This mental health consultation report summarizes an evaluation of a patient presenting with apathy and refusal of care. The patient has a history of substance abuse and medical issues. A brain scan showed evidence of multiple infarcts and ischemic changes. On examination, the patient displayed slowed thinking, underproductive speech, odd and vague affect, and disengagement. There are three possible diagnoses: vascular dementia due to multiple brain infarcts, alcoholic dementia, or a schizoid/schizotypal personality disorder. The consultant recommends increasing the patient's antidepressant medication to address apathy, reviewing medications that could exacerbate it, and engaging the patient in enjoyable activities.

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Mental Health Consultation
Patient Name: xxxx xxxxxxx Facility: XXXX
Date: x-xx-xx
For the sake of brevity and timeliness, the following sections will not be included in this report:
Background Information: Current Medications: Medical History: That information can be
found elsewhere in this chart.
Reasonfor Referral: xx-year-old, xxxx, single, male… I was asked to evaluate him “because
of refusal of care and failure to thrive”. He was admitted from XXX on xx-xx-xx where he was
treated for “C. diff, polysubstance abuse, colitis, CKB and failure to thrive”. While he was at
XXX he was seen by psychiatry and deemed to lack decision-making capacity. A CT Scan of his
head revealed “no evidence of intracranial hemorrhage, midline shift or mass effect but did show
remote infarcts involving the bilateral posterior frontal lobes, the right occipital lobe, the left
basal ganglia and the left pons… chronic small vessel ischemic changes… left frontal lobe
hypodensity”
Included in his many medical diagnoses are: Hyperlipidemia, HTN, Cocaine Abuse, Cannabis
Abuse, Alcohol Abuse, Chronic Kidney Disease, Atrial Fibrillation, Congestive Heart Failure,
COPD, Unspecified Personality Disorder, history of TIA’s with residual deficits, Diabetes
Mellitus, hyperparathyroidism with hypercalcemia, CVA, Anemia of renal disease.
He is only psychotropic medication was Remeron 15mg qhs.
Mental Status Exam: I found him in bed fully dressed at midmorning staring at the ceiling
stereotypically rubbing his head. A strong smell of body odor attested to his poor personal
hygiene habits. With a little effort, it was possible to engage him in an interview but his thinking
was slow and his speech nonspontaneous and underproductive. The little speech he did produce,
however, was coherent and relevant. He said that he used to work at XXX as an aid and his wife
left him “I guess because she just got tired of me”. His affect was bland, odd and vague. He
seemed disengaged and unconcerned about anything. The one word which seem to characterize
him best as was apathetic. He denied depression or anxiety, as well as, biological signs of
depression such as early morning awakening, loss of appetite with weight loss, anedonia, low
energy and crying spells. He had some very odd things to say, borderline delusional. For
example, he said, “I was in the hospital but a plane crashed into it and I had to be transferred”.
He was oriented to name only. He gave the year as 2014 and the place as somewhere in xxxxx;
he didn’t know he was in a nursing home. He said, he was content at XXXX but he should be
somewhere else because “I am a city man”… “After five minutes I don’t have anything more to
say to these farm people”. He vehemently denied ever having abused drugs or alcohol. I don’t
think he was lying. I believe he does not remember his substance use. His insight and judgment
were absent.
Findings and Recommendations: There are three diagnoses which could account for his
profoundly bland presentation and apathy and all of them have some support in his history: The
first we can be sure of because of neuroimaging. He has a multi-infarct (cortical and subcortical)
and small vessel disease, form of Vascular Dementia (VaD) with frontal systems dysfunction.
The signs and symptoms of this disease include: memory impairment, poor judgment, lack of

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spontaneity, perseveration, psychomotor slowing, general dilapidation in cognitive functioning,
apathy and fatigue. Infarcts involving subcortical structures such as the basal ganglia and the
pons can lead to impaired arousal and lethargy. Basal ganglia lesions can produce: atypical
aphasia, anxious foreboding, intense worry and anxiety, restlessness and difficulty concentrating,
decreased appetite, denial of illness and emotional disinhibition. People with frontal lobe
impairment show: apathy, decreased speech output, social withdrawal, poor judgment, passivity
and disinterest in social situations and behavioral disinhibition
Given his history of alcohol abuse, alcoholic dementia is another possibility. He does show some
of the characteristic signs: a.) profound memory impairment
b.) possible confabulation - filling in gaps in memory with false memories
c.) disorientation in time and place e.) lack consistency from one moment to another
g.) apathy towards surroundings h.) a general lack of initiative and spontaneity
i.) inattention characterized by indifference and perseveration j.) poor judgment
He said, his wife left him because “she just got tired of me” and he was admitted with a
personality disorder diagnosis. A third possibility is schizoid or schizotypal personality disorder.
Schizoid individuals are usually socially isolated loners who display a poverty of affect and
thought, peculiarities of behavior, impaired interpersonal skills, apathy and passivity. They
usually display a bland exterior and seem indifferent to the approval or criticism of others. These
people to lack a desire for intimacy.
Schizotypal personality is more severe and includes: poverty of affect, peculiarities of speech
and behavior, poorly organized thinking and severely impaired interpersonal skills.
Unfortunately, these individuals are very difficult to treat and neither medications nor behavioral
approaches are likely to meet with dramatic success. The treatment of apathy is treatment of its
cause. For most Nursing Home residents, apathy is due to a dementia or a stroke usually
affecting the frontal system.
1. Remeron in low doses such as 15mg qhs is sedating; in higher doses it is activating. Since
this current dose of Remeron is acting as a sedative I would increase the dose to 45mg
qhs and observe. Modafinil a psychostimulant or Wellbutrin an antidepressant have been
helpful in these cases. If we see no improvement with the increased Remeron we could
try the Modafinil starting at 100mg bid.
2. Review his medications and discontinue or lower the dosage of all drugs that may cause
or exacerbate apathy.
3. Check with friends and family in order to find out what activities he enjoys most and use
these as rewards to motivate him. Pair these with care by offering them with care or
directly after care.
4. I will offer more at a later date.
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Drew Chenelly, Psy.D.
Clinical Neuropsychologist