Marilyn Segal

Chronic renal failure in lithium‐using geriatric patients: effects of lithium continuation versus discontinuation—a 60‐month retrospective study

Lithium remains an important treatment in bipolar disorder. Although lithium is often discontinued because of signs of renal failure, it is unclear if this alters the course of renal function in the majority of patients. We hypothesize that in geriatric patients with chronic renal failure (CRF), who have a high burden of medical illness, lithium continuation does not significantly impact renal function (glomerular filtration rate (eGFR)).

The McGill Geriatric Lithium-Induced Diabetes Insipidus Clinical Study (McGLIDICS)

Objective: Despite being a common and potentially serious condition, nephrogenic diabetes insipidus (NDI) remains poorly understood in older lithium users. Our main objective was to compare the prevalence of NDI symptoms and decreased urine osmolality ([UOsm] < 300 milli-Osmoles [mOsm/kg]) among geriatric and adult lithium users. We also assessed NDI symptoms, serum sodium (Na+), and urine specific gravity (USG) as possible surrogate measures of decreased UOsm, and ascertained whether potential etiologic factors independently correlated with decreased UOsm. Method: This was a cross-sectional study of 100 consecutive outpatients treated with lithium from 6 tertiary care clinics, of which 45 were geriatric (aged 65 years and older) and 55 adult (aged 18 to 64 years). Patients completed a symptom questionnaire and underwent laboratory tests, including UOsm, serum Na+, and USG. Results: Geriatric and adult lithium users had similar rates of decreased UOsm (12.5%, compared with 17.9%, P = 0.74), but geriatric patients reported less symptoms (P < 0.05). Although UOsm did not correlate with symptoms or current serum Na+, USG of less than 1.010 was suggestive of UOsm of less than 300 mOsm/kg. Age, lithium duration, and serum lithium level were independently associated with UOsm. Conclusions: The prevalence of decreased UOsm is similar in geriatric and adult lithium users, but older patients are less likely to report urinary and thirst symptoms. Although subjective symptoms do not correlate with UOsm, USG may be a cost-efficient clinical surrogate measure for UOsm. We suggest clinicians increase their vigilance for decreased UOsm, especially in lithium users with advanced age, longer duration of lithium exposure, and higher lithium levels. This may potentially prevent lithium intoxication, falls, hypernatremic events, and renal dysfunction.

Renal function in geriatric psychiatry patients compared to non-psychiatric older adults: effects of lithium use and other factors.

Objectives: Chronic renal failure is very common, affecting 30%–40% of community-dwelling elderly. We wished to verify whether geriatric psychiatry patients are at increased risk of renal dysfunction compared to elderly controls, as well as whether lithium exposure and other factors are important predictors of risk.Method: This is a four-year retrospective cohort and nested case-control study at a Canadian tertiary-care hospital using data from March 2007 to March 2011. We compared 82 geriatric psychiatry outpatients and 200 psychotropic-naïve family medicine controls aged ≥65. Our main continuous measure of renal outcome was change in estimated glomerular filtration rate (eGFR). Multivariate analyses were performed to determine potential risk factors for renal dysfunction in geriatric psychiatry patients, including age, hypertension, diabetes mellitus, diuretics, and lithium duration.Results: Clinically important decreases in eGFR (>8 mL/min/1.73 m2) were found in 40.2% of geriatric psychiatry patients compared to 29.5% of controls (p = 0.040). Multivariate analyses found that lithium duration was independently associated with adverse renal outcome in patients with eGFR < 60 mL/min/1.73 m2. In this sub-population, lithium users had clinically important decreases in eGFR when compared to non-lithium users: 10.3 vs. 0.40 mL/min/1.73 m2 (p = 0.017).Conclusion: Geriatric psychiatry patients are at a greater risk for clinically important decreases of renal function than similarly aged controls. Lithium appears to be an important risk factor for renal dysfunction when eGFR is <60 mL/min/1.73 m2. However, in the majority of older adults who have normal kidney function, lithium use appears to be safe.

Diabetes mellitus onset in geriatric patients: does long‐term atypical antipsychotic exposure increase risk?

Diabetes mellitus (DM) in common in adults using psychotropic medications. However, it remains largely unknown whether there is an additional risk of diabetes mellitus (DM) in elderly psychiatric outpatients, particularly those with long‐term exposure to atypical antipsychotics (AP).

Mobile Health Technology in Late-Life Mental Illness: A Focused Literature Review

OBJECTIVE In an era of rising geriatric mental health care needs worldwide, technological advances can help address care needs in a cost-effective fashion. Our objective in this review was to assess whether mobile health technology, such as tablets and smartphones, are feasible to use in patients with late-life mental and cognitive disorders, as well as whether they were generally reliable modes of mental health/cognitive assessment. METHODS We performed a focused literature review of MEDLINE, PsychInfo, and Embase databases, including papers specifically assessing the implementation of mobile health technologies: electronic tablets (e.g., iPad), smartphones, and other mobile computerized equipment in older adults (age ≥65 years) diagnosed with or at risk of a mental and/or cognitive disorder. RESULTS A total of 2,079 records were assessed, of which 7 papers were of direct relevance. Studies investigated a broad variety of mobile health technologies. Almost all examined samples with dementia/cognitive dysfunction or at risk for those disorders. All studies exclusively examined the use of mobile health technologies for the assessment of cognitive and or mental illness symptoms or disorders. None of the studies reported participants having any difficulties using the mobile health technology assessments and overall reliability was similar to paper-and-pencil modes of assessment. CONCLUSION Overall, mobile health technologies were found to be feasible by patients and had promising reliability for the assessment of cognitive and mental illness domains in older adults. Future clinical trials will be necessary to assess whether portable communication interventions (e.g., symptom tracking) can improve geriatric mental health outcomes.

Using hypernatraemic events to predict reduced renal function in elderly lithium patients: a brief report

Diabetes insipidus (DI) is a recognized adverse effect of lithium use, and studies have shown an association between decreased renal function and DI in patients using lithium. We hypothesize that hypernatraemic events that occur in DI predict decreased renal function in elderly patients on lithium.

Statins in the prevention of lithium-associated diabetes insipidus: preliminary findings

Dalia El-Gamal, Saša Frank, Seth Hallström and Gunther Marsche Institute of Experimental and Clinical Pharmacology, Medical University of Graz, Graz, Austria; Institute of Molecular Biology and Biochemistry, Medical University of Graz, Graz, Austria and Institute of Physiological Chemistry, Medical University of Graz, Graz, Austria Correspondence: Gunther Marsche, Institute of Experimental and Clinical Pharmacology, Medical University of Graz, Universitätsplatz 4, Graz 8010, Austria. E-mail: gunther.marsche@medunigraz.at

Health Canada Warning on Citalopram and Escitalopram—Its Effects on Prescribing in Consultation-Liaison Psychiatry

BACKGROUND Reports have suggested that citalopram and escitalopram may prolong the QTc interval, leading Health Canada to issue a warning to limit their dosages in 2012. Little is known about the effects of this warning and similar ones (e.g., by the Food and Drug Administration) on antidepressant prescribing in inpatients with acute medical illness, who are theoretically at high risk of QTc prolongation. The main objective of our study is to examine the effect of the Health Canada warning on citalopram/escitalopram prescribing patterns in the consultation-liaison (C-L) psychiatry setting. METHODS We performed a retrospective cohort study including 275 randomly selected inpatients with medical illness assessed by the psychiatric C-L team of a large Canadian academic hospital between 2008 and 2014. We grouped patients based on whether they were assessed by the C-L team before or after the citalopram Health Canada warning. Our primary outcome was change in citalopram/escitalopram prescribing patterns. RESULTS We found that of patients seen before the Health Canada warning, a significantly higher number were prescribed citalopram/escitalopram (44.1% vs. 22.3%, χ(2) = 14.835, p < 0.001), even after controlling for confounders. However, the percentage of patients using a citalopram/escitalopram dose exceeding those recommended by the Health Canada warning was similar in both groups (8.9% vs. 12.1%, χ(2) = 0.233, p = 0.63). CONCLUSIONS Overall, C-L psychiatrists were less likely to prescribe citalopram/escitalopram following the Health Canada warning, which did not translate into safer dosing. Clinicians should not avoid prescribing citalopram/escitalopram appropriately in medically vulnerable inpatients when benefits outweigh disadvantages.

Is environmental temperature related to renal symptoms, serum lithium levels, and other laboratory test results in current lithium users?†

Lithium continues to be an important mood disorder treatment. Although patients exposed to higher environmental temperatures may have serum lithium level elevations due to dehydration, there is conflicting data in the literature. In addition, no study has assessed the association between temperature and other renal laboratory tests and symptoms in lithium users.

Does lower urine-specific gravity predict decline in renal function and hypernatremia in older adults exposed to psychotropic medications? An exploratory analysis.

Background Exposure to psychotropic agents, including lithium, antipsychotics and antidepressants, has been associated with nephrogenic diabetes insipidus (NDI). This is especially concerning in older adults already at risk of developing chronic kidney disease (CKD) and hypernatremia with advanced aging. This study investigates whether commonly performed random urine-specific gravity (USG) tests can predict adverse NDI outcomes (CKD and hypernatremia) in psychotropic-exposed older adults. Methods This was a retrospective longitudinal study of 173 geriatric psychiatry patients (age ≥65 years) exposed to psychotropic medications. Our main continuous outcome was ‘decrease in estimated glomerular filtration rate (eGFR) >10 mL/min/1.73 m2’ over 5-year follow-up. Hypernatremia and acute kidney injury (AKI) were secondary outcomes. Whether baseline USG <1.010 predicted outcomes was assessed in bivariate and multivariate analyses. Results USG <1.010 predicted hypernatremia episodes (sodium concentration ≥150 mmol/L—28.1 versus 12%, χ2 = 4.7, P = 0.03). USG <1.010 [odds ratio 2.36 (95% confidence interval 0.93–6.0), P = 0.07], baseline eGFR and typical antipsychotic use independently predicted decrease in eGFR >10 mL/min/1.73 m2. Patients with a single baseline sodium concentration of ≥140 mmol/L and USG <1.010 have a 26.3% incidence of AKI and a 57.9% incidence of hypernatremia over the ensuing 5 years. Conclusions In psychotropic-exposed older adults, there appears to be a clinically important association between low USG and developing both hypernatremia and CKD. USG may be a useful surrogate measure for NDI-related outcomes in large administrative database studies, where ideal measures such as 24-h urine volume may not be available.