Child + Geriatric Psychiatry Flashcards
what is pseudodementia?
apparent decline in cognitive and memory function caused by symptoms of major depression
∆ btwn dementia and pseudodementia in terms of
- onset
- sundowning
- how they answer when they don’t know an answer
- insight to problem
- cognitive improvement with antidepressants
DEMENTIA
- onset: insidious, slow
- sundowning: +
- how they answer: confabulate/guess at answers
- insight to problem: unaware
- cognitive improvement with antidepressants: no
PSEUDODEMENTIA
- onset: more acute
- sundowning: -
- how they answer: “i dont know”
- insight to problem: aware
- cognitive improvement with antidepressants: yes
treatment of pseudodementia
antidepressants: SSRI (preferred over MAOi and TCAs)
supportive psychotherapy
community resources
If using TCAs in the elderly, which one should you use and why?
nortriptyline - fewest anticholinergic effects
“no trip”
benefit of using mirtazapine in the elderly with pseudodementia
increases appetite and is also sedating - best for patients who suffer from decreased appetite and sleep ∆s
benefits of using methylphenidate in elderly with pseudodementia
used to treat patients with psychomotor retardation
5 stages of grief
denial anger bargaining depression acceptance
What is bereavement?
Normal grief - encompasses intense feelings of guilt and sadness, sleep ∆s, appetite changes, illusions; usually abate within 6 months of the loss
what is complicated bereavement?
bereavement that lasts >6 months
what is bereavement associated depression? how is it different from complicated bereavement?
bereavement associated depression = major depression; has generalized feelings of hopelessness, helplessness, severe guilt/worthlessness and SI
complicated bereavement = bereavement that lasts >6 months
When should you treat bereavement associated depression?
when patients have had 2 straight weeks of depressive symptoms 6-8 weeks after the precipitating loss
What are some age-related effects of the body’s response to alcohol?
1) decreased OH dehydrogenase - higher blood alcohol levels (BALs)
2) increased CNS sensitivity to EtOH
most common psychiatric disorder in the elderly:
MDD
result of concurrent EtOH use and H2 blockers
higher BALs
result of concurrent EtOH use and benzodiazepines, TCAs, narcotics, barbiturates, anti-histamines
increased sedation
result of concurrent EtOH use and NSAIDs/Aspirin
prolonged bleeding time, irritation of gastric lining
result of concurrent EtOH use and metronidazole, sulfonamides, long-acting hypoglycemics
N, V
result of concurrent EtOH use and reserpine, NTG, hydralazine
increased risk of hypotension
result of concurrent EtOH use and acetaminophen, isoniazid, phenylbutazone
hepatotoxicity
result of concurrent EtOH use and anti-HTN, anti-diabetics, ulcer Rx, gout Rx
worsens underlying disease
visual hallucinations early in dementia suggests a diagnosis of:
What should you do in this case?
lewy body dementia
DO NOT GIVE ANTIPSYCHOTICS
main 3 psychiatric manifestation of dementia
behavioral disinhibition, agitation, aggression
how to treat sleep disturbances in the elderly? 2
hydroxyzine (Vistaril) or trazodone - both are safer than benzodiazepines
why do most elderly suffer from more drug ADRs because of these 3 reasons
1) decreased lean body mass
2) impaired liver fxn
3) impaired kidney fxn
mental retardation/intellectual disability is coded on which axis?
axis II
how is mental retardation/intellectual disability diagnosed in DSM?
IQ score <70 + ∆s in adaptive skills (conceptual skills, social skills, and practical skills)
onset before 18 yo
which type of mental retardation is still functionally able to hold jobs? What IQ score corresponds to this?
mild mental retardation
IQ 55-70
what are the common causes of mental retardation?
idiopathic
down syndrome
fragile X syndrome most common inherited form
ToRCH infections
What is a learning disorder?
academic achievement (in reading, math, written language) that is significantly lower than expected for chronological age, level of education, and level of intelligence
(fyi - often due to ∆ cognitive processing)
what should you do before diagnosing learning disorders?
always rule out sensory deficients (hearing, vision, etc)
treatment for learning disorders?
remedial education
DSM criteria for oppositional defiant disorder (ODD), include duration
> 6 months of negativistic, hostile, and defiant behavior during which there is
- a frequent loss of temper
- arguments with adults
- defying adult’s rules
- deliberately annoying people
- easily annoyed
- anger and resentment
- spitefulness
- blaming others for mistakes/misbehaviors
oppositional defiant disorder (ODD) is usually comorbid with
substance abuse
mood disorders
ADHD
DSM criteria for conduct disorder (CD), include duration
1 year of persistent pattern where there is
- aggression towards people/animals
- property destruction
- deceitfulness/theft
- serious violations of rules
higher risk of substance abuse and suicidal ideations/attempts
conduct disorder (CD) is usually comorbid with
ADHD
learning disorders
treatment for conduct disorder (CD)
- multimodal treatment approach involving both family + community
- consistent rules and consequences
3 diagnostic criteria of ADHD
impulsivity
inattention
hyperactivity
pathophysiological cause of ADHD?
decreased DA and NE tracts in the prefrontal cortex -> hyperactivity + impulsivity
DSM criteria for ADHD, include duration
≥ 6 sx of inattentiveness, hyperactivity, or both that
- lasted for 6 mo
- onset prior to age 7
- observed in ≥1 setting (home + school)
ADHD is highly comorbid with:
conduct disorder anxiety disorder mood disorder personality disorder ODD
ADHD = CAMP O
∆ btwn stimulants (methylphenidate, dextroamphetamine, amphetamine salts) and atomoxetine (non-stimulant)
how quickly do they work?
how does this affect sleep?
who are these usually given to?
stimulants (methylphenidate, dextroamphetamine, amphetamine salts)
- RAPID onset
- ADR: insomnia
atomoxetine - non-stimulant
- GRADUAL onset (2-3 weeks)
- ADR: sedation
- given to people/families with substance abuse
What alternatives are there to stimulants (methylphenidate, dextroamphetamine, amphetamine salts) and atomoxetine (non-stimulant) for treatment of ADHD?
When is it usually given?
clonodine, guanfacine (both alpha-2 agonist)
usually given if patients cannot tolerate 1st line treatments, or as an adjunct therapy to stimulants (help with sleep disturbances/agitated behavior
What is pervasive developmental disorder (PDD)?
developmental disorder that results in impairment in multiple areas of development (social, communicative, cognitive)
5 types pervasive developmental disorder (PDD)
Austistic d/o Asperger d/o Rett d/o Childhood disintegrative disorder PDD-NOS
DSM criteria for Autistic disorder, include duration
symptoms present by age 3:
≥ 2 problems in social interaction (lack of reciprocity, lack of relationships)
≥ 1 problem in communication (delayed speech, lack of make-believe/imaginative play)
stereotyped patterns of behavior and activities (spinning wheels, toe walking, hand flapping)
(side note: 70% have IQ < 70)
In evaluating a toddler who shows no interest or does not speak unless spoken to directly, it is important to order what test before making a diagnosis of autism
hearing test
Autistic disorder is associated with these 3 medical problems
fragile x
tuberous sclerosis
seizures
neurochemical composition of children with autistic disorder
higher peripheral serotonin levels
What are the 2 most important predictors of prognosis in autistic disorder?
level of intellectual functioning communicative competence (ie language skills)
What Rx can you use to control the aggression, hyperactivity, and mood lability commonly seen in children with autistic disorder?
antipsychotic Rx
How is autistic disorder different than asperger disorder?
children with Asperger disorder have NORMAL language and cognitive development
but same symptoms in SOCIAL INTERACTION (lack of reciprocity, lack of relationships, lack of interest in sharing enjoyment with others) & REPETITIVE STEREOTYPED BEHAVIOR (spinning wheels, toe walking, hand flapping)
DSM criteria for Asperger disorder
same symptoms as Autistic disorder in terms of problems with SOCIAL INTERACTION (lack of reciprocity, lack of relationships, lack of interest in sharing enjoyment with others) & REPETITIVE STEREOTYPED BEHAVIOR (spinning wheels, toe walking, hand flapping), but children with Asperger disorder have NORMAL language and cognitive development
Children with Asperger disorder are at risk of what psychiatric disorder in adolescence and why?
depression because the social difficulties often lead to chronic frustration and ultimately depression
What is Rett disorder?
developmental disorder where there is normal physical and psychomotor development during the first 5 months after birth, followed by
- a decreasing rate of head growth
- loss of previously learned purposeful hand skills btwn ages 5-30 months
- development of stereotyped hand movements (hand wringing, hand hashing), impaired language and psychomotor retardation, problems with gait or trunk movements
risk of abnormal EEGs, seizures, & sudden death are common
How does Rett disorder differ from Childhood disintegrative disorder
Rett disorder - slowed head growth, unusual hand movements present
Childhood disintegrative disorder - normal head growth, no unusual hand movements
What is Childhood disintegrative disorder?
normal development in the first 2 years of life (in ALL aspects), but by the age of 10, there is a loss of previously acquired skills
≥ 2 in
- language skill
- social skills
- adaptive behavior
- bowel/bladder control
- play
- motor skills
≥ 2 in
- impaired social interactions
- impaired communication
- restricted, stereotyped behaviors and interests
What are examples of motor tics?
eye blinking
shoulder shrugging
neck jerking
What are examples of vocal tics?
grunting
sniffing
snorting
using obscene words
DSM criteria for Tourette Syndrome
onset of MOTOR + VOCAL tics prior to 18 years; occurs almost daily for >1 year with no tic-free period >3 months
Tourette Syndrome is highly comorbid with these 2 psychiatric disorders
- OCD
- ADHD
Tourette Syndrome - neurochemical basis and treatment 2
increased DA + decreased GABA in the caudate nucleus
first-line agents: alpha-2 agonist (clonodine, guanfacine)
Adjunct agents: atypical neuroleptics (risperidone)
Tourette Syndrome - possible infectious cause; how to diagnose?
PANDAS
- get anti-streptolysin O (ASO) and anti-streptococcal DNAse B (anti-DNAse B)
(can also cause OCD along with the tics)
Why is the use of stimulants in ADHD-associated with tic disorders controversial?
it can exacerbate tics
when is urinary incontinence generally established by
4 yo
definition of enuresis
∆ btwn 1˚ and 2˚ enuresis
What must you rule out?
enuresis - involuntary voiding of urine after age 5 (> 2x/week for 3 consecutive months)
1˚ enuresis - occurs in a child without previous history of dryness
2˚ enuresis - occurs in a child who has achieved continence
must rule out: infection (ie UTI), diabetes, seizures
definition of encopresis
What must you rule out?
involuntary or intentional passage of feces in appropriate places by age 4 (> 1x/month for 3 months)
must rule out: hypothyroidism, anal fissure, IBD, dietary factors
Enuresis and encopresis may be associated with this psychiatric disorder
conduct disorder
what could be a possible cause of enuresis? 2
small bladder
low nocturnal levels of ADH
what could be a possible cause of encopresis? 2
lack of sphincter control
constipation with overflow incontinence
pharmacological therapy for enuresis
anti-diuretics (DDVAP)
TCAs (imipramine)
What is selective mutism?
refusal to speak in certain situations for ≥ 1 month despite the ability to comprehend and use language; more common in girls
What is separation anxiety disorder?
How do children normally present?
excessive fear ≥ 4 weeks of leaving one’s parents or 1˚ caretaker, usually precipitated by a stressful live event (ie parent receives a life threatening disease)
refuse OR complain of physical symptoms to avoid going to school or sleeping alone
when forced to separate, they become extremely distressed and worry excessively about losing their parents forever
treatment of separation anxiety disorder?
low-dose SSRI (fluoxetine); MUST MONITOR FOR SUICIDAL THOUGHTS
