Actor portrayal of a resident with Pseudobulbar Affect, or PBA, crying symptoms

Pseudobulbar Affect (PBA) symptoms are prevalent in residents with various underlying neurologic conditions

The number of residents experiencing involuntary, sudden, frequent laughing and/or crying episodes in your residential or assisted living community may be higher than you think.


In an observational, retrospective study of long-term care (LTC) residents, a Center for Neurologic Study-Lability Scale (CNS-LS) score of 13 or greater, suggesting the presence of PBA symptoms, was reported in 17.5% (N = 412) of residents with a neurologic disorder that could be associated with PBA. 1

Continue reading to learn more about recognizing PBA's impact on LTC residents, listening for signs of PBA, and identifying the right treatment for those in your care.

Identifying residents with PBA

In LTC settings, like assisted living facilities, PBA may affect residents with neurologic conditions or brain injuries, including but not limited to: 1

  • Stroke
  • Dementia or Alzheimer's disease
  • Parkinson's disease
  • Hemiplegia

PBA is a distinct neurologic condition that occurs secondary to these other neurologic conditions or brain injuries. PBA also commonly co-occurs with depression and other mood or behavioral disorders. 2 In a study by Foley and colleagues, residents with PBA symptoms were more likely to have a documented mood disorder, particularly depression or anxiety. 1

Consider screening for PBA if your resident is experiencing involuntary, sudden, frequent laughing and/or crying episodes that appear exaggerated or incongruent to their underlying mood. If they have been diagnosed with and treated for depression but excessive crying episodes have persisted despite treatment, consider following the Steps to Diagnosis.

Nurses and caregivers play a key role in facilitating an accurate PBA diagnosis. In a U.S. survey of 256 nurses and paid caregivers in geriatric LTC facilities, 29.4% of participants reported that they witnessed symptoms that suggest PBA daily. They were most likely to record these symptoms in behavior monitoring logs (84.9%), nursing notes (89.4%), and resident care plans (70.6%). 3

PBA’s impact on your residents and their community

Actor portrayal of a resident with Pseudobulbar Affect, or PBA, crying symptoms

I cared for a resident who had a history of cerebrovascular accident or stroke. She had been struggling with depression and uncontrollable crying for years ... she stayed self-isolated in her room, never spoke to her roommate and did not attend communal dining or activities.

— Kandise Wilson, RN, director of nursing at a long-term care facility

PBA laughing and/or crying symptoms can have a substantial impact on residents living in long-term care facilities. Because PBA episodes are unpredictable, residents may have an uncontrollable episode during group activities, affecting their ability to participate. 3

Residents’ PBA episodes can also affect the larger community. Nurses and staff may need to spend more one-on-one time with those residents to help manage unpredictable episodes. Other residents may feel frustrated if PBA episodes disrupt their routine or activities. 3

Listening for PBA

Your residents with complex neurologic conditions may not be able to talk to you about their symptoms and their caregivers may not understand what they are going through. To find out if PBA may be impacting a resident in your care, ask yourself:

Do I hear any of my residents with a neurologic condition or brain injury laughing or crying inappropriately?

A proper diagnosis is crucial to prescribing the correct treatment

Residents in long-term care or assisted living facilities may be living with multiple conditions and require a complex treatment plan. As such, it is important to make a proper PBA diagnosis to prescribe the appropriate regimen.

NUEDEXTA is the first and only FDA-approved treatment for PBA.5 NUEDEXTA is classified as "Central Nervous System - Other." It is not categorized as an antipsychotic medication or controlled substance.6

Review NUEDEXTA’s safety profile

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References: 1. 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. 2. Colamonico J, Formella A, Bradley W. Pseudobulbar affect: burden of illness in the USA. Adv Ther. 2012;29(9):775-798 3. Vernon M, Poon JL, Dornberger S, Frandsen B, Kulus J, Eliopoulos C, Yonan C. Burden of care for patients with symptoms of pseudobulbar affect residing in long-term care facilities: Results of a caregiver survey. Poster presented at: The 46th Annual Meeting and Exhibition of the American Society of Consultant Pharmacists; October 30 – November 1, 2015; Las Vegas, NV 4. Centers for Disease Control and Prevention (CDC). International Classification of Diseases. Tenth Revision, Clinical Modification (ICD-10-CM). Accessed June 21, 2021. 5. NUEDEXTA [package insert]. Rockville, MD: Otsuka America Pharmaceutical, Inc. 6. The United States Pharmacopeia (USP). USP Medicare model guidelines v8.0. Updated February 1, 2020. Accessed June 21, 2021.

INDICATION and IMPORTANT SAFETY INFORMATION for NUEDEXTA® (dextromethorphan HBr and quinidine sulfate)


NUEDEXTA 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 (e.g., 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 (e.g., 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 (e.g., 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.

Adverse Reactions: 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.

To report SUSPECTED ADVERSE REACTIONS, contact Otsuka America Pharmaceutical, Inc. at 1-800-438-9927 or FDA at 1-800-FDA-1088 (