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Delusion Dilemmas

Delusion Dilemmas . Monica Tegeler, MD Assistant professor clinical medicine, Geriatrics, IU IDND 23 July 2013. Patient #1. 73 y/o female admitted to hospital Found wandering streets, incontinent of urine, confused, agitated Several episodes of wandering into traffic

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Delusion Dilemmas

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  1. Delusion Dilemmas Monica Tegeler, MD Assistant professor clinical medicine, Geriatrics, IU IDND 23 July 2013

  2. Patient #1 • 73 y/o female admitted to hospital • Found wandering streets, incontinent of urine, confused, agitated • Several episodes of wandering into traffic • PMH: anemia, goiter, GERD, Hep C, endometrial CA • SH: retired childcare worker, married, no alcohol use

  3. Pt #1 hospital summary • Delirium w/u negative • CT Head – mild/moderate small vessel ischemic disease • Dx’d with DAT with agitation • Started on Seroquel 25mg qAM & 25 qHS with Haldol 2.5mg PO PRN • BIMS (Brief Inventory of Mental Status) 3/15 • PHQ9 (Patient Health Questionnaire) 4/27

  4. Pt #1 transferred to NH • 5/23 admitted to NH; intrusive wandering, refusing meds • 5/24 “this is my house,” “looking for my husband,” cursing • 5/25 combative w/ personal care, refused meds, takes other residents’ items • 5/27 pulls covers off another resident at 0200 thinking it was her aunt, tries to get other residents to “fight her”

  5. Pt #1 aggression, delusions • 5/29 tries to hit staff w/ broom, “get out of my house;” given PRN Haldol • 5/30 screaming at staff & residents, gathering items from DR & residents’ rooms; given PRN Haldol • 5/31 staff “accused me of killing my baby when my baby died at 9 mos/days from heart defect,” refusing all meds and food • 6/1 Zyprexa IM started • 6/4 consent for psychiatrist signed, compliant w/ injections • 6/7 changed to ZyprexaZydis & seen by psychiatrist

  6. Pt #1 delusions, paranoia • 6/9 easily redirected • 6/13 “this is my mother” referring to another resident, redirected outside • 6/17 pacing, reports husband “no good.. I’m cutting him out… messing around w/ younger woman.. Hasn’t been home in 3 days… mother always takes up for him…” • 1:1, cleaning DR tables, outside walk, juice & snack – none effective, given IM Zyprexa

  7. Pt #1 summary • Difficult transition to NH • No physical aggression and less paranoia/delusions after starting Zyprexa • More redirectable, still with verbal aggression

  8. Pt #2 • 70 y/o female with DAT • Hospitalized 9/23-10/4/2011 • Admitted to LTC 10/4 • LOA 1/4/12, refused to return • 2/10/12 fall at home with humerusfx • Readmitted to LTC

  9. Pt #2 • PMH: DAT with delusions, visual hallucinations, HTN, celiac, CAD, DM2, fibromyalgiaFH: mother died 82 y/o from DAT, brother in 70’s with alcoholism, dementia • SH: married, 6th grade education, GED

  10. Pt #2 • c/o bugs coming in the chimney (no chimney in house), thinks husband is gay • Meds on admission: • Galantamine 4 mg BID • Risperdal 1mg qHS • Namenda 10 BID • Depakote 250 qPM & qHS • Cymbalta 60 qPM

  11. Pt #2 • Successful GDR Risperdal 4/2012 • 8/2012 Packs up items, “going home” • 11/2012 tearful when family leaves • 1/2013 thinks children around & bad things happening to husband but resolves with 1:1 attention • Cymbalta increased 4/2013 for depressive sxs • 5/2013 cries daily, not redirectable, started on Nuedexta, seen by geropsych for 1st time, started on Zyprexa 5 BIDfor delusions causing crying spells

  12. Pt #2 • 5/2013 Kissing paper thinks it is a person, “touching baby” – Zyprexaincreased • 6/2013 Nuedexta stopped and restarted a week later after crying spells resumed • Attempting to kiss other residents & staff, tearful b/c she ate “5 watermelons” & because she was “trying to get into the factory”

  13. Pt #2 BIMS – Brief Inventory of Mental Status PHQ9 – Pt Health Questionnaire

  14. Pt #2 Summary • Several transitions from hospital to LTC including home • Persistent delusions over course of stay, but only intermittently severe enough to impair functioning and trigger on PHQ9 • Different opinions on cause of crying spells (depression, delusions, pseudobulbar affect) & resultant polypharmacy

  15. Discussion points • No standard set of behavior interventions from facility to facility • No consensus on when to start antipsychotic • Nuedexta current popular option as not considered focus medication for GDR by Medicare

  16. Questions • 1. Suggestions for behavioral modifications for pts with delusions. • 2. Suggestions for criteria for starting an antipsychotic for delusions.

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