Poster Number: EI 41 - Treatment Issues in an Elderly Female with Repeat Inpatient Psychiatric Admissions

Abstract

Introduction: Ms. S., is a seventy year old African American widowed female, living alone, with a previous psychiatric history of schizoaffective disorder and a past medical history of uncontrolled diabetes mellitus. She has had over thirty inpatient lifetime psychiatric admissions and a longstanding history of noncompliance. She has been followed by an Assertive Community Treatment (ACT) team for the last two years. In spite of ACT Team follow up, she has had numerous admissions which on many occasions were back to back admissions. Her inpatient stays were characterized by extended periods, some of which were up to sixty days. On one occasion, she was readmitted within twelve hours of discharge. On this occasion, she was admitted for manic and aggressive behavior in the context of medication noncompliance within days of discharge from a different hospital. On our unit, the patient refused medications consistently and was uncooperative with vital signs and fingerstick glucose monitoring. She was observed to demonstrate extreme mood swings, quickly escalating to violent and aggressive behavior towards staff and other patients and then becoming calm. This poster explores difficulties in management and discharge of patient. At times, she required intramuscular injections of Haloperidol and Lorazepam to calm her. She refused psychiatric, diabetic, and hypertensive medications, so a forced medication order was obtained through the local mental hygiene court. She showed clinical improvement on a regimen of Aripiprazole titrated to a dose of twenty milligrams per day orally and Sodium Valproate one thousand milligrams per day orally. She was extremely inconsistent on Sodium Valproate so it was discontinued. She was eventually discharged on four hundred milligrams of intramuscular long acting Aripiprazole. Multiple meetings were held with her ACT team to ensure a safe discharge. Issues which emerged prior to discharge included obtaining her consent to make a duplicate key for her apartment, ensuring that her house was habitable, obtaining a referral for visiting nurse services for monitoring of her diabetes and hypertension, educating her on the importance of diabetic monitoring and compliance with her medication regimen, and obtaining home care services for an adequate amount of time. Unfortunately, she was ineligible for home care services as her personal income was in excess of the threshold required for eligibility. Also, the absence of a responsible family member who could provide adequate support made her discharge challenging. Eventually, she was discharged home with referral to visiting nurse services and ACT Team follow up. This case highlights the challenges in maintaining elderly psychiatric patients with comorbid medical issues who are only partially cooperative with their treatment regimen in the absence of community resources and social supports.