REVIEW OF: Christ J et al, Pharmacopsychiatry 2023;56(5):188–196 STUDY TYPE: Delphi survey Lithium remains a cornerstone treatment for bipolar disorder (BD), but it requires extra care when used in older adults. As the population ages, bipolar diagnoses in older adults are becoming more common, which means clinicians need to know how to use lithium safely in this group. This study provides some expert guidance.

Researchers conducted a Delphi survey, a structured method for reaching consensus among experts. They tapped into the expertise of 24 German specialists in geriatric medicine and lithium therapy. After two rounds of questionnaires, they reached a consensus on 21 key recommendations for starting, monitoring, and stopping lithium in older adults.

Starting: Lithium is recommended for long-term maintenance of BD, as an add-on for treatment-resistant depression, and for suicide prevention in older adults. There’s no strict age cutoff for starting lithium. It can be used with medications like angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, opioids, and diuretics, but monitor closely. Mild cognitive impairment and a history of falls do not contraindicate starting lithium. Check the patient’s creatinine, estimated glomerular filtration rate (eGFR), blood count, electrolytes, thyroid stimulating hormone (TSH), triiodothyronine (T3), thyroxine (T4), ECG, weight, blood pressure, and heart rate before prescribing lithium.

Monitoring: Regularly follow a patient’s creatinine, eGFR, blood count, electrolytes, TSH, T3, T4, ECG, weight, and blood pressure. Cystatin C, a protein that can give a more accurate picture of kidney function than creatinine alone, might be worth monitoring in certain cases. Depending on the situation, you might want to consider thyroid sonography, neurological examination, and psychological examination. The recommended serum lithium levels are 0.4–0.7 mmol/L for those aged 60–79, and 0.4–0.6 mmol/L for those 80 years old and up. Stopping: If kidney function declines, consult a nephrologist. When you do stop, taper slowly over three months to reduce the risk of a relapse. Consider lamotrigine, valproate, or quetiapine as alternatives.

Not everything in the survey was cut and dry—there wasn’t consensus on using lithium during acute manic episodes, in patients with schizoaffective disorder, or alongside nonsteroidal ­anti-inflammatory drugs or digoxin. The experts also disagreed on how often to check lithium levels and eGFR when a patient has other meds in the mix, and on specific contraindications like frailty, dementia, or being underweight.

Carlat Take Treating older adults with lithium is a balancing act. While the experts agree on many points, the gaps in consensus show that there’s still a lot we don’t know. Clearly, lithium can be a powerful tool for mood stabilization and suicide prevention in older adults, but it requires lower therapeutic doses and careful, individualized management. For more on prescribing lithium in older adults, see “Considerations in Prescribing Lithium in Older Adults” in CGPR Oct/Nov/Dec 2024.