report

1. 1
Mental Health Consultation
Patient Name: paranoid personality disorder/VaD Facility: XXXX
Date: 7-16 -13 Room: 000
Reasonfor Referral: XX-year-old, white, xxxxx, male… I was asked to see him to clarify his
diagnoses, as well as, offer assistance with his many behavior problems. Reportedly, he often “refuses
care… yells… swears… strikes out and generally frightens staff and other residents” He has eloped
from the facility. He is preoccupied with the notion of being discharged from XXXX and moving to
Arizona where he plans to find an apartment. At times, he “apologizes for his behavior” and he has also
been seen “crying”.
Background Information: There is very little useful history available. Highlights of what there is
follows:
 He was admitted to the XXXX on 4-18-13 where he was treated for a bowel obstruction. While
at the XXXX he was described as “confused, disoriented and belligerent” He referred to himself
as the “Mayor of Buffalo” and was kept in restraints for most of his stay. He reportedly, had a
grand mal seizure just prior to admission. He was transferred to XXXX on 5-2-13.
 According to family he was in decline for many months prior to admission to the XXXX: he
purchased a car and totaled it… wasn’t paying his bills… failed to pay his rent and was evicted
from his apartment. He had a drinking problem most of his adult life, hanging out in bars but has
not been a drinker for 20 years. He was always an angry person who used extremely bad
language which offended people but he loved his family and his ex-wife’s dog. Because of his
abusive behavior he “burned all of his bridges with the family”
 There is no neuroimaging available. Recent labs are unremarkable. He has a Health Care Proxy.
His daughter-in-law is designated the Health Care Agent. She also has POA.
Current Medications: Coreg, Aricept, Zoloft 50mg qd, Seroquel 50mg qhs and 25mg bid prn, Haldol
0.5mg q8hr prn, Ativan 0.5mg tid prn, Compazine prn
Medical History: Hyperlipidemia, Hypertension, Peripheral Vascular Disease, dementia.
Mental Status Exam: He was a fit looking elderly gentleman with a full head of silver hair who was
readily engageable. He was restless moving about as he spoke. He exhibited bilateral hand tremors, and
when I asked him to walk, a stooped posture and a shuffling gait with short steps. His speech was
spontaneous but laden with word finding pauses and semantic paraphasic errors. His affect was mostly
flat but could be labile alternating between laughing and joking and flashes anger. He ruminated on his
desire to leave the nursing home and set up shop Arizona. He was preoccupied with the many injustices
which were perpetrated on him. When I asked about depression, he said “I know my son and the others
don’t want me but I understand” He carefully avoided answering my questions about orientation. He
became animated when I asked about his experiences during the Korean War. He was quite paranoid but
not hallucinated or delirious.

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Findings and Recommendations:
There are several interacting and compounding issues here:
Based on his history and his clinical presentation what we appear to have here is a man with a premorbid
paranoid personality disorder. According to his family, he has a lifelong history of abusive behavior
“angry…yelling…swearing”. He has “burned all of his bridges” with them because of this behavior.
Individuals with a Paranoid Personality Disorder are mistrustful of others and suspicious of the motives
and intentions of those around them. They tend to be loners with few close, personal relationships. They
can be impressive even charming, but are always looking for hidden meanings in the speech and
behavior of the people they encounter. They can be argumentative and quarrelsome and their impatience
is often expressed in angry, emotional outbursts. They sometimes convey an attitude of superiority,
arrogance and grandiosity which antagonizes other people. They can unconsciously create the following
self-defeating vicious cycle: They expect to be rejected; as a result, they are hostile to others and reject
before they are rejected; because of their defensiveness and hostility, others reject them; this confirms
their original belief that most people are hostile to them and the cycle is repeated over and over again
with each new interpersonal contact.
The above has been compounded and complicated by the onset of a vascular dementia (VaD). Despite
the lack of neuroimaging this appears to be VaD because of the risk factors and his clinical presentation.
I am ruling out alcohol dementia because his family said he stopped drinking 20 years ago and Lewy
body because of the absence of hallucinations and wide swings in consciousness. Patients with VaD are
especially vulnerable to delirium. Irritability and mild paranoia are often seen in these patients.
Neurological signs of this disease include: gait problems and falls, weakness, ataxia, rigidity, dysarthria,
parkinsonism and urinary incontinence. Neuropsychiatric findings include: memory impairment, poor
judgment, lack of spontaneity, perseveration, psychomotor slowing, loss of vigor, general dilapidation in
cognitive functioning and apathy. Nocturnal confusion, fluctuating mental status and delirium like
episodes are also often seen. The vascular dementia as led to some degree of disinhibition which has
intensified the yelling and swearing. Disinhibition is also responsible for the reported “crying”. We
could be seeing some atypical depression not uncommon in VaD. He was not grossly psychotic or
delirious but he was paranoid. Sounds like he was delirious at the XXXX.
He exhibited pronounced Parkinson’s signs including bilateral hand tremors, a stooped posture and a
shuffling gait with short steps. This is probably a reflection of his VaD. It seems unlikely that it could be
EPS secondary to the Haldol given the fact that he rarely takes the Haldol. Idiopathic Parkinson’s
Disease cannot be completely ruled out.
Because of the severity of his dementia he lacks the capacity to make choices concerning living
arrangements. In order to provide informed consent for living arrangements, the patient must be able to
satisfy the following criteria:
1) Can the person make and communicate, by spoken words or otherwise, choices concerning his or
her own life?
2) Can the person offer any reasons for the choices made?
3) Are the reasons underlying the choice “rational”? That is, does the patient start with a plausible
premise about the facts surrounding a specific situation and reason logically from that premise to
a conclusion?
4) Is the person able to understand the likely risks and benefits of the choices?
5) Does the person understand the implications of those choices?

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Therefore, he cannot choose to leave the nursing home; that decision is in the hands of his Health Care
Agent. A Guardianship would be preferable.
His aggressive behavior is part of a lifelong ingrained personality style worsened now by compromised
brain functioning. We will be able to manage the problem behaviors and diminish them somewhat with
medications and, more importantly, consistent behavioral approaches but we will not be able to stop
them.
1. The Seroquel was a good choice because of its low antidopaminergic properties considering
XXXX pronounced Parkinson’s signs however the dose is much too low to have any effect.
Therefore, I would increase the Seroquel to 50mg TID. We can titrate up from there if we need
to. Continue the Ativan prn; by all accounts this has worked for him. Would DC the prn Seroquel
and start Risperdal 0.5mg bid prn PO. This is highly antidopaminergic which is not good in this
situation but onset of action is 30 min. vs. the 2 hrs. for the Seroquel. Staff can chose between
the two prns.
2. To treat any possible atypical depression (i.e. anxiety, agitation, irritability, emotional
incontinence) symptoms, as well as, disinhibition would discontinue the Zoloft and start him on
Lexapro 10mg qd times two weeks then increase to 20mg qd. The Lexapro and Seroquel will
interact synergistically.
3. His room is devoid of personal objects. Ask his son to bring in family photographs including
photos of XXXX ship and his dog and bring in objects which are of sentimental significance to
him and place them about his room. Try to create a soothing and familiar environment in his
room. Ask the son to bring in some examples of XXXX leather tooling to pump up his self-
esteem.
4. Would refer him to the Neurology Clinic at the XXXX to address the issue of “grand mal
seizure PTA” and to rule in or rule out Idiopathic Parkinson’s Disease. It looks like the surgeon
at the XXXX also wanted this to happen. It would be helpful if they did neuroimaging, as well.
5. His hobby was leather tooling. Perhaps the activities folks could find something similar for him
to do such as wallet making. The better he feels about himself the less he will act out.
6. He is very attached to his ex-wife’s dog. Ask her to bring the dog in on occasion.
7. Staff should avoid appearing directive with him. He would see this as a threat to his self-esteem
and become oppositional as a means of asserting his autonomy.
8. Model self-regulation by speaking and moving, calmly and slowly when dealing with him. He
seems to have a bit of a sense of humor. When it seems appropriate, try to diffuse a tense
situation with humor.
9. Do not allow him to make you feel responsible for immediately solving his problems. Do not
allow him to lure you into agreeing with his criticisms. Do not be intimidated by him. Do not try
to win his approval.

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10. Always allow him a face saving way out of a conflict or situation. When he talks about leaving
the nursing home never say he has to stay, change the subject to one you know he is interested in
such as: his dog, the Navy or his family.
11. When he does become abusive guide him back to his room. Say nothing other than walk with
me. Do not engage him in a back and forth. If necessary use a few silent people to help guide
him. Offer him a prn. Say you will talk to him when he gets better control of himself. Tell him
you know being out of control is as frightening to him as it is to other people. Do not indirectly
reward his aggressive behavior.
12. Stability and predictability will limit frustration and emotional outbursts. Establish a predictable
and consistent daily routine for him. Keep him busy with simple tasks but not excessively
stimulated.
13. Try not to ask questions which draw attention to his memory loss and general cognitive
impairment.
14. Please try to obtain additional history on this gentleman specifically any neurology and/or
psychiatry records which might be available. Start with the XXXX.
___________________________
Drew Chenelly, Psy.D
Clinical Neuropsychologist