A 68-year-old man is brought to the emergency department by his wife due to "uncharacteristic behavior." The patient started buying large numbers of lottery tickets and decided to quit his job 2 weeks ago. He has maxed out multiple credit cards buying expensive jewelry for his wife. The patient has had difficulty sleeping recently and stays up watching TV into the early morning hours. He says, "I feel really good and finally like what I'm doing." The patient has no psychiatric history. Medical history includes recently diagnosed restless leg syndrome, treated with ropinirole. Temperature is 37.1 C (98.8 F), blood pressure is 130/80 mm Hg, and pulse is 86/min. Physical examination is within normal limits. The patient is restless, appears to be easily distracted, and speaks rapidly. Complete blood count and basic metabolic panel are within normal limits. Urine drug screen is negative. Which of the following is the most appropriate initial step in management?

Question

A 68-year-old man is brought to the emergency department by his wife due to "uncharacteristic behavior."  The patient started buying large numbers of lottery tickets and decided to quit his job 2 weeks ago.  He has maxed out multiple credit cards buying expensive jewelry for his wife.  The patient has had difficulty sleeping recently and stays up watching TV into the early morning hours.  He says, "I feel really good and finally like what I'm doing."  The patient has no psychiatric history.  Medical history includes recently diagnosed restless leg syndrome, treated with ropinirole.  Temperature is 37.1 C (98.8 F), blood pressure is 130/80 mm Hg, and pulse is 86/min.  Physical examination is within normal limits.  The patient is restless, appears to be easily distracted, and speaks rapidly.  Complete blood count and basic metabolic panel are within normal limits.  Urine drug screen is negative.  Which of the following is the most appropriate initial step in management?

Quizplus · Accepted Answer

This elderly patient with no psychiatric history now has symptoms suggestive of mania (ie, impulsive overspending, abruptly quitting job, elevated mood, insomnia, pressured speech). New-onset behavioral changes in an older patient with no psychiatric history should prompt consideration of medical and substance-/medication-related causes. This patient recently started taking ropinirole, a dopamine agonist medication (used for restless leg syndrome) that has high affinity for D2 and D3 receptors. Treatment with dopamine agonists, even at therapeutic doses, increases the risk of impulse control disorders that may present with manic-like signs and symptoms. In the absence of a history of impulse control problems, manic or depressive episodes, or medical conditions known to cause mania, this patient is most likely experiencing a dopamine agonist-induced impulse control disorder. Other impulsive behaviors that may occur with dopamine agonist therapy include pathological gambling, compulsive shopping and eating, and hypersexuality. The best initial step is to discontinue the offending medication (ie, ropinirole) and monitor the patient's mental status. Medication-induced behavioral changes are usually reversible and resolve quickly once the medication is stopped. (Choice A) Vitamin B₁₂ deficiency has been associated with neuropsychiatric symptoms including depression, psychosis, cognitive impairment, and dementia. It is an unlikely cause of manic symptoms in this patient who has a normal complete blood count and no neurologic findings. (Choice B) An MRI of the head may potentially be part of the workup of behavioral changes, but it would not be considered the first step in this patient with no focal neurologic findings. The first step would be to discontinue ropinirole. (Choices C and D) Both lithium and lorazepam may be used in the treatment of an acute manic episode in the context of bipolar disorder; however, most cases of bipolar disorder present at a younger age, and the temporal relationship with the recent diagnosis of restless leg syndrome is more suggestive of ropinirole-induced manic-like adverse effects. Educational objective: Ropinirole and other dopamine agonists can induce impulse control disorders that may present with a manic-like syndrome. The treatment of choice in these situations is discontinuation of the offending agent. References: Increased risk for new-onset psychiatric adverse events in patients with newly diagnosed primary restless legs syndrome who initiate treatment with dopamine agonists: a large-scale retrospective claims matched-cohort analysis. (http://www.ncbi.nlm.nih.gov/pubmed/31538593) Dopamine agonists and impulse control disorders: a complex association. (http://www.ncbi.nlm.nih.gov/pubmed/28861870)

A 68-Year-Old Man Is Brought to the Emergency Department by His