clinical report: consult

1. Mental Health Consultation
Patient Name: Benztropine Facility: XXXX
Date: xx-x-13
Additional history can be found elsewhere in this chart and will not be repeated here.
Reasonfor Referral: xx-year-old, white, widowed, female… I was asked to evaluate her
because of her extensive psychiatric history and current psychotropic medications...“insurance is
reluctant to pay for her Cogentin”. She was admitted from xxxxx on xx-x-13.
Background Information: See the Article 81 Guardianship Assessment dated 5/12/11.
In 2011, incontinent…wearing soiled cloths…living in squalor…diagnosis of alcohol
dependence in remission… last drink 15 years ago. 2011 MMSE = 30/30. 11-1-13 “resident
defecated and urinated on the floor in her room”. Recent MMSE= 23/30
Current Medications: Cogentin 0.5mg qam, Geodon 20mg bid, Synthroid, Insulin, Zantac,
Prednisone (I may not have a complete list of her current medications since she is not taking a cholesterol lowering drug
despite a diagnosis Hyperlipidemia and she is not taking Coumadin or similar drug despite a diagnosis of Atrial-Fibrillation).
Medical History: GERD, Type II Diabetes Mellitus, Hypertension, Coronary Artery Disease,
Atrial-Fibrillation, Parkinsonism, chronic back pain, Alcohol Dependence- in remission, Bipolar
Disorder, Depressive Disorder, Osteoarthritis, Osteoporosis, COPD, Hypothyroidism, Anemia,
Hyperlipidemia----allergic to VPA.
Mental Status Exam: I found her in bed awake and alert, she was cooperative and dressed but
disheveled with unkempt bleached blond hair. She smelled of smoke and had a smoky voice. Her
speech was coherent and relevant but underproductive. She mostly limited herself to yes or no
answers. Her affect was constricted but not inappropriate. She denied depression and anxiety.
And said: “I have not had hallucinations in years” There were no overt signs of psychosis such
as delusions. Her insight and judgment were limited. Her orientation was uncertain; seemed
oriented.
Findings and Recommendations: She is not schizophrenic therefore the bipolar diagnosis is
probably accurate. Even if she had only residual schizophrenia we would see signs such as;
autism and inability to relate to others, disorganized speech and thinking and an odd and
inappropriate affect but we don’t see these in her presentation. However, Bipolar disorder
generally does not result in patients soiling themselves and living in squalor. I would expect that
kind of behavior from an active alcoholic with ETOH dementia but according to reports she has
been abstinent for 17 years. There is something going on here we do not know about. She was
once a respectable person. This behavior represents a major change. It is not clear what has
caused this change. I suspect that it is organic. Her Bipolar diagnosis is by history only since we
do not currently see the following signs of that illness:
1. Persistent, elevated, expansive, irritable mood and labile affect.
2. Inflated self-esteem and grandiosity.
3. Flight of ideas plus the subjective experience of racing thoughts (i.e. “My mind works so fast,
I can hardly keep up with it”).

2. 4. Distractibility and inattention.
5. Absence of insight and grossly impaired judgment.
6. Well-developed paranoid trend in her thinking.
7. Aggressiveness and verbal abuse.
There is no indication for her taking Benztropine (Cogentin) and in fact it could be the cause of
her incontinence and confusion.
Benztropine is used to treat symptoms of Parkinson's disease or involuntary movements due to
the side-effects of highly antidopaminergic antipsychotics such as haloperidol. Benztropine
(Cogentin) is an anticholinergic and not used to treat Bipolar disorder as her orders indicate.
Anticholinergics are used to treat acute extrapyramidal symptoms (EPS) but are not helpful in
treating movement problems caused by tardive dyskinesia and other tardive disorders and may
worsen them.
“Non-anticholinergic antiparkinson’s agents should be considered first for treatment of
Parkinson disease (Beers criteria) because anticholinergics are not well tolerated by the elderly,
due to bowel, bladder, and CNS effects.”
Benztropine should not be used as prophylaxis against extrapyramidal symptoms in the elderly
and Geodon, a 2nd generation drug, is not likely to cause extrapyramidal symptoms (EPS) and
40mg total a day is not a high dose.
In the treatment of bipolar disorder, Geodon is used for the treatment of acute manic episodes or
as maintenance therapy only as an adjunct to lithium or valproate neither of which she is
currently taking. In fact, she is allergic to VPA. Therefore, she is not currently taking any drug(s)
as prophylaxis against Bipolar disorder, manic episodes.
Do we know for certain that she has not been drinking recently and this is not Wernicke’s
encephalopathy?
1. Would DC the Cogentin and reassess after a few weeks. May need to rethink the Geodon
in the future as well. Behavioral recommendations later.
2. New comprehensive labs including: CBC, CMP, Thiamine level, folate, UA with C&S.
___________________________
Drew Chenelly, Psy.D.
Clinical Neuropsychologist

3. Mental Health Consultation
Patient Name: Cogentin Facility: XXXX
Date: x-x-15
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, white, married, male… I was asked to evaluate him because
“He is up all night… Loud… Striking out… Delusional… Grandiose”. He was admitted from
xxxxx General Hospital on x-x-14 where he was treated for acute and chronic renal failure,
hyperkalemia with metabolic acidosis, acute respiratory failure, atrial fibrillation, congestive
heart failure, acute exacerbation of COPD. He also had diagnoses of schizoaffective
schizophrenia, Type II diabetes mellitus, hypertension and a seizure disorder. Acute stroke was
ruled out with a CT scan of the head. Mental retardation was mentioned as a diagnosis and then
withdrawn in a later note. He was placed on a ventilator and IV hydrated for volume depletion.
Recent labs showed: low hemoglobin and hematocrit, high WBC, high glucose, high creatinine
and high BUN. It looks like he was in Medina Memorial Hospital with COPD exacerbation and
acute kidney injury. No VPA levels and no neuroimaging.
Current medications include: 3/12- Seroquel XR 200mg bid change to Seroquel XR 100mg qid,
3/12- Divalproex sprinkle reduced to 500mg bid, prednisone 40mg qd, Remeron 30mg qhs,
Benztropine (Cogentin) 0.5mg bid.
Mental Status Exam: He was slumped in a wheelchair listing to the left. I had to take off his
visor cap in order to make eye contact with him. He was boisterous with pressured often
incoherent, dysarthric speech. He was friendly. His affect was labile. His mood was elevated at
times. He denied depression or anxiety. He kept himself amused, “My name is Tommy Gun that
spelled BAR… my wife works here in activities”. His orientation seem to shift during the course
of the interview. He said he had two children, one boy and one girl. When I asked about military
service he responded “a jar head… in Korea for 20 years… I killed Japs… I am a jungle
fighter… I was a Lieutenant” He also said, “I’m a doctor too” He made many grandiose
comments which appeared to be compensatory. His insight and judgment were impaired.
Findings and Recommendations: This is a complicated case which needs much sorting out:
1.) The question is how much of what we are seeing is the result of a delirium versus a
schizophrenic psychosis. I believe most of what we are seeing is due to a delirium. We
need to know his baseline mental status. In order to determine this, we need a treatment
summary from his mental health provider. Also, I need more information about his recent
labs; the high WBCs are they due to infection or are they due to the prednisone he is
taking? It looks like his kidney functioning is disturbed enough to cause a delirium. If he
was accurate about his wife working here she could tell us about his baseline mental
status. He seemed accelerated and his delusions were grandiose in nature. These
symptoms could also be suggestive of bipolar manic.

4. 2.) Is he taking Divalproex for a seizure disorder or a mood disorder? He has a seizure
disorder diagnosis. Who started him on this medication when and why? We need an
immediate VPA level.
3.) He is taking Benztropine which is Cogentin. Cogentin should not be used as prophylaxis
against extrapyramidal symptoms in the elderly. Also he is not taking any highly
antidopaminergic drugs which would produce extrapyramidal side-effects such as Haldol.
It should be discontinued. I suspect it was started when he was taking an EPS causing
first generation antipsychotic drug but not discontinued when that drug was discontinued.
4.) He is taking a fairly high dose of Seroquel which is not the best choice considering the
fact that many of his symptoms are due to delirium versus functional psychosis and
delirium symptoms respond to antipsychotic medications which are highly
antidopaminergic. Seroquel is low in antidopaminergic properties. However, I would not
make any changes here until we gather more of his psychiatric history. There is no need
to spread out doses of Seroquel XR which is the extended release form of Seroquel. So
why was the dose changed from Seroquel XR 200mg bid change to Seroquel XR 100mg
qid? Did I read that correctly?
5.) He had a CT scan of the head done at xxxxx General Hospital in June 2014. Please obtain
a copy of that report.
___________________________
Drew Chenelly, Psy.D.
Clinical Neuropsychologist
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