“I WILL ONLY TAKE KLONOPIN!”; A CASE OF A 69-YEAR-OLD WOMAN WITH CO-OCCURRING SUBSTANCE USE DISORDER AND SCHIZOAFFECTIVE DISORDER, LIVING WITH HER 89-YEAR-OLD CAREGIVER

Introduction Geriatric psychiatric patients constitute a challenging population that requires special surveillance. Substance abuse is described as a growing, but frequently overlooked problem in this population (Kuerbis et al., 2014). According to Yarnell (2019), substance use disorders (SUDs) in later life is expected to double from 2.8?million in 2006 to 5.7?million in 2020, representing one of the fastest growing health problems in the country. SUDs are known to exacerbate co-occurring medical and psychiatric conditions in this vulnerable patient population, leading to increased hospitalization rates and healthcare costs, mechanical injuries, and cognitive impairment. Prescription medication abuse, compounded by polypharmacy, is especially hazardous in the elderly. Thus, effective identification and treatment of late-life SUDs is essential given the rapidly growing public health trend. The case report here highlights some of the challenges in managing co-occurring disorders in non-adherent older psychiatric patients and emphasizes the challenges associated with discharge planning, such as connecting geriatric patients to local mental health services within the community following short term hospitalization, housing arrangements for patients already domiciled in senior housing, and elder-to-elder abuse at home. Methods The specifics of this case report were reviewed in detail prior to summarizing the case and posing a meaningful discussion related to the relevant literature review and suggestions towards further research. Results MM is a 67-year-old Puerto Rican woman with past psychiatric history of schizoaffective disorder and hypnotic use disorder and past medical history of diabetes mellitus type 2 and hypertension domiciled in senior housing with her cognitively intact 89-year-old mother, who serves as her caregiver. The patient has a history of several emergency department visits and psychiatric admissions, and presented to the emergency department with paranoid ideation and aggressive behavior towards her mother. On initial evaluation, the patient was calm and cooperative, exhibiting paranoia associated with fearfulness and delusions of persecutory ideation toward her mother while referring to her as “the lady who is organizing a prostitution ring and making lies about me to send to the hospital”. The patient's mother reported that the patient exhibited assaultive behavior towards her, but the patient adamantly denied this. Collateral information confirmed the abuse of the mother along with history of paranoia towards neighbors, evidenced by persecutory delusions and subsequent threatening behavior. The patient was also reportedly approaching multiple practitioners, requesting prescriptions of benzodiazepines. During the hospital course, the patient displayed drug-seeking behavior demanding benzodiazepines “every 4 hours”. Patient was non-compliant with treatment during hospitalization stating she will only take Metformin and Klonopin, and a court order for treatment over objection was obtained. Once treated with Depakote, Invega, and Invega Sustenna the patient improved as she was notably less delusional and eventually stabilized for discharge. Issues which impacted discharge planning included potential homelessness if the patient was not allowed to live with her mother in her current senior housing; caregiver support to elderly; reluctance of elderly mother to have patient evicted from her apartment. Eventually a plan was formulated that included the patient returning to live with her mother in senior housing, court ordered outpatient treatment connection to assertive community treatment. A referral was also made to Adult Protective Services for the patient's mother. Conclusions This case highlights the importance of an interdisciplinary approach, including the coordination of mental health services between inpatient and community support services, consideration of approaching the court system for court-ordered medications in an older patient and managing geriatric psychiatric patients with comorbid substance abuse and history of violence. It is important to keep in mind that substance use disorders may be underdiagnosed and under-recognized in the aging population (Chhatre et al., 2017). Withdrawal from benzodiazepines may be unrecognized and complicate immediate and ongoing treatment of co-occurring conditions. Homelessness and impending homelessness due to interpersonal conflicts stemming from disruptive and aggressive behavior may further impact the care of this subgroup of patients. This research was funded by: Not applicable