A 51-year-old man with a long-standing history of schizophrenia is evaluated for agitation and oppositional behavior at a group home. He was admitted to the group home yesterday after his mother, with whom he previously lived, moved to an assisted care facility. A staff member reports the patient was cooperative and calm when he arrived and did not talk much, which seems to be his baseline. He did not sleep well last night, and today he has been pacing around and yelling at other residents and staff. The patient has no other medical conditions. Medications include clozapine. He does not use tobacco or illicit drugs but does use alcohol. Temperature is 36.7 C (98.1 F), blood pressure is 152/94 mm Hg, and pulse is 114/min. On physical examination, the patient appears anxious and diaphoretic and is fidgeting in his seat. Marked hand tremors are present. He is alert and oriented to person, place, and time. Which of the following is the best next step in the management of this patient?

Question

A 51-year-old man with a long-standing history of schizophrenia is evaluated for agitation and oppositional behavior at a group home.  He was admitted to the group home yesterday after his mother, with whom he previously lived, moved to an assisted care facility.  A staff member reports the patient was cooperative and calm when he arrived and did not talk much, which seems to be his baseline.  He did not sleep well last night, and today he has been pacing around and yelling at other residents and staff.  The patient has no other medical conditions.  Medications include clozapine.  He does not use tobacco or illicit drugs but does use alcohol.  Temperature is 36.7 C (98.1 F), blood pressure is 152/94 mm Hg, and pulse is 114/min.  On physical examination, the patient appears anxious and diaphoretic and is fidgeting in his seat.  Marked hand tremors are present.  He is alert and oriented to person, place, and time.  Which of the following is the best next step in the management of this patient?

Quizplus · Accepted Answer

Although it can go unrecognized, substance use disorder can co-occur in patients with schizophrenia, with up to 50% of patients newly diagnosed with schizophrenia already holding a diagnosis of alcohol or drug use disorder. In this patient with schizophrenia and a history of alcohol use, the constellation of physical symptoms and their timing is concerning for alcohol withdrawal. Some of the presenting symptoms of alcohol withdrawal are nonspecific and not uncommon in psychiatric patients. However, clues to the diagnosis in this patient include the acute onset (eg, calm and cooperative the first day, restless and yelling the second day) of symptoms, combined with manifestations of sympathetic hyperactivity (elevated blood pressure and pulse, diaphoresis, tremor), within hours following admission to the group home, a supervised setting where he likely no longer had access to alcohol. Withdrawal symptoms typically start within 8-12 hours after the last drink. Alcohol withdrawal seizures can occur within 12-48 hours, and delirium tremens (ie, disorientation, severe agitation, fever) typically begins within 48-96 hours. Benzodiazepines are used as first-line therapy for psychomotor agitation associated with alcohol withdrawal and to prevent progression to seizures and delirium. Supportive psychological therapies may help with anxiety, but they do not slow down the progression of alcohol withdrawal (Choice E). (Choice A) Benztropine is an anticholinergic medication used to treat extrapyramidal symptoms such as akathisia, which can cause restlessness, and antipsychotic-induced parkinsonism, which can cause tremor. However, these effects are most commonly associated with high-potency, first-generation antipsychotics rather than second-generation antipsychotics (eg, clozapine); in addition, this patient's acute-onset symptoms with hypertension, tachycardia, and tremors are likely due to alcohol withdrawal. (Choice B) Selective serotonin reuptake inhibitors are indicated for major depression or anxiety disorders and take up to 2 weeks to take effect. They would not be effective in managing acute anxiety or any adjustment symptoms that may have resulted from the patient's move to the group home. (Choice C) Neuroleptic malignant syndrome, which can develop in patients on antipsychotic agents and requires medication discontinuation, can present with agitation and autonomic instability. However, this patient does not have the characteristic hyperthermia or muscle rigidity; and the acute onset of symptoms after admission to a supervised setting makes alcohol withdrawal more likely. Clozapine is generally used in patients refractory to other antipsychotic medications; its discontinuation in this patient would likely result in significant worsening of his psychiatric condition. Educational objective: Alcohol withdrawal should be considered in patients who are newly admitted to supervised settings and develop tremor, agitation, and elevated pulse and blood pressure within 12-48 hours following admission. Benzodiazepines are indicated for the treatment of alcohol withdrawal. References: Alcohol withdrawal syndrome: diagnostic and therapeutic methods. (http://www.ncbi.nlm.nih.gov/pubmed/29912213)

A 51-Year-Old Man with a Long-Standing History of Schizophrenia Is