have pledged ourselves to act concurrently with your committee, and are bound by its
action. We therefore respectfully suggest that we have no power or authority to act independently of the committee, or make
any declaration at variance with the propositions submitted in accordance with its action. There ought to be and can be no
such thing as personal antagonism in this contest. We socially and emphatically disclaim even the remotest approach to a
feeling of this kind toward any person. We fraternize with and are ready to support any citizen who loves the cause of pure
Republicanism, and with this declaration we submit the whole subject to your deliberate judgment and wise consideration.
James A. Beaver.
William Henry Rawle.
Marriott Brosius.
W. T. Davies.
John M. Greer.
At the meeting of the Independent State Committee, July 27th, the propositions of the Regular
Committee were unanimously rejected, and a committee appointed to draft a reply, which was done in
the following terms:
Thomas V. Cooper, Esq., Chairman Republican State Committee.
Dear Sir: I am instructed to advise you that the Independent Republican State Committee have considered the four
suggestions contained in the minutes of the proceedings of your committee, forwarded to me by you on the 12th instant.
I am directed to say that this committee find that none of the four are methods fitted to obtain a harmonious and honorable
unity of the Republican voters of Pennsylvania. All of them are inadequate to that end, for the reason that they afford no
guarantee that, being accepted, the principles upon which the Independent Republicans have taken their stand would be
treated with respect or put into action. All of them contain the probability that an attempt to unite the Republicans of the
State by their means would either result in reviving and strengthening the political dictatorship which we condemn or would
permanently distract the Republican body, and insure the future and continued triumph of our common opponent, the
Democratic party.
Of the four suggestions, the first, second and fourth are so inadequate as to need no separate discussion: the third, which
alone may demand attention, has the fatal defect of not including the withdrawal of that “slated” ticket which was made up
many months ago, and long in advance of the Harrisburg Convention, to represent and to maintain the very evils of control
and abuses of method to which we stand opposed. This proposition, like the others, supposing it to have been sincerely put
forward, clearly shows that you misconceive the cause of the Independent Republican movement, as well as its aims and
purposes. You assume that we desire to measure the respective numbers of those who support the Harrisburg ticket and
those who find their principles expressed by the Philadelphia Convention. This is a complete and fatal misapprehension. We
are organized to promote certain reforms, and not to abandon them in pursuit of votes. Our object is the overthrow of the
“boss system” and of the “spoils system.”
In behalf of this we are willing and anxious to join hands with you whenever it is assured that the union will be honestly
and earnestly for that purpose. But we cannot make alliances or agree to compromises that in their face threaten the very
object of the movement in which we have engaged. Whether your ticket has the support of many or few, of a majority or a
minority of the Republican voters, does not affect in the smallest degree the duty of every citizen to record himself against the
abuses which it represents. Had the gentlemen who compose it been willing to withdraw themselves from the field, as they
were invited to join in doing, for the common good, by the Independent Republican candidates, this act would have
encouraged the hope that a new convention, freely chosen by the people, and unembarrassed by claims of existing candidates,
might have brought forth the needed guarantee of party emancipation and public reform.
This service, however, they have declined to render their party; they not only claim and receive your repeated assurances of
support, but they permit themselves to be put forward to secure the use of the Independent Republican votes at the same
time that they represent the “bossism,” the “spoils” methods, and the “machine” management which we are determined no
longer to tolerate. The manner in which their candidacy was decreed, the means employed to give it convention formality, the
obligations which they incur by it, the political methods with which it identifies them, and the political and personal plans for
which their official influence would be required, all join to make it the most imperative public duty not to give them support
at this election under any circumstances.
In closing this note, this committee must express its regret, that, having considered it desirable to make overtures to the
Independent Republicans, you should have so far misapprehended the facts of the situation. It is our desire to unite the
Republican party on the sure ground of principle, in the confidence that we are thus serving it with the highest fidelity, and
preserving for the future service of the Commonwealth that vitality of Republicanism which has made the party useful in the
past, and which alone confers upon it now the right of continued existence. The only method which promises this result in the
approaching election is that proposed by the Independent Republican candidates in their letter of July 13th, 1882, which was
positively rejected by your committee.
On behalf of the Independent Republican State Committee of Pennsylvania,
With this communication ended all efforts at conciliation.
The election followed, and the Democratic ticket, headed by Robert E. Pattison of Philadelphia,
received an average plurality of 40,000, and the Independent Republican ticket received an average vote
of about 43,000–showing that while Independence organized did not do as well in a gubernatorial as it
had in a previous off-year, it yet had force enough to defeat the Republican State ticket headed by Gen.
James A. Beaver. All of the three several State tickets were composed of able men, and the force of both
of the Republican tickets on the hustings excited great interest and excitement; yet the Republican vote,
owing to the division, was not out by nearly one hundred thousand, and fifty thousand more
Republicans than Democrats remained at home, many of them purposely. In New York, where
dissatisfaction had no rallying point, about two hundred thousand Republicans remained at home, some
because of anger at the defeat of Gov. Cornell in the State nominating convention—some in protest
against the National Administrations, which was accused of the desire for direct endorsement where it
presented the name of Hon. Chas. J. Folger, its Secretary of the Treasury, as the home gubernatorial
candidate,—others because of some of the many reasons set forth in the bill of complaints which
enumerates the causes of the dissatisfaction within the party.
At this writing the work of Republican repair is going on. Both the Senate and House at Washington
are giving active work to the passage of a tariff bill, the repeal of the revenue taxes, and the passage of a
two-cent letter postage bill—measures anxiously hastened by the Republicans in order to anticipate
friendly and defeat unfriendly attempts on the part of the Democratic House, which comes in with the
first session of the 48th Congress.
In Pennsylvania, as we close this review of the struggle of 1882, the Regular and Independent
Republican State Committees—at least the heads thereof—are devising a plan to jointly call a Republican
State Convention to nominate the State ticket to be voted for in November, 1883. The groundswell was
so great that it had no sooner passed, than Republicans of all shades of opinion, felt the need of
harmonious action, and the leaders everywhere set themselves to the work of repair.
The Republicans in the South differed from those of the North in the fact that their complaints were
all directed against a natural political enemy—the Bourbons—and wherever there was opportunity they
favored and entered into movements with Independent and Readjuster Democrats, with the sole object
of revolutionizing political affairs in the South. Their success in these combinations was only great in
Virginia, but it proved to be promising in North Carolina, Mississippi, and Louisiana, and may take more
definite and general shape in the great campaign of 1884.
The Democratic party was evidently surprised at its great victory in 1882, and has not yet formally
resolved what it will do with it. The Congress beginning with December, 1883, will doubtless give some
indication of the drift of Democratic events.
The most notable law passed in the closing session of the 47th Congress, was the Civil Service Reform
Bill, introduced by Senator Geo. H. Pendleton of Ohio, but prepared under the direction of the Senate
Judiciary Committee. The Republicans, feeling that there was some public demand for the passage of a
measure of the kind, eagerly rushed to its support, at a time when it was apparent that the spoils of office
might slip from their hands. From opposite motives the Democrats, who had previously encouraged,
now ran away from it, but it passed both Houses with almost a solid Republican vote, a few Democrats in
each House voting with them. President Arthur signed the bill, but at this writing the Commission which
it creates has not been appointed, and of course none of the rules and constructions under the act have
been formulated. Its basic principles are fixed tenure in minor places, competitive examinations, and
non-partisan selections.
POLITICAL CHANGES—1883.
In the fall of 1883 nearly all of the States swept by the tidal wave of 1882 showed that it had either
partially or completely receded, and for the first time since the close of the Hayes administration (always
excepting the remarkable Garfield-Hancock campaign), the Republican party exhibited plain signs of
returning unity and strength. Henry Ward Beecher has wittily said that “following the war the nation
needed a poultice, and got it in the Hayes administration.” The poultice for a time only drew the sores
into plainer view, and healing potions were required for the contests immediately following. The
divisions of 1882 were as much the result of the non-action of the Hayes administration, as of the
misunderstandings and feuds which later on found bitter manifestation between the Stalwarts and Half-
Breeds of New York.
The Independents took no organized form except in New York and Pennsylvania, and yet the
underlying causes of division for the time swept from their Republican moorings not only the States
named, but also Massachusetts, Connecticut, Ohio, Indiana, Michigan, Kansas, Colorado and California.
The year 1882 seemed the culmination of every form of Republican division, and then everything in
the States named gave place to faction. Very wisely the Republican leaders determined to repair the
mischief, as far as possible, in the otherwise uneventful year of 1883. Their efforts were in most
instances successful, especially in Massachusetts where Robinson overthrew Gen. Butler’s State
administration by 20,000 majority; in Pennsylvania, where the Republican State ticket received about
20,000 majority, after the reunion of the Regular and independent factions. In Pennsylvania the efforts
at reconciliation made in the Continental Conference, and in subsequent conventions, gave fruit in 1883,
and at this writing in July, 1884 there is no mark of division throughout the entire State, if we except
such as must inevitably follow the plain acceptance of Free Trade and Protective issues. Very few of the
Republicans of Pennsylvania favor Free Trade, and only in the ranks of this few could any division be
traced after the close of the elections of 1883.
Ohio was an exception to the Republican work of reconciliation. Division still continued, and Judge
Hoadly, a leading and very talented Democrat, was elected Governor by about 15,000 majority, after a
contest which involved the expenditure of large sums of money. In the Convention which nominated
Hoadly, Senator Pendleton was practically overthrown because of his attachment to the Civil Service law
which takes his name, and later on he was defeated for U. S. Senator by Mr. Payne, the McLean and
Bookwalter factions uniting for his overthrow, which was accomplished despite the efforts of Thurman,
Ward and other leaders of the older elements of the party. Both the Hoadly and Payne battles were won
under the banners of the “Young Democracy.”
Any compilation of the returns of 1883 must be measurably imperfect, for in only a few of the States
were important and decisive battles waged. Such as they were, however, are given in the table on the
next page:
State Elections of 1882 and 1883, compared with the Presidential Election of 1880.
1880.[67]
STATES. Garfield, Hancock, Weaver, Dow,
Rep. Dem. Gbk. Pro.
Alabama 56,221 91,185 4,642
Arkansas 42,436 60,775 4,079
California 80,348 80,426 3,392
Colorado 27,450 24,647 1,435
[68]Connecticut 67,071 64,415 868 40
Delaware 14,133 15,275 120
Florida 23,654 27,964
Georgia 54,086 102,470 969
Illinois 318,037 277,321 26,358 443
Indiana 232,164 225,522 12,986
Iowa 183,927 105,845 32,701 592
Kansas 121,549 59,801 19,851 25
Kentucky 106,306 149,068 11,499 258
Louisiana 38,637 65,067 439
Maine 74,039 65,171 4,408 93
Maryland 78,515 93,706 818
Massachusetts 165,205 111,960 4,548 682
Michigan 185,341 131,597 34,895 942
Minnesota 93,903 53,315 3,267 286
Mississippi 34,854 75,750 5,797
Missouri 153,567 200,699 35,135
Nebraska 54,979 28,523 3,950
Nevada 8,732 9,613
New Hampshire 44,852 40,794 528 180
New Jersey 120,555 122,565 2,617 191
New York 555,544 534,511 12,373 1,517
North Carolina 115,874 124,208 1,126
Ohio 375,048 340,821 6,456 2,616
Oregon 20,619 19,948 249
Pennsylvania 444,704 407,428 20,668 1,939
Rhode Island 18,195 10,779 236 20
South Carolina 58,071 112,312 556
Tennessee 107,677 128,191 5,917 43
Texas 57,893 156,428 27,405
Vermont 45,567 18,316 1,215
Virginia 84,020 128,586
West Virginia 46,243 57,391 9,079
Wisconsin 144,400 114,649 7,986 69
Total 4,454,416 4,444,952 308,578 10,305
Plurality 9,464
Total vote 9,219,947
1882.[69]
STATES.
Rep. Dem. Gbk. Pro.
Alabama 46,386 100,591
Arkansas 49,352 87,675 10,142
California 67,175 90,694 1,020 5,772
Colorado 27,552 29,897
[68]Connecticut 54,853 59,014 607 1,034
Delaware 10,088 12,053
Florida 20,139 24,067 3,553
Georgia 24,930 81,443 68
Illinois 254,551 249,067 11,306 11,202
Indiana 210,234 220,918 13,520
Iowa 149,051 112,180 30,817
Kansas [70]98,166 [70]61,547 [70]23,300
Kentucky 79,036 110,813 736

Louisiana 33,953 49,892
Maine 72,724 63,852 1,302 395
Maryland 74,515 80,725 1,833
Massachusetts [70]134,358 [70]116,678 [70]4,033 [70]2,141
Michigan [70]157,925 [70]149,443 [70]1,572 [70]4,440
Minnesota 92,802 46,653 3,781 1,545

Mississippi 30,282 48,159
Missouri 128,239 198,620 33,407
Nebraska 43,495 28,562 16,991
Nevada [69]7,362 [69]6,906
New Hampshire 38,299 36,879 449 338

New Jersey 97,860 99,962 6,063 2,004
New York [70]409,422 [71]482,822 [71]10,527 [71]16,234
North Carolina 111,320 111,763

Ohio 297,759 316,874 5,345 12,202
Oregon 21,481 20,069
Pennsylvania [72]359,232 [72]355,791 [72]23,996 [72]5,196
Rhode Island 10,056 5,311 120

South Carolina 67,458 17,719
Tennessee [73]91,693 [73]123,929 [73]9,538
Texas 41,761 142,087 41,825

Vermont 35,839 14,466 1,535
Virginia 100,690 94,184
West Virginia 43,440 46,661
Wisconsin 94,606 103,630 2,496 13,800
Total 3,620,844 4,051,035 277,691 76,303
Plurality 130,195
1883.[68]
STATES.
Rep. Dem. Gbk. Pro.
Alabama
Arkansas
California
Colorado [68]
Connecticut 51,749 46,146

Delaware
Florida
Georgia 23,680
Illinois
Indiana
Iowa 164,182 139,093 23,089
Kansas
Kentucky 89,181 133,615
Louisiana
Maine
Maryland 80,707 92,694 1,881
Massachusetts 160,092 150,228 13,950
Michigan 122,330 127,376
Minnesota 72,404 57,859
Mississippi
Missouri
Nebraska 52,305 47,795
Nevada
New Hampshire
New Jersey 97,047 103,856 2,960 4,153
New York 429,252 445,817 7,187 19,368
North Carolina
Ohio 347,164 359,793 2,937 8,362
Oregon
Pennsylvania 319,106 302,031 4,452 6,602
Rhode Island 13,068 10,907
South Carolina
Tennessee
Texas
Vermont
Virginia
West Virginia
Wisconsin
Total 1,998,587 2,040,890 40,629 54,316
Plurality 42,303

POLITICAL CHANGES—1884.
The Republican National Convention met at Chicago, in the Exposition Building, on Tuesday, June 3d,
1884. It was called to order by Senator Sabin, the Chairman of the National Committee, who at the
conclusion of his address, at the request of his Committee, presented the name of Hon. Powell Clayton,
of Arkansas, for temporary President. Gen. Clayton, as a friend of Blaine, was antagonized by the field,
which named Hon. John R. Lynch for the place. An exciting debate followed, at the close of which Mr.
Lynch received 431 votes to 387 for Clayton. Ex-Senator Henderson of Missouri was made permanent
President without a contest. The contested seats were amicably settled, the most notable being that of
the straight-out Republicans of Virginia against Gen. Mahone’s delegation. The latter was admitted, the
only contest being in the Committee. The Blaine leaders did not antagonize, but rather favored Mahone’s
admission, as did the field generally, for the State Convention which elected this delegation had openly
abandoned the name of the Readjuster Party and taken that of the Republican. None of the Straightouts
expressed dissatisfaction at what appeared to be the almost universal sentiment.
Candidates for the Nomination.
On the third day the following candidates were formally placed in nomination, after eloquent eulogies,
the most notable being those of Judge West of Ohio, in behalf of Blaine; Gen. H. H. Bingham, of Penna.,
for President Arthur; and Geo. W. Curtis for Senator Edmunds:
James G. Blaine, of Maine.

Chester A. Arthur, of New York.
John Sherman, of Ohio.
George F. Edmunds, of Vermont.
John A. Logan, of Illinois.
Joseph R. Hawley, of Connecticut.
On the adjoining page is given the result of the ballots.

The convention sat four days, completed its work harmoniously, and adopted a platform without a
negative vote. [We give it in full in our Book of Platforms, and compare its vital issues with that of the
Democratic in our comparison of Platform Planks.]
The Democratic National Convention.
This body assembled at Chicago, in the Exposition Building, on Tuesday, July 8th, 1884, and was
called to order by Ex-Senator Barnum, the Chairman of the National Committee. The Committee
presented Governor Richard B. Hubbard, of Texas, for temporary chairman. After his address a notable
contest followed on the adoption of the unit rule, the debate being participated in by many delegates.
Mr. Fellows, of New York, favored the rule, as did all of the advocates of Governor Cleveland’s
nomination for President, while John Kelly opposed it with a view to give freedom of choice to the
twenty-five delegates from New York who were acting with him. The contest was inaugurated by Mr.
Smalley, of Vermont, who was instructed by the National Committee to offer the following resolution:
Resolved, that the rules of the last Democratic Convention govern this body until otherwise ordered,
subject to the following modification: That in voting for candidates for President and Vice-President no
State shall be allowed to change its vote until the roll of the States has been called, and every State has
cast its vote.
Mr. Grady, of New York, offered the following amendment to the resolution:
When the vote of a State, as announced by the chairman of the delegation from such State is
challenged by any member of the delegation, then the Secretary shall call the names of the individual
delegates from the State, and their individual preferences as expressed shall be recorded as the vote of
such State.
After discussion the question was then put, the chairman of each State delegation announcing its vote
as follows:
THE VOTE IN DETAIL.
First Ballot.
States. No. Sherman, Sherma
Delegates. Blaine. Arthur. Edmunds. Logan. John. Hawley. Lincoln. W. T.
[74]Alabama 20 1 17 1
Arkansas 14 8 4 2
California 16 16
Colorado 6 6
Connecticut 12 12
Delaware 6 5 1
Florida 8 1 7
Georgia 24 24
Illinois 44 3 1 40
Indiana 30 18 9 1 2
Iowa 26 26
Kansas 18 12 4 1 1
Kentucky 26 5½ 16 2½ 1 1
[74]Louisiana 16 2 10 3
Maine 12 12
Maryland 16 10 6
Massachusetts 28 1 2 25
Michigan 26 15 2 7
Minnesota 14 7 1 6
Mississippi 18 1 17
Missouri 32 5 10 6 10 1
Nebraska 10 8 2
Nevada 6 6
New
Hampshire 8 4 4
New Jersey 18 9 6 1 2
New York 72 28 31 12 1
North
Carolina 22 2 19 1
Ohio 46 21 25
Oregon 6 6
Pennsylvania 60 47 11 1 1
Rhode Island 8 8
South
Carolina 18 1 17
Tennessee 24 7 16 1
Texas 26 13 11 1
Vermont 8 8
Virginia 24 2 21 1
West Virginia 12 12
Wisconsin 22 10 6 6
Territories.
Arizona 2 2
Dakota 2 2
Idaho 2 2
Montana 2 1 1
New Mexico 2 2
Utah 2 2
Washington 2 2
Wyoming 2 2
Dist. of
Columbia 2 1 1
Total 820 334½ 278 93 63½ 30 13 4

Textbook Bipolar Disorder in Older Age Patients 1St Edition Susan W Lehmann Ebook All Chapter PDF

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Textbook Bipolar Disorder in Older Age Patients 1St Edition Susan W Lehmann Ebook All Chapter PDF

Uploaded by

Copyright:

Available Formats

Bipolar Disorder in Older Age Patients

1st Edition Susan W. Lehmann

Acetabular Fractures in Older Patients Assessment and

The Treatment of Bipolar Disorder : Integrative

Urban Regeneration: A Manifesto for transforming UK

Communication and Learning in an Age of Digital

Aeromedical Evacuation Management of Acute and

Destination China Angela Lehmann

Fit at Any Age It s Never Too Late 1st Edition Susan

Project business management 1 Edition Edition Lehmann

Bipolar Disorder in Older

Harvard Medical School

ISBN 978-3-319-48910-0 ISBN 978-3-319-48912-4 (eBook)

Library of Congress Control Number: 2016955929

© Springer International Publishing AG 2017

Printed on acid-free paper

This Springer imprint is published by Springer Nature

Fortunately, in recent years, there has been increased interest in understanding

Baltimore, MD, USA Susan W. Lehmann

1 Epidemiology of Older Age Bipolar Disorder . . . . . . . . . . . . . . . . . . 1

Olusola Ajilore Psychiatric Institute, University of Illinois at Chicago, Chicago,

Susan W. Lehmann Department of Psychiatry and Behavioral Sciences, Johns

Worldwide population reports project signiﬁcant increases in the population of

Researchers have deﬁned OABD in different ways, contributing to methodological

N. Leistikow (&) S.W. Lehmann

© Springer International Publishing AG 2017 1

Table 1.1 Deﬁning older age bipolar disorder

1.4 Prevalence in the Community

1.5 Prevalence in Treatment Settings

However, in contradistinction to low prevalence rates among older people living

1.6 Age of Onset

The clinical heterogeneity of older individuals with bipolar disorder is an ongoing

1.6.1 Bimodal Distribution

1.6.2 Cutpoints and Proportionality of Early- Versus

It is important to recognize that although an estimated 90 % of patients who will

1.7 Demographic Distinctions

1.8 Heterogeneous Etiologies—Including Cerebrovascular

The bimodal distribution of age of onset, demographic differences, and possible

In addition to strokes causing mania, there is a growing literature suggesting a

Fig. 1.1 Possible causes of late-life mania

Clinical Vignette 1.1

1.9 Bipolar 1 Disorder Versus Bipolar 2 Disorder

1.10 Natural History and Course of Illness

1.10.1 Initial Presentation

Clinical Vignette 1.2

1.10.2 Natural Course

The European Mania in Bipolar Longitudinal Evaluation of Medication

Clinical Vignette 1.3

When younger, Ms. M returned to her baseline with independent func-

1.10.3 Increased Morbidity and Mortality

1.10.4 Medical Comorbidity

1.10.5 Psychiatric Comorbidity

substance abuse prevalence rate of 61 % and a lifetime prevalence of drug and

The following call was issued by Chairman McKee, of the

To the Independent Republicans of Pennsylvania:

Frank Willing Leach, Secretary.

On the part of the Republican State Committee, appointed by Chairman Cooper.

On the part of Senator Mitchell’s Independent Republican Committee.

Philadelphia, May 3d, 1882.

To the Independent Republicans of Pennsylvania:

Very respectfully, your obedient servants,

Hon. Thomas V. Cooper, Chairman, etc.

With this communication ended all efforts at conciliation.