Abstract
Dear Sir,
The psychiatric effects of brain injury are well recognized, but treatment evidence is only emerging.1,2 We report a case where cognitively enhancing medications led to substantial clinical benefit. Written informed consent was obtained from the legal guardian.
A 67-year-old man presented with a 6-month history of emotional dysregulation, persecutory delusions, and threatening behaviour related to short-term memory impairment and confabulation. Three years earlier, he had developed a dural arteriovenous fistula causing venous congestion. He had numerous unsuccessful attempts at embolisation and ultimately required craniotomy for clipping. This left him with cognitive dysfunction requiring inpatient brain injury rehabilitation. Despite the acquired brain injury, he had lived at home with family and carer support until the onset of psychiatric symptoms.
Investigation revealed no new organic cause for his change in presentation. Montreal Cognitive Assessment (MoCA) revealed deficits in attention and recall, scoring 17/30. No improvement was observed with quetiapine 400 mg BD and lamotrigine 100 mg BD. He required management under the Mental Health Act in an inpatient setting. There was significant carer burnout in nursing staff with frequent security attendance and need for intramuscular benzodiazepines.
Antipsychotics can impair cognition, and evidence is limited for psychosis after brain injury.1,2 However, aripiprazole may improve cognition due to its unique action. 2 Medications that enhance acetylcholine in the sub-acute phase may improve cognition and neuropsychiatric symptoms. 1 There is evidence that combination galantamine and memantine improves cognitive, positive and negative symptoms of schizophrenia. 3
Pharmacotherapy was changed to galantamine 24 mg/day and memantine 20 mg/day. Quetiapine was then changed to aripiprazole 20 mg/day with dramatic improvement after 4 weeks. MoCA scores improved to 20/30 and more dramatically, psychosis resolved. Family and staff whom he had involved in persecutory delusions were reintroduced. He developed insight and could engage in cognitive interventions. Aripiprazole was reduced to 15 mg due to parkinsonism without relapse. Improvements were sustained at 6 months.
All three medications were commenced within a short space of time; hence, it was difficult to distinguish between medicines. Pharmacotherapy demonstrated benefit here, but further research is needed.
