Difficult neuropsychiatry case

[MedMan80]

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Hey guys,

Have a difficult case on the outpatient service, 65 y/o patient s/p head trauma and subsequent SDH, protracted hospital course (was in rehab for months afterwards). Likely development of delirium in the hospital and d/c on Abilify 10mg daily. Question to me was should we continue the abilify? No agitation at home, mood reportedly okay, however complaints of apathy, amotivation from spouse. For now I d/c the abilify and asked them for followup in a few weeks, also sent to neuropsychologist however workup might not be done by the time they come back.

I was thinking maybe stimulant for the amotivation (doesn't want to do PT/get out of wheelchair as much). Any screening tests I can administer?

 

[Shikima]

Stop and see what happens. Follow-up with q2wk visits and monitor for changes. Use MOCA/Folstein to objectively track progress.

 

[WisNeuro]

Where was the head trauma, and how significant was it? Other current meds?

 

[MedMan80]

He's also on Aricept and Namenda I believe, he was AAOx2 I believe on the day of my exam. He fell back and hit the back of his head, was at an OSH so unclear of exact course but SDH I believe, they didn't operate on it.

Shikima - have q2 followup, he's coming in a week..can probably do MOCA but folstein in a 30 min followup?

 

[F0nzie]

I would consider discontinuing the Abilify if was given only for delirium and not for an existing mood or psychotic disorder. Because delirium in the elderly can last weeks to months, instead of stopping abruptly, I would taper and monitor for recurrence of delirium sxs.

For depressive sxs consider using the GDS (geriatric depression scale) and if treatment is indicated an antidepressant.


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[Shikima]

He's also on Aricept and Namenda I believe, he was AAOx2 I believe on the day of my exam. He fell back and hit the back of his head, was at an OSH so unclear of exact course but SDH I believe, they didn't operate on it.

Shikima - have q2 followup, he's coming in a week..can probably do MOCA but folstein in a 30 min followup?

Kinda hard, could run into the next appointment. But you've got a good handle on it.

 

[WisNeuro]

If you have the choice, do the MoCA over the MMSE, they are both very limited screeners, but the MoCA has much better psychometrics. Also, more sensitive to attention/EF issues and possible vascular problems.

 

[MedMan80]

Thank you guys, was I completely off base on thinking about a stim for the reported lack of motivation?

 

[F0nzie]

Given her recent history of delirium, stimulants place her at a higher risk for developing psychotic symptoms. A stimulant to treat lack of motivation is unorthodox practice. The antidepressant benefit stimulants offer, if any, would likely not last very long. You can get away with using stimulants off label in the geriatric population for quality of life issues if you are pressed for time for a response i.e. you don't have 3 to 4 weeks to wait because pt will likely not live that long. There are other potential off-label uses for stimulants but data is greatly lacking.


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[shan564]

Agree completely with Fonzie's comments. Antipsychotics for delirium should generally be short-term. Even if you're not sure about potential disinhibition secondary to TBI, you still need to discontinue the drug because it was started for delirium, and the patient isn't delirious anymore. You don't know if the patient needs an antipsychotic for other reasons, and it's not appropriate to give an antipsychotic prophylactically just because the TBI *might* have caused problems. If behavioral problems arise later, then you can re-start the antipsychotic... it might look awkward to stop it and re-start it, but it's justified because the indication is different. And I'd probably taper it slowly rather than d/c'ing it rapidly.

I'd also be concerned about starting a stimulant when you're actively concerned about behavioral dysregulation and delirium. I'd probably wait until you've seen the effects of stopping the antipsychotic.

I disagree with the comment that starting a stimulant for amotivation is "unorthodox" - it's not an unusual practice in neurorehabilitation settings (i.e. this patient). A lot of neuropsychiatrists use stimulants or dopamine agonists for treatment of amotivation. But you have to recognize that antipsychotics can cause amotivation, so I'd say the patient needs a trial off the Abilify before making a decision about the stimulant.

 

[thoffen]

I'd go with a taper rather than abrupt d/c, though, unless there was evidence the Abilify was causing harm.

 

[MedMan80]

Should've specified but the patient already ran out of the Abilifiy a week before he saw me, no significant change in that interim. I'll update you guys.