Dementia/delerium/sleep disorders/health anxiety disorders

Question 1

Delirium

general and Sx

Answer 1

• waxing & waning level of consciousness w/ rapid onset
• rapid decrease in attention span + level of arousal
• key sx: disorganized thinking, hallucinations (often visual), sleep disturbances, cognitive dysfunction, agitation

Question 2

Delirium

Screening

Answer 2

• clinical
• EEG: abrnomal in delerium (normal in dementia)

CRAM
- evalates for 4 fundamental features of delerium
- acute onset & fluctuating course, inattention, disorganized thinking, or altered LOC

Question 3

Delirium

Tx

Answer 3

• correct underlying cause (tx infection, assisted withdrawal)
• maintain O2 levels, treat pain, maintain hydration
• calm, quiet environment for recovery
• Haloperidol (PRN- tx psychotic symptoms)

Question 4

Delirium

Pearls
What to avoid

Answer 4

• reversible (esp anti-cholinergics)
• usually secondary to other illness or stressors (CNS diseases, infection, trauma, substance abuse/withdrawal)

on boards: often is post-op development of fever w/ associated infection

avoid benzodiazepines, can worsen psychotic sx

Question 5

Dementia

General and Sx

Answer 5

• progressive decline in cognition and motor function w/ normal level of consciousness
• key sx: memory loss/deficits, impaired judgement, personality changes, loss of motor function (late stages)
• seen in elderly pts
• irreversible disease progress

Types
- Alzheimer’s (60%)
- Infarction (20%- caused by stroke)
- Lewy Body (Parkinson Disease)

Question 6

Dementia

Dx

Answer 6

clinical (but screen for other causes of memory loss like depression, hypothyroidism, HIV, vitamin deficiencies)

Question 7

Narcolepsy

general and Sx

Answer 7

• excessive daytime sleepiness despite being awake and well-rested
• hypnagogic hallucination (just before going to sleep) and hyponopompic hallucinations (just before awakening)
• sleep paralysis (nocturnal & narcoleptic sleep episodes that begin w/ REM sleep)
• cataplexy (loss of all msk tone following strong emotional stimuli)

Question 8

Narcolepsy

Criteria

Answer 8

• recurrent episodes of rapid onset, overwhelming sleepiness >3x wkly for the last 3 mo
• due to decreased orexin (hypocretin) production in lateral hypothalamus & dysregulated sleep-wake cycles

Question 9

Narcolepsy

Tx

Answer 9

good sleep, daytime stimulants (amphetamines) or nighttide sodium oxybate (GHB)

Modafinil: non-amphetamine CNS stimulant to promote wakefulness (first line)

Question 10

Stages of sleep

Answer 10

lack of sleep can cause exhaustion, drowsiness, axnxiety, depression, physiological impacts (cardiac, metabolic)

Stages
N1: lightest; theta waves; least amount of sleep occurs here

N2: medium; theta complexes (K-complexes + sleep spindle); bruxism (teeth grinding); largest percentage of sleep

N3: deepest sleep; delta waves; sleep walking, enuresis occurs here; night terrors

REM: dreams/nightmares; sawtooth pattern; penile tumescence

Cycles: NREM cycle is usually 90min; more cycles = longer REM

Question 11

Sleep Terror Disorder

general and Sx

Answer 11

periods of inconsolable terror w/ screaming in the middle of the night

no memory of arousal episode

Question 12

Sleep Terror Disorder

triggers

Answer 12

emotional stress, fever, lack of sleep

Question 13

Sleep Terror Disorder

Tx

Answer 13

usually self limiting

Question 14

Malingering Disorder

general

Answer 14

fake/exaggerate sx

consciously falsified medical symptoms
usually done for secondary external gain (worker’s compensation, opioids)
watch for poor compliance w/ tx or follow up of dx tests

Question 15

malingering

Tx

Answer 15

ends when secondary gain is achieved

Question 16

Munchausen Syndrome/Factitious Disorder

Answer 16

fake/exaggerated sx

Key: frequent stays in hospital, reluctance to allow Drs to talk to friends/families, conditions worsening despite tx or for no reason, inconsistent sx, extensive knowledge of medical terms/diseases

• by proxy: fake/exaggerated sx imposed on others (caregiver falsifies medical sx) ABUSE; MANDATORY REPORT
• factitious disorder imposed on self
• unconsciouslly falsified medical symptoms

Risk Factors: female gender, unmarried, prior or current HCP

Question 17

Munchausen Syndrome/Factitious Disorder

Tx

Answer 17

NOT SELF LIMITING (usually have significant hx of getting medical tx)

Question 18

Somatic Symptom Disorders

general

Answer 18

present for 6+ mo

1+ physical sx that cause distress (but normal HPI/PE)

can lead to dysfunctional thoughts, feelings, or behaviors associated w/ physical sx (like MDD)

can co-occur w/ medical illnes

unconscious, unintentional sx

Risk Factors: female gender, lower SES, lower education, ethnic minority

Question 19

Somatic Symptom Disorders

Tx

Answer 19

regular office visits w/ same PCP along with psychotherapy

Question 20

Pain Disorder

General

Answer 20

characterized by chronic pain causing significant distress or impairment

psychologic factors appear to worsen pain

unconscious, unintentional sx

Risk Factors: female gender, lower SES, lower education, ethnic minority

Question 21

Pain Disorder

tx

Answer 21

regular office visits w/ same PCP along with psychotherapy

Question 22

Illness Anxiety Disorder

general

Answer 22

present for 6+ mo

hypocondriasis
excessive care/worry about having or acquiring a serious illness leading to dysfunctional behaviors associated w/ health

constant check ups
minimal somatic sx (no physical findings)

unconscious, unintentional sx

Risk Factors: female gender, lower SES, lower education, ethnic minority

Question 23

Illness Anxiety Disorder

Tx

Answer 23

regular office visits w/ same PCP along with psychotherapy

Question 24

Conversion Disorder

general

Answer 24

Functional Neurologic Symptom Disorder

loss of sensory/motor function w/out affecting day to day function (paralysis, blindness, mutism, seizures)
often follows acute stressors

la belle indifference (indifferent to the loss of sensory/motor function, so does not affect day to day function)

unconscious, unintentional sx

Risk Factors: female gender, lower SES, lower education, ethnic minority

Question 25

Conversion Disorder

tx

Answer 25

regular office visits w/ same PCP along with psychotherapy