Severe recurrent hypothermia in an elderly patient with refractory mania associated with atypical antipsychotic, valproic acid and oxcarbazepine therapy

Hypothermia is a rare but serious condition that has been associated with various psychiatric medications. We present a 76-year-old woman with refractory mania who developed multiple episodes of severe hypothermia associated with several psychiatric medications including olanzapine, quetiapine, valproic acid and oxcarbazepine. These episodes resolved following discontinuation of the agents. The patient had never experienced hypothermia before, despite having been on these or similar agents for many years. With traditional treatments for mania not feasible, other medications were used to treat her including lithium, clonazepam, gabapentin and the novel protein kinase c inhibitor tamoxifen. The regimen resulted in some success and importantly, without triggering hypothermia. This case alerts clinicians to the rare side effect of hypothermia in response to various psychiatric medications, the fact that patients can suddenly develop this intolerance and suggests possible medications that may be used safely without triggering hypothermia

Substance Use Disorders in Elderly Admissions to an Academic Psychiatric Inpatient Service over a 10-Year Period

Objective: There is a paucity of research on substance use disorders (SUDs) in the elderly psychiatric population. This study examines SUDs in a geriatric psychiatry inpatient service over a 10-year period. Methods: Data from 1788 elderly psychiatric inpatients from a ten-year period was collected. Variables collected included psychiatric diagnoses, SUD, number of psychiatric admissions, and length of stay. Those with and without a SUD were compared using Chi-Square or Student’s -test as appropriate using SPSS. Results: 11.7% ( = 210) of patients had a SUD, and the most common substance was alcohol at 73.3% ( = 154) or 8.6% of all admissions. Other SUDswere sedative-hypnotics (11%), opiate (2.9%), cannabis (1%), tobacco (1.4%), and unspecified SUD(38.6%). SUD patients were significantly younger, divorced, male, and less frequently readmitted and had shorter lengths of stay.The most common comorbid diagnoses were major depression (26.1%), bipolar disorder (10.5%), and dementia (17.1%). Conclusions: Over 10% of psychogeriatric admissions were associated with a SUD, with alcohol being the most common. Considering the difficulties in diagnosing SUD in this population and the retrospective study design, the true prevalence in elderly psychiatric inpatients is likely higher.This study adds to sparse literature on SUD in elderly psychiatric patients

Treatment of Tardive Dyskinesia with High Dose Vitamin B6 Associated with Depression

Tardive dyskinesia (TD) is a movement disorder associated with dopamine receptor blocking medications. Recommended treatments for TD include discontinuing the causative agent, adding vesicular monoamine transporter 2 (VMAT2) inhibitors, or adding vitamin B6. We present a 66-year-old Caucasian male with bipolar I disorder who developed TD while on lithium and quetiapine having been euthymic on this regimen for three years. He was initially treated with 1200 mg B6 daily. This failed to improve his TD and was associated with a depressive episode. He switched to valbenazine 40 mg daily which improved his TD and concurrently his mood, but months later the TD symptoms worsened again. Our case adds to the literature by demonstrating that some patients with TD will not respond to vitamin B6. To our knowledge, ours is the first case suggesting association of high dose vitamin B6 with depression. This case also demonstrates that response to valbenazine may not last and further studies are needed

Musical Hallucinations Treated with Atypical Antipsychotics in a Geriatric Population – A Case Series

Musical hallucinations have been likened to the auditory equivalent of Charles Bonnet Syndrome, which involves complex visual hallucinations, most often in the context of visual impairment. Musical hallucination frequently take the form of hymns, carols, and show-tunes and are strongly associated with hearing loss, with some studies suggesting a prevalence of 2.5–3.6% in the hearing impaired. Musical hallucinations are typically treated with anticonvulsant and anticholinesterase medications, with some studies having evaluated the efficacy of sedative hypnotics, antipsychotics and antidepressants in various psychiatric and medical subpopulations suggesting a heterogeneous spectrum of causes for this disorder. We present two cases of musical hallucinations in both a 70-year-old African American female with past psychiatric history of major depressive disorder who developed hymnal auditory hallucinations during an acute medical and psychiatric admission and an 86-year-old Caucasian female, who complained of hearing gospel music with eventual onset of visual hallucinations after a fall at age 80. Our patients were successfully treated in both the inpatient and outpatient settings with atypical antipsychotics. The presented cases add to the paucity of literature regarding utilization of atypical antipsychotics for treatment of musical hallucinations and demonstrate efficacy to this effect. This study lends further validity to the use of psychopharmacologic agents for novel purposes that have yet to be fully explored

Topical administration of psychotropic medications in pluronic lecithin organogel to treat patients with dementia: A retrospective observational study

OBJECTIVE: Treatment of mood and behavioral symptoms in geriatric patients with advanced dementia may be impeded by poor compliance with oral medications. Pluronic lecithin organogel (PLO) is a compounding substrate that can be used for the topical administration of psychotropic medications. METHODS: Charts of patients treated with psychotropic medications compounded with PLO cream were reviewed for treatment outcomes. All patients were treated by a nursing home outreach service. RESULTS: Records from twenty-four patients, mean age 86.8 + 5.9, were reviewed. Common psychiatric symptoms included agitation, aggressive behavior, and depression. Medications most commonly administered as a PLO cream included quetiapine and venlafaxine. All patients had mild to marked improvement in psychiatric symptoms. CONCLUSIONS: Pluronic lecithin organogel (PLO) may be an effective option for the topical administration of psychiatric medications in geriatric patients with dementia who are not compliant with oral medications

Substance Use Disorders in Elderly Admissions to an Academic Psychiatric Inpatient Service over a 10-Year Period

Objective. There is a paucity of research on substance use disorders (SUDs) in the elderly psychiatric population. This study examines SUDs in a geriatric psychiatry inpatient service over a 10-year period. Methods. Data from 1788 elderly psychiatric inpatients from a ten-year period was collected. Variables collected included psychiatric diagnoses, SUD, number of psychiatric admissions, and length of stay. Those with and without a SUD were compared using Chi-Square or Student's -test as appropriate using SPSS. Results. 11.7% ( = 210) of patients had a SUD, and the most common substance was alcohol at 73.3% ( = 154) or 8.6% of all admissions. Other SUDs were sedative-hypnotics (11%), opiate (2.9%), cannabis (1%), tobacco (1.4%), and unspecified SUD (38.6%). SUD patients were significantly younger, divorced, male, and less frequently readmitted and had shorter lengths of stay. The most common comorbid diagnoses were major depression (26.1%), bipolar disorder (10.5%), and dementia (17.1%). Conclusions. Over 10% of psychogeriatric admissions were associated with a SUD, with alcohol being the most common. Considering the difficulties in diagnosing SUD in this population and the retrospective study design, the true prevalence in elderly psychiatric inpatients is likely higher. This study adds to sparse literature on SUD in elderly psychiatric patients

Buspirone for the treatment of dementia with behavioral disturbance

Behavioral disturbances are common but serious symptoms in patients with dementia. Currently there are no FDA approved drugs for this purpose. There have been case reports and small case series of the use of buspirone. In this retrospective study, we review 179 patients prescribed buspirone for treatment of behavioral disturbance in dementia to better characterize the efficacy and potential side effects. All patients prescribed buspirone for behavioral disturbance due to dementia from a geropsychiatric outreach program were reviewed. Data was collected and analyzed using SPSS. One hundred-seventy-nine patients met criteria for the study with a mean age of 83.8 + 7. Alzheimer’s dementia was the most common dementia (n=111; 62%) followed by vascular type (n=81; 45.5%). Behavioral disturbances were mainly verbal aggression (n= 125; 72.3%), and physical aggression (n=116; 47.5%). Using the Clinical Global Impression scale, 72.8% of patients responded to buspirone, with 30.8% being moderately to markedly improved. The mean dose of buspirone was 25.7 mg ±12.50. Buspirone appears to be effective in treating behavioral disturbances in dementia. Future prospective and double blinded studies are needed

Use of Memantine in Autism Spectrum Disorder: a Case Report

Autism Spectrum Disorder (ASD) is a neurodevelopmental disorder of varying severity and phenotypic expression that is characterized by persistent deficits in social relatedness, communication skills, and interfering repetitive behaviors. Associated behavioral pathology can include inattention, aggression, irritability, hyperactivity, anxiety, and self-injury. Currently, FDAapproved treatments exist to treat secondary symptoms but not core symptomatology. The etiology of autism and other ASD is thought to be multifactorial but is not well understood. Some studies suggest that glutamate excitotoxicity may play a role in the pathogenesis of ASD. Memantine, an NMDAreceptor antagonist, could potentially address core symptoms in ASD by targeting disease-specific pathophysiology. Our patient, an 11-year-old Caucasian male, began treatment with memantine following parental request after learning of a phase II clinical trial utilizing the drug for treatment in autism. Following one month of receiving memantine 5mg daily the patient reportedly began showing increased verbal communication at home. Despite the patient not exhibiting verbal communication on patient interview at the clinic, the guardians reported that the patient had begun using 30 plus newly learned words, and had learned to communicate via sign language. Continued improvement in communication was noted over the course of one year of treatment with memantine. Memantine is not yet approved for treatment of ASD. However, in this case it appeared effective for treating core deficits in verbal and non-verbal communication in a child with autism