Q:  Concerned about Elderly Mother taking Lithium

My mother has been manic depressive for over thirty years and has been
treated with Lithium during this period quite successfully thanks to close
monitoring of her moods and medication adjustments overseen by my father and their
doctor.

My father died five years ago now and since this time my mother has been on an
endless rollercoaster of highs and lows with very few periods of "normal" mood.
These bouts can be directly linked to the inability of the UK system to monitor her
closely enough and to ensure the correct levels of drugs in her system.

As a direct result of one incident my mother became toxic with sores on her body,
mouth etc, extreme confusion, manias and even aggression which once again confined
her to hospital.

Since this time she has had a series of urinary tract infections that seem to knock
her sideways and she ends up back in the mental hospital with the mania, confusion
etc etc

My question is, do you think that aged nearly 70 she has been on Lithium too long?
Does the fact that she has been allowed to become toxic on more than one occasion
affect her mental state (much more confused and spacey) as well as her renal
function (constant urinary tract infections)?  Should she even been on Lithium with
such a history?  As we speak she remains in hospital, confused, various manias and
no help in sight.

Appreciate your thoughts and guidance.


Dear Jackie --

Sorry to hear about this unfortunate course of events. Knowing nothing more than this, one of the things that stands out the most is when a stabilizing influence on things your father had: your mother tolerated lithium well when he was around. Alternatively, his passing may have been really overwhelming for her. Probably both are true -- as well as the difficulties that can arise from lithium when blood levels are not monitored closely. (The experience of people with mental health problems in the United States is so disastrous sometimes, it is hard to imagine that things could be any worse in the UK system; perhaps we romanticize it, but generally the idea that any one can get treatment, regardless of income, makes your system extremely attractive compared to ours. The experience you describe suggests that perhaps there are problems in your system as well.

Treatment of elders with lithium is recognized as carrying much more risk than in younger folks. Having had episodes of lithium toxicity does increase the risk further. I sometimes seen it recommended that a person who has had severe lithium toxicity not be treated without medication thereafter, but sometimes making that leap to an alternative approach is difficult if a person has done extremely well on lithium prior to that time.

Urinary tract infections can really throw people sideways, all right. They can cause a "pseudo-dementia", in which people look like they have Alzheimer's, but can recover well once the infection is treated. So recurrent infections could indeed cause a lot of trouble. At this point I would presume that the hospital team will be looking at alternatives to lithium, but be careful not to raise hopes too high that an alternative approach will be vastly better. It can be difficult to find a really effective alternative sometimes (e.g. low- dose Depakote, or low- dose risperidone) when there are simultaneous medical problems. 

I hope things do indeed get better, and quickly.

Dr. Phelps