Geri-psych advice

[DebDynamite]

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Hello everyone,

I'm an intern, currently rotating off-service in IM/on the general medicine floor (I'm in a VA right now). I have a pt who was transferred to me from the unit. Here's his story:
-early 70's YO, CM
-he currently lives in a NH for "vascular dementia"
-he was admitted to the MICU for urosepsis, treated there and transferred to me once he was more stable, and on PO abx
- he has a h/o aspiration PNA; sec to dysphagia. He had a feeding tube in the past, has compromised it so many times when he sundowns that he is now mostly fed with soft diet/CNA standing over him. I believe he has a new tube placement pending.
-He is an extreme sundowner. His AMS begins every day about 30 min before sunset, then lasts 'till breakfast, if left untreated. During the day (from the limited interaction I've had with him) he seems at baseline demented- oriented X's1.
- in the unit, they had him on haldol around the clock, trying to keep him less agitated
- wife tells me in frustration that the NH where he lives "waits for him to become all upset at night, then calls me to try and calm him down"
-when he sundowns he takes off all of his clothing, becomes violent and screams incessantly

I tried to switch him to dissolving sl olanzapine (have to stay within VA formulary confines) last week, but only had him for about a day. He crumped and I had to send him back to the MICU. He's returning back to me tomorrow.

What do you suggest for this poor pt? I want to send him to the NH: #1- On a med he can actually take PO, and afford/obtain. And, #2- on one that they might leave him on. I feel sorry for his wife, don't want to snow him, and have to stick with the VA's formulary. Any thoughts?

 

[DebDynamite]

I've already placed a psych consult.

 

[OldPsychDoc]

What do you all think about some trazodone in a case like this (assuming you're trying to placate the VA budget police AND the zealous nurse educators who are there to remind us that "JCAHO is watching" everytime Doc Samson overrides that Black Box Warning about antipsychotics in dementia).

 

[michaelrack]

What do you suggest for this poor pt? I want to send him to the NH: #1- On a med he can actually take PO, and afford/obtain. And, #2- on one that they might leave him on. I feel sorry for his wife, don't want to snow him, and have to stick with the VA's formulary. Any thoughts?

I recommend discussing loxitane with your psychiatric consultant. It's a fairly cheap typical antipsychotic with some atypical properties.

 

[Doc Samson]

Hello everyone,

I'm an intern, currently rotating off-service in IM/on the general medicine floor (I'm in a VA right now). I have a pt who was transferred to me from the unit. Here's his story:
-early 70's YO, CM
-he currently lives in a NH for "vascular dementia"
-he was admitted to the MICU for urosepsis, treated there and transferred to me once he was more stable, and on PO abx
- he has a h/o aspiration PNA; sec to dysphagia. He had a feeding tube in the past, has compromised it so many times when he sundowns that he is now mostly fed with soft diet/CNA standing over him. I believe he has a new tube placement pending.
-He is an extreme sundowner. His AMS begins every day about 30 min before sunset, then lasts 'till breakfast, if left untreated. During the day (from the limited interaction I've had with him) he seems at baseline demented- oriented X's1.
- in the unit, they had him on haldol around the clock, trying to keep him less agitated
- wife tells me in frustration that the NH where he lives "waits for him to become all upset at night, then calls me to try and calm him down"
-when he sundowns he takes off all of his clothing, becomes violent and screams incessantly

I tried to switch him to dissolving sl olanzapine (have to stay within VA formulary confines) last week, but only had him for about a day. He crumped and I had to send him back to the MICU. He's returning back to me tomorrow.

What do you suggest for this poor pt? I want to send him to the NH: #1- On a med he can actually take PO, and afford/obtain. And, #2- on one that they might leave him on. I feel sorry for his wife, don't want to snow him, and have to stick with the VA's formulary. Any thoughts?

1) Review his med list and parse out all the deliriogenics incl. benzos, anticholinergics, antihistamines, and opiates. Don't forget Ambien (which I tenderly refer to as "pure evil").

2) Don't know what's on the VA formulary these days, but if I had to choose an oral agent, it'd be Risperdal (the most typical atypical). Conveniently available in soluble M-tabs. Weight the doses more heavily in the PM and HS.

3) Consider an acetylcholinesterase inhibitor (Exelon will reach steady state faster than Aricept)

4) Figure out what "vascular dementia" means. Dementia after stroke? (important to know what part of the brain he's missing). Small vessel disease? (unlikely to leave him this f-ed up - start looking for something else).

 

[OldPsychDoc]

1) Review his med list and parse out all the deliriogenics incl. benzos, anticholinergics, antihistamines, and opiates. Don't forget Ambien (which I tenderly refer to as "pure evil").

2) Don't know what's on the VA formulary these days, but if I had to choose an oral agent, it'd be Risperdal (the most typical atypical). Conveniently available in soluble M-tabs. Weight the doses more heavily in the PM and HS.

3) Consider an acetylcholinesterase inhibitor (Exelon will reach steady state faster than Aricept)

4) Figure out what "vascular dementia" means. Dementia after stroke? (important to know what part of the brain he's missing). Small vessel disease? (unlikely to leave him this f-ed up - start looking for something else).

 

[DebDynamite]

sorry duplicate post, my badness

 

[DebDynamite]

hey hey thanks everyone.

right now I have 12 medicine patients, and he's "awaiting placement"...so, I just have to sit have down and weed through his chart/imaging to get a better grasp on the dementia etiology.

what about seroquel/600 before sundown and depakote? this was suggested by one of my sr residents...

post-call, going to sleep......awesome thread- much appreciated.

 

[Doc Samson]

hey hey thanks everyone.

right now I have 12 medicine patients, and he's "awaiting placement"...so, I just have to sit have down and weed through his chart/imaging to get a better grasp on the dementia etiology.

what about seroquel/600 before sundown and depakote? this was suggested by one of my sr residents...

post-call, going to sleep......awesome thread- much appreciated.

Depakote is fine. Seroquel is more anticholinergic than I'd like for a potential delirium, unless he has any Parkinsonism.

 

[DebDynamite]

I really appreciate all the help here. I ended up sending him out on Depakote and Trazodone (other interns on call had been giving him hydroxyzine and/or ativan-which I removed). This combo appeared to be working- wish I had longer with him. Such is the way of inpatient IM.