report

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Mental Health Consultation
Patient Name: Alcoholic Dementia Facility: XXXX
Date: 7-23-13
Additional history can be found elsewhere in this chart which will not be repeated here.
Reason for Referral: xx-year-old, white, xxxx, male… I was asked to evaluate him because he has
episodes where he… “Slams doors and throws wheelchairs Yells:...niggers…fat asses…fucking
animals”.
Background Information: 7-3-13 and 8-22-11 CT scans of the head = “cortical and central atrophy
greater than expected for age… markedly enlarged space over the frontal lobes...moderate enlargement
of the lateral and third ventricles”. On an MMSE, he achieved a score of 22/30 and showed very
concrete thinking. He decided not to go home to live with his brother because he feared he needed more
help than was available there. Until “several years” ago he drank about a quart of liquor a day.
Current Medications: Cymbalta 60mg qd, Depakote ER 1250mg q pm and 1500mg q am, Ativan
0.5mg 4hr prn, Prilosec, Albuterol
Medical History: Depressive Disorder, Renal Failure, Paranoid State, Alcoholic Dementia,
Cholelithiasis, dysphagia, Hypertension
Mental Status Exam: I found him in bed, fully dressed, awake in the dark, staring at the wall. He later
said, he was “thinking about going home”. He was easy to engage and his speech was spontaneous but
his affect was flat and his thinking was slow. He denied current depression but remarked “I was
depressed when I first came in here; I was a mess; it was the alcohol; I’m okay now” He thought the
year was 2002 and couldn’t name the nursing home. He said “I lose control and yell at the nurses;
there’s no warning and it is for no reason; it’s gone in seconds”. He became very interested when I
explained disinhibition to him and how it’s treated. He said he wants to try to change and get better
control of himself. He seemed personable and was able to laugh at himself. His story was full of
confabulations and disorientations in time. He talked about being treated by Dr. XXXX as if it occurred
yesterday not in the 1970s. He said his two sisters were alive and living in XXXX when in fact they are
long dead. He talked about a nonexistent daughter and the details of his history constantly shifted. He
did not appear to be hallucinated.
Findings and Recommendations: This man suffers from a classic Alcoholic Dementia typically
characterized by profound memory impairment while most other areas of cognitive intellectual
functioning remain intact. He unconsciously compensates for his memory impairment through the use of
confabulation. He fills in gaps in his memory with false memories. These false memories often have a
bizarre quality such as “My Father was 104 –years-old”. He genuinely believes these statements. These
patients betray disorientation in time and place, misidentification of those around them and an inability
to grasp their immediate situation. Many of their remarks are irrational and lack consistency from one
moment to another. He said his sisters were alive when in fact they were dead. He spoke about being
treated by Dr. XXXX as if it was a few months ago when in fact it occurred in the 1970s. His story

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changes with each telling. We are likely to see some degree of anterograde amnesia which is a failure of
memory formation and storage. New information is processed normally, but almost immediately
forgotten.
He exhibits apathy towards his surroundings, a general lack of initiative and spontaneity and a form of
inattention characterized by indifference and perseveration seen in patients with alcoholic dementia. I
found him in the dark, in bed, alert but staring at the wall at 2:00PM.
People with alcoholic dementia show poor judgment and coarse, socially inappropriate behavior. They
have poor impulse control, make vulgar often sexual or racial remarks and engage in aggressive
behavior. This reflects damage to the frontal lobes (The CT scan showed a markedly enlarged space
over the frontal lobes). Frontal lobe dysfunction causes behavioral and/or emotional disinhibition
syndrome. Disinhibition is a disorder of the expression of emotion not a disorder of emotion. Angry
outbursts are sparked by trivial stimuli and do not reflect extreme feelings of rage. Patients with
disinhibition syndrome are unable to control or modulate the expression of emotion. (Reportedly, xxxx
cried when told his ranting upset the other residents showing that he did not have much control over the
behavior). These patients display rapidly shifting moods and irritability. Damage to the inferior orbital
surface of the frontal lobes can lead to outbursts of rage and violent behavior. Damage to the frontal
lobes can also cause impairment in Executive Functions (the ability to organize, plan, monitor and
correct behavior, self-awareness and the ability to learn from experience, the ability to carry out
purposeful action and solve problems).
A patient with deficits in self-awareness shows an inability to: 1) perceive himself as others perceive
him 2) recognize his internal motivations 3) critique his own behavior 4) accurately identify his
strengths and limitations 5.) change a course of action when conditions change 6.) perceive the long-
term consequences of his acts. Most patients with deficits in self-awareness lose the ability to learn from
experience, develop a generally more demanding attitude and exhibit reduced frustration tolerance.
Deficits in self-awareness worsen over time. Denial of deficits in patients with brain disorder is
commonly manifested as anger because of institutional placement, which the patient believes, is
unnecessary. His denial is not complete, however, since he is aware that he “blows up for no reason”
and wants to do something about it. This is a positive sign.
Alcoholic Dementia is caused by a Thiamin deficiency. I did not have the opportunity to check for gaze
or gait abnormalities seen in Korsakoff’s syndrome. We don’t know if he had a period of Wernicke’s
encephalopathy when he stopped drinking which some notes say was several years ago. It would be
useful to know when he stopped drinking and if he was treated with Thiamin at the time. Dilatation of
the lateral and third ventricles as seen on the CT scan is suggestive of normal pressure hydrocephalus. I
will have to look into this.
1. A mood stabilizer should help with disinhibition. Valproic acid (VPA) has been given a fair trial.
Therefore, it is time to switch; would try him on [carbamazepine] Tegretol. I believe this is a
better choice in any case. However, we need to taper him completely off the VPA before starting
the Tegretol. Would start tapering the VPA by about 250 mg bid every three days to DC. While
doing so, would obtain the following in preparation for starting carbamazepine: 1) CBC with
differential 2) serum electrolytes 3) liver function tests 4) EKG. If all is well, then start
carbamazepine extended-release 200mg qd (100mg bid) on day one then Increase by100mg to
200mg per week to dose range of 400-800 mg/day in divided bid doses; not to exceed 1200

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mg/day. Blood levels should be done weekly for the first 6 weeks then monthly thereafter. The
carbamazepine will start to metabolize itself after 6 weeks and the dose will have to be adjusted.
This drug has many interactions. Would continue Cymbalta and prn Ativan. Also, order B12,
Folate and Thiamin levels
2. The next time he has an outbursts, move him immediately to his room or other quiet area.
Remind him of the conversation he had with me concerning James Brady, President Reagan’s
press secretary and the need for him to visualize a situation which he finds pleasant and calming
in an attempt to regain control of his emotions. Ask him to describe the situation to you. Given
his memory problems, staff will have to remind him about this process each and every time. Staff
should record the incident on the attached form utilizing the ABC criteria on the back of the
form. This will give us information concerning what triggers xxxx’s outbursts. I will try to
explain all this to the staff working directly with xxxx.
3. Provide him with tools to compensate for memory deficits:
A. Help him create a memory log including:
a. autobiographical information
b. facts about the facility
c. information about his brain injury
d. a detailed daily schedule
e. a calendar with scheduled appointments, activities, etc.
f. things to do list
g. list of important names with identifying information.
B. Repeat all important information/instructions many times each day.
C. Establish routine schedules D. Use external cueing.
4. Try to keep him occupied and stimulated without causing fatigue or frustration. I suspect that we
may find these two among the triggers for his outbursts.
5. Increase attention focused on him when he is behaving well and to the extent possible (short of
an outburst) ignore negative behaviors.
6. Explain disinhibition to all the staff and when possible other residents.
7. Model self-regulation by speaking and moving, calmly and slowly when dealing with him.
___________________________
Drew Chenelly, Psy.D.
Clinical Neuropsychologist