Approach to Disturbed Behaviour

Question 1

How are symptoms clustered when considering psychiatric disorders?

Answer 1

Positive symptoms
Negative symptoms
Cognitive symptoms
Functional symptoms
Impaired insight

Question 2

List 3 positive symptoms of scizophrenia

Answer 2

Delusions
Hallucinations
Disorganisation

Question 3

List 6 negative symptoms of scizophrenia

Answer 3

Affective blunting
Anhedonia
Amotivation/avolition
Poor self care
Social withdrawal
Alogia

Question 4

How should a psychotic pt be managed?

Answer 4

Anti-psychotics (some sedative effect will help acutely, anti-psychotic effect takes 3-13 days to set in)
If remains agitated, add other sedatives
Environmental manipulations (e.g. hospital admission in contained environment)

Question 5

How common is delirium in older patients admitted to hospital?

Answer 5

14-24%

Question 6

What % of deliriums are recognised and appropriately managed?

Answer 6

30-50%

Question 7

What % of older people develop features of delirium during a hospital stay?

Answer 7

25-50%

Question 8

What are some of the risks associated with delirium?

Answer 8

Increased morbidity and mortality

Longer hospital admissions

Question 9

What behaviours are characteristic of hyperactive delirium?

Answer 9

Repetitive behaviours
Wandering
Hallucinations
Verbal and physical aggression

Question 10

What behaviours are characteristic of hypoactive delirium?

Answer 10

Quiet, withdrawn (may be misdiagnosed as depressed)

Question 11

List 5 factors which predispose to delirium

Answer 11

Age
Pre-existing cognitive deficits (e.g. dementia, past cerebral damage)
Polypharmacy
Sensory impairment and/or deprivation
Multiple chronic medical conditions

Question 12

List some precipitating factors for delirium

Answer 12

Medications
Infection/sepsis
Dehydration
Hypoxia
Fever or hypothermia
Surgery and anaesthetics
Substance withdrawal
Acute brain pathology
Disturbed sleep
Pain and discomfort (frequent cause)
Unfamiliar environment
Immobility
Absence of sensory aids

Question 13

What are the requirements for a diagnosis of delirium by Confusion Assessment Method (CAM)?

Answer 13

Need 1, 2 and EITHER 3 or 4:

1. Acute onset and fluctuating course
2. Inattention
3. Disorganised thinking
4. Altered conscious state

Question 14

List the 6 BPSD

Answer 14

Agitation
Psychosis
Mood disorders
Sexual/social disinhibition (especially in  males)
Eating problems
Abnormal or inappropriate vocalisations

Question 15

What is the rough diagnostic criteria for dementia?

Answer 15

Memory impairment plus one or more of:
Aphasia
Apraxia
Agnosia
Disturbed executive functioning
AS WELL AS: significant impairment in social or occupational functioning, or significant decline from previous functioning
Deficits are not exclusively during the course of delirium, other neurologic or psychiatric disorder

Question 16

How do you interpret the MMSE score?

Answer 16

25-30: normal
21-24: MCI
14-20: moderate CI
<13: severe CI

Question 17

What are the 4 main categories of differential diagnoses for psychosis? Give an example of each

Answer 17

Organic psychoses (medical cause): epilepsy
Drug-induced psychosis: including withdrawal
Mood disorders with secondary psychotic symptoms: bipolar, MDD
Personality disorder: characterised by transient psychotic symptoms

Question 18

List 2 cognitive symptoms of schizophrenia

Answer 18

Executive dysfunction

Memory impairment

Question 19

What are the most common symptoms of dementia?

Answer 19

Cognitive deficits including memory, executive function and language
BPSD

Question 20

What are the 5 areas of cognitive functioning tested by the MMSE? What areas is it lacking in?

Answer 20

Orientation
Registration
Attention and calculation
Recall
Language
Lacking in frontal and executive functioning testing

Question 21

What are the 4 main types of dementias?

Answer 21

Vascular dementias
Alzheimer’s disease
Dementia with Lewy bodies
Other

Question 22

Identify 2 types of dementias with Lewy bodies

Answer 22

PD

Diffuse Lewy body disease

Question 23

Identify 4 other types of dementias

Answer 23

Frontal lobe dementia
Creutzfeldt-Jakob disease
HIV-associated dementia
Alcohol-related dementia (ARD)

Question 24

Distinguish between delirium and dementia in terms of development and duration

Answer 24

Delirum sudden onset, dementia slow

Delirium days to weeks, dementia months to years

Question 25

Describe the variation of delirium and dementia at night

Answer 25

Delirium almost always worse at night

Dementia often worse at night (“sundowning”)

Question 26

How do delirium and dementia differ in terms of the presence or absence of co-morbidities?

Answer 26

Delirium almost always present (e.g. severe illness, medications)
Dementia may have none

Question 27

Distinguish between delirium and dementia in terms of their symptoms, in particular with regards to attention, level of consciousness, orientation to surroundings, use of language, memory and mental function

Answer 27

Attention: greatly impaired in delirium, maintained until late stages in dementia
Consciousness: fluctuates in dementia (from lethargy to agitation), normal in dementia until late stages
Orientation: varies in delirium, impaired in dementia
Use of language: slow, often incoherent and inappropriate in delirium, word-finding difficulty in dementia
Memory: jumbled and confused in delirium, lost (esp recent events) in dementia
Mental function: losses are variable and unpredictable in delirium (relatively consistent in dementia)