June 1, How many times have we all jotted down a list to take with us to the supermarket? Even a simple vertical column of ordinary household items requires more than we realize. We scan areas of the house and pull from memory different food stuffs or supplies that need to be replenished or replaced: All this information requires a flow of memory, organization, and planning.
Treatment of Mania An adequate review of effective, evidenced-based psychosocial interventions for bipolar disorder is beyond the scope of this column. However, the capacity of psychosocial interventions to prevent hospitalization associated with recurrence makes awareness of these interventions crucial to good care.
Readers are referred to the works of Miklowitz and colleagues6,7 for a review of the evidence. There is a growing consensus based on expert opinion,8 published guidelines,9,10 and the STEP-BD reports11,12 that antiepileptics, called mood stabilizers in this context, are preferable both for acute treatment and prevention of recurrence in late-life mania and bipolar disorder depression.
The anticonvulsant divalproex is increasingly considered first choice for treatment and prevention of mania. A therapeutic level is available; while hepatic toxicity is a risk, it is infrequent.
Divalproex inhibits hepatic enzymes that metabolize medications frequently used by older adults. Dose, precautions, and therapeutic levels for other mood stabilizers appear in Table 3.
Due to the delay in the anti-manic effects of mood stabilizers, a 3-week period including titration to a therapeutic range is the minimum time required to establish treatment responsiveness.
In the interim, people whose manic excitement is extreme, exhausting, or overly aggressive will require an antipsychotic or benzodiazepine. As shown in Table 3, numerous atypical antipsychotics are Food and Drug Administration approved for the treatment of mania. Based on meta-analyses, they appear to be equally superior to placebo13 such that the choice of an individual agent is based on Conclusion on bipolar disorder profiles and patient vulnerabilities.
However, the available data on the treatment of mania in the STEP-BD study as well as the meta-analyses14 includes few older adults.
They must have a current Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition,17 diagnosis of bipolar disorder, Type 1 manic, mixed, hypomanicbe medically stable, and be free of schizophrenia and dementia.
These patients will be randomized to receive monotherapy with lithium or divalproex with dose titration to be completed within 3 weeks Table 4. Doses are increased or decreased based on side effects as well as therapeutic levels across initial, intermediate, and final target ranges.
Lithium mg or divalproex mg is initiated BID and is adjusted by increasing or decreasing on a step by step basis, with one step equaling one of the twice daily doses. An increase or decease of one to two steps is made depending upon where the therapeutic level falls in the initial, intermediate, or final range.
Therapeutic levels, side effects, and symptomatic response or lack thereof are obtained on days 4, 9, 15, and 21 following baseline.
Blood work to ensure safety is collected at baseline and weeks 3, 6, and 9 and includes complete blood count, transaminases, and amylase.
The onset of diabetes insipidous polyuria, polydipsia may also be cause for discontinuation of lithium. Lorazepam, then risperidone, may be added during the first 3 weeks for as needed use when agitation, aggression, anxiety, hyperactivity, or insomnia are excessive.
Although study results are not expected to appear beforethe GERI-BD protocol provide an expert opinion for aggressive treatment of late-life mania. Nonetheless, numerous concerns argue for caution when considering lithium for the initiation of treatment.
Advanced age, absence of family history of bipolar disorder, mania secondary to another medical condition particularly strokeor dementia predict poor response to lithium.
The age-related decline in renal function means older adults are at increased risk of toxicity because lithium is cleared solely by the kidneys.
Structural brain changes which may not be clinically apparent are associated with higher risk of toxicity. Drug interactions which are less dangerous and less common in younger patients complicate the use of lithium in older adults. Laboratory tests which should be checked at least annually in patients treated with lithium include fasting blood sugar, thyroid function, creatinine clearance, blood urea nitrogen, and electrolytes.
Diabetes insipidous polydipsia, polyuriahyperglycemia, thyroid abnormalities, congestive heart failure or arrhythmia, and psoriasis are among the more frequent reasons for changing to an alternative treatment.
Toxicity in older adults may occur at plasma levels below the therapeutic range of 1. However, mild tremor and nystagmus without functional consequences frequently accompany lithium treatment and should not be considered signs of toxicity.
Toxicity may result when dehydration due to vomiting, diarrhea, fever, or sweating contracts the extracellular volume of distribution. Lithium is reabsorbed in preference to sodium leaving little margin for error.
Renal failure, diuretics, reduced intake of salt or fluids, and concomitant use of nonsteroidal anti-inflammatory agents excepting aspirin and sulindacincrease the risk of toxicity. In acute renal failure, dialysis or forced saline diuresis will be required.
It may be particularly useful in cases of medication inefficacy or intolerance, imminent suicidal risk, or morbid nutritional status. Advanced age, concurrent antidepressants, and heart disease increase the risk of adverse reactions, with cardiovascular complications being the most frequent events.
The cognitive impairment associated with ECT includes transient postictal confusion, anterograde or retrograde amnesia, and less commonly a permanent amnestic syndrome in which recall of events surrounding the treatment is blank. Treatments may be limited to twice weekly and applied bifrontally or unilaterally to the non-dominant hemisphere to minimize confusion.
However, bilateral treatment may be more effective.Section. Category of Impairments, Mental Neurocognitive disorders Schizophrenia spectrum and other psychotic disorders.
Catatonic Disorder Due to Another Medical Condition. Clinicians use this classification when there is evidence from the history, physical examination, or laboratory findings that the disturbance is the direct pathophysiological consequence of another medical condition.
Indeed, he is famous for his argument about the stability of a bipolar world. In a article, written at the height of the Cold War, Waltz argued that the U.S.-Soviet rivalry was likely to be. Bipolar disorder is the modern term for mood swings that used to be called manic depression.
It is a fairly common yet serious mental illness, affecting between one and five per cent of Americans. BJPsych Advances distils current clinical knowledge into a single resource, written and peer-reviewed by expert clinicians to meet the CPD needs of consultant psychiatrists.
Each issue includes commissioned articles dealing with physical and biological aspects of treatment, psychological and sociological interventions, management issues and treatments specific to the different psychiatric.
Objective: This article reviews the epidemiology, etiology, assessment, and management of bipolar disorder. Special attention is paid to factors that complicate treatment, including nonadherence, comorbid disorders, mixed mania, and depression.