Is It Neurologic or Psychiatric?

At this year’s annual Summit, Dr. Steven Posar, a clinical professor of Geriatric Neuropsychiatry at St. Mary’s College in Notre Dame, Indiana, updated us on this important area of medicine.  

Primary neurologic conditions that produce dementia can be secondarily complicated by depression, anxiety, agitation, aggression, apathy, fear, panic, hoarding, lability, impulsivity, disinhibition, OCD, inappropriate sexual behaviors, PBA (Pseudobulbar Affect), partial complex seizures, and psychosis.  In fact, over the course of these dementias some of these troubling psychiatric symptoms (BPSD –Behavioral and Psychiatric Symptoms of Dementia) will appear in virtually 100% of our patients.  However, in this category of residents, there is often no documented or reported history of premorbid major psychiatric illness.  These secondary symptoms may occur in delirium, so this syndrome always needs to be excluded.   

However, some of our residents do have a pre-dementia serious psychiatric illness like bipolar affective disorders or primary psychotic disorders.   Both of these disorders always have their onset before age 40.  Unfortunately, the primary psychotic disorders have a 25-fold greater risk of emergent dementia, so these residents eventually may become long-stay residents and may continue to struggle with psychotic episodes and have problem behaviors.  For these problem behaviors, the FDA has approved antipsychotic medications, which were excluded from being publically reported in 2012 by CMS.  However, for primary dementia related BPSD, no medication has been approved, so use of antipsychotics will be publically reported and should only be prescribed after obtaining informed consent from the patient (DPOA if resident lacks decisional capacity).  

Unfortunately, some clinicians have misdiagnosed schizophrenia in seniors, and sometimes this has been encouraged by a facility nurse, or other member of the facility team, who realizes this antipsychotic Rx for BPSD won’t be publicly reported or calculated into the quality measures.  This pattern has likely resulted in a significant increase in the diagnosis of schizophrenia in nursing homes (NHs) since 2012.  On Sept 21, 2021, the New York Times reported, “Phony Diagnoses Hide High Rates of Drugging at Nursing Homes”.  This article reported a 70% increase in the diagnosis of schizophrenia since 2012 in NHs with 1 in 9 residents diagnosed with this disorder.  This contrasts with the known fact that only 1% of the population has schizophrenia and it never emerges after age 40.  In 2018, the OIG (Office of Inspector General) reported that one-third of long-stay NH residents diagnosed with schizophrenia had no prior Medicare record of treatment for this diagnosis.  A study in 2015 reported that facilities with low staffing correlated with increased use of antipsychotics.  The NYT article unfortunately did not acknowledge that antipsychotics are actually medically reasonable, necessary and helpful for some residents with a variety of diagnoses, instead basically echoing the unfortunate but widely parroted consumer advocacy position that antipsychotics are poison and any use of antipsychotics is “drugging” or chemically restraining our patients—whether for an appropriate clinical scenario or not, and whether FDA approved for the indication or not.  

In any event, CMS is now working through the QIOs (Quality Improvement Organizations) and the Federal and State surveyors to assess and cite facilities that misdiagnose schizophrenia to justify the use of antipsychotics and avoid their public reporting.  The Federation of State Medical Boards has recommended that physicians be disciplined if they have a pattern of misdiagnoses of schizophrenia in NHs.  

Dr. Posar gave helpful advice to help us avoid a misdiagnosis.  We should seek information to confirm their psychiatric history, which is usually substantial and well documented.  These records might include social histories, PASRR (Level 2) reports, acute psychiatric hospitalization records, family reports, as well as PCP, and outpatient psychiatry history.  

If you haven’t yet downloaded this presentation or purchased a license to this recording, I would recommend it as money well spent.  

In addition, the AMDA on-the-Go podcast of 10/8/21 has a free informative discussion on this subject by Dr. Lea Watson (AMDA Behavioral Health workgroup co-leader)  who agrees with the concerns raised the NY Times article, but offers us a constructive way forward.  

I suspect some facilities are vulnerable in this area.  If so, consider assembling a team to audit the diagnoses of schizophrenia in your facility so that potential misdiagnosis is corrected or clarified prior to your next state or federal survey.  


AMDA Podcast - October 8

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Comments on "Is It Neurologic or Psychiatric?"

Comments 0-5 of 2

Dan Osterweil - Monday, November 01, 2021

Dr Gieseke, gave a very thorough review of this excellent talk. I believe that CALTCM should make the lecture on free access. It has the potential to impact practice in CA NH which are fraught with inappropriate management of Behavioral disorders associated with Dementia .

Karen Klink - Monday, November 01, 2021

Thank you! These are exactly the issues that we as caregivers (Essential Caregivers) and our loved ones deal with and often have trouble exppressing. We also get shuffled between psychiatrist's and Neurologist's. Both of them saying it is the other's issue. Our Memory Care facility is clueless.

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