Cognitive Decline in Older Adults with Schizophrenia-Bipolar Spectrum Disorder

Abstract

Mr. S is a 67-year-old man with psychiatric history of an unspecified psychotic disorder (schizophrenia vs schizoaffective disorder vs bipolar I disorder) and medical history of hypertension and hyperlipidemia who presented to the emergency department (ED) for inability to care for self after being picked up by emergency medical services (EMS) while wandering outside. Psychiatry was consulted due to a chart history of bipolar I disorder with concern for active mania given disorganization and agitation. On chart review, the patient had seven ED visits in two months prior to the current presentation, all for wandering. The patient was born in Jamaica, attended college, and worked as a paralegal before repeated hospitalizations for mania and/or psychosis. His mid-life history is unclear, but for the last 15+ years he was living in a group home without any hospitalizations. He was maintained on a stable regimen of clozapine, lithium, and valproic acid, until an episode of acute psychosis in 2015. Afterwards, he had 5+ admissions between 2017 and 2021 for altered mental status with pre-renal acute kidney injuries & lithium toxicity. After a particularly severe admission for lethargy in 2021, with creatinine increase to 2.9, clozapine and lithium were discontinued, and the patient has since remained on a regimen of valproic acid 500mg BID and haloperidol 15mg BID. On exam in the ED, he was awake, alert, with no evidence of head injury, and moving all extremities symmetrically and purposefully; his mood was "melancholy," affect flat, thought process ruminative and goal directed. He endorsed passive suicidal ideation, exhibited paranoid delusions about family and staff, and denied any hallucinations. Urine toxicology screen was negative for illicit substances and showed an undetectable valproic acid level. No acute abnormalities were found on a non-contrast head CT, and non-specific white matter abnormalities and volume loss were noted on an MRI one year prior. He was admitted to a general psychiatric inpatient unit after 48 hours in the ED, where he was stabilized on home valproic acid and haloperidol with the addition of aripiprazole for mood and negative symptoms. Even once his psychiatric symptoms stabilized, the patient required considerable nursing support for completion of activities of daily living, with marked memory impairments. He scored a total of 16/30 on the Montreal Cognitive Assessment (MoCA), with impairments in executive function, language, and delayed recall. Occupational therapy (OT) evaluation using the Kohlman Evaluation of Living Skills demonstrated a need for assistance in all five domains of daily living with a recommendation for 24/7 assistance and a secure environment given memory loss and cognitive deficits. A hearing was held to assign his sister legal guardianship, and the patient was discharged to a skilled nursing facility with a secure unit after a total of 56 days of inpatient hospitalization.