A Case of Post-CovidConfusion in an Older Adult Olufemi Talabi CT1, Emily Taberham Inpatient AssistantPsychologist, Bindu Gurung CT1 and Dr Jennifer FordConsultant Old Age Psychiatrist.

Background:• 67 y/o male – first contact with mental health services.• 3 month history of acute changes in personality, observed transition from introverted and reserved to extroverted.

• Personality and behavioural changes started following contraction of Covid-19 (during the first wave of the pandemic).•• Noted to be: distractible, inattentive, disinhibited, elevated in mood, exhibiting grandiose beliefs and presenting with episodes of confusion. • Vacant episodes with repeated presentation noted in A&E department.

• Initial admission to Neurology, found to be MSFD following assessment. Later admitted to Old Age Psychiatry

History• Personal • Reported unremarkable childhood. • Reported usual developmental milestones

• Employment • Manual & physical labour jobs: forklift driver • Did not attend higher education • Currently retired

• Social • Family man • Long-term relationship with supportive partner

• Forensic • Recreational drug use: Cannabis and Cocaine • First generation relatives: drug use and incarcerationPast Medical History

• Atrial Fibrillation • Hypercholesterolemia• Prostatic enlargement • Oesophagitis

Investigations during hospital admission in neurology and old age psychiatry •• Carotid Arch angiography –NAD • CT Head – Nil Acute changes• MRI – no obvious abnormality• No significant antibody reactivity • EEG –non-specific finding, no epileptiform discharges. • Bloods –Grossly normal • NCS and EMG: Reported normal (no evidence to suggest anterior horn disease)•• CSF –NAD • CT CAP –Nil Acute changes • MDT review at a national CJD referral center – presentation not consistent with CJD

Initial Assessment & AdmissionInitial Assessment• Presented as: well-kempt, distractible, occasionally suspicious when grandiose beliefs challenged, elevated in mood, tangential speech, nil formal thought disorders, nil perceptual abnormalities. Had little insight.

Cognitive & Neuropsychological testing•• MOCA 17/30 (very distractible)• FAB (Frontal Assessment Battery) 14/18 (distractible)

• MDT intervention • Engagement with Allied Health Professions • Psychology: neuropsychological testing & 1:1 talking sessions • Physiotherapy assessment(s) • Occupational Therapy assessment(s)

• Final observations • Following multi-factorial intervention Mr X presented as: • More settled • Substantially less grandiose • Discharged with outpatient follow ups

• Medications • Risperidone • Clonazepam • Physical health medications

Outcome

MOCA(very distractible)17/30 FAB

(distractible)14/18

Readmission• Attended Accident and Emergency department shortly after having auditory hallucinations commanding him to buy cocaine, paranoid about neighbours trying to harm him and allegedly holding a knife to harm himself and others.• Initially constant suicidal thoughts of harming self by stabbing with a knife, preoccupied about buying cocaine with vacant episodes at times

MSE on MSE on admissionPresented as: well-kempt, engaged in conversation, good eye contact elevated in mood, speech was normal in rate , tone and volume ,euthymic mood , nil formal thought disorders, auditory hallucinations telling Mr X to buy Cocaine. He appeared to have little insight into his admission

Investigations during readmission• CT Head – Nil Acute changes•• MRI – age related involuntional changes, no acute intracranial pathology• No significant antibody reactivity • EEG –non-specific finding, no epileptiform discharges• NCS and EMG: Reported normal (no evidence to suggest anterior horn disease)• MRA head –NAD • Bloods –Grossly normal • DAT Scan negative •• UDS positive for cocaine and amphetamines • Change in presentation; mostly isolated in own room, sleeping a lot, lack of motivation, at other times agitated, euphoric and sexually disinhibited on occasion. Reduced appetite and weight loss.• Fluctuation in engagement with other service users, sta and therapeutic activities encouraged by Allied Health Professionals.•• Occasional unarousable events: catatonia like presentation which led to visits to the A and E department.• MDT approach- reviewed by Occupational therapy, physiotherapy, psychology and neurology.• He was continued on risperidone• Made significant clinical progress, presenting as more settled, with no evidence of hallucinations, alongside a decrease in grandiose beliefs.

Learning Points • The Covid-19 virus has been shown to worsen pre-existing psychiatric conditions or result in new psychiatry syndromes including: psychosis, cognitive disorder, mania and catatonia.1,2

•• These psychiatric changes can have a severe impact on functioning, highlighting a fundamental need for the role of multidisciplinary team involvement in the optimal management of individuals in this group.3

• Evidence is expanding as regarding the potential long-term neuropsychiatric eects of the Covid 19 virus.4

References1. https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(20)30287-X/fulltext2. https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(20)30462-4/fulltext3. https://www.rcpsych.ac.uk/docs/default-source/events/faculties-and-sigs/neuropsychiatry-2020/beth-mccausland.pdf?sfvrsn=3c510e23_24. https://blogs.bmj.com/jnnp/2020/05/01/the-neurology-and-neuropsychiatry-of-covid-19/