Mohammed T. Abou-Saleh

458 PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRYTable 8.3 Affective morbidity and side effects in patients on lithium,divided according to age (results shown as mean+SEM)Age (years) n AMI BDI a Side effects559.9 61 0.16+0.02 6.3+0.9 8.8+1.060.0–69.9 51 0.14+0.02 5.8+0.7 8.7+1.3470.0 16 0.06+0.01 a 6.9+1.7 7.6+1.4a Beck Depression Inventory.with b-blockers, resulting in the slowing of heart rate, and similarinteractions have been noted when lithium is combined withdigoxin, with reports of increased risk of sudden cardiovasculardeath on this combination in predisposed patients. The elderly,however, are commonly prescribed thiazide diuretics for hypertension,which reduce lithium clearance and increase plasmalithium levels by reducing plasma volume, causing an increase inlithium and sodium reabsorption. This interaction is not observedwith potassium-sparing diuretics and loop diuretics, such asfrusemide. Amiloride, however, has been used for treatinglithium-induced polyuria and diabetes insipidus. Finally, thewidely used non-steroidal anti-inflammatory drugs have beenreported to reduce lithium clearance and increase plasma levels,except for aspirin and sulindac. Ibuprofen was shown to causesignificant decrease in renal lithium clearance and was linked tocases of lithium intoxication. Indomethacin, however, has beenused to treat lithium-induced polyuria.CONCLUSIONGood management calls for a comprehensive reassessment of thepatient’s condition to review diagnosis and to identify the reasonsfor treatment failure by a diligent assessment of the adequacy ofprevious treatments.With regard to therapeutic strategies, these involve twoconcepts: alternative and adjunct therapy (Figure 80.1). Theadjunct approach takes primacy over the alternative treatmentapproach. Adjunct treatments include lithium 49,50 , folate and T4/T3, and also cognitive or interpersonal psychotherapy. Alternativebasic treatment involves changing the conventionalantidepressant to a new one, such as a selective serotoninreuptake inhibitor (SSRI) or the use of ECT. In mania, adjunctor alternative treatments are essentially anticonvulsants, principallyvalproate added to lithium or neuroleptics.GUIDELINES FOR LONG-TERM THERAPYIN THE ELDERLYThe long-term management of recurrent affective disorders in theelderly starts with a careful assessment of the patient’s psychiatric,physical and social condition. This involves full psychiatricexamination and physical investigation for careful diagnosis,including the pattern of symptoms, previous episodes and theirnature and treatment. Patients who have recovered from an acuteepisode of illness should be maintained for a minimum of 6months at the same dosage, and those with a delusional firstepisode in late life, or who had recurrent (minimum of twoepisodes in 5 years) illnesses, should be considered for prophylaxiswith antidepressants or lithium. The choice of antidepressant willdepend on the physical condition of the patient. Conventionalantidepressants should only be considered for the physically well.Otherwise, the new generation of antidepressants, includingthe SSRIs, should be considered. Lofepramine, fluoxetine,fluvoxamine, paroxetine and sertraline are safer antidepressants,with no cardiotoxic effects. Fluoxetine and sertraline have beensuccessfully evaluated as maintenance and prophylactic treatments.It is prudent to start with low doses and build up the dosegradually, with careful monitoring of side effects. Lithium isparticularly effective in bipolar illness and in delusional unipolarillness, either given alone or as an adjunct in those who arealready receiving antidepressants with incomplete response.Carbamazepine and valproate is a useful adjunct in bipolarpatients who have failed to respond to lithium. ECT is a highlyeffective treatment for relapses–recurrences, whilst continuing onmaintenance or prophylactic medication. The elderly requireregular follow-up, to monitor their physical, psychiatric and socialconditions and to deal with any emergent problems andcomplications, with careful attention to their social network.REFERENCES1. Katona CLE. The epidemiology and natural history of depression inold age. In Ghose K, ed., Antidepressants for Elderly People. London:Chapman and Hall, 1989; 27–40.2. Post F. The management and nature of depressive illnesses in late life:a follow-through study. Br J Psychiat 1972; 121: 393.3. Blessed G, Wilson ID. The contemporary natural history ofdepression in old age. Br J Psychiat 1982; 141: 59.4. Christie AB. Changing patterns in mental illness in the elderly. Br JPsychiat 1982; 140: 154.5. Murphy E. The prognosis of depression in old age. Br J Psychiat1983; 142: 111–19.6. Baldwin RC, Jolley DJ. Prognosis of depression in old age. 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