mental health Flashcards
define generalised anxiety disorder
worry that is:
- disproportionate
- pervasive
- uncontrollable
- widespread
range of somatic, cognitive, and behavioural symptoms
aetiology of GAD
multifactorial
environmental
genetic
chronic illness
substance abuse
management of GAD step 1
assess severity using GAD-7 questionnaire
ask about comorbidities and environmental stressors
written material about GAD and treatment options
active monitoring of symptoms, functioning, and response to treatment
managemet of GAD step 2
if no improvement following step 1 management
low intensity psychological interventions
psychoeducational groups
self-help, non-facilitated and guided
when to escalate management of GAD to step 3
if marked functional impairment or no improvement following step 2 interventions
management of GAD step 3
individual high-intensity psychological intervention, eg. CBT
drug treatment: SSRI, SNRI, pregabalin if SSRI/SNRI contraindicated
- review effectiveness every 2-4 weeks in first 3 months, then every 3 months
do not offer what medications for GAD
benzodiazepines (antipsychotic) in primary care except as short term measure during crises
antipsychotics in primary care
cautions for SSRI/SNRIs
<30yrs: increased risk of suicidal thinking and self-harm
monitor weekly for first month
when to escalate management of GAD to step 4 (referral for specialist treatment)
severe anxiety
marked functional impairment
no improvement following step 3
self harm
self neglect
signifcant comorbidity
suicide
define dementia
chronic and progressive deterioration in coginitive ability due to organic brain disease
- irreversible
- no impaired consciousness
- all types present with progressive memory loss + impaired cognition
Types of dementia
- Alzheimers (70%)
- Vascular (25%)
- Lewy body
- Frontotemporal dementia- affects frontal/temporal brain lobes
pathophysiology of Alzheimer’s
- degeneration of neurons in cerebral cortex
- beta amyloid plaques deposit outsde neurons and tau tangles develop in neurons
- causes brain atrophy (narrow gyri, wide sulchi, larger ventricles)
- affects ACh neurons => reduced ACh release
risk factors for Alzheimer’s
- increasing age
- genetic susceptibility
risk factors for dementia
- older age
- learning disability
- genetics
- CVD
- Cerebrovascular
- Parkinson’s
Modifiable
- higher levels of education
- hearing impairment (less cognitive stimulation)
- obesity
- hypertension
- depression
pathophysiology of vascular dementia
brain damage due to repeated attacks of cerebrovascular disease (strokes/TIAs)
pathophysiology of lewy body dementia
- deposition of lewy bodies (abnormal proteins) in brainstem
- has parkinsonian symptoms
general presenting symptoms of dementia
Cognitive impairment
- memory loss (can’t learn new info, forget recent events)
- can’t make decisions
- poor communication
- poor coordination (can’t dress themselves)
- disorientation
- poor planning/judgement
Behavioural
- psychosis (hallucinations/ delusions)
- depression/anxiety
- withdrawal
- agitation/ mood swings
- motor disturbance - wandering, pacing, restlessness, repetitive activity
- affects activities of daily living
presenting symptoms of Alzheimer’s
- Insidious onset (episodic memory loss- repeated questionning, forgets recent events, can’t learn new info)
- short term memory loss
- motor skills affected- apraxia (can’t do familiar movements)
- language affected- aphasia (can’t communicate)
- long term memory affected
- disorientated
presenting symptoms of Vascular dementia
- step-wise deterioration
- gait problems
- attention problems
- personality change
- focal neurological problems (visual field defects)
presenting symptoms of Lewy body dementia
- visual hallucinations
- fluctuating cognition
- Parkinsonian features- bradykinesia, rest tremor, or rigidity
- memory loss usually later
presenting symptoms of Frontotemporal dementia
- personality/behaviour change
- poor hygiene
- aphasia
- memory usually preserved
History taking for dementia
- onset (acute => infection/delerium, chronic => dementia)
- ask about recent head traum
- PMHx - parkinson’s, stroke, depression, epilepsy
- DHx- anticholinergics, benzodiazepine, opioids (cause confusion)
- FHx- dementia
- Safety - Activities of daily living, support at home, drive
- SHx - smoking, alcohol
- Collaborative history
Examinations for dementia
Neuro exam
- gait
- sensory- neuropathy
- motor- tremor, rigidity, bradykinesia (parkinsonian features)
- visual
Investigations for dementia
Bloods: (exclude other causes)
- FBC (WCC-infection)
- ESR/CRP
- TFTs (hypothyroidism)
- serum B12/folate
- Calcium (hypercalcemia-pschycic groans)
- HbA1c (hypoglycaemia)
- LFTs
Assess cognition
How to assess congition in dementia
10- cognition score
- 3 temporal orientation questions (year, month, date)
- 3-word recall
- 4 point scaled animal naming task
*score = 8 is normal (<8= probably cognitive impairment)
Management of dementia
- acetylecholinesterase inhibitors (donepezil)
differentials for dementia (memory loss/confusion)
- delerium
- hypothyroidism- TFTs
- infection
- low B12/folate
- hydrocephaleus
- expanding brain lesion (tumours)- CT scan
- medication (anticholinergics, benzodiazepine)
define delirium
reversible acute confusional state usually in susceptible individuals (elderly/multiple comorbidities) caused by a precipitating factor
predisposing factors for delirium
- older age
- multiple comorbidities/ frail
- immobility
- XS alcohol consumption
- dementia
- sensory impairment - visual/hearing
precipitating factors that trigger delirium
- infection- UTI, pneumonia
- CO-MORBIDITIES: CVD/MI, stroke, thyroid dysfunction, COPD, Cushing’s, hypo/perglycaemia
- alcohol withdrawal
- medication- benzodiazepine, opioids, CCBs
- depression
- change in environment
- poor sleep
- PAIN
- malnutrition
- Constipation
History taking for delirium (confusion/behaviour change)
- onset of symptoms (acute
- PMHx- cormorbidities (dementia), recent hospital admission, falls
- DHx- medicine compliance
- SHx- alcohol intake, food/fluid intake, PAIN, recent changes in environment
- safety - care packages, who’s at home- support
- GP cognition assessement score
presenting symptoms of delirium
acute behavious change (hours-days)
- impaired cognition (memory loss/ confusion/ disorientation)
- disorganised thoughts (rambling speech)
- inattention
- hallucinations/delusions
- impaired consciousness
types of delirium behaviour
- hyperactive- agitated, restlessness, wandering, sleep disturbance
- hypoactive (most common) - withdrawn, reduced appetite, lethargic, reduced movement, anhedonia
- mixed
investigations for delirium
Identify cause:
Bedside:
- urinalysis- UTI
- sputum culture- chest infection
- ECG- arrythmias
Bloods:
- FBC- WCC (infection), anaemia
- ESR/CRP (infection/inflammation)
- TFTs - hypothyroidism
- Calcium (hypercalcemia)
- U&Es- AKI, dehydration
- B12/folate
- drug toxicity
- HbA1c- hypoglycaemia
Imaging
- CXR- chest infection
What criteria are used to diagnose delirium?
- short-CAM/confusion assessment method - confusion, inattention, disorganised thinking, altered consciousness
- DSM-5 -
- 4 A’s- ACUTE, alertness, attention, cognition (memory loss/confusion)
management for delerium
treat cause
- antibiotics for infection
- analgesia for PAIN
- fluids for dehydration
- correct electrolyte imbalances
- reduce/replace dosage of drugs (avoid WITHDRAWAL)
- treat constipation (laxatives)
- treat sensory impairments (remove wax, glasses)
- reorientate patient (date, clocks, calendars)
- advise carers to support (reorientate, maintain mobility -avoid restraints), place in low stimulation environment
- avoid giving anti-psychotics
define depression
persisitent low mood/ loss of interest in activities (anhedonia) for >2 weeks which affects functioning
- diagnosed with DSM-5 criteria (5/9)
risk factors for depression (in the history)
- FEMALE
- older age
PMHx:
- Hx of depression
- chronic comorbidites (PAIN/ disability/ CVD/ diabetes)
- other mental health problems (dementia)
FHx of depression
DHx: corticosteroids
SHx:
- Adverse childhood experiences (poor parent-chid relationship, abuse)
- Recent psychosocial trauma - divorce, unemployment, poverty, homeless
- recent childbirth (port-partum depression)
DSM-5 criteria for diagnosis of depression
>1 CORE + 5/9 needed
- CORE (2): low mood, anhedonia
- PHYSICAL: low appetite, anergia (low energy/ fatigue/lethargy), distubed sleep, slowed movements
- PSYCHOLOGICAL: suicidal thoughts, guilt/feelings of worthlessness, poor concentration
How to classify depression
- subthreshold depression- <5 symptoms
- mild- >5 symptoms + minor functional impairment
- moderate- >5 symptoms + some impaired function
- severe- most symptoms + severe impaired function +/- psychotic symptoms
- seasonal affective disorder - symptoms occur around same time of the year
How to assess for depression?
- patient health questionnaire/PHQ-9 (GP)
- Hospital anxiety and depression scale (HAD)
Investigations for depression
Not routinly done for depression but can exclude other causes/ differentials
Bloods:
- FBC- infection (high WCC)
- TFTs - hypothyroidism (low T4/TSH)
- Calcium - hypercalcemia
- U&Es, creatinine
- ESR-inflammation
- low glucose - hypoglycaemia
Imaging:
- CT/MRI - head injury (hypopituitarism)
differentials for depression
- Grief reaction (loss)
- anxiety disorders
- bipolar disorder
- neurological conditions (Parkinson’s)
- Obstructive sleep apnoea
- Hypothyroidism
- Substance misuse / CO poisoning
Management of depression
- manage suicide risk
- safeguarding for children
- advise patient about medication side effects/withdrawal, hive leaflets for self-help and numbers to contact
- routine follow-up/ monitoring
mild/moderate
- low intensity psychosocial intervention (guided self-help)
- CBT
moderate/severe
- anti-depressants (SSRIs- sertraline, citalopram, fluoxetine)
- high intensity pschycologial intervention (individual CBT)
*Mirtazapine (SNRI)- depression/anxiety + sleep problems
What antidepressants should be given for people taking
- NSAIDs
- anticoagulants (Warfarin/ heparin)
- antiplatelet (aspirin)
- anti-epileptics
- had a previous overdose
- Mirtazapine (avoid SSRIs)
- Mirtazapine (avoid TCAs, SSRIs, SNRIs)
- Mirtazapine (avoid SSRIs, SNRIs)
- SSRIs
- avoid TCAs
complications of depression
- SUICIDE
- increased risk of substance use
- pain exacerbation
- increased morbidity/mortality in comorbid conditions
- lower quality of life
- medication side effects: SSRIs=>suicide risk, hyponatremia, agitation, weight gain
- medication withdrawal effects: mania
