| Course | NUR-7643 Advanced Assessment, Differential Diagnosis, and Management of Psychiatric Disorders Geriatric Populations Part B |
|---|---|
| Module | Module 2 |
| Paper type | Case analysis: bipolar mania in an older adult |
| Length | About 1,047 words, 6 pages |
| Format | APA 7 student paper |
| School | Thomas Edison State University |
| Program | M.S. in Nursing, Psychiatric Mental Health Nurse Practitioner |
| Updated | October 2026 |
Free sample paper for NUR 7643 Module 2
She Stopped Lithium for Her Kidneys: Treating Mania and Choosing a Mood Stabilizer for a 68-Year-Old With Bipolar I Disorder
Student Name
M.S. in Nursing, Psychiatric Mental Health Nurse Practitioner, Thomas Edison State University
NUR-7643: Advanced Assessment, Differential Diagnosis, and Management of Psychiatric Disorders: Geriatric Populations Part B
Mentor Name
Month Day, Year
She Stopped Lithium for Her Kidneys: Treating Mania and Choosing a Mood Stabilizer for a 68-Year-Old With Bipolar I Disorder
The Return of Mania
Carol, an invented patient, is 68 and kept the books for a group of car dealerships in Monmouth County until she retired. She was diagnosed with bipolar I disorder at 26 after a manic episode that led to her first hospital stay, and she has taken lithium for most of the forty years since, with two further manic episodes, both after stopping it. Six months ago her primary care clinician told her that her kidney function had declined to an estimated filtration rate of 54, in the range of stage 3 chronic kidney disease. Frightened, she tapered off the lithium on her own.
Three weeks ago her husband noticed she was sleeping three hours a night, cleaning the house at 2 a.m., talking quickly and making plans to buy a second home at the shore. She has opened two new credit cards and argued with neighbors. She is irritable when interrupted and says she has never felt better. For blood pressure she takes lisinopril with a thiazide, and she reaches for ibuprofen most days for sore knees. She has no history of dementia, and her last cognitive screen two years ago was normal.
Assessment in Later Life
The paper confirms a manic episode by its features and duration and then asks what is different at 68. A new mania late in life can signal a neurological cause, such as a stroke, tumor or early dementia, but Carol's long history of the same illness, with episodes after stopping lithium, makes a relapse of her known disorder far more likely. Her blood tests show normal thyroid, calcium, sodium and blood sugar, and a urine drug screen is negative. A brief cognitive screen shows distractibility consistent with mania, and the paper plans to repeat it after recovery, since older adults with bipolar disorder have higher rates of cognitive decline.
Sajatovic et al. (2015), reporting for the International Society for Bipolar Disorders Task Force, describe older-age bipolar disorder as a condition marked by medical illness, more medicines and concerns about cognitive impairment and decline, with too little research focused on older adults. They urge clinicians to address medical comorbidity and cognition alongside mood, which the paper applies to Carol's kidneys, her blood pressure drugs and her memory.
Lithium or Divalproex?
Young et al. (2017) randomly assigned 224 inpatients and outpatients aged 60 or older with bipolar I disorder in a manic, hypomanic or mixed episode to lithium, aimed at a blood level of 0.80 to 0.99, or divalproex, aimed at a valproate level of 80 to 99, for nine weeks. The investigators expected divalproex to be better tolerated and more effective. Instead, both were similarly tolerated, with no difference in sedation, though lithium caused more tremor. Response rates at nine weeks were similar, 79 percent with lithium and 73 percent with divalproex, but the change in mania scores over time favored lithium. Few patients needed added risperidone.
Weighing the Kidneys
Shine et al. (2015) analyzed laboratory records from a large population in Oxfordshire, comparing people with and without lithium in their blood tests over many years. After adjusting for age, sex and diabetes, lithium was linked with a higher risk of stage 3 chronic kidney disease, with a hazard ratio of 1.93, and of hypothyroidism and raised calcium. The risks appeared early in treatment and were higher when lithium levels were above the median. Women had greater risk of kidney and thyroid problems than men.
For Carol, this means her worry was reasonable. Her kidney decline may be partly due to lithium, and partly to her age, blood pressure and regular ibuprofen. The paper does not dismiss the risk; it sets it beside the history of three manic episodes after stopping lithium and the trial showing lithium works in older patients.
After a long discussion with Carol and her husband, divalproex is chosen for this episode, with the target level kept at the lower end, because her kidney function is already reduced and her blood pressure drugs include a diuretic and an ACE inhibitor, both of which raise lithium levels. A low dose of quetiapine at night is added for two weeks to restore her sleep. Liver tests, a blood count with platelets and a valproate level are checked at baseline, at one week and then monthly. If divalproex fails or is not tolerated, lithium at a lower target level with close kidney monitoring and her nephrologist's input remains an option she is willing to consider.
| Option | Evidence | Concerns for Carol |
|---|---|---|
| Lithium at a lower level | Favored in GERI-BD; long record for her | Kidneys, thyroid, calcium; needs close levels |
| Divalproex | Similar response in GERI-BD | Weight, tremor, liver tests, falls, platelets |
| Short-term antipsychotic | Fast control of mania | Metabolic effects, falls |
Protecting Her Kidneys and Her Money
Her ibuprofen is stopped and replaced with acetaminophen and a knee injection referral. Her kidney function is rechecked in three months. Her husband, with her agreement, holds the new credit cards until the mania settles, and the shore house plan is put on hold for at least six months. Her sleep schedule is fixed, and she agrees to a nightly bedtime routine.
Relapse Prevention
Carol and her husband review her early warning signs, which have been the same for forty years: less sleep, late-night cleaning and grand plans. A written plan states that if two nights of short sleep occur, she will call the clinic the next day. A psychoeducation group for older adults with bipolar disorder meets at the hospital, and she agrees to attend. Her cognitive screen will be repeated once she is well.
Conclusion
Carol has a manic relapse of long-standing bipolar I disorder after stopping lithium out of a reasonable fear for her kidneys. A neurological cause was considered and judged unlikely. GERI-BD shows lithium and divalproex both work in older adults, with lithium slightly ahead, and a large laboratory study confirms lithium's risks to the kidneys, thyroid and calcium. Divalproex, chosen with her and her husband because of her reduced kidney function and interacting blood pressure drugs, is started with monitoring, ibuprofen is stopped and a relapse plan built on her familiar warning signs completes her care.
References
Sajatovic, M., Strejilevich, S. A., Gildengers, A. G., Dols, A., Al Jurdi, R. K., Forester, B. P., Kessing, L. V., Beyer, J., Manes, F., Rej, S., Rosa, A. R., Schouws, S. N., Tsai, S., Young, R. C., & Shulman, K. I. (2015). A report on older-age bipolar disorder from the International Society for Bipolar Disorders Task Force. Bipolar Disorders, 17(7), 689-704. https://doi.org/10.1111/bdi.12331
Shine, B., McKnight, R. F., Leaver, L., & Geddes, J. R. (2015). Long-term effects of lithium on renal, thyroid, and parathyroid function: A retrospective analysis of laboratory data. The Lancet, 386(9992), 461-468. https://doi.org/10.1016/S0140-6736(14)61842-0
Young, R. C., Mulsant, B. H., Sajatovic, M., Gildengers, A. G., Gyulai, L., Al Jurdi, R. K., Beyer, J., Evans, J., Banerjee, S., Greenberg, R., Marino, P., Kunik, M. E., Chen, P., Barrett, M., Schulberg, H. C., Bruce, M. L., Reynolds, C. F., & Alexopoulos, G. S. (2017). GERI-BD: A randomized double-blind controlled trial of lithium and divalproex in the treatment of mania in older patients with bipolar disorder. American Journal of Psychiatry, 174(11), 1086-1093. https://doi.org/10.1176/appi.ajp.2017.15050657
What the NUR 7643 Module 2 instructions ask for
Bipolar disorder in later life falls within the geriatric prescribing and disease management that TESU sets out for NUR-7643, and without a published syllabus, module two follows an older woman's manic relapse. Expect an analysis that confirms the episode, considers neurological causes of mania in later life, weighs lithium and divalproex using trial evidence from older adults, explains long-term risks to the kidneys, thyroid and calcium, checks interacting drugs such as diuretics, ACE inhibitors and anti-inflammatory pain relievers, writes the laboratory schedule for the chosen drug and plans relapse prevention with the family. Other versions of the task use late-life bipolar depression or mania that begins after a stroke. See whether your brief wants target levels, a nephrology referral or a cognitive follow-up plan.
How the NUR 7643 Module 2 example is put together
Carol's forty years of bipolar disorder, her decision to stop lithium for her kidneys and her new manic episode open the paper. Neurological causes are considered and set aside, and the task force report frames her care as an older adult. GERI-BD is reported with its levels, response rates and the result that surprised its authors. The laboratory study of lithium's long-term effects is reported, and her kidney decline is set in that light. A three-row table weighs the options, and divalproex is chosen with her and her husband, with a short course of quetiapine for sleep and a monitoring schedule. Stopping ibuprofen, protecting her money and a relapse plan close the case. Margin notes explain the neurological check and the shared decision.
Where the marks sit in the NUR 7643 Module 2 rubric
Late-life bipolar cases are graded on confirming the episode, considering neurological causes in an older adult, choosing a mood stabilizer from evidence in older patients, explaining long-term risks with data, identifying interacting drugs and writing a monitoring schedule, and planning relapse prevention with the family. Mentors credit a decision reached with the patient that respects a reasonable fear rather than dismissing it. Stopping a drug that harms the kidneys, such as regular ibuprofen, is often noted as careful prescribing. Repeating a cognitive screen after recovery shows attention to the higher rate of decline in older adults with bipolar disorder. Quote the GERI-BD response rates and the Oxfordshire hazard ratios correctly, and lay out why divalproex won for Carol.
NUR 7643 Module 2 help from the desk
Students often restart lithium at the old dose without checking kidney function or the drugs that raise its level; review diuretics, ACE inhibitors and anti-inflammatory pain relievers. Another gap is skipping neurological causes of mania in an older adult. Do not dismiss a patient's fear about side effects; answer it with data. Write the laboratory checks for whichever drug is chosen, including platelets and liver tests for divalproex. Protect money and sleep during mania. Repeat the cognitive screen when well. An older-adult mood case of your own can start with the rubric; the first custom draft is free.
Write yours, or have the desk draft it
This paper is an original model document written by our desk, not a submitted student paper and not an official Thomas Edison State University document. Read it for the moves, then write your own to the instructions in your classroom. If you want one built to your exact prompt and rubric, the first custom sample is free and arrives in 24 to 48 hours.
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NUR 7643 Module 2 questions, answered
Where can I find a free NUR 7643 Module 2 sample paper?
Carol's late-life bipolar case, from stopping lithium to a shared choice of divalproex, is printed in full above.
Is lithium or divalproex better for mania in older adults?
In GERI-BD, both worked with similar response rates, 79 and 73 percent, but mania scores improved more over time with lithium.
Does lithium damage the kidneys?
A large laboratory study linked lithium with a higher risk of stage 3 kidney disease, low thyroid and raised calcium, especially at higher levels.
Which drugs raise lithium levels?
Water pills of the thiazide type, ACE inhibitors, ARBs and over-the-counter pain relievers like ibuprofen or naproxen all push lithium levels up.
Why consider a neurological cause of mania in an older adult?
New mania late in life can come from stroke, tumors or early dementia, so these are considered before assuming a relapse.