Lithium is frequently used as a mood stabilizer in patients with mood disorders. Lithium has a narrow therapeutic index and high toxicity. Predisposing factors for intoxication are advanced age, diet disturbances, comorbid medical conditions affecting heart, kidneys or central nervous system and polypharmacy. CASE REPORT: Here we present a case of a 74-year-old woman with a history of Parkinson’s disease, hypertension and bipolar disorder. She was using quetiapine, valsartan with hydrochlorothiazide and levodopa with carbidopa. She presented with altered mental status and muscle rigidity. The patient was admitted with acute lithium intoxication after her second dose of treatment. Blood lithium level increased to 3.58 mEq/L. The woman was hospitalized in the Internal Medicine Intensive Care Unit. With hydration, her symptoms resolved and her lithium level returned to normal after 118 hours. CONCLUSIONS: Prescribing physicians and emergency room physicians should be aware of conditions which may cause a decreased threshold for intoxication.
One of the dreaded life-threatening complications of diabetes mellitus (DM) is diabetic ketoacidosis (DKA). American Diabetic Association (ADA) came out with 2018 guidelines on the management of DM and its complications, but these are woefully silent on the clinical conundrums that accompany DKA in elderly patients. In elderly patients, DKA is often complicated by sepsis, atrial fibrillation, polypharmacy, nonketotic hyperosmolar states, atypical clinical presentations, acute kidney injury (AKI), dementia, and noncompliance with medications. Here in we highlight these conundrums that need to be addressed to improve morbidity and mortality in elderly patients.
Although antipsychotic prescribing in elderly patients using polypharmacy has not been studied in well-designed clinical trials and meta-analyses, there is an urgent need to monitor prescribing practice in this population. One of the possible approaches to optimize pharmacotherapy may be the involvement of clinical pharmacists (CPs). The aim of this research was to examine whether the involvement of a CP can improve treatment guidelines adherence and change the total number of medications per patient in older patients who are treated with excessive polypharmacy that includes antipsychotics.
This cohort retrospective study included older patients (65 years or older) treated with at least one antipsychotic and excessive polypharmacy (10 or more medications concurrently) between 2012 and 2014 in primary care. The main outcome measures were antipsychotic treatment guidelines’ adherence and the total number of medications per patient after the CP’s interventions. Only interventions including antipsychotics were studied in detail (i.e., discontinuation, switching, initiation, dose adjustment, change of another medication because of a drug-related problem). Data on diagnoses, patient pharmacotherapy and the CP’s interventions were obtained from clinical records and medical reviews. Age and acceptance of the CP’s interventions were used as predictive factors for antipsychotic treatment guidelines’ adherence.
Forty-nine patients were included. The CP suggested 21 different interventions of which nine (42.8%) were accepted by the general practitioners. The number of medications that patients received decreased after the CP’s interventions (N of medications before: 15.4; N of medications after: 12.0, p < 0.05). The acceptance of the CP’s recommendations, but not age, improved antipsychotic treatment guidelines’ adherence (p = 0.041).
These results show that a collaborative care approach including a CP in primary care significantly improved the adherence to treatment guidelines. The results also support the implementation of this service in the Slovenian healthcare system, although more studies are needed.
There is almost no data on antidepressant prescribing in older adults treated with polypharmacy, although this population represents approximately 50% of older patients. These patients are frequently excluded from double-blind randomized controlled trials, meta-analyses and existing treatment guidelines. The main aim of this paper was to identify data on antidepressant prescribing in depressed older adults on polypharmacy using a systematic review.
Randomized controlled clinical trials (RCTs) and other clinical trials in Medline/PubMed without language limitation (-2017) were searched to identify those with older depressed patients on polypharmacy. Only elderly patients (>65 years as mean) were included. Only approved antidepressants were included.
The systematic search identified 26 different clinical trials, although only one clinical open label trial with sertraline met the final inclusion criteria. This sertraline trial indicated the absence of clinically important drug-drug interactions and confirmed the effectiveness and safety of sertraline in routine clinical practice. Heterogeneity in this trial was high in almost all the categories except attrition and reporting bias.
Sertraline has the highest evidence level in older adults with depression on polypharmacy. According to the results of this review and due to a low number of appropriate trials, a basic understanding of psychopharmacology is the possible approach to avoid serious problematic drug combinations in these patients. Newer RCTs are also urgently needed. This is the first systematic review including patients treated with polypharmacy, and therefore, its results are important in the field of evidence-based medicine.