Characteristics: delusions, hallucinations (auditory>visual), thought disorganization
Ddx: schizophrenia, schizoaffective, MDD w/ psychosis, bipolar w/ psychosis, malingering, substance-induced (cocaine, amphetamines, MJ, bath salts, hallucinogens, EtOH), less frequently OCD/PTSD/borderline PD, intellectual disability, dementia, due to another medical condition (delirium, epilepsy, AIP, paraneoplastic limbic encephalitis)
• New onset psychotic disorders in patients >50 is fairly rare. Medical cause of psychotic symptoms in this age group (delirium, CNS pathology, dementia) is more likely unless known psych diagnosis.
Labs: CBC, BMP, UA, Utox+VPAIN, serum tox including EtOH, UA, med levels, delirium workup
• Refer to psych: outpatient = always, inpatient = if decompensated (can be associated with fear, agitation, aggression)
Confirm home antipsychotics/mood stabilizers early in admission, continue only if patient reliably taking; otherwise, dose reduce. Ask if patient on long-acting injectable medication/date of last injection, ask which PRN medications work well for patient. Obtain Depakote, lithium, clozapine levels.
• Best practice is generally to avoid multiple antipsychotics in 1 patient. If med list includes >1 antipsychotic, be sure to confirm before ordering as it is unlikely they’re taking all in outpatient setting. Continue patient’s home Cogentin (benztropine) if prescribed to reduce EPS sx (particularly common in 1st gen high potency antipsychotics like Haldol). Clozapine is typically prescribed for treatment resistant schizophrenia/schizoaffective in the US but has the notable side effect of agranulocytosis. If patient on clozapine, consult psychiatry early to continue medication in house.
• Include lithium, Depakote, lamotrigine, some antipsychotics. Confirm compliance with lamotrigine given risk of SJS
• Consider lithium toxicity in patients who present with n/v/AKI/new NSAID/ACE/ARB/diuretic use: sx include nausea, vomiting, diarrhea, tremor, ataxia, confusion/agitation seizures, nonconvulsive status, encephalopathy if severe
#Psychosis #diagnosis #management #psychiatry #treatment