Different Strokes for Impaired Folks: A Medical-Legal Case Report on Psychosis and Grave Disability following Cerebrovascular Accident

Introduction At least 30% of cerebrovascular accident (CVA) survivors suffer from neuropsychiatric symptoms as a direct sequela of their stroke, with poor long-term outcomes due to underdiagnosis and undertreatment. A 2018 systematic review of 76 studies looking at psychotic symptoms following stroke found an increased prevalence in delusional disorders, schizophrenia-like diagnoses, and mood disorders with congruent psychotic features. Right hemispheric lesions accounted for approximately 80% of patients demonstrating subsequent psychotic symptoms in studies with identification of lesion location. Among the many issues arising in management of these patients in addition to behavioral stabilization is decision-making concern should the patient be deemed gravely disabled. In this report, we present a case of a 58-year-old male with psychosis and mood disturbances following right-hemispheric ischemic stroke, and the resulting ethical and legal discussions regarding conservatorship and decision-making capacity. Methods Case report: this is the case of a 58-year-old male with psychiatric history of posttraumatic stress disorder, methamphetamine use disorder, cannabis use disorder and medical history pertinent for hypertension, hyperlipidemia, coronary artery disease, and dilated ischemic cardiomyopathy who was hospitalized for subacute onset of altered mental status following ischemic cerebrovascular accident. Magnetic resonance imaging (MRI) two weeks following initial vascular event confirmed right hemispheric ischemic stroke with subsequent hemorrhagic conversion. Additionally, in the two weeks after the initial vascular event, the patient had begun to exhibit significant behavioral changes mostly notable for an increase in psychotic and labile mood symptoms not previously present at patient's baseline mental status. These included auditory hallucinations, disorganized thinking and behavior, avolition, hypersexuality, emotional lability, irritability, and distractibility that persisted over the course of the following six weeks. He did not have a history of a bipolar disorder or a psychotic disorder, and had recently completed rehabilitation of polysubstance use at the West LA Veterans Administration Domiciliary. Urine drug screen was negative. Patient was managed by neurosurgery and neurology, with psychiatry consultation-liaison team providing recommendations for behavioral management. Psychiatry advised an involuntary hold for grave disability owing to patient's ongoing psychotic symptoms following medical stabilization. Of pertinent concern was the degree of to which patient's behavioral symptoms were interfering with his decision-making. Throughout the course of his hospitalization, patient needed repeated encouragement to participate in assessment, vitals, labs, and med administration, all of which he would refuse on a regular basis without appropriate reason. Bioethics review of patient's case affirmed that he lacked capacity to make major decisions regarding his healthcare and that his girlfriend, who held no legal status with relation to the patient, could serve as medical surrogate. Patient's refusal of medical intervention necessitated psychiatry consultation team to file a petition for prolonged involuntary hold as well as court-ordered medication administration. The patient's psychosis was initially managed with increased doses of his home aripiprazole (30mg), which was later tapered and cross-titrated with risperidone (5mg) for management of his psychotic symptoms and impulse control. Following stabilization of acute medical concerns, patient was subsequently transferred to psychiatric unit for persistent psychosis and for continued psychotropic medication management as well as assessment of legal and social status. Results N/a, case report. See ‘Conclusion' for discussion of case outcome. Conclusions The patient's condition ultimately improved to the point of being able to participate in a capacity declaration, designate a durable power of attorney, and forego the need for probate conservatorship. He continues to be seen by psychiatry for ongoing management of his mood, posttraumatic stress disorder, and mild cognitive impairment stemming from vascular insult. Management of psychiatric and behavioral symptoms following stroke continues to be an important component of the post-cerebrovascular vascular accident treatment plan. In particular, contingency plans need to be anticipated preventively in patients who may have higher risk of considerable decompensation following cerebrovascular stroke. In this particular case, the patient carried several premorbid psychiatric, vascular, and social risk factors that converged into a challenging management scenario post-CVA. Continued assessment and stratification of patients with these types of risk factors should continue to be an essential component to management of the geriatric patient. Funding None.