List I - Act Core Conditions Flashcards
What is parasuicide?
- An apparent attempt at suicide, commonly called a suicidal gesture, in which the aim is not death
- For example, a sublethal drug overdose or wrist slash.
- Previous parasuicide is a predictor of suicide. * The increased risk of subsequent suicide persists without decline for at least two decades
What types of self harm occur more frequently?
- The majority of self-poisoning episodes involve prescribed or over-the-counter medication, and a minority involve illicit drugs, other household substances, or plant material
- The majority of self-injury episodes involve cutting
- Less common methods include burning, hanging, stabbing, drowning, swallowing objects, insertion, shooting and jumping from height’s or in front of vehicles
What is thought to be the reason for self harm / parasuicide?
- Self harm refers to an intentional act of self poisoning or self injury, irrespective of the motivation or apparent purpose of the act, and is an expression of emotional distress
How common is self harm?
- 1/4 of 16-24 year old women report having self harmed at some point, men 1/10 in the same age range
- Around one in every 20 men and one in every 12 women have attempted suicide at some point with highest rates in women aged 16–24 years and men aged 25–34 years.
What is thought to be the reason why although there is overall a higher rate of self harm in women, the rate of suicide in men is higher overall?
- In males it is thought to be the choice of more lethal methods (firearms and hanging vs cutting and poisoning)
What are the risk factors for self harm?
- Age — self-harm rates peak in 16 to 24-year-old women and 25 to 34-year-old men. Suicide rates are highest in both men and women aged 45–49 years.
- Socio-economic disadvantage.
- Social isolation.
- Stressful life events, for example relationship difficulties, previous experience in the armed forces, child maltreatment, or domestic violence.
- Bereavement by suicide.
- Mental health problems, such as depression, psychosis or schizophrenia, bipolar disorder, post-traumatic stress disorder, or a personality disorder.
- Chronic physical health problems.
- Alcohol and/or drug misuse.
- Involvement with the criminal justice system (with people in prison being at particular risk)
What are the complications of self harm?
- Acute liver failure - paracetamol overdose
- Permanent scarring of skin and damage to tendons and nerves caused by cutting and other injuries
- Repetitive self harm is common - 1/6 self harmers will do it again within 1 year
- Elevated risk of suicide
- Suicide risk in people who self harm is thought to be particularly high in people who are:
- Male
- Repeatedly self harm
- Physical health problems
- Express suicidal intent
How should a person be managed following an act of self harm?
- Where possible see the person alone to maintain confidentiality (exceptions, lack capacity or significant mental illness)
- Examine physical injuries
- Assess the person’s emotional and mental state and for the presence of features that may increase the person’s risk such as:
- Depression
- Suicidal intent
- Hopelessness
- Associated mental health disorders or misuse of recreational drugs and/or alcohol
- Other risk factors (male, physical health, farmer, unemployment, bereavement, relationship change)
- Assess protective factors
- Coping strategies
- Supportive relationships
- Dependent children
- Religious beliefs
- Assess for safeguarding concerns
- Dependents
- Response to child maltreatment, domestic violence, etc
- Refer to ED if physical injuries or acute mental state are thought to pose a significant risk
- Use TOXBASE where there is uncertainty regarding need for referral
- Refer all children under 16 years who have self harmed to ED with suitable expertise
- Communicate the relevant findings of the psychological risk assessment to the department/personnel involved in the person’s care
When should people who have self harmed be followed up?
- Within 48 hours
* Ensure the person has had a full assessment of their psychosocial needs and risk
In self harm, when is it necessary to assess capacity?
- If a person declines or refuses management that is perceived to be in their best interests
- Mental capacity should be assumed in a person aged 16 years or over unless there is evidence to the contrary
What are the five key principles of the MCA 2005?
- Presumption of capacity - should always be presumed in adults unless the healthcare professional can prove otherwise
- Maximising decision making capacity - support the person to make the decision
- Freedom to make seemingly unwise decisions
- Best interests
- Least restrictive alternative
How is capacity assessed?
1) Confirm the person has an impairment of the mid or brain which means they are unable to:
* Understand relevant information about the decision to be made
* Retain that information
* Use or weigh that information as part of the decision making process or
* Communicate their decision (by talking, non-verbal communication or any other means).
What is the guidance regarding capacity and confidentiality of self harm and health issues with young people aged 16-17 years?
- For young people aged 16–17 years who lack capacity, parents can consent on their behalf if the decision to be made is felt to be within parental control. Healthcare professionals are, however, able to give treatment regardless of whether parental consent has been given, as long as the principles of the Mental Capacity Act (2005) are followed, and the decision is judged to be in the young person’s best interests.
- If a young person who self-harms and has capacity refuses to involve their family or carers in their treatment, or refuses consent to disclose issues relating to their safety to family or carers, healthcare professionals must weigh the young person’s right to confidentiality (and risk to the therapeutic relationship if confidentiality is breached) against providing family and carers with sufficient information to protect and care for the young person
What is the most common form of dementia?
What is dementia not?
- Alzheimer’s disease
* Dementia is never a part of normal ageing
How many people in the UK have dementia?
- 850,000 people
- 24% of men born in 2015 will develop dementia
- 35% of women will develop dementia
How many people under the age of 65 get AZD?
- In the UK there are 40,000 people under the age of 65 with AZD - this is called early onset AZD
- Most people who get AZD do so after the age of 65
What is the leading risk factor for AZD?
- Age (cannot be controlled) over 65 risk doubles every 5 years
Who is AZD more common in M/F?
- Females - thought to be related to lack of oestrogen after the menopause
In people with which condition, the risk of developing AZD is increased?
- Down’s syndrome
What is the inheritance pattern of AZD?
- In families with very clear inheritance it is very rare
- In such groups AZD tends to present before the age of 65
- For someone with a family member over the age of 65 diagnosed with AZD, their risk is increased but it does not mean it is inevitable
- Risk can be reduced by living a healthy lifestyle
How can risk factors for AZD be reduced?
- Maintaining a healthy lifestyle (especially from mid life onwards)
- Regular exercise
- Maintaining a healthy weight
- Not smoking
- Healthy balanced diet
- Drinking in moderation
- Lifestyle combining physical, social and mental activity will lower risk
What are the symptoms of AZD?
- Memory loss
- Struggle with language
- Challenges with visuospatial skills
- Poor concentration
- Orientation
How could memory loss present in AZD?
- Losing items around the house
- Struggling to find the right words in a conversation/forgetting someone’s name
- Forget about recent conversations or events
- Getting lost in a familiar place
- Forgetting appointments or anniversaries
How could language problems present in AZD?
- Struggling to follow a conversation or repeating themself
How could visuospatial problems present in AZD?
- Problems judging distance or seeing objects in three dimensions; navigating stairs or parking the car become more difficult
How could concentrating, planning or organising become more difficult with AZD?
- Patients have problems making decisions or carrying out a sequence of tasks
How might patients present in the early stages of AZD?
- Become withdrawn, lose interest in activities and hobbies
- Anxious, irritable or depressed
- Changes in mood
What happens in the later stages of AZD?
- Problems with memory loss, reasoning, orientation and communication become more severe
- Some may have delusions and/or hallucinations
- Agitation - calling out, repeating the same question, disturbed sleep patterns, reacting aggressively
- Require assistance with eating and walking and become increasingly frail
How often does AZD present with other dementia’s, what is the most common?
- 10% of patients have more than one type of dementia at the same time (mixed dementia)
- AZD with vascular dementia
What is atypical AZD?
- Earliest symptoms are not memory loss
- Underlying accumulation of plaques are present in the brain
- But… the hippocampus is not the first part of the brain to be affected
Who is atypical AZD more common in?
- Patients under the age of 65 (compared to those over)
What are the atypical forms of AZD?
- Posterior cortical atrophy
- Logopenic aphasia
- Frontal variant Alzheimer’s disease
What is posterior cortical atrophy?
- Damage to areas at the back and the upper rear of the brain
- Areas that process visual information and deal with spatial awareness
- Early problems are identifying objects, and reading (even if eyes are healthy)
- Patients may struggle to judge distances or seem uncoordinated
What is logopenic aphasia?
- Damage to areas on the left side of the brain associated with producing language
- Speech becomes laboured with long pauses
What is frontal variant Alzheimer’s disease?
- Damage to the lobes at the front of the brain
- Results in problems with planning and decision making
- Behaviour disturbances such as being socially inappropriate or seem not to care about the feelings of others
What are the medical treatments for AZD?
- Cholinestrase inhibitors
- Donepezil (Aricept)
- Rivastigmine (Exelon)
- Galantamine (Reminyl)
- Glutamate receptor antagonist
- Memantine
What is the mechanism of cholinesterase inhibitors?
- Blocks the normal breakdown of cholinesterase
- Results in more acetylcholine in the synaptic cleft
- Such mechanism has been seen to have a modest effect on cognition
What are the side effects of cholinesterase inhibitors?
- Vasodilation
- Constriction of pupils
- Increased sweating, saliva and tears
- Slow heart rate
- Mucus secretion and constriction of the respiratory tract
What is the mechanism of memantine?
- Acts on the gluamatergic system by blocking NMDA receptors
- Approved for people with moderate to severe AZD
- Believed to help prevent excess levels of glutamate from damaging the brain
- Glutamate is a substance required for carrying nerve signals
- AZD patients have too much glutamate in their brain - memantine is used to prevent excess glutamate from killing the nerve cells
What are the differential diagnoses for people with dementia?
- Drugs, delirium
- Emotions/depression
- Metabolic disorders
- Eye and ear impairment
- Nutritional disorders
- Tumours, toxins, trauma
- Infections
- Alcohol, arteriosclerosis
What are the dementia subtypes?
- Alzheimer’s disease
- Vascular dementia
- Mixed Vd & Azd
- Lewy body dementia
- Fronto-temporal dementia
- Parkinson’s disease dementia
- HIV dementia
- Huntingdon’s dementia
