Child, learning disability + old age psychiatry Flashcards
Autism spectrum disorders
Developmental disorder, triad of impaired social interaction + communication difficulties + stereotyped behaviours/interests
Develops before age 3
M>F, genetics/FH linked, more in premature babies
Common features:
- Social: few social gestures, poor eye contact, late social smile/response to name/interest in others, low awareness of social rules, difficulty with sustaining relationships
- Behavioural: restricted, repetitive stereotyped behaviour e.g. rocking, upset at change in routine, prefer the same food/clothes/games, fascination with sensory aspects of environment
- Communication: delayed speech, echolalia (repetition of words)
- Asperger’s: not really a thing anymore (?see paeds). Like ASD but doesn’t cause impairment in language
Management:
- bio: treat other disorders e.g. ADHD, melatonin for sleep disorders if severe, antipsychotics sometimes used for severe behaviour
- psych: CBT if can engage, psychoeducation for families
- social: modify environmental factors, support with daily living skills/coping strategies, special schooling
ADHD (hyperkinetic disorder)
More severe than individuals at same stage of development, present in more than 1 situation (eg home and score):
- Inattention e.g. not listening when spoken to, distractible, forgetting belongings
- Hyperactivity: restless, fidgeting, excessive talking, difficulty doing quiet activities
- Impulsivity: difficulty waiting turn, interrupting others, temper tantrums
Common to also have ASD/dyslexia/mood disorders
Always check hearing!
M:
- drugs if severe - methylphenidate, atomoxetine or dexamfetamine. drug holiday in school holidays
- psychoeducation, CBT, behavioural training (reinforce positive behaviour, manage disruptions)
Conduct disorder
Repetitive severe pattern of antisocial behaviour - aggression, destruction of property, deceitfulness, major violations of social expectations e.g. stealing/violence to animals etc
RF: male, child abuse, poor SES, parental psychiatric disorders, family conflict, rejection, inconsistent parenting
Emotional disorders of childhood/adolescence
- GAD: free-floating anxiety, fears of death/loss, somatic manifestations (nausea, abdo pain, headaches, sweating, palpitations), panic attacks (sudden onset, extreme fear, faintness, physical sx)
- Separation anxiety disorder: somatic sx, nightmares, school refusal
- OCD: obsessional thoughts + compulsive actions related to these
- Phobic disorders
- PTSD: persistently re-experiencing trauma, avoiding associated stimuli, increased arousal (sleep disturbance, irritability, poor concentration)
- Depression: persistent low mood, anhedonia, not always biological sx. M: CBT, fluoxetine has to be initiated by a specialist
- Eating disorders: rare in pre-adolescents, similar sx to adults, may cause delays in puberty + growth
- Psychotic illness - rare pre-puberty
What is dementia?
Generalised decline of memory, intellect + personality, without impairment of consciousness, leading to functional impairment of ADLs
What may cause dementia?
Irreversible:
- Neurodegenerative: AD, FTD, DLB, Parkinson’s disease dementia, Huntington’s disease
- Vascular: VD, multi-infarct dementia, post-stroke
- Traumatic head injury
- Infections: HIV, encephalitis, syphilis, CJD
- Toxins: alcohol, BZD, barbiturates
Reversible:
- Normal pressure hydrocephalus (dementia, urinary incontinence + gait disturbance)
- Brain tumours
- Chronic subdural haematoma
- Vitamin deficiencies: B12, folic acid, thiamine, nicotinic acid
- Endocrine: Cushing’s syndrome, hypothyroidism
Alzheimer’s dementia
Degeneration of cholinergic neurones causing ACh deficiency. A/w neurofibrillary tangles, beta-amyloid plaques, cortical atrophy (often hippocampal), widened sulci, enlarged ventricles
Most common type. Early onset <65y likely familial, late onset more common, insidious onset
Loss of memory (short term then long term), disorientation to T+P, impaired executive function (problem solving, abstract thinking, judgement, planning), visuospatial problems (getting lost, driving issues), language disturbances (finding words, vocab etc), apraxia (inability to carry out previously learned purposeful movements), agnosia (impaired recognition of sensory stimuli e.g. auditory agnosia), non-cognitive sx (perception-hallucinations, thought content-delusions, emotion-depresion/apathy, behaviour-wandering/aggression/restlessness)
Vascular dementia
Stroke/multiple infarcts/chronic arteriosclerosis.
- abrupt/gradual onset, stepwise deterioration
- personality changes + emotional depression/apathy occur earlier than memory loss. confusion. neurological signs (often UMN). signs of CV disease
Dementia with Lewy Bodies
If have PD and develop dementia after 12m then have PD + dementia; as opposed to DLB where dementia + parkinsonian features begin within 12m of each other
Lewy body protein in brainstem neurones/substantia nigra - within brainstem cause dopaminergic loss and parkinsonian sx, outside brainstem cause cholinergic loss
CF: day to day fluctuations in cognitive performance, recurrent visual hallucinations, motor signs of parkinsonism (tremor, rigidity, bradykinesia), recurrent falls/syncope , severe sensitivity to antipsychotic drugs
Fronto-temporal dementia
Atrophy of frontal + temporal lobes, subtype is Pick’s disease which involves Pick bodies
insidious development 50-60y, FH in 50%.
Early personality changes (disinhibition, apathy, restlessness), worsening social behaviour, repetitive behaviour, language problems. Insight lost early, memory preserved in early stages
Alcoholic dementia
Age-disproportionate cortical + white matter atrophy
Often gradual onset. Cognitive status fluctuates with drinking/withdrawal episodes
Memory problems, frontal features, depression common
Investigations in suspected dementia?
FBC-infection, anaemia U+E Calcium LFTs Glucose-hypos Vit B12+folate TFTs-hypothyroidism
Sometimes may do imaging - esp if <60/sudden decline/focal CNS signs - to r/o tumours abscesses + SDH.
Other specialist tests may be done for less common types but AD is a clinical diagnosis
Management of dementia
- Inform DVLA
- Advance planning
- Optimise CV RF
- Social support groups, assistance with ADLs, community dementia teams, home nursing, meals on wheels, befriending, massage, pet therapy
- Pharmacological:
- AChE inhibitors (donepezil, galantamine, rivastigmine). Mild-mod AD/DLB for non-cognitive sx that cause distress. Cautioned in arrhythmia + COPD + PUD, galantamine CI in severe hepatic/renal impairment. S/e: GI upset, bradycardia, muscle spasms. Rivastigmine can cause EPSEs
- Memantine: NMDA receptor antagonist. Moderate AD/if AChE inhibitors CI. Useful for behavioural sx
- Avoid: anticholinergics (cognitive deterioration), BZDs (falls, cognitive decline), antipsychotics (due to risk of stroke/falls/cognitive decline, may need acutely as a last line)
Causes of delirium
Acute transient global organic disorder of CNS function causing impaired consciousness + attention
‘He is not maad’
- Hypoxia (resp failure, MI, HF, PE)
- Endocrine (high/low thyroid, high/low glucose, Cushing’s)
- Infection (UTI, pneumonia, encephalitis, meningitis)
- Stroke/other brain stuff like RICP/SOL/trauma/epilepsy
- Nutritional (low thiamine, nicotinic acid, B12)
- Other (severe pain, sensory deprivation, sleep deprivation, relocation)
- Theatre (post-op period due to anaesthetic/opiates)
- Metabolic (hypoxia, electrolyte imbalance, hypoglycaemia, hepatic or renal impairment)
- Abdominal (faecal impaction, malnutrition, urinary retention)
- Alcohol (intoxication, withdrawal)
- Drugs (BZD, opioids, anticholinergics, anti-Parkinsonian, steroids)
Features of delirium
Acute onset, fluctuating course, often worse at night
Features of delirium:
- Disordered thinking
- Emotions: euphoric/fearful/depressed/angry
- Language impairment
- Illusions
- Reversal of sleep-wake pattern
- Inattention
- Unaware/disoriented
- Memory deficits
Types:
- Hypoactive: lethargy, reduced motor activity, apathy
- Hyperactive: agitation, irritability, restlessness, delusions, hallucinations
- Mixed
