Clinical Handbook - Old Age and Child Psychiatry Flashcards
Define delirium
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.
What are the causes of delirium?
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
Give some risk factors for delirium
Male sex
Older age ≥65
Multiple co-morbidities
Dementia
Physical frailty
Renal impairment
Severe illness
Sensory impairment
Previous episodes
Give some key clinical features of delirium
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
Give 6 key differences between delirium and dementia
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
How would you investigate a delirious patient?
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)
DDx for delirium?
Dementia
Mood disorders: depression or mania (bipolar)
Late onset schizophrenia
Dissociative disorders
Hypothyroidism and hyperthyroidism (may mimic hypo- and hyperactive delirium respectively).
Define autism
Autism is a pervasive developmental disorder characterized by a triad of impairment in social interaction, impairment in communication, and restricted, stereotyped interests and behaviours.
Give some risk factors for autism
male
family hx
advancing parental age
parental psych disorders
prematurity
maternal medication use esp sodium valproate
What is the ICD-10 autism triad ?
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)
What is the ICD-10 diagnostic criteria for autism?
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.
Ix for suspected autism?
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).
What questions could you ask a parent in a hx of suspected ASD?
‘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)
DDx for autism?
Asperger’s syndrome
Rett’s syndrome
Childhood disintegrative disorder
Learning disability
Deafness
What medical conditions are associated with autism?
visual / hearing impairment
sensory issues
epilepsy
ADHD
sleep disorders
constipation
What non pharmacological mx options are available for children with autism?
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)
What is hyperkinetic disorder? (ADHD)
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.
Risk factors for ADHD?
male
family hx
environmental risk factors e.g. family conflict and parental cannabis and alcohol exposure
What is the ICD-10 criteria for diagnosis of ADHD?
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.
Ix for child with suspected ADHD?
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.
DDx for ADHD?
Learning disability/Dyslexia
Oppositional defiant disorder
Conduct disorder
Autism
Hearing impairment
What questions could you ask a parent of a child with suspected ADHD?
- 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?’
- Hyperactivity: are they… constantly fidgeting, jumping or running around? unable to remain still? difficult to engage in quiet activities?’
- Impulsivity: ‘…can they wait their turn when playing in groups?’, do they blurt out answers to questions before the question has been completed?’
What mx options are available for ADHD?
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
Side effects of CNS stimulants for mx of ADHD?
headache, insomnia, loss of appetite and weight loss
Define learning disability
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.
What is the ICD-10 criteria for dx of LD?
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)
Give some physical features of Down’s syndrome
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
Give some medical problems seen in down’s syndrome
visual disturbance (cataracts, strabismus, keratoconus)
hearing loss
heart defects (ventricular and atrial septal defects, ToF)
GI problems (oesophageal/duodenal atresia, Hirschsprung’s, coeliac)
hypothyroidism
Which psychiatric conditions are more common in patients with LD?
Early-onset Alzheimer’s disease
schizophrenia
anxiety and depressive disorders
autism and ADHD
eating disorders, personality disorders
Give some investigations for LD
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.
Which members of the MDT may support patients with LD?
psychiatrist, SLT, specialist nurses, psychologist, occupational therapist, educational support, social worker, and paediatrician
