CHAPTER
4
Beyond the Diagnostic Ds
Other Common Clinical Challenges
Unusual Experiences, Irritability, and Labile Mood
The diagnostic Ds discussed in Chapter 3 provide a framework to diagnose and manage common mental health problems in older adults. In this chapter, we will cover the diagnostic workup and management of other common mental health problems in older adults. These common problems are mood changes such as irritability and labile mood, unusual experiences such as hallucinations and delusions, agitation and aggression, sexual dysfunction, and suicide and end-of-life concerns. These diagnoses should be included with the diagnostic Ds to ensure a comprehensive mental health assessment in the older adult.
DELIRIUM AND SUBSTANCE- AND MEDICATION-RELATED DISORDERS
While on service for the weekend, you are called to see Daniel, a 59-year-old man who was hospitalized a week ago for a chronic obstructive pulmonary disease (COPD) exacerbation and pneumonia. He has responded well to his antibiotic regimen, and his steroid taper was started 2 days ago. The nurses report that Daniel has not been sleeping well for the past 2 nights and has become increasingly agitated. His workup for delirium yesterday was negative. When you see Daniel, he is jumping up and down on the bed and announcing, “I am the son of God, and I will be the first man to fly!” You try to redirect Daniel, but he continues to talk rapidly about how he is in special communication with NASA to learn how to fly. He requires two intramuscular injections of haloperidol 0.5 mg to fall asleep. You call his daughter Samira, who tells you that when Daniel has required outpatient steroid tapers for his COPD in the past 2 years, he has occasionally “said some strange stuff, but it always goes away, so we just ignore him.” Daniel requires low-dose oral haloperidol during the rest of his steroid taper; after that is completed, he returns to his baseline, so you stop the haloperidol.
The case example of Daniel illustrates the importance of recognizing medications as a potentially reversible cause of mania. Practitioners should always exclude delirium, medications, and illicit or over-the-counter substances as causes of sudden changes in behavior. In particular, when patients develop sudden-onset psychotic symptoms in an acute medical or surgical setting, delirium should be considered. In the clinical literature, particular psychotic symptoms suggest different etiologies; for example, visual hallucinations are common during alcohol withdrawal, whereas delusional parasitosis is more typical of stimulant intoxication. Delirious patients can exhibit a variety of psychoses, but they less frequently experience mania.
MOOD DISORDER SECONDARY TO MEDICAL ILLNESS AND MAJOR NEUROCOGNITIVE DISORDER DUE TO FRONTOTEMPORAL DEMENTIA
You continue to see Daniel in your outpatient clinic. Six months after Daniel’s hospitalization, Samira calls you and reports, “My father is acting strange again.” When Daniel comes to see you, he insists that he is in the middle of preparing to win a reality cooking show and become a world-famous chef. He has been staying up all night trying out new recipes and has spent nearly $20,000 on cookbooks in the past month. He is very energetic, is talking quickly, and becomes irritated whenever you try to interrupt him. On further questioning, Samira reports that Daniel had a head injury from a mechanical fall about 2 months ago and lost consciousness for a couple of minutes. He “appeared fine” by the time the emergency department doctor saw him and was sent home. You diagnose Daniel with manic symptoms secondary to traumatic brain injury (TBI). You conclude that he is gravely disabled by his condition and offer him psychiatric hospitalization. After he declines, you speak again with Samira, who says that she is unable to care for her father at home in his current state, so you reluctantly conclude that Daniel requires involuntary hospitalization to treat his manic episode. He responds well to empiric treatment with valproic acid while you pursue a definitive cause. His initial serum and urine studies are unremarkable, and he refuses to lie still for brain magnetic resonance imaging (MRI), so you order a head computed tomography scan, which is also unremarkable. Daniel does well and is discharged home on valproic acid. At your recommendation, he takes the medication for a few months, before discontinuing the medication against your recommendation.
Samira brings Daniel back 3 months later because his behavior has worsened; he is even more disinhibited. In public, he interrupts strangers with non sequiturs. In private, he eats several family-size bags of chips each day. With Samira’s encouragement, Daniel consents to a brain MRI, which shows moderate bilateral frontotemporal atrophy. You diagnose him with behavioral variant frontotemporal dementia and refer him to a geriatric psychiatrist and behavioral neurologist for further management.
Typically, the onset of mania among older adults in a medical or surgical setting can be attributed to a medication or other substance. Corticosteroid use, particularly during titration or taper, is associated with both manic and depressive symptoms. Antidepressants and light therapy can trigger substance-induced mania in susceptible individuals. Caffeine and stimulant intoxication can cause hypomanic or manic symptoms. In most cases, substance-induced manic symptoms resolve once the offending agent is discontinued or its withdrawal period ends. Still, it is prudent to follow a person over time to be certain of the diagnosis.
In an older adult, the development of mania or psychosis should initially raise suspicion of an undiagnosed medical or neurological disorder rather than a primary psychiatric disorder. The presentation of mania or psychosis as a primary psychiatric disorder typically occurs as the brain develops in adolescence or early adulthood, rather than as the brain declines with age. When an adult older than age 50 experiences mania or psychosis for the first time, the practitioner should do a workup for substances and medical or neurological causes, as outlined in Table 4–1, before diagnosing a bipolar disorder or schizophrenia.
Neurological examination (with a focus on soft neurological and frontal release signs) |
Serum laboratory workup for potential medical or neurological causes |
Complete blood count |
Chemistries and electrolytes, including creatinine, calcium, and magnesium |
Liver function panel |
Thyroid-stimulating hormone and other thyroid tests as indicated |
Vitamin B12 and folate levels |
Heavy metal screen if clinically indicated |
Urine workup for potential medical or neurological causes |
Urinanalysis |
Urine toxicology screen |
Cognitive screen such as the Montreal Cognitive Assessment (MoCA) |
Medication review (with a focus on temporal association with symptoms) |
Neuroimaging, if clinically indicated |
Magnetic resonance imaging (MRI) is preferred to head computed tomography because of the increased anatomic resolution |
Positron emission tomography can be used if patient has contraindication to MRI or if MRI does not show any definitive findings consistent with a particular type of dementia |
Electroencephalography, if clinically indicated, to evaluate for seizures |
Cerebrospinal fluid (including beta amyloid and tau markers to measure for Alzheimer’s disease and the 14-3-3 marker to measure for prion disease), if clinically indicated (Muayqil et al. 2012) |
For many older adults, the development of a neurological disorder is associated with their initial experience of manic or psychotic symptoms. In the literature, about 5%–10% of people with Huntington’s disease develop mania, and more than 10% have psychotic symptoms (Rosenblatt 2007). Up to 60% of people with Parkinson’s disease can be affected by psychosis, especially as the disease progresses and as dopaminergic agents are prescribed to treat motor symptoms (Forsaa et al. 2010). Impulse-control symptoms, which can sometimes be similar to manic symptoms, affect about 13.6% of patients with Parkinson’s disease (Weintraub et al. 2010). Less commonly, about 10% of patients with TBI develop mania or psychotic symptoms (Jorge 2015; Jorge et al. 1993; Shukla et al. 1987). Poststroke mania and poststroke psychosis are even rarer (Rabins et al. 1991; Santos et al. 2011). A careful history, including a thorough family history, can be quite helpful in the evaluation of potential neurological disorders.
As the case of Daniel illustrates, however, untangling the initial presentation of a neurological disorder from the first presentation of manic or psychotic symptoms can be difficult. Daniel’s manic symptoms were originally thought to be from the TBI. Sometimes, however, practitioners can be misled by seemingly related events that turn out to be unrelated—such as a TBI causing cognitive difficulties and a spousal death causing depression—and an undiagnosed disorder sometimes takes time to declare itself. Manic symptoms can be associated with a TBI but usually self-resolve after a few months (Jorge et al. 1993). With Daniel, it eventually became clear that he had developed an undiagnosed neurodegenerative disorder. The diagnosis of early, atypical, rapidly progressive dementias, such as major neurocognitive disorder due to frontotemporal dementia, can be difficult to make because caregivers often describe behavioral rather than cognitive symptoms. In these challenging diagnostic situations, it may be beneficial to make a subspecialty referral. A geriatric psychiatrist or behavioral neurologist can help diagnose early-onset atypical dementias such as frontotemporal dementia and Huntington’s disease, which can be identified around age 50 or even younger (Bang et al. 2015; Epping et al. 2016).
SCHIZOPHRENIA
Nowadays, more adults with schizophrenia are living to advanced age and in the community. In many cases, there is “positive aging” in schizophrenia, meaning that as some patients age, they have fewer positive psychotic symptoms such as hallucinations and require hospitalization less frequently. Many older patients with schizophrenia, however, continue to struggle with negative symptoms, such as cognitive problems, amotivation, and minimal social interaction. Slowly tapering off antipsychotics to geriatric-appropriate doses when clinically appropriate and removing anticholinergic medications used to manage extrapyramidal symptoms are important strategies for reducing the side effects from these medications, such as increased risk of metabolic syndrome, stroke, death, and cognitive impairment. See Chapter 16 (“Psychopharmacological Interventions”) for more information about medication discontinuation.
SLEEP-RELATED HALLUCINATIONS AND VISUAL HALLUCINATIONS DUE TO VISUAL IMPAIRMENT
Esther, a 91-year-old woman with stage 4 congestive heart failure and COPD who requires supplemental oxygen and is legally blind in her right eye because of macular degeneration, presents to your office concerned about auditory hallucinations. While falling asleep recently, she has been hearing the voices of people from her childhood who have died. You review her medication list, discontinue her zolpidem, and recommend sleep hygiene measures. On a subsequent visit, she reports that her auditory hallucinations have resolved but wonders if they are related to the strange visions she has experienced since she lost sight in her right eye. She sometimes sees small cats wandering around her house, even though she does not own any pets and knows the cats are not really there.
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