The consult attending was a little annoyed at me but I think I did the right thing

[ExcaliburPrime1]

I was on night float at the VA when I got a call from the ED attending at about 11 pm. He was telling me about a 91-year old male in the ED who he wanted me to see. Basically, he had a fall a couple of weeks prior, was admitted on a medicine unit for about 5 days, and then discharged to a rehab facility to get his strength up. He has no known past psychiatric history but is on Depakote. He also has "advanced dementia", prior stroke without lasting deficits, HTN and DM2. While at the facility, he became combative and struck one of the other residents. Apparently his behavior has been increasingly agitated. Could I come down and see him?

Now, already I'm thinking, no known past psych history, elderly, has dementia. Probably just worsening dementia with maybe a sprinkling of delirium depending on what's happening. I go see him. Sure enough, no past psych history, Depakote was started a couple of days ago at the rehab facility to "stabilize his mood". The guy is really pleasant now but a poor historian so his son provided the history. Patient did say that he was urinating a lot more but no pain/burning. No cough. Has some bruises from the fight but otherwise looking good for his age. He needs help with his ADLs though and previous PT assessment said he needs 24-hour care. Family is already working with a case manager to get him to a long-term nursing care facility after the subacute rehab is done.

I tell this to the overnight attending and propose that the patient be admitted to medicine for dementia, rule out possible delirium. His real issue is needing to get stabilized and then dispo, which he can get far more easily out of a medical than psych unit. Haldol 0.5 mg PO/IM q12h for psychotic agitation, otherwise all the usual delirium/sleep protocol (frequent reorientation, encourage family to bring personal items, early ambulation with help of PT, pain control, lights on during day and off at night, no benzos/anticholinergics, no restraints) and of course thorough work-up for any underlying cause of delirium (the UA was still pending when I was called, asked to add-on TSH, RPR, B12, folate, etc.) Attending rubber stamps, I share with the ED, they are on-board after I explain that the Depakote was recently added, and everyone is happy.

Next day, consult attending is sounding angry and wants to give me some "feedback" about how I handled it, but she then got an urgent consult and didn't see me. Will probably find me tomorrow. I keep looking at the case and I feel that I did the right thing. I wouldn't want to admit someone like this to inpatient psych as they won't get any particular benefit from the unit and there are no SI/HI/psych issues per se.

Does anything glaring pop out to anyone? Would be much obliged to have your thoughts.

 

[splik]

Well hopefully the attending will give you whatever feedback they wanted to give you. I certainly wouldn't be angry with you (but then I'm fairly easy going anyway and you havent done anything egregious). You're right that this pt doesn't warrant psych admission and it would cause more issues. Were you not sure if the patient was delirious or not? Features of delirium would include deficits of arousal and/or attention, perceptual distortions (illusions, hallucinations), distractibility, emotional lability, day/night reversal, impairment in other domains of cognition that is clearly due to one or more physiological causes. If there is no clear impairment in attention or arousal, then the patient is not delirious. Also TSH, RPR, B12 and folate are NOT part of a work up for delirium. Hopefully these were investigated prior dementia diagnosis though hypothyroidism and B12 deficiency and usually innocent bystanders. syphilis FTA-Abs now preferred over RPR and should only be done if the patient is from a county of high syphilis prevalence as noted by the CDC (i.e. not for most pts) and is not part of a delirium workup. In 91 year old with falls history (and possible unwitnessed falls too) a non-contrast Head CT may be appropriate (head CTs not usually helpful as part of a delirium workup) but there is the possibility of chronic subdurals.

You mentioned "psychotic agitation" - is the pt psychotic or not? You otherwise said the patient had psychiatric history and was not psychotic. If there is no psychosis then refrain from using the term "psychotic" especially as other services might see that and think pt needs to come to psych, or it could adversely effect placement. haldol (particularly IV where there is lower risk of EPS) can be helpful for agitation in the context of hyperactive delirium but in the absence of such is unlikely to be the drug of choice and we want to avoid neuroleptics anyway. In general we give the half the IV dose as we do PO, so 0.5mg IV = 1mg PO (imperfect as this calculation is). PO and IM routes have greater EPS while IV route has greater risk of QT prolongation.

Depakote was faddish in managing behavioral disturbances in dementia some years ago when people were trying to avoid neuroleptics. However I've never seen it work and the evidence does not support its use. I'm sure some people think it does something sometimes.

SSRIs like citalopram (or escitalopram is my staple) are where it's at for managing behavioral disturbances in dementia including VaD in the longer term. start low, go slow.

 

[michaelrack]

Worsening dementia/possible delirium is a standard admission to any psych unit that does geriatric psych even if uti is contributing...the er should have started treatment for any uti before calling you however.
What unit to admit to would depend on typical hospital practice and if there were dedicated geriatric psych beds on the psych unit

 

[Armadillos]

At one of my hospitals this would be a slam dunk geriatric psych admission. At the other we would have probably refused to admit because it doesn't have a dedicated Geri unit, medicine would refuse to admit and patient would still be in the ER and the services would be fighting it out to figure who is going to have to place this patient.

 

[Armadillos]

As you your question, maybe your attending didn't like the haldol? Or maybe your unit actually does have the ability to care for Geri psych on your unit, but you didn't realize it?

You mentioned "no SI/HI" just a reminder that these aren't the only things we admit folks for, as this is a trap I see a lot of new interns fall into.

 

[wannabie]

At one of my hospitals this would be a slam dunk geriatric psych admission. At the other we would have probably refused to admit because it doesn't have a dedicated Geri unit, medicine would refuse to admit and patient would still be in the ER and the services would be fighting it out to figure who is going to have to place this patient.

Sounds exactly like my two hospitals. OP's consult was at a VA hospital. If it's anything like the VA hospital I work at, HI/SI is the only reason to admit. Other legitimate reasons such as stabilization of mania and psychosis are non-starters. And disposition has to be in place before admission. Also, needing assistance with ADL's is also a non-starter for admission. Anyway, based on what you mentioned so far, the diagnosis is not clear and admission to medicine makes sense.

Can anyone comment on antipsychotic use in geriatric patients? I know there's an FDA warning for atypical antipsychotic use for increased risk of pneumonia, but antipsychotics are still commonly used. I don't remember why. And can't something with strong anticholinergic effects like haloperidol worsen this patient's mental status? How do you select your PRN medication?

 

[hamstergang]

I know there's an FDA warning for atypical antipsychotic use for increased risk of pneumonia, but antipsychotics are still commonly used. I don't remember why. And can't something with strong anticholinergic effects like haloperidol worsen this patient's mental status?

Antipsychotics increase risk of pneumonia? Haldol is a very weak anticholinergic agent, so I'm confused by that statement too.

 

[ExcaliburPrime1]

Thanks for all the feedback. Attending still has not seen me so I really don't know what's going on. I talked the case over with my chief resident this morning and he basically said that he didn't see anything flagrantly wrong, but that people will have their own views and the best thing to do is learn from their perspectives, which I agree with 100%.

As for the case, I appreciate the comments above. I neglected to mention the head-CT but it was done the next day and didn't show anything acute. Still, should have been something I recommended. We do use the FTA-Abs but I wrote "RPR" for ease. Our population has a high rate of syphilis (and HIV too for that matter) so we usually recommend it. (Was negative).

I suspected delirium given fluctuating levels of consciousness by history although when I saw him, he was pleasant and at his baseline A&Ox2, answering questions as best as he could. I had low threshold for concern given urinary frequency he reported, advanced age, and history of dementia, the latter two (I think?) are risk factors for delirium. In any case, his subsequent work-up was negative.

I didn't believe the patient was psychotic at all but I made the PRN clearly for "psychotic agitation" because at our hospital they are quite "trigger happy" and will give Haldol very quickly. I wanted it to be clear that he should only get it if he is psychotic (which he was not at the time). My hospital's policy is not to give IV Haldol because of QT-prolongation unless a patient is on a cardiac monitor, instead we recommend PO or IM dosing only. I didn't know about the conversion to IV though, so that's great to pick up on. We also rec'd discontinuing the Depakote (no clear indication) but did not put in recs for an SSRI long-term. I think that would be helpful to start prior to placement and I'll remember to comment on that in future.

Additionally, my VA does not have a geriatric psych unit, although we have a couple of geriatric psychiatrists for outpatient work. I have certainly received the above sort of patient while off-service in medicine, but never in my inpatient unit (at main hospital or VA hospital) although again neither has a geriatric dedicated unit.

Finally, I have heard about the (recent?) FDA warning about avoiding the use of atypical antipsychotics in elderly patients with dementia. There is a 1.7-1.8 fold risk of death although the cause is not exactly known (the warning mentions cardiovascular or infectious (e.g. pneumonia) as possibilities). That's part of the reason I went with Haldol (also would be good if he did have delirium), but I think the warning also says that anecdotally, even typical antipsychotics may be harmful, so that's why I was explicit about "psychotic agitation" being the only good reason to give Haldol.

 

[michaelrack]

the fda warning is for all antipsychotics.
The preferred antipsychotic in the elderly appears to be seroquel

 

[clausewitz2]

Can anyone comment on antipsychotic use in geriatric patients? I know there's an FDA warning for atypical antipsychotic use for increased risk of pneumonia, but antipsychotics are still commonly used. I don't remember why. And can't something with strong anticholinergic effects like haloperidol worsen this patient's mental status? How do you select your PRN medication?

Just finishing up my geri rotation right now, so I feel confident weighing in on some of this.

FDA blackbox on atypicals in demented folks is for all-cause mortality, not just pneumonia. I agree 100% with splik that citalopram/escitalopram has a robust evidence base for reducing acute agitation but many people get freaked out by the black box warning about prolonged QTc above 20 so we have difficulty convincing caregivers/family to allow us to go up to 30, which is where the evidence for this having an effect is. Our geri folks get around this sometimes by using sertraline instead and have reasonable success with fairly small doses.

Neuroleptics still get used because if someone is properly aggressive they are going. to slow. them. down. We tend to use Zyprexa at low doses (typically 2.5) for acute agitation along the lines of "Mr. Jones is about to slug someone again" because an IM formulation exists and because it is unlikely to induce very much EPS at that dosing. For scheduled neuroleptics (which we use if someone has failed SSRIs) we tend to favor risperidone at small doses because there is more evidence for it specifically in dementia than there is for other neuroleptics and we can end up going higher because it is less anticholinergic than Zyprexa.

Reportedly some repackaging of quinidine/DMT is in trials right now seeking an indication for agitation in dementia, we will see if it pans out. Our institution doesn't let us start this as an inpatient so for really refractory cases (or for the kinds of pseudobulbar affect where palliative sedation is the other meaningful option) there has been some tinkering with DMT + prozac as in principle the same enzyme ought to be inhibited, but I don't know if we have any data.

 

[clausewitz2]

the fda warning is for all antipsychotics.
The preferred antipsychotic in the elderly appears to be seroquel

I know this gets done a lot, but our dementia research folks hate seroquel with a firery passion and believe it is basically useless in managing agitation in the elderly except as a sedative.

 

[michaelrack]

Quetiapine safety in older adults: a systematic literature review.

El-Saifi N, Moyle W, Jones C, Tuffaha H.

J Clin Pharm Ther. 2016 Feb;41(1):7-18. doi: 10.1111/jcpt.12357. Review.

PMID: 26813985

Agree that it's probably less effective, but a favorable safety profile compared to other antipsychotics; although of course need to monitor for metabolic effects

 

[splik]

Reportedly some repackaging of quinidine/DMT is in trials right now seeking an indication for agitation in dementia, we will see if it pans out. Our institution doesn't let us start this as an inpatient so for really refractory cases (or for the kinds of pseudobulbar affect where palliative sedation is the other meaningful option) there has been some tinkering with DMT + prozac as in principle the same enzyme ought to be inhibited, but I don't know if we have any data.

Nuedexta can work for agitation in TBI and AD. I don't use it for pathological affect since it's nothing a good old SRI or TCA can't sort out but nuedtexta is a nice3rd or 4th line treatment for agitation in these pts

 

[clausewitz2]

Nuedexta can work for agitation in TBI and AD. I don't use it for pathological affect since it's nothing a good old SRI or TCA can't sort out but nuedtexta is a nice3rd or 4th line treatment for agitation in these pts

Good to know, I wish we could use it (as do our pharmacists, actually). I imagine it will be harder for the institution to say no to inpatient starts when it has an actual agitation indication rather than being off-label for a very specific diagnosis.

 

[splik]

Good to know, I wish we could use it (as do our pharmacists, actually). I imagine it will be harder for the institution to say no to inpatient starts when it has an actual agitation indication rather than being off-label for a very specific diagnosis.

Sometimes what we have to do is write an outpatient rx for inpatients and have the family fill the rx and bring it in otherwise we have to wait ages to get it in (it's non formulary)

 

[clausewitz2]

Sometimes what we have to do is write an outpatient rx for inpatients and have the family fill the rx and bring it in otherwise we have to wait ages to get it in (it's non formulary)

Ahh, see, UPMC just last year for the first time took in more money from insurance premiums than it did from actual medical billing, so I would anticipate our administration coming down like a construction site's worth of bricks on that sort of deviousness.

...do kind of wish I could get away with that, though.

 

[Armadillos]

If we want nudexta and can't get it we tend to use Prozac+Dex to approximate its MOA

 

[clausewitz2]

If we want nudexta and can't get it we tend to use Prozac+Dex to approximate its MOA

Yeah, I mentioned that in my earlier post. Has it ever worked for you? Obviously not a place where data is abundant.

 

[Armadillos]

Yeah, I mentioned that in my earlier post. Has it ever worked for you? Obviously not a place where data is abundant.

Honestly kind of hard to tell to be completely honest because I feel like we always fiddle with more than one thing at a time due to pressure to decrease length of stay

 

[Liquid8]

Don't see any major issue with OP's management - could just be that the boss is a micro-manager type and wants everything run past them

Can anyone comment on antipsychotic use in geriatric patients? I know there's an FDA warning for atypical antipsychotic use for increased risk of pneumonia, but antipsychotics are still commonly used. I don't remember why. And can't something with strong anticholinergic effects like haloperidol worsen this patient's mental status? How do you select your PRN medication?

I think the bigger concern in the elderly when using antipsychotics is the potential for cardiac complications.

In general, for geris I’d stick with the “Start low, go slow” motto.

Used to work in a multi-D team that managed BPSD for various nursing home sites. Had some success with low dose risperidone (0.25mg BD), olanzapine (2.5mg BD) or valproate (eg. 100-200mg BD) for BPSD when behavioural interventions didn't cut it. We always had to be careful because in this setting staff were often less qualified than nurses and there was a trend to be very quick to medicate agitated patients. Would probably only have used Seroquel if I suspected Lewy Body Dementia, as one of my bosses had a particularly bias against it to the point where he’d stop it if it was charted by someone else.

Delirium management is when I would generally use haloperidol as a first line. Again, low doses eg. 0.5mg BD/TDS. Important thing to remember is that it shouldn’t be a long term treatment and once the delirium subsides it should be ceased. When I worked in C/L, it was important to discuss management with the home team otherwise you’d see patients getting discharged on it as a regular medication which could contribute to future long term side effects.

 

[Madden007]

I love these clinical posts...I don't see anything terribly wrong with your management. R/o delirium is very important. Delirum is a non-psychiatric, medical emergency.

 

[mopsych]

Sounds like some ****ty politics. As an aside any Elderly on depakote-->Get a free and total depakote level and look at the percent free duder

 

[thoffen]

Would probably only have used Seroquel if I suspected Lewy Body Dementia, as one of my bosses had a particularly bias against it to the point where he’d stop it if it was charged by someone else.

I wonder if patient had some parkinsonism, VH, dysautonomia or some such that might suggest danger in using high potency antipsychotics. That might be a legit beef here.

Only way to know is talk to the attending.

 

[calvnandhobbs68]

OP you must have had a chance to talk to the attending by now don't leave everyone hanging.

 

[ExcaliburPrime1]

OP you must have had a chance to talk to the attending by now don't leave everyone hanging.

It's funny, I sort of escaped her the first day when she got the urgent consult. On Friday, I sent her a text message, basically saying: "You wanted to give me some feedback but it never happened. I'm ready at your convenience" and she said: "Oh, if I have a chance this afternoon I'll stop by" but she never did. I am now suspecting that she never had a problem with my consult but maybe another one on the same day.

I chart-checked the patient as well. Has been doing okay on the medicine unit, basically just waiting for placement which will take some time, but in general not agitated, family visits daily, A&Ox2, and working with PT/OT. I feel good about the whole thing. If she ends up giving me feedback, I'll update, but I think it's case closed.

 

[smalltownpsych]

It's funny, I sort of escaped her the first day when she got the urgent consult. On Friday, I sent her a text message, basically saying: "You wanted to give me some feedback but it never happened. I'm ready at your convenience" and she said: "Oh, if I have a chance this afternoon I'll stop by" but she never did. I am now suspecting that she never had a problem with my consult but maybe another one on the same day.

I chart-checked the patient as well. Has been doing okay on the medicine unit, basically just waiting for placement which will take some time, but in general not agitated, family visits daily, A&Ox2, and working with PT/OT. I feel good about the whole thing. If she ends up giving me feedback, I'll update, but I think it's case closed.

This is the type of variable ratio reinforcement schedule that led me to become exceptionally skilled at hiding out waiting for things to blow over during my adolescence. I could literally spend an entire semester avoiding a teacher if I had to. It is a skill that still serves me well at times.

 

[bashir]

As much as the phrase "I want to give you some feedback on how you handled that consult" would inspire utter dread in me, I still wish I got more feedback from attendings on things I could have handled better. I suspect there's a lot of learning opportunities that go by because attendings don't bother to sit me down and let me know when I could have done better, or even when I plain screwed up. Sometimes of course you can figure it out yourself via chart checking. Anyway, just wanted to say good for you for actively seeking feedback and following up on how the patient did. It's a reminder to me to try to do better at both.