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 Zyprexa Zydis & 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 humerus fx Readmitted to LTC

9. Pt #2 PMH: DAT with delusions, visual hallucinations, HTN, celiac, CAD, DM2, fibromyalgia FH: mother died 82 y/o from DAT, brother in 70’s with alcoholism, dementia SH: married, 6 th 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 1 st time, started on Zyprexa 5 BID for delusions causing crying spells

12. Pt #2 5/2013 Kissing paper thinks it is a person, “touching baby” – Zyprexa increased 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 Oct 2011 Nov 2011 Dec 2011 Feb 2012 May 2012 Nov 2012 Jan 2013 May 2013 BIMS39839478 PHQ93200301911 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.