Cocaine, Coffee, Constipation: (1) Leveraging Concrete Relatedness in Paraphrenia to Address Stimulant Use and (2) Monitoring Constipation with AIMS to Titrate Tetrabenazine

Abstract

Our patient is a 75-year-old man, non-combat Army veteran ('66-'69), divorced, domiciled in his own apartment, retired from the post office, with a medical history of asthma and osteoarthritis, a psychiatric history of primary psychosis beginning in his late fifties (without affective symptoms, substance use, or cognitive decline with a MoCA 26/30), cocaine use disorder in partial remission, and depression in remission, one prior admission, without suicidality or violence, who follows with geriatric psychiatry for psychosis, tardive dyskinesia, and cocaine use.Our patient's symptoms began at age 51 with depressive symptoms (low mood, anhedonia, low self-worth, insomnia) that resolved with sertraline, bupropion, and trazodone in primary care. At age 59, he experienced delusions (with possible auditory hallucinations) about a female neighbor he believed to be squatting upstairs. At age 62, he started using cocaine weekly to have the energy to mount a defense against his neighbors but was never violent. Later that year, an inpatient team treated his paranoia with risperidone 4 mg at bedtime. At age 68, he established care in geriatric psychiatry and stabilized on olanzapine 15 mg, lurasidone 40 mg, trazodone 100 mg, mirtazapine 15 mg, and melatonin 3 mg, all daily. Lurasidone was discontinued due to tardive dyskinesia symptoms: bilateral upper extremity tremors and jaw/tongue movements (AIMS 3 initially, max 4). While undergoing a titration of tetrabenazine 12.5 mg every 2 weeks, his AIMS scores were relatively stable (2-3) for 3-4 months. His titration was paused at 87.5 mg daily because he suffered side effects of constipation and dry mouth. One month later, he had managed his constipation with dietary changes and his tremors had subsided. His AIMS was 1 for ongoing subtle tongue movements.At age 75, the patient continued to present for care and maintained a routine on olanzapine 25 mg, trazodone 200 mg, mirtazapine 15 mg, and melatonin 6 mg all at bedtime, although his delusional symptoms adopted a more elaborate narrative. He also started to suffer from decreased energy without other depressive symptoms. Eventually, he started using cocaine biweekly to have more energy to complete household tasks and to address the squatters. He had not considered alternatives to using cocaine. Through motivational interviewing and supportive psychotherapy, the patient became amenable to drinking coffee to stimulate his daytime energy. The patient is now managing psychotic symptoms, abstaining from cocaine, and sleeping well on olanzapine 30 mg, trazodone 200 mg, mirtazapine 15 mg, and melatonin 6 mg all at bedtime.