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

Abstract

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.

What is the optimal serum level for lithium in the maintenance treatment of bipolar disorder? A systematic review and recommendations from the ISBD/IGSLI Task Force on treatment with lithium

“…For the elderly there was also no consensus. However, the majority of the members endorsed the recommendation that the standard therapeutic level should be 0.40‐0.60 mmol/L, with the option to go to maximally 0.70 of 0.80 mmol/L in elderly 65‐79 years and to maximally 0.7 mmol/L in elderly 80 years and older (Figure ), which is in line with the recommendations on the use of lithium in the elderly from the ISBD Task Force on Older Adults with Bipolar Disorder: that although “the balance between lithium toxicity and efficacy has not been studied in older patients and the recommendations are mainly based on clinical judgement and fear of drug‐related adverse events” , the upper limit should be lower than in younger adults …”

The 2020 Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders

“…The benefits of lithium in severe mood disorders, and the risks of discontinuing treatment in those with bipolar disorder should be considered carefully. However, lithium should be used with greater caution in the elderly given increased susceptibility to worsening of cognitive function which can occur even at low serum levels (Malhi et al, 2016c; Shulman et al, 2019). There are concerns regarding ECG changes and cardiac safety with lithium therapy, which should prompt regular ECG monitoring (Mehta and Vannozzi, 2017).…”

Clinical use of lithium salts: guide for users and prescribers

“…In older patients, doses of lithium should be about 20% lower than those for younger patients, as determined by the attending clinician (Shulman et al 2019). Common adverse effects in the elderly, in addition to those already described, can include: confusion or worsening of cognitive functions, unsteady balance and gait (ataxia), restless movements (akathisia), declining kidney function, hypothyroidism, possible worsening of diabetes mellitus, and leg-swelling (peripheral edema).…”