Clinical Handbook - Old Age and Child Psychiatry Flashcards

1
Q

Define delirium

A

Delirium is an acute, transient, global organic disorder of CNS functioning resulting in impaired consciousness and attention.

There are different types of delirium: hypoactive, hyperactive and mixed.

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2
Q

What are the causes of delirium?

A

HE IS NOT MAD

Hypoxia
Endocrine

Infection
Stroke

Nutritional
Others - severe pain, sensory deprivation
Theatre - post-op e.g. due to anaesthetic /opioids

Metabolic - hyponatraemia, hypoglycaemia
Abdominal - faecal impaction, malnutrition, urinary retention
Alcohol
Drugs - benzos, anticholinergics

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3
Q

Give some risk factors for delirium

A

Male sex
Older age ≥65
Multiple co-morbidities
Dementia
Physical frailty
Renal impairment
Severe illness
Sensory impairment
Previous episodes

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4
Q

Give some key clinical features of delirium

A

DELIRIUM

Disordered thinking

Euphoric / depressed (change in mood)

Language impairement

Illusions, delusions and hallucinations

Reversal of sleep-wake pattern: i.e. may be tired during day and hyper-vigilant at night

Inattention

Unaware/disoriented

Memory deficits

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5
Q

Give 6 key differences between delirium and dementia

A

conscious level is impaired in delirium versus usually not in dementia

sleep wake cycle disrupted in delirium, usually normal in dementia

attention usually markedly reduced in delirium, may be normal in dementia

duration is hours to weeks for delirium versus months to years for dementia

course is fluctuating for delirium, usually stable or slowly progressing in dementia

psychomotor activity usually abnormal in delirium, usually normal in dementia

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6
Q

How would you investigate a delirious patient?

A

Routine investigations:

Urinalysis (UTI)

Bloods: FBC (infection); U&Es (electrolyte disturbance); LFTs (alcoholism, liver disease); calcium (hypercalcaemia); glucose (hypo-/hyperglycaemia); CRP (infection/inflammation); TFTs (hyperthyroidism); B12, folate, ferritin (nutritional deficiencies)

ECG (cardiac abnormalities, acute coronary syndrome)

CXR (chest infection)

Infection screen: blood culture (sepsis) and urine culture (UTI)

ABG (hypoxia)

CT head (head injury, intracranial bleed, CVA), and you may consider lumbar puncture (meningitis), EEG (epilepsy

Diagnostic questionnaire:
Abbreviated Mental Test (AMT)
Confusion Assessment Method (CAM)

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7
Q

DDx for delirium?

A

Dementia
Mood disorders: depression or mania (bipolar)
Late onset schizophrenia
Dissociative disorders
Hypothyroidism and hyperthyroidism (may mimic hypo- and hyperactive delirium respectively).

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8
Q

Define autism

A

Autism is a pervasive developmental disorder characterized by a triad of impairment in social interaction, impairment in communication, and restricted, stereotyped interests and behaviours.

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9
Q

Give some risk factors for autism

A

male
family hx
advancing parental age
parental psych disorders
prematurity
maternal medication use esp sodium valproate

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10
Q

What is the ICD-10 autism triad ?

A

ABC

Asocial (lack of eye contact, social smile, interest in others, awareness of social rules)

Behaviour restricted (stereotyped, upset at changes in routine, obsessive interests)

Communication impaired (distorted and delayed speech, echolalia)

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11
Q

What is the ICD-10 diagnostic criteria for autism?

A

A. Presence of abnormal or impaired development before the age of three.
B. Qualitative abnormalities in social interaction.
C. Qualitative abnormalities in communication.
D. Restrictive, repetitive and stereotyped patterns of behaviour, interests and activities.
E. The clinical picture is not attributable to other varieties of pervasive developmental disorder.

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12
Q

Ix for suspected autism?

A

Full developmental assessment including family history, pregnancy, birth, developmental milestones, daily living skills and assessment of communication, social interaction and stereotyped behaviours

Hearing tests if required

Screening tools including CHAT (CHecklist for Autism in Toddlers).

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13
Q

What questions could you ask a parent in a hx of suspected ASD?

A

‘Does your child ever engage in pretend play alone or with others?’, ‘Does your child struggle to interact with others and make friends?’ (social interaction poor)

‘Have you noticed any patterns in their behaviour?’, ‘Does your child insist on the same toys, activities or foods?’, ‘Have you noticed them making any abnormal movements such as flapping their hands or walking on tiptoes?’ (repetitive, stereotypical behaviour)

‘Do they struggle to communicate with you?’, ‘Have you noticed that their speech is monotonous or repetitive?’ (impaired communication)

‘What sort of games does your child play and with what toys?’ (unimaginative play)

‘Do you have any concerns about your child’s development?’ (developmental history)

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14
Q

DDx for autism?

A

Asperger’s syndrome
Rett’s syndrome
Childhood disintegrative disorder
Learning disability
Deafness

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15
Q

What medical conditions are associated with autism?

A

visual / hearing impairment
sensory issues
epilepsy
ADHD
sleep disorders
constipation

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16
Q

What non pharmacological mx options are available for children with autism?

A

CBT
family support
access to self-help groups such as the National Autistic Society group
special schooling
social- communication intervention (e.g. play-based strategies)

17
Q

What is hyperkinetic disorder? (ADHD)

A

characterized by an early onset, persistent pattern of inattention, hyperactivity and impulsivity that are more frequent and severe than in individuals at a comparable stage of development, and are present in more than one situation.

18
Q

Risk factors for ADHD?

A

male
family hx
environmental risk factors e.g. family conflict and parental cannabis and alcohol exposure

19
Q

What is the ICD-10 criteria for diagnosis of ADHD?

A

A. Demonstrable abnormality of attention, activity and impulsivity at home, for the age and developmental level of the child.
B. Demonstrable abnormality of attention and activity at school or nursery , for the age and developmental level
C. Directly observed abnormality of attention or activity
D. Does not meet criteria for a pervasive developmental disorder, mania, depressive or anxiety disorder.
E. Onset before the age of 7 years.
F. Duration of at least 6 months.
G. IQ above 50.

20
Q

Ix for child with suspected ADHD?

A

collateral hx from parents
Blood tests including TFTs (to rule out thyroid disease)
Hearing tests: Examine middle/inner ear with an otoscope and consider a pure tone audiogram
Rating scales: e.g. Conners’ rating scale and the Strengths and Difficulties questionnaire.

21
Q

DDx for ADHD?

A

Learning disability/Dyslexia
Oppositional defiant disorder
Conduct disorder
Autism
Hearing impairment

22
Q

What questions could you ask a parent of a child with suspected ADHD?

A
  1. Inattention: ‘are they reluctant to engage in activities which need sustained mental effort, such as schoolwork?’, ‘do they often leave play activities unfinished? regularly lose their possessions? not listen when spoken to?’
  2. Hyperactivity: are they… constantly fidgeting, jumping or running around? unable to remain still? difficult to engage in quiet activities?’
  3. Impulsivity: ‘…can they wait their turn when playing in groups?’, do they blurt out answers to questions before the question has been completed?’
23
Q

What mx options are available for ADHD?

A

In severe ADHD in school-aged children, drug treatment is first-line with methylphenidate (Ritalin) being the usual choice.

Atomoxetine is second-line

If this fails, dexamfetamine is the alternative

24
Q

Side effects of CNS stimulants for mx of ADHD?

A

headache, insomnia, loss of appetite and weight loss

25
Q

Define learning disability

A

Learning disability (LD) is a state of arrested or incomplete development of the mind. It is characterized by impairment of skills manifested during the developmental period, and skills that contribute to the overall level of intelligence.

26
Q

What is the ICD-10 criteria for dx of LD?

A

Mild → IQ = 50–70 (Mental age = 9–12)

Moderate→ IQ = 35–49 (Mental age = 6–9)

Severe → IQ = 20–34 (Mental age = 3–6)

Profound → IQ = <20 (Mental age <3 years)

27
Q

Give some physical features of Down’s syndrome

A

PROBLEMS

Palpebral fissure (up slanting)
Round face
Occipital + nasal flattening
Brushfield spots (pigmented spots on iris)
Brachycephaly
Low-set small ears
Epicanthic folds
Mouth open + protruding tongue
Strabismus (squint)/Sandal gap deformity/Single palmar (Simian) crease

28
Q

Give some medical problems seen in down’s syndrome

A

visual disturbance (cataracts, strabismus, keratoconus)

hearing loss

heart defects (ventricular and atrial septal defects, ToF)

GI problems (oesophageal/duodenal atresia, Hirschsprung’s, coeliac)

hypothyroidism

29
Q

Which psychiatric conditions are more common in patients with LD?

A

Early-onset Alzheimer’s disease

schizophrenia

anxiety and depressive disorders

autism and ADHD

eating disorders, personality disorders

30
Q

Give some investigations for LD

A

Before birth: Amniocentesis, chorionic villus sampling, genetic testing and karyotyping

For Down’s syndrome: Two methods
(1) Serum screening (β-hCG and PAPP-A) + nuchal translucency
(2) Quad test (β-hCG, α-fetoprotein, inhibin A, estriol)

After birth:
Bloods: FBC (infection), TFTs (hypothyroidism), glucose (hypoglycaemia), serology (ToRCH infections)
Brain imaging: CT head and/or MRI
IQ (intelligence quotient) test.

31
Q

Which members of the MDT may support patients with LD?

A

psychiatrist, SLT, specialist nurses, psychologist, occupational therapist, educational support, social worker, and paediatrician