bipolar

what is bipolar disorder?

disorders in which individuals experience extremes of mood polarity

a manic episode is required for this dx

a depressive episode is not required for this dx

episodes begin suddenly and escalate rapidly; they last a few days to several months

manic episodes must be present for at least a week for dx

relapse is common- 37%

what is a manic episode?

elevated, expansive, irritable mood for at least 1 week

mood disturbances causing social, work, or interpersonal problems

3 of the following:

• inflated self esteem, grandiosity

• decreased need for sleep

• hyperverbal

• flight of ideas, racing thoughts

• distractibility

• increased goal directed activity, agitation

• excessive involvement in pleasurable activity

manic behaviors

disturbed speech patterns

altered social, interpersonal, and occupational relationships

alterations in activities and appearance

alterations of affect

alterations of perception

impaired judgment, social blunders occur, involvement with alcohol common

functioning decreases

excess is common- spending sprees, sexual indiscretions, loud clothing, excessive makeup

what are some signs of a manic episode?

less sleep

risky behavior

irritability

flight of ideas

rapid speech

hypersexuality

what is a hypomanic episode?

impairment less severe than manic episode

length of episode is at least 4 days

not severe enough to warrant hospitalization

does not cause “marked impairment” at home, school, work- but it is observable by others and is distinctly different behavior

persistent elevated, expansive, or irritable mood plus 3 of the following:

• increased self esteem or grandiosity

• decreased need for sleep

• distractibility

• increased goal directed activity

what is a depressive episode?

causes more suffering and is more disabling than manic or hypomanic

tends to be more debilitating- state of depression about 70% of the time

typically develops at a lower age than unipolar depression

more likely to express paranoid thoughts, irritability, and experience hallucinations

depressive episode signs

withdrawal

passivity

insomnia, daytime sleepiness

anorexia or hyperphagia- craving for carbs

sluggish thinking

difficulty concentrating

diminished interest in activites

decrease in speech

excessive, inappropriate feelings of guilt

fatigue

high rate of suicide

what are the types of bipolar disorder?

type 1

type 2

hypomanic

cyclothymic

what is bipolar 1?

patient experiences swings between manic episodes and major depression

with rapid cycling

with melancholic features- loss of pleasure

with psychotic features- delusions or hallucinations

anxious distress- feeling keyed up, difficulty concentrating

what is bipolar 2?

patient experiences swings between hypomania and depression

has NEVER experienced a manic episode- only hypomanic

experienced major depression (lasting at least 2 weeks) as well as a hypomanic episode (lasting at least 4 days)

5-15% go on to develop a full manic episode at some point

what is cyclothymic disorder?

between hypomania and dysthymia

swings from one to the other but does not experience extremes of either arc

symptoms occur for at least 2 years and without remission for more than 2 months

experiences many hypomanic episodes and numerous dysthymic-level episodes

15-50% go on to develop bipolar disorder

altered relationships

failed relationships

job loss and job failure

overbearing behavior

increased sex drive

alienation of family

mood lability leads to falling in and out of love

a need to engage people (even strangers); can become intrusive and overbearing

causes of relationship problems

manipulation of others’ self esteem

ability to find vulnerability in others

ability to shift responsibility

testing limits

alienation of family

comorbidity

87% of individuals with a manic-hypomanic disorder have a comorbid mental health disorder

substance abuse is common

those who abuse drugs have a higher hospitalization rate and poorer chance of recovery

methamphetamine abuse can mimic mania

nursing management for bipolar disorder

the goal is to get acute mania under control, preventing acute relapse when remission occurs, and returning to prior level of functioning

using a matter of fact tone minimizes the need for pt to respond defensively and avoid power struggles; conveys control of situation and provides empathy

giving clear, concise directions and comments; keep remarks breif but simple, many cannot tolerate lengthy discussion

limit setting; protect vulnerable pts and keep them from being drawn into the anger the manic pt feels; keep calm instead of angry, avoid arguing, and do not debate issues

nursing interventions for bipolar disorder

reinforce reality

respond to legitimate complaints to defuse irritability and to develop trust

redirect pts to healthier activities

provide portable food/snacks and drinks

high protein, high calorie foods

daily multivitamins

weight pt regularly

provide a quiet environment for sleep

structure to avoid stimulating activities during the evening

reduce caffeine intake

assess sleep-rest patterns

milieu management for bipolar disorder

protect the pt and others in the environment

assess the pt for self harm or suicide risk

assure staff consistency

reduce environment stimuli- lighting, noise, unnecessary activity

refrain from escalating the pt’s behavior- move with pt to a quiet area

reinforce hygiene and appropriate attire

engage in achievable milieu activities that increase self esteem

promote established mileu routines to avoid anxiety and confusion

offer meds as rx

pt education for bipolar

teach about bipolar illness and management

inform how to identify symptoms of relapse

educate about meds (side effects, therapeutic effects)

teach pt coping skills for living with bipolar

community services, bipolar support groups

consistent follow ups

seek emergency tx if s/s are out of control

antimanic drugs

tx of manic pts with bipolar

stabilizes mood, resulting in more functional behavior

adherence is priority

lithium

absorbed in the Gi tract, excreted through kidneys

plasma half life is 24 hrs

narrow therapeutic index: 0.6-1.2 mEq/L

take at the same time daily

report vomiting, coarse tremor, sedation, weakness, vertigo

maintain self intake and a balanced diet

illness with fever, excessive sweating may require a dose adjustment

lithium level: morning lab work- 8-12 hours after last dose

common side effects of lithium

mild hand tremor

hypocalcemia

decreased libido

erectile dysfunction

polyuria/polydipsia (70%)

weight gain

bloated feeling

sleeplessness

lightheadedness

lithium toxicity

toxic serum level of lithium: greater than 1.5 to 2.0 mEq/L

v/d

drowsiness

confusion

lack of coordination

coarse hand tremor

muscle twitching

T wave depression on EKG

acute toxicity: seizures, oliguria, circulatory failure, coma, death

special considerations for lithium

pt should visit the doctor regularly to check their lithium levels

assess renal and thyroid function to ensure proper excretion

lithium is eliminated from the kidney, so dose adjustment may be needed in older adults with decreased kidney function

loss of water from the body (sweating, v/d) may cause lithium level to rise which requires a temporary lowering of the daily dose

actual damage of the kidney is uncommon in people whose blood levels of Li have stayed within the therapeutic range

lithium nursing interventions

elevate legs to reduce edema

maintain consistent salt intake and increase with heavy sweating

use contraception- fetal CV malformation in 1st trimester, neonatal toxicity after

no driving until stabilized

monitor lithium levels

identify side effects

drink 10-12 glasses of water daily

anticonvulsants

can be used as mood stabilizers

originally developed to treat seizures, but they were found to help unstable moods as well

valproic acid (divalproex sodium)

for some people, especially with “mixed” s/s of mania and depression, or those with rapid cylic BD, valproic acid may work better than lithium

anticonvulsant examples

divalproex sodium- depakote

valproate sodium- depakon (injection)

carbamazepine- tegretol

lamotrigine- lamictal

oxcarbazepine- trileptal

gabapentin- neurontin

topiramate- topamax

divalproex (depakote)

used since 1960s as an antiepileptic agent

1995- approved for tx of mania

considered a first line agent

therapeutic level: 50-125 mcg/mL

rapid onset of action- can be used without trying Li in more acute situations

side effects: weight gain, tremors, GI upset, dose related thrombocytopenia

warnings: hepatotoxic, pancreatitis, teratogenic

nursing interventions: educate women of child bearing age, pregnancy test prior to tx, LFTs

carbamazepine (tegretol)

effective for pts who do not respond to Li or VPA

faster onset than Li

can be given in combo with Li

side effects: n/v, anorexia, sedation, drowsiness

agranulocytosis- weekly CBC