Lithium for older adults with bipolar disorder: Should it still be considered a first-line agent?

Cognition in older age bipolar disorder: An analysis of archival data across the globe

BACKGROUND

Cognitive deficits in bipolar disorder (BD) impact functioning and are main contributors to disability in older age BD (OABD). We investigated the difference between OABD and age-comparable healthy comparison (HC) participants and, among those with BD, the associations between age, global cognitive performance, symptom severity and functioning using a large, cross-sectional, archival dataset harmonized from 7 international OABD studies.

METHODS

Data from the Global Aging and Geriatric Experiments in Bipolar Disorder (GAGE-BD) database, spanning various standardized measures of cognition, functioning and clinical characteristics, were analyzed. The sample included 662 euthymic to mildly symptomatic participants aged minimum 50years (509 BD, 153 HC), able to undergo extensive cognitive testing. Linear mixed models estimated associations between diagnosis and global cognitive performance (g-score, harmonized across studies), and within OABD between g-score and severity of mania and depressive symptoms, duration of illness and lithium use and of global functioning.

RESULTS

After adjustment for study cohort, age, gender and employment status, there was no significant difference in g-score between OABD and HC, while a significant interaction emerged between employment status and diagnostic group (better global cognition associated with working) in BD. Within OABD, better g-scores were associated with fewer manic symptoms, higher education and better functioning.

LIMITATIONS

Cross-sectional design and loss of granularity due to harmonization.

CONCLUSION

More research is needed to understand heterogenous longitudinal patterns of cognitive change in BD and understand whether particular cognitive domains might be affected in OABD in order to develop new therapeutic efforts for cognitive dysfunction OABD.

Lithium Dispensed for Adults Aged ≥ 50 Years Between 2012 and 2021: Analyses of a 10% Sample of the Australian Pharmaceutical Benefits Scheme

BACKGROUND

Lithium use seems to be declining in clinical practice. We examined the proportion of adults aged ≥ 50 years dispensed lithium between 2012 and 2021, and investigated the proportion of lithium users dispensed other medications.

METHODS

We used a 10% random sample data of the Australian Pharmaceutical Benefits Scheme from 2012 to 2021, and limited our analyses to adults aged ≥ 50 years. We retrieved data on lithium, other mood stabilisers, antipsychotics, antidepressants, anxiolytics and hypnotics, and medications for the treatment of other health systems.

RESULTS

We received 7081939 person-years records (53.2% women). The proportion of participants dispensed lithium decreased with age: 0.4% for those aged 50-59 years to < 0.1% for people aged ≥ 90 years. The dispensing of lithium increased over 10 years for those aged 50-69 and decreased in those older than 80 years. Among people dispensed lithium, nearly 1 in 5 were dispensed another mood stabiliser. Antipsychotics and antidepressants were dispensed to about 60% of participants dispensed lithium, with antidepressants dispensed more frequently to women than men. About 20% of people dispensed lithium were dispensed anxiolytics/hypnotics, more frequently for women than men. Medications to treat diseases of the alimentary, cardiovascular, endocrine and nervous systems were commonly dispensed to those dispensed lithium, as were antibiotics.

CONCLUSIONS

While the dispensing of lithium increased among young older adults since 2015 when guidelines for the management of mood disorders were published, our findings suggest that lithium may be under-utilised for the management of bipolar disorder in later life.

Impact of lithium on mortality among older adults with major psychiatric disorders: A 5-year prospective multicenter study

OBJECTIVE

Prior studies report conflicting results about the association between lithium use and all-cause mortality. In addition, data are scarce on this association among older adults with psychiatric disorders. In this report, we sought to examine the associations of lithium use with all-cause mortality and specific causes of death (i.e., due to cardiovascular disorder, non-cardiovascular disease, accident, or suicide) among older adults with psychiatric disorders during a 5-year follow-up period.

METHODS

In this observational epidemiological study, we used data from 561 patients belonging to a Cohort of individuals with Schizophrenia or Affective disorders aged 55-years or more (CSA). Patients taking lithium at baseline were first compared to patients not taking lithium, and then to patients taking (i) antiepileptics and (ii) atypical antipsychotics in sensitivity analyses. Analyses were adjusted for socio-demographic (e.g., age, gender), clinical characteristics (e.g., psychiatric diagnosis, cognitive functioning), and other psychotropic medications (e.g. benzodiazepines).

RESULTS

There was no significant association between lithium use and all-cause mortality [AOR=1.12; 95%CI=0.45-2.79; p=0.810] or disease-related mortality [AOR=1.37; 95%CI=0.51-3.65; p=0.530]. None of the 44 patients taking lithium died from suicide, whereas 4.0% (N=16) of patients not receiving lithium did.

CONCLUSION

These findings suggest that lithium may not be associated with all-cause or disease-related mortality and might be associated with reduced risk of suicide in this population. They argue against the underuse of lithium as compared with antiepileptics and atypical antipsychotics among older adults with mood disorders.

Neurotoxicity in chronic lithium poisoning

BACKGROUND

Lithium-induced neurotoxicity typically occurs with chronic accumulation rather than following acute overdose. There is little emphasis in the literature on the protracted nature of lithium neurotoxicity long after the lithium concentration returns to the therapeutic range.

AIMS

To characterise lithium neurotoxicity, with a view of increasing awareness of this important phenomenon.

METHODS

This is a retrospective observational study of patients presenting with lithium-induced neurotoxicity over a 5-year period to a clinical toxicology unit. Patients were identified through the unit's database, and clinical notes were analysed.

RESULTS

There were 22 patients, with a median age of 65 (range: 36-89) years. Six patients (27%) had previous lithium toxicity, and nine (41%) were regularly prescribed medications that impair lithium excretion. The median lithium concentration on presentation was 2.2 mmol/L, taking a median of 3 days to return to the therapeutic range. Reversible acute kidney injury was observed in 21 patients (95%) on presentation. The median length of stay was 13 (range: 3-95) days due mostly to delayed neurological recovery. Confusion was the predominant symptom, present in 21 (95%) patients, followed by tremors (18(82%)) and ataxia (16(73%)). Multiple investigations were performed to exclude delirium differentials, including 11 computed tomography (CT) and five magnetic resonance imaging (MRI) brain scans, all unremarkable.

CONCLUSIONS

Lithium neurotoxicity has a prolonged course. Its severity correlates poorly with lithium concentrations, which normalise quickly. Most poisonings occur in elderly patients with acute kidney injury. Prolonged delirium often prompts multiple unnecessary investigations. Rationalisation of lithium therapy is important in elderly patients.

Effect of age on the severity of chronic lithium poisoning

Objectives: Severe lithium toxicity is commonly observed in older people. We aimed to determine the extent to which age is associated with increased severity of chronic lithium poisoning and of which a range of possible factors might explain the associations.Method: We did a retrospective review of patients aged ≥15 years old with serum lithium concentrations ≥1.3 mmol/L from three hospitals. Clinical details, treatment and outcomes were recorded. eGFR, creatinine and lithium clearance were calculated. The severity of lithium toxicity was graded into five categories (Amdisen score). ANOVA was used to quantify the association between age and severity. Spearman correlation coefficient was used to explore relationships between age and different factors expected to alter severity. Ordinal regression analysis was used to determine the interdependence of age and these factors and age on severity of lithium toxicity.Results: From 2008-2018, there were 242 patients with a median age of 56.5 years (IQR: 41-69). There were 156 females (64%). There was a statistically significant association between Amdisen severity scores and age (p = .0004). The median calculated eGFR was 65 mL/min/1.73 m² (IQR: 41-91) with a corresponding estimated lithium clearance of 18 mL/min (IQR: 13.8-22.8). There was no correlation of age with initial serum lithium concentration (p = .76). There was a strong correlation between age and estimated lithium clearance (r = -0.72, 95% CI: -0.78 to -0.66, p < .001), lithium daily dose (r = -0.65, 95% CI: -0.72 to -0.57, p < .0001) and lithium concentration/dose (r = 0.62, 95% CI: 0.53-0.69, p < .0001). There was a weak correlation between age and infection (r = 0.18, 95% CI: 0.04-0.31, p = .009) and drug interactions (r = 0.25, 95% CI: 0.11-0.37, p = .0003). Ordinal regression indicated the independent predictors for severity of lithium toxicity were lithium concentration (p < .0001) and lithium clearance (p = .03) adjusted for age and dose.Conclusions: Despite lower lithium doses, older patients had more severe toxicity. Increased severity of lithium toxicity in the elderly is largely explainable by decreased lithium clearance from multiple factors such as age-related decline in renal function, drug interactions and infection.

Psychiatric and physical outcomes of long-term use of lithium in older adults with bipolar disorder and major depressive disorder: A cross-sectional multicenter study

OBJECTIVE

Although lithium is widely used in current practice to treat bipolar disorder (BD) and treatment-resistant major depressive disorder (MDD) among older adults, little is known about its efficacy and tolerability in this population, which is generally excluded from randomized clinical trials. The objective of this study was to evaluate the efficacy and tolerability of long-term use of lithium among older adults with BD and MDD.

METHOD

Data from the Cohort of individuals with Schizophrenia and mood disorders Aged 55 years or more (CSA) were used. Two groups of patients with BD and MDD were compared: those who were currently receiving lithium versus those who were not. The effects of lithium on psychiatric (i.e., depressive symptoms severity, perceived clinical severity, rates of psychiatric admissions in the past-year), geriatric (overall and cognitive functioning) and physical outcomes (i.e., rates of non-psychiatric medical comorbidities and general hospital admissions in the past-year) were evaluated. All analyses were adjusted for age, sex, duration of disorder, diagnosis, smoking status, alcohol use, and use of antipsychotics, antiepileptics or antidepressants.

RESULTS

Among the 281 older participants with BD or MDD, 15.7% were taking lithium for a mean duration of 12.5(SD = 11.6) years. Lithium use was associated with lower intensity of depressive symptoms, reduced perceived clinical global severity and lower benzodiazepine use (all p < 0.05), without being linked to greater rates of medical comorbidities, except for hypothyroidism.

LIMITATIONS

Data were cross-sectional and data on lifetime history of psychotropic medications was not assessed.

CONCLUSION

Our results suggest that long-term lithium use may be efficient and relatively well-tolerated in older adults with BD or treatment-resistant MDD.

Delphi survey of maintenance lithium treatment in older adults with bipolar disorder: An ISBD task force report

OBJECTIVES

Despite the growing numbers and proportion of older adults with bipolar disorder (OABD), there are very limited guidelines for the use of lithium with its double-edged potential for effectiveness and toxicity in this population. The primary aims of this Delphi survey were: (a) To determine the place of lithium among the preferred choices for maintenance treatment of OABD. (b) To provide detailed clinical guidelines for the safe and effective use of lithium in OABD.

METHODS

In the face of limited evidence, the Delphi survey method was used to achieve consensus by a group of 25 experts in OABD from nine countries. An oversight committee monitored and analyzed the results of each survey and formulated more focused questions with each subsequent iteration.

RESULTS

A 100% response rate was achieved for all three iterations of the survey. Lithium was the preferred choice for maintenance monotherapy in OABD. Serum levels of 0.4-0.8 mmol/L were recommended for ages 60-79 and serum levels of 0.4-0.7 mmol/L were recommended for ages 80 and over. Specific recommendations achieved consensus for second line monotherapy as well as for other drugs to be used in combination with lithium if necessary. Guidelines for routine monitoring of lithium in OABD were provided for laboratory investigations and clinical assessments.

CONCLUSIONS

Lithium remains the preferred choice for maintenance monotherapy in OABD. Laboratories should report the therapeutic range for serum levels of lithium separately for older adults.

Recommencing lithium in Older Adults with Bipolar I Disorder

OBJECTIVES

This paper addresses considerations in recommencing lithium in elderly patients with Bipolar I Disorder and medical comorbidity. We focus on nephrotoxicity and cognitive impairment.

METHODS

Case reports and review of relevant literature.

RESULTS

Three elderly psychogeriatric inpatients admitted with severe manic relapse following lithium cessation are described. In all cases, lithium was recommenced safely with good response.

CONCLUSIONS

Even with medical comorbidity it may be possible to recommence modified lithium therapy.

An observational study of 110 elderly lithium-treated patients followed up for 6 years with particular reference to renal function

BACKGROUND

Recent observational studies have focused on lithium treatment in the elderly, with particular reference to safety in terms of thyroid and renal functions. The purpose of this study was to compare the clinical characteristics of patients starting lithium treatment before (N = 79) or after (N = 31) the age of 65 years. Patients were followed up for 6 years with focus on renal function and prescription of levothyroxine and methimazole.

RESULTS

At baseline, median lithium serum concentration was 0.55 mmol/l. The estimated glomerular filtration rate was lower than 60 ml/min/1.73 m² in 43 (39%) patients. In a multiple regression analysis controlling for age and gender, we found a significant effect of duration of lithium treatment on estimated glomerular filtration rate (-0.85 ml/min/1.73 m² per year of prior exposure). The annual decline during follow-up was 2.3 ml/min/1.73 m². Two patients were prescribed levothyroxine, and two were prescribed methimazole for the first time during follow-up.

CONCLUSIONS

Median lithium serum concentration in this cohort of elderly patients with mainly bipolar disorders was lower than the therapeutic range indicated for younger adults. The decline in glomerular filtration rate may be accelerated by long-term lithium use. Thyroid and renal functions continue to require close monitoring throughout the course of lithium treatment. Trial registration NP/2013/3836. Registered 24 June 2013.

Lithium in late-life mania: a systematic review

The prevalence of mania among >65-year-olds ranges from 0.1% to 0.4% and its treatment is a particular challenge for clinicians. Although lithium is the treatment of choice for bipolar disorder (BD), its use in elderly population was recently questioned. This study provides a comprehensive review of literature on the efficacy and tolerability of lithium as a pharmacologic treatment for mania in elderly BD patients. We conducted a systematic review, based on PRISMA guidelines, of articles published between 1970 and August 2016 and indexed in the following databases: EMBASE, MEDLINE, Cochrane Library Databases and PsycINFO. The key words "age", "late-life", "geriatric", "elderly", and "older" were combined with words indicating pharmacologic treatments, such as lithium and other mood stabilizers and with the diagnostic terms "bipolar disorder" and "mania". Fifteen out of 196 retrieved studies met our inclusion criteria. Seven studies evaluated both the efficacy and tolerability of lithium treatment in elderly BD patients; a further three evaluated only the efficacy and five assessed tolerability. Only limited data on the treatment of elderly BD patients are available, but evidence suggests that lithium is effective and tolerated in this subgroup of patients and thus should remain a first-line drug. It seems to be more effective at lower doses and close monitoring of plasma concentrations is necessary.

Lithium Use in Older Adults is Associated with Increased Prescribing of Parkinson Medications

OBJECTIVE

To test the hypothesis of an increased incidence of antiparkinson drug prescribing or Parkinson disease (PD) diagnostic codes after chronic lithium treatment compared with chronic valproic acid or antidepressant treatment among older adults.

METHODS

A retrospective cohort study using healthcare administrative databases in Ontario, Canada included 1,749 lithium users, 1,787 valproic acid users, and 285,154 other antidepressant users ≥ 66 years old having used the drug continuously in monotherapy for at least 1 year. Outcome measures were start of (1) a dopaminergic medication (levodopa or a dopamine agonist), (2) any antiparkinson drug (levodopa, dopamine agonists, anticholinergic medication, amantadine, monoamine oxidase B inhibitors), (3) any antiparkinson drug or a diagnostic code for PD, and (4) any antiparkinson drug in the absence of a diagnostic code for PD.

RESULTS

For patients with no previous antipsychotic use, lithium monotherapy was associated with an increased incidence of dopaminergic drug use (adjusted HR: 1.87; 95% CI: 1.06-3.30) and an increased incidence of antiparkinson drug use or a PD diagnosis (adjusted HR: 1. 68; 95% CI: 1.13-2.48) compared with antidepressant monotherapy.

CONCLUSION

Chronic lithium use is associated with an increased incidence of dopaminergic drug use compared with antidepressants, identifying a prescribing cascade related to lithium use in the elderly. Whether this reflects inappropriate treatment of action tremor or treatment of drug-induced parkinsonism should be addressed by a close examination of prescribing practices.

Two years' outcome of acute mania in bipolar disorder: different effects of age and age of onset

BACKGROUND

Information about differences between younger and older patients with bipolar disorder and between older patients with early and late age of onset of illness during long-term treatment is scarce.

OBJECTIVES

This study aimed to investigate the differences in treatment and treatment outcome between older and younger manic bipolar patients and between early-onset bipolar (EOB) and late-onset bipolar (LOB) older patients.

METHOD

The European Mania in Bipolar Longitudinal Evaluation of Medication study was a 2-year prospective, observational study in 3459 bipolar patients on the treatment and outcome of patients with an acute manic or mixed episode. Patients were assessed at 6, 12, 18, and 24 months post-baseline. We calculated the number of patients with a remission, recovery, relapse, and recurrence and the mean time to achieve this.

RESULTS

Older patients did not differ from younger bipolar patients in achieving remission and recovery or suffering a relapse and in the time to achieve this. However, more older patients recurred and in shorter time. Older patients used less atypical antipsychotics and more antidepressants and other concomitant psychiatric medication. Older EOB and LOB patients did not differ in treatment, but more older LOB patients tended to recover than older EOB patients.

CONCLUSION

Older bipolar manic patients did not differ from younger bipolar patients in short-term treatment outcome (remission and recovery), but in the long term, this may be more difficult to maintain. Distinguishing age groups in bipolar study populations may be useful when considering treatment and treatment outcome and warrants further study.

Does lithium prevent Alzheimer's disease?

Lithium salts have a well-established role in the treatment of major affective disorders. More recently, experimental and clinical studies have provided evidence that lithium may also exert neuroprotective effects. In animal and cell culture models, lithium has been shown to increase neuronal viability through a combination of mechanisms that includes the inhibition of apoptosis, regulation of autophagy, increased mitochondrial function, and synthesis of neurotrophic factors. In humans, lithium treatment has been associated with humoral and structural evidence of neuroprotection, such as increased expression of anti-apoptotic genes, inhibition of cellular oxidative stress, synthesis of brain-derived neurotrophic factor (BDNF), cortical thickening, increased grey matter density, and hippocampal enlargement. Recent studies addressing the inhibition of glycogen synthase kinase-3 beta (GSK3B) by lithium have further suggested the modification of biological cascades that pertain to the pathophysiology of Alzheimer's disease (AD). A recent placebo-controlled clinical trial in patients with amnestic mild cognitive impairment (MCI) showed that long-term lithium treatment may actually slow the progression of cognitive and functional deficits, and also attenuate Tau hyperphosphorylation in the MCI-AD continuum. Therefore, lithium treatment may yield disease-modifying effects in AD, both by the specific modification of its pathophysiology via inhibition of overactive GSK3B, and by the unspecific provision of neurotrophic and neuroprotective support. Although the clinical evidence available so far is promising, further experimentation and replication of the evidence in large scale clinical trials is still required to assess the benefit of lithium in the treatment or prevention of cognitive decline in the elderly.

The clinical management of bipolar disorder complexity using a stratified model

OBJECTIVE

To provide practical and clinically meaningful treatment recommendations that amalgamate clinical and research considerations for several common, and as yet understudied, bipolar disorder complex presentations, within the framework of a proposed stratified model.

METHODS

A comprehensive search of the literature was undertaken using electronic database search engines (Medline, PubMed, Web of Science) using key words (e.g., bipolar disorder, anxiety, rapid cycling, and subsyndromal). All relevant randomised controlled trials were examined, in addition to review papers, meta-analyses, and book chapters known to the authors. The findings formed the basis of the treatment recommendations within this paper.

RESULTS

In light of the many broad presentations of bipolar disorder, a stratified model of bipolar disorder complexity was developed to facilitate consideration of the myriad of complexities that can occur during the longitudinal course of illness and the appropriate selection of treatment. Evidence-based treatment recommendations are provided for the following bipolar disorder presentations: bipolar II disorder, subsyndromal symptoms, mixed states, rapid cycling, comorbid anxiety, comorbid substance abuse, and for the following special populations: young, elderly, and bipolar disorder around the time of pregnancy and birth. In addition, some key strategies for countering treatment non-response and alternative medication recommendations are provided.

CONCLUSIONS

Treatment recommendations for the more challenging presentations of bipolar disorder have historically received less attention, despite their prevalence. This review acknowledges the weaknesses in the current evidence base on which treatment recommendations are generally formulated, and additionally emphasises the need for high-quality research in this area. The stratified model provides a means for conceptualizing the complexity of many bipolar disorder presentations and considering their management.

Psychotropic drug-related problems in the elderly

Almost any drug therapy has the potential to cause iatrogenic complications for older people, but the risk is particularly significant for those being treated for major psychiatric illnesses. In the past, focus was centered mostly upon relatively obvious forms of drug-related harm, such as adverse drug reactions and drug interactions, but it is clear that this approach substantially under-represents the extent of the problem. Other, more inclusive categorization systems can be used to capture a broader representation of the profile and severity of medication-related problems, and these can provide insight into more subtle concerns. Analysis of psychotropic drug-related problems in the elderly provides a basis for individual interventions to lessen the impact of iatrogenic harm, as well as systematic approaches that can be used in the clinical setting to diminish the likelihood of preventable problems in a vulnerable patient population.

The effects of lithium on renal function in older adults--a systematic review

Chronic renal failure (CRF) and nephrogenic diabetes insipidus (NDI) are potential consequences of chronic lithium use, while acute renal failure (ARF) has been described in lithium intoxication. We performed a systematic review of all studies pertaining to the effects of lithium on the kidney in older adults. The ARF incidence was 1.5% per person-year and concurrent loop diuretic and angiotensin-converting enzyme inhibitor use with lithium increased the risk. The CRF prevalence estimates varied from 1.2% to 34%, with risk factors including age, previous lithium intoxication, polyuria, previously impaired renal function, and decreased maximal urine osmolality. The prevalence of NDI varied widely from 1.8%  to 85%. Risk factors included lithium duration, dose, level, slow-release formulation, and clinical nonresponse. Except for amiloride use in NDI, there is little evidence for treatment of other lithium-induced adverse renal effects. Currently, there is no compelling evidence to suggest that lithium should be avoided in elderly patients for fear of renal side effects.

The science and practice of lithium therapy

INTRODUCTION

Despite more that 60 years of clinical experience, the effective use of lithium for the treatment of mood disorder, in particular bipolarity, is in danger of becoming obsolete. In part, this is because of exaggerated fears surrounding lithium toxicity, acute and long-term tolerability and the encumbrance of life-long plasma monitoring. Recent research has once again positioned lithium centre stage and amplified the importance of understanding its science and how this translates to clinical practice.

OBJECTIVE

The aim of this paper is to provide a sound knowledge base as regards the science and practice of lithium therapy.

METHOD

A comprehensive literature search using electronic databases was conducted along with a detailed review of articles known to the authors pertaining to the use of lithium. Studies were limited to English publications and those dealing with the management of psychiatric disorders in humans. The literature was synthesized and organized according to relevance to clinical practice and understanding.

RESULTS

Lithium has simple pharmacokinetics that require regular dosing and monitoring. Its mechanisms of action are complex and its effects are multi-faceted, extending beyond mood stability to neuroprotective and anti-suicidal properties. Its use in bipolar disorder is under-appreciated, particularly as it has the best evidence for prophylaxis, qualifying it perhaps as the only true mood stabilizer currently available. In practice, its risks and tolerability are exaggerated and can be readily minimized with knowledge of its clinical profile and judicious application.

CONCLUSION

Lithium is a safe and effective agent that should, whenever indicated, be used first-line for the treatment of bipolar disorder. A better understanding of its science alongside strategic management of its plasma levels will ensure both wider utility and improved outcomes.

Use of lithium in the treatment of bipolar disorder in late-life

Lithium is the oldest and still one of the most frequently prescribed mood stabilizers in the treatment of bipolar disorder. Nonetheless, the evidence for lithium efficacy in older patients with bipolar disorder is almost entirely extrapolated from younger adult patients. Here we review the literature on lithium in older patients with bipolar disorder, concentrating on the past 3 years. A definitive study demonstrating the efficacy and safety of lithium in older patients with bipolar disorder is still missing. However, several lines of indirect evidence suggest that it is beneficial and advantageous over other mood stabilizers in the acute and maintenance treatment of late-life bipolar disorder. In addition, lithium may have unique properties as a regenerative therapeutic with specific benefits in reducing the cognitive impairment and suicide rates associated with bipolar disorder across the adult lifespan. Aging-associated pharmacokinetic and pharmacodynamic changes as well as increased rates of medical comorbidities and polypharmacy predispose older patients to a higher risk of lithium toxicity. Careful monitoring and adjustment of lithium dosage is especially important in older adults to minimize the risk of toxicity.