Lithium. Introduction. Patient Information Leaflet Andrew Nielsen Updated 21 September 2007.

Transcription

1 Lithium Patient Information Leaflet Andrew Nielsen Updated 21 September Introduction Lithium was discovered to be effective in treating elevated mood in 1949 by the Australian psychiatrist John Cade. Lithium is used to treat elevated mood (mania) and depressed mood (depression) in people with bipolar affective disorder. Lithium also increases the effectiveness of antidepressant medications. It is given with antidepressant medications to treat depression in people who are depressed but do not experience episodes of elevated mood. (Lithium can also be used to decrease aggression, self-injury and steroid-induced psychosis.) Lithium is also effective in treating depression in people with major depression who do not become manic or have bipolar disorder; however, antidepressants are more effective and have fewer side effects. Lithium is thought to have an effect via several mechanisms. It substitutes for some of the sodium, potassium, magnesium and calcium ions that pass in and out of the nerve cells in the brain (neurons). It also has an effect inside the brain cells by altering the mechanism of the cell and altering the chemical communication between cells. Lithium can change the quantity of neurotransmitter receptors on cells, and this might be the mechanism by which lithium helps other drugs stop depression. Lithium has been shown to protect neurons in the brain, and to restore the amount of cells in the hippocampus, a part of the brain that might be effected in some people by depression and/or posttraumatic stress disorder. Lithium is one of only two drugs that have been shown to decrease the risk of suicide. This effect is not fully explained by its ability to make mood normal. Lithium is the third element of the periodic table. Technically, lithium is a metal; it is given as a salt, the same way iron in iron tablets is given as a salt. Taking Lithium In Australia, lithium is sold in standard and slow-release preparations. The standard preparation is called Lithicarb and the slow release formulation is called Quilonum SR. The slow release preparations cause fewer side effects but are more expensive for the government; Quilonum is available in public hospitals only with a prescription to a community pharmacy. Lithicarb comes in 250mg tablets and Quilonum comes in 450mg tablets; this helps stop mix-ups about which type of lithium tablets someone is on. Lithium can be taken once or twice a day. Taking it twice a day might increase its effectiveness. Taking it once a day is easier to remember. A dosette box helps people to remember to take their tablets. A dosette box is a box with separate compartments where tablets are stored for each day of the week, and sometimes, time of the day. They can be bought from the pharmacy were you get your medication. If even more help is needed, a pre-packaged Webster Pack containing tablets for two weeks can be obtained from the pharmacy where you get your medication. If you miss a dose of lithium, you should not take an extra one the next day to catch up. Before, or shortly after you start lithium, you need to have blood tests that check the function of your thyroid gland and kidneys, your levels of calcium, phosphate and glucose, and to ensure that you are

2 not pregnant. An ECG (electrocardiogram) might be done to check the electrical impulses of your heart. This is done by briefly attaching recording wires across your chest and to your arms. You should have a physical examination done by a doctor, such as your GP, before, or shortly after, you start taking lithium. Some authorities recommend that lithium treatment is started in hospital, but this is not necessary. Stopping Lithium Lithium should not be stopped suddenly except in an emergency. It should be stopped over 1 to 2 months. If lithium is used to treat BPAD, stopping it suddenly can cause an episode of manic, elevated mood. There is some evidence that if lithium is stopped, it will not work as well for elevated mood when it is restarted. It is also possible that intermittent treatment with lithium makes the overall course of bipolar disorder worse. This means that once lithium is started, it should only be stopped after careful consideration. Talk to your doctor before you stop the lithium (unless there is an urgent reason to stop the lithium). In one study, stopping lithium increased the risk of suicide twenty fold. Side Effects of Lithium that Start Soon After Treatment The side effects of lithium that might start soon after treatment are listed below. Most are not common. Fine tremor, especially of the hands Diarrhea Muscle weakness Thirst, which causes increased fluid intake and urine production Memory and concentration problems Changes in creativity Weight gain Epileptic seizures Psoriasis, acne and/or follicular keratosis (a lumpy rash) Muscle stiffness or increased muscle tension The tremor that is caused by lithium usually stops with time. On the other hand, it worsens during activities that need fine control. The tremor can be reduced by stopping caffeine (tea, coffee, cola, energy drinks, chocolate), decreasing anxiety, and by taking medications called beta-blockers. Betablockers include medications such as atenolol. Beta-blockers should not be taken by people who have insulin-dependent diabetes, asthma, heart failure, heart rhythm/ecg (electrocardiogram) disturbances or low blood pressure. Lithium also rarely causes a tremor like the one that occurs with Parkinson s disease. Thirst can be decreased by taking lithium once a day.

3 Lithium can cause thinking and memory problems. On the other hand, studies of writers and artists found that most of them were more creative when they were taking lithium, because they were more organized. Some people feel inspired by having a high mood and others just enjoy the feeling of being high. This is unfortunate as the best thing for thinking and concentration is to have a mood that is neither elevated nor depressed. Lithium can decrease the seizure threshold. That is, it can make epilepsy worse, and if you do not have epilepsy, there is a very slight chance that you could have an epileptic seizure. However, this is not usually a reason to stop people driving or to make them have supervised baths when they start taking lithium. There is a theoretical risk of the side effect of tightening of the muscles in the throat making it hard to breath. Lithium can also change the electrical reading of the heart when an ECG recording is make; this is of little practicable significance. Alcohol and Lithium Because lithium causes drowsiness, it increases the effect of alcohol. This is especially important in driving, operating machinery, caring for children or walking near traffic. For example, if your blood alcohol level was 0.05, you might be just as impaired as if your blood alcohol level was, say, 0.08 and you were not taking lithium. (If there are doubts about driving, driving ability can be tested by occupational therapists.) Lithium also increases the drowsiness caused by other medications, such as antihistamines and benzodiazepines, or by other things, such as missing sleep. Lithium and Your Kidneys Kidneys Your kidneys are kidney-shaped organs that are about 10cm long and located in your back, deep to your lower ribs. They produce urine which is stored in your bladder until you pass it. The production of urine has several important roles. If you drink more water than you need, you pass the un-needed water as urine. If you are unable to drink water, your kidneys stop producing as much urine, so you do not become dehydrated. In a similar way, the kidneys also regulate the amount of various salts (dissolved molecules) in your blood. The kidneys also excrete wastes and medications from the body. Lithium carbonate is a salt of a lithium atom and a carbonate molecule, and it is excreted from the body by the kidneys. Polydipsia, Polyuria and Nephrogenic Diabetes Insipidus If someone has been treated with lithium for some time, the ability of thier kidneys to concentrate urine is sometimes decreased. If this has happened to someone, they will pass more urine. Because they pass more urine, they need to drink more water. The inability to concentrate urine caused by lithium is called nephrogenic diabetes insipidus. Drinking extra water because of excess thirst is called polydipsia. Passing extra urine is called polyuria. People usually pass less than two liters of urine per day. Someone with polydipsia might pass 10 liters of water per day. Polyuria is diagnosed by collecting a whole day s urine and sending it for analysis at a pathology laboratory, where the volume of urine and its make up are measured. If someone develops polyuria, further investigation might require a brief admission to a medical hospital. Lithium-induced nephrogenic diabetes insipidus is treated with a specific type of diuretic. (Diuretics ( fluid tablets ) usually increase urine production, but when they are used in this way, they decrease urine production to normal levels.) If someone with diabetes insipidus is unconscious, they might need to be given fluid in a drip, so they do not become dehydrated.

4 Lithium and Renal (Kidney) Failure. The healthy kidneys have a great deal more capacity than they need. The only importance of a small reduction in renal function is if it is either 1) followed by further decrease in renal function or 2) represents an underlying problem that should be fixed. A small reduction in kidney function occurs in about 20% of people who take lithium for greater than 20 years. This is significant only after a patient has been on lithium for many years and also is elderly or has other kidney disease. Lithium very rarely causes another problem with the kidneys called interstitial nephritis. This is an inflammation of the kidneys and is more damaging. Some authorities recommend that people on lithium have their kidney function checked each year by measuring their creatinine clearance. Creatinine is a protein in the blood that is flushed out by the kidneys. How quickly the kidneys flush it out reflects how well they are functioning in general. The creatinine clearance test involves checking how much creatinine your kidneys flush out in a day and comparing it to how much creatinine is in your blood. This is done by collecting 24 hours of urine and having a blood test when you bring it into the pathology centre. Because this test measures the volume of urine passed over 24 hours, it can also detect polyuria before it becomes noticeable. Lithium and People who already have Renal Disease If someone has renal disease, their kidneys might be vulnerable to further damage by lithium. This means that they should not take lithium. If someone all ready has complete renal failure, produces no urine, and is on dialysis, they can take lithium, as it will not further hurt their kidneys. They might be eligible for a renal transplant in the future, however. If someone has a renal (kidney) disease, their kidneys might flush out less than the usual amount of lithium. If it was safe for them to take lithium, they would need to take less than the usual dose of lithium. Lithium Toxicity If the levels of lithium in your blood become too high, the lithium might become poisonous, or toxic. You need to know the symptoms of lithium toxicity. If people around you know about your illness, it would be best if they knew about the signs of lithium toxicity too. If you may be experiencing lithium toxicity, seek medical attention immediately. Signs of lithium toxicity can be remembered by dividing them up into brain, digestive tract (gut) and muscle signs. On the other hand, the first sign of lithium toxicity can be feeling generally unwell. So, if you re feeling yuck, think lithium. The signs of lithium toxicity are feeling generally unwell or like you have the flu drowsiness (sleepiness) poor co-ordination slurred speech decreased appetite (being not hungry) nausea (feeling like you want to throw up) vomiting diarrhea worsening tremor (having the shakes ) muscle twitches On the other hand, mild tremor is a normal side effect of lithium and does not necessarily mean that lithium toxicity has occurred. Lithium toxicity is caused by either taking too much lithium or by the kidneys flushing out less or not

5 enough. The kidneys flush out less lithium if you take medication that stops them working as well or if the blood supply to your kidney is reduced. The blood supply to your kidney is reduced by dehydration or by heart failure. All this sounds complicated, but the most important causes of lithium toxicity are listed below. The most important causes of lithium toxicity are: Not drinking enough water or drinking less water than usual Vomiting Diarrhea Increased sweating o o from hot weather from increased exercise Other medications. These are discussed in the section Lithium and Other Medications. Changing to a very low salt diet Lithium overdose o o accidental intentional Not drinking enough, vomiting, diarrhea and excessive sweating are all causes of dehydration. You can get dehydrated by doing sport or exercise that you are not used to or by particularly hot weather. Early signs of dehydration include feeling thirsty and having dark urine. If you become dehydrated, the lithium levels will only become too high if you continue to take lithium before you replenish your fluid levels (and have pale urine again or the usual color). That means that if the weather is particularly hot, or you can not keep up your fluid intake, or you have done unusual exercise, or have diarrhea or vomiting, you should make sure that your lithium levels do not get too high. Do this by missing a dose or two until you have had enough fluid and given your kidneys time to flush out the same amount of lithium that they usually do before the next dose. You can work this out by making sure that your urine is pale, that you are not thirsty and you have recovered from what might have made you dehydrated. If you need to miss more than a dose or two, or if you are unsure, you should contact your doctor. Severe lithium toxicity can cause renal (kidney) damage and brain damage. Mild episodes of lithium toxicity increase the risk of long term kidney failure from lithium. Lithium and Your Thyroid Gland The thyroid gland is a gland in the neck, just in front of and below the voice box (larynx). It controls the metabolic rate of the body, that is, the rate that the body burns food and energy. It controls the body s metabolic rate by releasing thyroid hormone. The more thyroid hormone in the blood, the

6 higher the metabolic rate. A goitre is a large lump that appears at the front of someone s neck if their thyroid gland is enlarged. (The American spelling of goitre is goiter. ) Lithium can have a number of effects on the thyroid gland. It can cause the thyroid gland to produce too little thyroid hormone, a condition called hypothyroidism. ( Hypo- means not enough of something.) This makes the metabolic rate of the body decrease and weight gain to occur. Low levels of thyroid hormone are detected by regular blood tests before any harm is done. The problem is fixed by taking tablets with thyroid hormone, also called thyroxine. Thyroid hormone tablets in Australia are called Oroxine or Eutroxsig. The thyroid gland usually returns to normal if the lithium is stopped. It is quite common for lithium to cause hypothyroidism. It occurs in 20% of middle aged women on lithium, for example. Taking thyroid hormone tablets with lithium can be an advantage, because thyroid hormone is often used to help manage bipolar affective disorder or depression. Lithium can also cause goitre with normal thyroid hormone levels. This is also treated by taking thyroid hormone. Rarely, lithium can cause thyroid hormone levels to be increased. Lithium can very rarely cause exopthalmos, a condition where one s eyes bulge forward a little, which is associated with the thyroid side effects of lithium. Lithium and your Parathyroid Gland Lithium can occasionally effect the parathyroid glands. These small glands are located in the neck, beside the thyroid gland. They control the body s levels of calcium and phosphate. The parathyroid glands are monitored by measuring calcium levels with the other blood tests that are done for lithium treatment. Lithium and Peripheral Neuropathy Lithium very rarely causes peripheral neuropathy. That is, it very rarely decrease the sensation of the feet. It very rarely can cause downbeat nystagmus, where the eyes have trouble moving up and down normally. Lithium and Idiopathic Intracranial Hypertension Very rarely, lithium can cause benign intracranial hypertension, a condition were the pressure in the cerebrospinal fluid around the brain increases. This causes symptoms such as double vision, decreased vision, headache and ringing in the ears. In the unlikely event that you have a new onset of these symptoms (particularly visual ones), you should see a doctor, who will make sure that you have not developed idiopathic intracranial hypertension. Lithium and Your Heart Lithium can slightly change the electrical pattern of the heart shown on an ECG (electrocardiogram). These changes are usually of little importance. Very rarely, lithium can exacerbate cardiac arrhythmias (abnormal electrical conduction of the heart) or cause new arrhythmias. These problems can be detected by having an ECG. Lithium does not alter the QTc (corrected QT interval) of the ECG; this is important as someone needs to have their ECG measured if they are on more than one drug that alters the QTc. Lithium and Medical Illnesses As mentioned above, if someone s kidneys do not work well, they might need to take less than the usual amount of lithium. Other things can stop the kidney flushing out as much lithium. If someone

7 has heart failure, or is elderly, they will also need to be on a lower dose of lithium. Do not take lithium if you have low sodium (Na+) or Addison s disease or are on a very low salt diet. You should stop taking lithium 24 hours before having an operation. Lithium and Blood Tests Lithium Level Blood tests need to be done to check to serum (blood) level of lithium. This is because the amount of the drug in your blood stream needs to be kept in a narrow range. If you have too little of the drug in your blood stream, it will be less effective. If you have too much in your blood stream, side effects are more likely and toxicity might occur. The blood tests are usually done between 5 and 7 days after you start the lithium or change the dose of the lithium. This is done so the level of the drug in your system has had time to stabilize at a particular level. Levels stabilizing at (or reaching) a particular level is called reaching steady state. Early in treatment, lithium levels are measured regularly. After it is clear that the level is stable, it should be checked every 3 to 6 months. Other blood tests mentioned can be done at the same time. The blood test is done about 12 hours after your last dose of lithium. (Between 10 and 14 hours after the last dose is alright, but between 11½ and 12½ is better). This is done so that lithium is not still being absorbed into your blood stream when the blood test is taken. This means that the blood test is taken first thing in the morning, whether you take all your lithium at night or take it twice a day. The lithium level should usually be between 0.4 and 0.6 mmol/l (0.8 to 1.2 milli moles of lithium per liter of blood). If someone is very unwell, they will need to have higher lithium levels. Some people are very sensitive to lithium and need much lower blood levels. Lithium and Other Medications Lithium interacts with numerous other medications. Sometimes this means they can not be taken with lithium. At other times, other precautions, such as decreasing the dose of lithium, need to be taken. Your doctor needs to know about all the prescription medications, over-the-counter (from the chemist or supermarket) medications, herbs, health foods and injections you take. This section names many medications. It is important to note that new medications are coming on the market all the time and that important medications might not be on this list. Lithium concentrations are reduced by medications that contain bicarbonates, such as sodium bicarbonate and potassium bicarbonate. Many of these medications are available over-the-counter. They include antacids used for reflux, indigestion and heartburn (Alka-Seltzer, Eno, De-Gas, De Witt s Antacid Powder, Gaviscon, Meracote, Mylanta, Salvital). Drugs used to make urinary tract infections less painful by making the urine less acidic (Citravescent, Uracol, Ural). Drugs to fix low potassium levels in the blood (hypokalemia) (Chlorvescent, K-Sol). Movicol, used to treat constipation. Sodibic, used in some kidney disorders. Gastrolyte, used to adjust salts in the blood of people with dehydration. If these medications are taken with lithium, they decrease the blood levels of lithium. If they are being taken in the long term with lithium, the dose of lithium might need to be increased. Nonsteroidal anti-inflammatory drugs (NSAIDs) are used to treat pain and can be bought over-thecounter from the chemist or supermarket. Some NSAIDs need a prescription. There are many different types of these medications. There are only two NSAIDs that can be taken with lithium with out interactions - they are aspirin (which has many trade names) and sulindac (trade names Aclin and Clinoril). All the other NSAIDs decrease how much lithium is flushed out by the kidney. It is best to avoid taking these NSAIDs, but if you did, the dose of lithium could be reduced by between one third and one half and the blood levels of lithium would need to be monitored; this would usually not be

8 practicable if you were starting and stopping the NSAID. There are many trade names for the NSAIDs that interact with lithium. The generic names of these drugs are ibuprofen, naproxen, indomethacin, meloxicam, diclofenac, piroxicam, diflunisal, mefenamic acid, ketoprofen, tiaprofenic acid and ketorolac. Some creams that are rubbed into sore joints contain NSAIDs; they should not be used with lithium because a small amount of the NSAID is released into the circulation. ACE inhibitors are a group of medications that interact with lithium. They are used to treat hypertension (high blood pressure) and heart failure. There are many of these drugs on the Australian market. The generic name of these drugs usually ends with the letters -pril. Angiotensin II receptor antagonists are another class of drugs that interact with lithium. They are used to treat hypertension. There are lots of these medications on the Australian market. The generic name usually ends with the letters -sartan. Calcium channel blockers are another class of drugs that interact with lithium. They are used to treat high blood pressure and heart failure. The generic names of these medications are verapamil, diltiazem, nifedipine, amlodipine, lercanidipine and nimodipine. They can increase the blood level of lithium, and even if they do not, they can increase toxicity. Carbamazepine (Tegretol, Teril) can increase the risk of toxicity with lithium. In spite of this, lithium and carbamazepine are frequently and safely used together. Carbamazapine and lithium can both be used to treat bipolar effective disorder. Carbamazapine can be used to treat epilepsy (but lithium is not). Methyldopa (Aldomet, Hydopa) is used to treat high blood pressure (hypertension) and can increase the toxicity of lithium without increasing the blood level of lithium. COX-2 inhibitors are a new type of NSAID. They interact with lithium in the same way most NSAIDs do. Their names are celecoxib (Celebrex) and parecoxib (Dynestat). Potassium iodide can increase the risk of lithium decreasing how much thyroid hormone the thyroid gland produces. If the drugs are taken together, thyroid hormone levels should be monitored. Iodine is sometimes added to vitamin supplements and to table salt. Serotonin syndrome involves symptoms such as agitation, confusion, high temperature, rapid pulse, diarrhea an muscle jerks. Lithium can cause this side effect when given with certain other medications: some antidepressant, sibutramine and some migraine medications. On the other hand, antidepressant medications are routinely used with lithium. The antidepressants with an increased risk of toxicity are the serotonin reuptake inhibitors (SSRIs) fluoxetine (Prozac, Lovan, Auscap, Zactin and several brands with Fluoxetine in the name), fluvoxamine (Luvox, Faverin and Movox, and the antidepressant venlafaxine (Efexor, Efexor-XR). If you start on an SSRI while you are on lithium, you should have your lithium level checked soon afterwards. Sibutramine (Reductil) is a medication used for weight loss. The effect of this drug is similar to the effect of antidepressant medications. Sumatriptan (Imigran, Suvalan), zolmitriptan (Zolmig) and naratriptan (Naramig) are used to treat migraine headaches (after the headache has all ready started). Theoretically, if they are used with lithium, they can cause serotonin syndrome. Some fluid tablets or diuretics interact with lithium. The most important ones belong to the group of drugs called the thiazide diuretics. There are only two drugs in this group; hydrochlorothiazide (which has numerous trade names and is in preparations with more than one drug in the same tablet) and chlorthalidone (Hugoton). If these medications are used with lithium, the dose of lithium needs to be reduced by between a third and a half, and blood levels of lithium need to be monitored. Thiazide diuretics are used to treat

9 nephrogenic diabetes insipidus, which can be caused by lithium. Another group of fluid tablets that interact with lithium are called loop diuretics. The loop diuretics are called frusemide, bumetanide and ethacrynic acid (they have numerous trade names). These diuretics effect the level of lithium less than thiazide diuretics. A third group of diuretics is called the potassium-sparing diuretics. They are spironolactone (Spiractin, Aldactone) and amiloride (Kaluril, Midamore), and they decrease the renal clearance of lithium. Indapamide also decreases the renal clearance of lithium. Herbal diuretics can increase the blood levels of lithium and cause toxicity. There might be an increased risk of toxicity if lithium is used with the antipsychotic medications clozapine (Clozaril, Clopine) and haloperidol (Serenase, Haldol). They can still be used together. Caffeine, found in tea, coffee, chocolate and cola, might decrease lithium levels. Theophylline (Nuelin) might have the same effect. There is much debate about whether or not lithium should be given at the same time as electroconvulsive therapy (ECT). Lithium might increase the risk of confusion from ECT. On the other hand, stopping and restarting lithium might decrease its effectiveness. Some believe that taking lithium and having ECT at the same time can produce permanent neurological damage. Lithium and Pregnancy It is important to the baby that their mother has the best possible mental health. If a mother-to-be has poor mental health, it can effect the baby through poor prenatal care, poor care of the baby after birth, poor self-care by the mother during pregnancy and self-harm by the mother during or after pregnancy. Overall, lithium is associated with 4 to 12 percent total birth defects, compared about 3 percent for the general population. Lithium is better to take in pregnancy than the mood stabilizers such as valproate and carbamazapine. Lithium is worse to take in pregnancy than other drugs that can treat mania, such as haloperidol. Lithium is worse to take in pregnancy than other drugs used to treat depression, such as Zoloft/sertraline. Antidepressant and antipsychotic drugs can be used instead of lithium during pregnancy. In many cases, it is best for the mother to stay on lithium throughout pregnancy because the risks of stopping the lithium are greater than the risks of staying in the lithium. Lithium causes 1 in 1000 chance of heart (cardiac) defects (malformations) occurring in the unborn child if it is taken in the first seven weeks of pregnancy. This means that the baby s heart development starts before most women know they are pregnant. The baby s heart forms during the first seven weeks. The 1 in 1000 risk of cardiac malformation is low compared to the normal birth defect rate of the general population of people taking no medication when they are pregnant of about 30 per 1000 babies borne. Heart abnormalities in an unborn child can be detected early with an ultrasound scan. If you wish to become pregnant and decide to stop taking lithium, the lithium should be stopped gradually over one or two months. Stopping lithium suddenly can cause an episode of mania (high mood) which can be harmful. If you stop lithium and start taking it again, it might not work as well as it used to. This means that if you intend becoming pregnant, you should discuss this with your doctor, and if you do not intend to become pregnant, you need to use contraception. If you are so busy that you occasionally forget to take the oral contraceptive pill, you might prefer to take a contraceptive injection every four months. During pregnancy, the kidneys flush out extra lithium and the dose might need to be increased. After delivery, the kidneys flush out much less lithium and the lithium might need to be stopped temporarily

10 (withheld) and the dose adjusted. After birth, the kidneys rapidly return to removing lithium from the blood at the same rate they did before pregnancy; after delivery, the dose should be changed back to the dose before pregnancy. Lithium can cause newborn babies to be floppy, less responsive, have cardiac arrhythmias (abnormal electrical activity of their heart) and goitre. This suggests that someone could consider stopping, or decreasing their dose of lithium before the time they are due to deliver. However, giving birth is a high-risk time for relapse of bipolar affective disorder; as many as 7 in 10 women with bipolar affective disorder relapse after giving birth if they are not on moodstabilizing medication. Lithium and Breastfeeding Lithium is transferred into breast milk and babies kidneys are not very good at flushing out the lithium. This means that you should not breast feed if you are taking lithium. If you did breastfeed when you were taking lithium, the baby would need various blood tests and examinations to make sure that (s)he had not become dehydrated. Lithium and the Elderly People who are elderly need less lithium than older people. Their kidneys remove lithium from the blood slowly. Even with the same blood levels, they will have more side effects. Most of the medical conditions mentioned above are more frequent in the elderly. Falls Lithium increases the risk of falls in the elderly; it can make people a little less alert and cocoordinated. Lithium does not effect blood pressure. (Many psychiatric medications decrease blood pressure, and this is one of the reasons psychiatric medications increase the risk of falls in the elderly).