Actor portrayal of a resident with PseudoBulbar Affect (PBA) crying symptoms

In your residents with neurologic conditions or brain injury, it’s important to evaluate them carefully to see if they have pseudobulbar affect (PBA).

Symptoms to look for are frequent, sudden, uncontrollable outbursts of laughing and/or crying in residents with underlying neurologic conditions or brain injury, including but not limited to stroke, dementia, traumatic brain injury (TBI), Parkinson's disease (PD), amyotrophic lateral sclerosis (ALS), or multiple sclerosis (MS).1,2

PBA symptoms may be noted as emotional lability. Your staff may report that the resident seems sad or depressed, but when asked for details, they describe what might be the incongruent or exaggerated laughing and/or crying outbursts of PBA.1

Do their episodes seem exaggerated or disproportionate in relation to their mood?

Actor portrayal of a resident with crying symptoms exaggerated or incongruent with their underlying emotional state

She cries frequently and can’t explain why.

He says he doesn’t even feel sad while he’s crying.

The laughing and crying outbursts are so intense but they come and go quickly.

If nurses and other staff members report that their residents’ laughing and/or crying are exaggerated or incongruent with their underlying emotional state, it may be time to evaluate for PBA.

Look for some of these terms on resident charts that may describe symptoms of PBA3
  • Sudden outbursts of laughing and/or crying
  • Exaggerated response
  • Emotional lability
  • Mood incongruence
  • Incongruent emotions

PBA symptoms are prevalent in residents with various underlying neurologic conditions


In a retrospective study of long-term care residents, a Center for Neurologic Study-Labilty Scale (CNS-LS) score ≥13 suggesting the presence of PBA symptoms was reported in 17.5% (72/412) of residents with a neurologic disorder that could be associated with PBA.4,a

Foley Study Design

aAs determined by a score of ≥13 on the Center for Neurologic Study-Lability Scale (CNS-LS).

References: 1. NUEDEXTA [package insert]. Aliso Viejo, CA: Avanir Pharmaceuticals, Inc. 2. Brooks BR, Crumpacker D, Fellus J, Kantor D, Kaye RE. PRISM: a novel research tool to assess the prevalence of pseudobulbar affect symptoms across neurological conditions. PLoS ONE. 2013;8(8):e72232. 3. Data on File. Avanir Pharmaceuticals, Inc. 4. Foley K, Konetzka T, Bunin A, Yonan C. Prevalence of pseudobulbar affect symptoms and clinical correlates in nursing home residents. Int J Geriatr Psychiatry. 2016;31(7):694-701.


NUEDEXTA® (dextromethorphan HBr and quinidine sulfate) is indicated for the treatment of pseudobulbar affect (PBA). PBA occurs secondary to a variety of otherwise unrelated neurologic conditions, and is characterized by involuntary, sudden, and frequent episodes of laughing and/or crying. PBA episodes typically occur out of proportion or incongruent to the underlying emotional state. PBA is a specific condition, distinct from other types of emotional lability that may occur in patients with neurologic disease or injury.



Quinidine and Related Drugs: NUEDEXTA contains quinidine, and should not be used concomitantly with other drugs containing quinidine, quinine, or mefloquine.

Hypersensitivity: NUEDEXTA is contraindicated in patients with a history of NUEDEXTA-, quinine-, mefloquine-, or quinidine-induced thrombocytopenia, hepatitis, bone-marrow depression, lupus-like syndrome, or known hypersensitivity to dextromethorphan (eg, rash, hives).

MAOIs: NUEDEXTA is contraindicated in patients taking monoamine oxidase inhibitors (MAOIs), or in patients who have taken MAOIs within the preceding 14 days, due to the risk of serious and possibly fatal drug interactions, including serotonin syndrome. Allow at least 14 days after stopping NUEDEXTA before starting an MAOI.

Cardiovascular: NUEDEXTA is contraindicated in patients with a prolonged QT interval, congenital long QT syndrome, history suggestive of torsades de pointes, heart failure, patients receiving drugs that both prolong QT interval and are metabolized by CYP2D6 (eg, thioridazine and pimozide), patients with complete atrioventricular (AV) block without implanted pacemaker, or at high risk of complete AV block.


Thrombocytopenia and Other Hypersensitivity Reactions: Quinidine can cause immune-mediated thrombocytopenia that can be severe or fatal. Non-specific symptoms, such as lightheadedness, chills, fever, nausea, and vomiting, can precede or occur with thrombocytopenia. NUEDEXTA should be discontinued immediately if thrombocytopenia occurs.

Hepatotoxicity: Hepatitis, including granulomatous hepatitis, has been reported in patients receiving quinidine, generally during the first few weeks of therapy. Discontinue immediately if this occurs.

Cardiac Effects: NUEDEXTA causes dose-dependent QTc prolongation. QT prolongation can cause torsades de pointes–type ventricular tachycardia, with the risk increasing as the degree of prolongation increases. When initiating NUEDEXTA in patients at risk for QT prolongation and torsades de pointes, electrocardiographic (ECG) evaluation of QT interval should be conducted at baseline and 3 to 4 hours after the first dose. Some risk factors include use with CYP3A4 inhibitors or drugs that prolong QT interval, electrolyte abnormalities, bradycardia, or left ventricular hypertrophy or dysfunction. If patients taking NUEDEXTA experience symptoms that could indicate the occurrence of cardiac arrhythmias (eg, syncope or palpitations), NUEDEXTA should be discontinued, and the patient further evaluated.

Concomitant Use of CYP2D6 Substrates: NUEDEXTA inhibits CYP2D6 and may interact with other drugs metabolized by CYP2D6. Adjust dose of CYP2D6 substrates as needed.

Dizziness: NUEDEXTA may cause dizziness. Take precautions to reduce the risk of falls.

Serotonin Syndrome: Use of NUEDEXTA with selective serotonin reuptake inhibitors (SSRIs) or tricyclic antidepressants increases the risk of “serotonin syndrome.”

Anticholinergic Effects of Quinidine: Monitor for worsening in myasthenia gravis.


The most common adverse reactions (incidence of ≥3% and two-fold greater than placebo) in patients taking NUEDEXTA are diarrhea, dizziness, cough, vomiting, asthenia, peripheral edema, urinary tract infection, influenza, increased gamma-glutamyltransferase, and flatulence.

These are not all the risks for use of NUEDEXTA. Please see Full Prescribing Information.

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