ELDER TIP The older adult at highest risk for suicide is at least age 85, is depressed, has high self-esteem, and needs to control his own life. Even a frail nursing home resident with these characteristics may have the strength to kill himself.
Signs and symptoms
Signs and symptoms vary widely, depending on whether the patient is experiencing a manic or a depressive episode.
During the assessment interview, the manic patient typically appears grandiose, euphoric, expansive, or irritable with little control over his activities and responses. He may describe hyperactive or excessive behavior, including elaborate plans for numerous social events, efforts to renew old acquaintances by telephoning friends at all hours of the night, buying sprees, or promiscuous sexual activity. He seldom hesitates to start projects for which he has little aptitude.
The patient’s activities may have a bizarre quality, such as dressing in colorful or strange garments, wearing excessive makeup, or giving advice to passing strangers. He commonly expresses an inflated sense of self-esteem, ranging from uncritical self-confidence to marked grandiosity, which may be delusional.
Note the patient’s speech patterns and concentration level. Accelerated and pressured speech, frequent changes of topic, and flight of ideas are common features of the manic phase. The patient is easily distracted and responds rapidly to external stimuli, such as background noise or a ringing telephone.
Physical examination of the manic patient may reveal signs of malnutrition and poor personal hygiene. He may report sleeping and eating less as well as being more physically active than usual.
Hypomania, more common than acute mania, can be recognized during the assessment interview by three classic symptoms: euphoric but unstable mood, pressured speech, and increased motor activity. The hypomanic patient may appear elated, hyperactive, easily distracted, talkative, irritable, impatient, impulsive, and full of energy but seldom exhibits flight of ideas. Delusions and other symptoms of psychotic intensity are never present.
The patient who experiences a depressive episode may report a loss of self-esteem, overwhelming inertia, social withdrawal, and feelings of hopelessness, apathy, or self-reproach. He may believe that he’s wicked and deserves to be punished. His growing sadness, guilt, negativity, and fatigue place extraordinary burdens on his family.
During the assessment interview, the depressed patient may speak and respond slowly. He may complain of difficulty concentrating or thinking clearly but is usually not obviously disoriented or intellectually impaired.
Physical examination may reveal reduced psychomotor activity, lethargy, low muscle tonus, weight loss, slowed gait, and constipation. The patient may also report sleep disturbances (falling asleep, staying asleep, or early morning awakening), sexual dysfunction, headaches, chest pains, and a heaviness in the limbs. Typically, symptoms are worse in the morning and gradually subside as the day goes on.
His concerns about his health may become hypochondriacal: He may worry excessively about having cancer or some other serious illness. In an elderly patient, physical symptoms may be the only clues to depression.
Suicide is an ever-present risk, especially as the depression begins to lift. At that point, a rising energy level may strengthen the patient’s resolve to carry out suicidal plans.
The suicidal patient may also harbor homicidal ideas — for example, thinking of killing his family either in anger or to spare them pain and disgrace.
Diagnosis
For characteristic findings in patients with this condition, see Diagnosing bipolar disorders, pages 452 and 453. Physical examination and laboratory tests, such as endocrine function studies, rule out medical causes of the mood disturbances, including intra-abdominal neoplasm, hypothyroidism, heart failure, cerebral arteriosclerosis, parkinsonism, psychoactive drug abuse, brain tumor, and uremia. Moreover, a review of the medications prescribed for other disorders may point to drug-induced depression or mania.
Treatment
Widely used to treat bipolar disorders, lithium has proved to be highly effective in relieving and preventing manic episodes. It curbs the accelerated thought processes and hyperactive behavior without producing the sedating effect of antipsychotic drugs. In addition, it may prevent the recurrence of depressive episodes; however, it’s ineffective in treating acute depression.
Because lithium has a narrow therapeutic range, treatment must be initiated cautiously and the dosage must be adjusted slowly. Therapeutic blood levels during the active manic period are 0.4 to 1.4 mEq/L. For safety, the level should never exceed 1.5 mEq/L. Therapeutic blood levels must be maintained for 7 to 10 days before the drug’s beneficial effects appear; for this reason, antipsychotic drugs commonly are used in the interim to provide sedation and symptomatic relief. Because lithium is excreted by the kidneys, any renal impairment necessitates withdrawal of the drug.
Anticonvulsants, such as carbamazepine, valproic acid, and clonazepam, are used either alone or with lithium to treat mood disorders. Carbamazepine and divalproex are effective in many patients who are lithium-resistant. Other anticonvulsant drugs have also been used. Electroconvulsive therapy is also effective.
Antidepressants are used to treat depressive symptoms, but they may trigger a manic episode.
Special considerations
For the manic patient:
❑ Remember the manic patient’s physical needs. Encourage him to eat. Alter the diet so that it’s high in calories, carbohydrates, and liquids.
❑ As the patient’s symptoms subside, encourage him to assume responsibility for personal care.
❑ Provide emotional support, maintain a calm environment, and set realistic goals for behavior.
❑ Provide diversionary activities suited to a short attention span; firmly discourage the patient if he tries to overextend himself. Provide structured activities involving large motor movements to expend surplus energy. Reduce or eliminate group activities during acute manic episodes.
❑ When necessary, reorient the patient to reality. Tactfully divert conversations when they become intimately concerned with other patients or staff members.
❑ Set limits in a calm, clear, and self-confident manner for the manic patient’s demanding, hyperactive, manipulative, and acting-out behaviors. Setting limits tells the patient that you’ll provide security and protection by refusing inappropriate and possibly harmful requests. Avoid leaving an opening for the patient to test you or argue with you.
❑ Listen to requests attentively and with a neutral attitude. Avoid power struggles if a patient tries to put you on the spot for an immediate answer. Explain that you’ll seriously consider the request and will respond later.
❑ Encourage solitary activities such as writing out one’s thoughts.
❑ Collaborate with other staff members to provide consistent responses to the patient’s manipulative or acting-out behaviors.
❑ Watch for early signs of frustration (when the patient’s anger escalates from verbal threats to hitting an object). Tell the patient firmly that threats and hitting are unacceptable. Explain that these behaviors show that he needs help to control his behavior. Inform him that the staff will help him move to a quiet area to help him control his behavior so he won’t hurt himself or others. Staff members who have practiced as a team can work effectively to prevent acting-out behavior or to remove and confine a patient.
❑ Alert the staff promptly when acting-out behavior escalates. It’s safer to have help available before you need it than to try controlling an anxious or frightened patient by yourself.
❑ After the incident is over and the patient is calm and in control, discuss his feelings with him and offer suggestions on how to prevent a recurrence.
❑ If the patient is taking lithium, tell him and his family to temporarily discontinue the drug and notify the physician if signs or symptoms of toxicity, such as diarrhea, abdominal cramps, vomiting, unsteadiness, drowsiness, muscle weakness, polyuria, and tremors, occur.
For the depressed patient:
❑ The depressed patient needs continual positive reinforcement to improve his self-esteem. Provide a structured routine, including activities to boost his self-confidence and promote interaction with others (for instance, group therapy). Keep reassuring him that his depression will lift.
❑ Encourage the patient to talk or to write down his feelings if he’s having trouble expressing them. Listen attentively and respectfully; allow him time to formulate his thoughts if he seems sluggish. Record your observations and conversations.
❑ To prevent possible self-injury or suicide, remove harmful objects (such as glass, belts, rope, or bobby pins) from the patient’s environment, observe him closely, and strictly supervise his medications. Institute suicide precautions as dictated by facility policy.
❑ Don’t forget the patient’s physical needs. If he’s too depressed to take care of himself, help him with personal hygiene measures. Encourage him to eat, or feed him if necessary. If he’s constipated, add high-fiber foods to his diet; offer small, frequent meals; and encourage physical activity. To help him sleep, give him back rubs or warm milk at bedtime.
❑ If the patient is taking an antidepressant, watch for signs of mania.
Pictures
Book Source Details
- Book Title: Professional Guide to Diseases (Eighth Edition)
- Author(s): Springhouse
- Year of Publication: 2005
- Copyright Details: Professional Guide to Diseases (Eighth Edition), Copyright © 2005 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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