Introduction
Mental health is one of the main issues within geriatric populations, as acute and chronic states of psychic disorders often take place. For instance, dementia is rather common among elderly patients, and its primary symptoms are not always visible to their surroundings. Several factors may induce various episodes like mania, mood liabilities, and psychosis. It is crucial for specialists like APRNs to differentiate between illnesses with similar symptoms to offer correct treatment. This paper reviews the case study of E. J., a 67-year old patient admitted to a hospital with agitation, hallucinations, and paranoia after a medication course. It is also important that it was his first disorder of a psychiatric character in a lifetime.
Diagnoses, Differentials, and ICD Codes
The case of E. J. demonstrates that psychosis and mood disorder had a rapid onset. The symptoms appeared after the patient had been treated with Prednisone, which allows viewing this medication as a trigger for his current state. Treatment of severe poison ivy exposure consequences required high doses of corticosteroids to be used over a short period. Unfortunately, there is no information on how long E. J. was on Prednisone, and on which types of medications, he was during the past 11 months.
Given the abovementioned facts, the diagnose for E. J. would be psychosis induced by corticosteroids. Features match most criteria developed for it in the DSM-V guide (American Psychiatric Association, 2013). Firstly, the patient had auditory hallucinations, which developed soon after receiving Prednisone, the latter known for being capable of producing such symptoms. Secondly, there had been no previous history of psychiatric abnormalities. Finally, the patient could not function appropriately in society and required help from family and hospital personnel to perform daily activities due to hallucinations. The current ICD classification has a group of substance-induced psychotic disorders, yet there is no separate category for corticosteroids as a cause. Consequently, it is most likely to be classified under either 6C4E.6 or 6C4G.6 codes (ICD-11 for mortality and morbidity statistics, 2019). It should also be differentiated from schizophrenia and other diagnoses of the group.
Corticosteroid-induced psychosis is not a very common adverse effect of treatment. For instance, in a studied population of 520 patients, 5.4% had this diagnosis (Kenna, Poon, de Los Angeles, & Koran, 2011). Other side effects of corticosteroid therapy include mania, depression, or delirium (Muzyk, Holt, & Gagliardi, 2010). Several risk factors contribute to the incidence of psychosis, including gender and dosage. Research suggests that the female population is more likely to experience psychiatric issues (Menon, Sunny, Pereira, Chikkaveeraiah, & Ramesh, 2018). There is also a straight correlation between dosage and the severity of symptoms (Menon et al., 2018). High doses of corticosteroids, which was the case of E. J., are more likely to result in a psychiatric episode.
However, the duration of symptoms described in the case of E. J. does not match the typical clinical picture for the diagnosis. Evidence-based literature suggests that stopping corticosteroid therapy results in the rapid disappearance of adverse psychotic symptoms (Menon et al., 2018). It usually takes days or weeks for improvement, while the case of E. J. demonstrates the patient is staying in the hospital for 11 months. Nevertheless, in some situations, psychosis may be sustained months after corticosteroid cessation (Gable & Dwayne Depry, 2015). Symptoms may be mixed, including delusions, hallucinations, and overall disorganization in behavioral patterns.
Corticosteroid-Induced Psychosis versus Dementia and Schizophrenia
In the studied case, E. J. is an elderly patient, which increases the risk of him developing dementia. The fact of him having auditory hallucinations may support this theory as one of the frequent psychiatric changes, which occur in 20-30 percent of patients having this diagnosis (Sadock, Sadock, & Ruiz, 2015). However, dementia is characterized by the gradual increase of cognitive deficits, which should have been noticed before corticosteroid treatment in the case of E. J. Even if the condition is classified as substance-induced, both memory impairment and aphasia, apraxia, agnosia, or disturbance in executive functioning must be present (Sadock et al., 2015). None of those symptoms are seen in E. J.’s behavior, and his grandson did not mention any of them.
Late-onset schizophrenia might also be possible for the patient, especially since his mother had this diagnosis. The character of auditory hallucinations he is having falls under the description of positive symptoms, stating that they often have persecutory tone and third-person comments (Vannorsdall & Schretlen, 2019). Cognitive functions remain relatively stable for elderly patients with late-onset schizophrenia, allowing them to perform many day-to-day activities (Hussein, El Shafei, Abd El Meguid, El Missiry, & Mahmoud, 2011). However, the DSM criteria for this diagnosis include a point that symptoms must not be induced by substance use (Vannorsdall & Schretlen, 2019). In the case of E. J., agitation and hallucinations clearly appeared after the corticosteroid treatment.
Medications
The first step in treating E. J. would be reducing the dosage of corticosteroids to a minimum if he still requires them. Psychopharmacologic course is needed for dealing with psychosis itself, including auditory hallucinations. Low-dose antipsychotics would be the primary type of medications used for this purpose. Olanzapine is one of the common drugs for treating such conditions, with many patients recovering from adverse symptoms (Muzyk et al., 2010). Some of the side effects include significant weight gain independent of the patient’s initial body mass, asthenia, and extrapyramidal symptoms. Drug-induced hypersensitivity syndrome is one of the rare ADRs for olanzapine.
Alcohol should not be taken when undergoing treatment with this medication since it may increase adverse reactions from the nervous system. A patient may lose concentration or experience thinking difficulties. Olanzapine, as well as other antipsychotics, should be prescribed carefully to patients with cardiac issues (Muzyk et al., 2010), so an APRN should control E. J.’s state regarding this factor. Glucose level should be another one of the monitoring points, as it tends to fluctuate during the treatment course.
Psychosocial Issues
The patient is 67 years old, meaning that he is most likely retired. The absence of day-to-day work activities may leave him with a feeling of social exclusion, especially if he is not a part of any community groups or events. Issues such as mood liability and agitation that appeared after the corticosteroid treatment may also be caused by various factors of the patient’s environment. It is critical to understand how well his family and friends support him, what kind of neighborhood he resides at, what is the quality of his interactions with other people. For example, studies show that most patients with late-onset schizophrenia live a rather lonely life (Hussein et al.). The case study suggests that E. J. was brought to the hospital by his grandson, which is a positive sign in this matter.
Variables Related to Aging and Mental Health
The patient has a family history of psychiatric illnesses, as his mother had schizophrenia. Although this illness develops in only three percent of people over 60 years old (Vannorsdall & Schretlen, 2019), it serves as an additional risk factor for E. J. Mental health in geriatric populations is one of the core issues, with psychotic symptoms being prevalent (Vannorsdall & Schretlen, 2019). Moreover, the patient has hypertension and coronary artery disease, which may be extremely dangerous, especially in the elderly population.
Recommendations
Firstly, it is critical to create a safe environment for the patient. The case study mentions that E. J. is having paranoia, which may be a source of his adverse behavior towards himself and the people surrounding him. An APRN should monitor that the assisted living facility, where the patient currently resides, suits all his needs in care and support. Additionally, cognitive-behavioral therapy should be provided to ensure that E. J. can function adequately in daily life. Psychological support should also be given, as the patient is most likely frightened and insecure due to the psychosis episode. Moreover, cardiometabolic risk factors must be one of the key monitoring points done by an APRN due to the medical history of E. J. and the proposed treatment scheme. Besides, it is a sensible step to take within the geriatric population. Finally, attention must be made to strengthening the patient’s ties to family and friends as a part of mental health risk prevention initiatives.
Conclusion
The 67-year old patient appears to have psychosis induced by being treated with high doses of corticosteroids. People who have dementia may have similar symptoms as E. J., yet this illness is developing slowly and is associated with cognitive malfunctions. Schizophrenia is also unlikely, as it does not develop as a result of medical substance use. The patient requires treatment with antipsychotics, which should be accompanied by cognitive-behavioral and psychological therapy. An APRN should also monitor his cardiometabolic state, as E. J. has a history of diseases associated with high pressure and issues with arteries. He also requires support from family and friends, as it contributes positively to mental health, especially in geriatric populations.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed). Arlington, VA: American Psychiatric Association.
Gable, M., & Dwayne Depry, D. O. (2015). Sustained corticosteroid-induced mania and psychosis despite cessation: A case study and brief literature review. Journal of Clinical Case Reports, 5(6), 1-3. Web.
Hussein, H., El Shafei, A., Abd El Meguid, M., El Missiry, M., & Mahmoud, T. (2011). Studying late-onset schizophrenia and non-schizophrenia psychosis in Elderly Egyptian patients. Middle East Current Psychiatry, 19(1), 12-22. Web.
ICD-11 for mortality and morbidity statistics. (2019). Web.
Kenna, H. A., Poon, A. W., de los Angeles, C. P., & Koran, L. M. (2011). Psychiatric complications of treatment with corticosteroids: Review with case report. Psychiatry and Clinical Neurosciences, 65(6), 549-560. Web.
Menon, V. B., Sunny, A. A., Pereira, P., Chikkaveeraiah, S., & Ramesh, M. (2018). Steroid psychosis: A case series of three patients. Indian Journal of Pharmacy Practice, 11(1), 51-54. Web.
Muzyk, A. J., Holt, S., & Gagliardi, J. P. (2010). Corticosteroid psychosis: Stop therapy or add psychotropics? Current Psychiatry, 9(1), 61-68. Web.
Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan and Sadock’s Synopsis of psychiatry: Behavioral sciences/clinical psychiatry (11th ed.). Philadelphia, PA: Wolters Kluwer.
Vannorsdall, T. D., & Schretlen, D. J. (2019). Late-onset schizophrenia. In L. D. Radvin & H. L. Katzen (Eds.), Handbook on the neuropsychology of aging and dementia (pp. 487-500). New York, NY: Springer.