Mental Health Flashcards
ADHD characteristics
Inattentiveness to work or school distractibility carelessness poor follow through concentration trouble
Hyperactivity of ADHD
expressed through: fidgetiness restlessness impulsivity don't consider consequences
ADHD facts
3-7% in children
3-4% in adults
dx as child have problems as adult
ADHD etiology
maternal smoking alcohol use toxin exposure IUGR common in combo with tourettes, genetic disorder, phych disorders
Diff Dx ADHD
hearing prob thyroid lead toxicity hepatic disease sleep apnea Fe def. drug interactions
ADHD evaluation
r/o metabolic with CBC, iron, TSH, lead
extensive history form parents and teachers
baseline weight
ADHD tx
Adderall Vyvance Ritalin *All stimulants to 1 month rx at a time* Strattera Wellbutrin
OCD defined
pt has obsessions or compulsions severe enough to cause distress
can affect children or adults
may be a response to anxiety
most after significant stressful event
OCD presentation
can keep under control until event or stressor sends out of control
obsessions: often concerned with bodily wastes, germs, fear of death, need for symmetry
compulsions: excess hand washing, checking locks, touching, counting or hoarding
Dx OCD
recurrent thoughts or impulses that are intrusive and cause anxiety and distress
try and suppress with some action or thought
recognizes the problem
repetitive behaviors aimed at preventing some dreaded event
not excessive worrying
can present with acute depression
Tx OCD
SSRIs in both children and adults
cognitive behavior therapy in combo with meds
Suicide facts
males more likely than females
males more violent in method
profound sense of hopelessness, no future or unacceptable future
Risk factors suicide
severe anxiety ruminations global insomnia depression with delusions substance abuse gauge how serious they are
Schizophrenia facts
very complex with varying penetration voices delusion fears or people trying to control or kill them withdrawn
4 symptom clusters of Schizophrenia
positive
negative
cognitive
affective
Pos symptoms Schizophrenia
hallucinations: sensory impression without basis of reality (auditory, olfactory, gustatory, kenesthetic, tactile or visual)
delusions: false believe, suspicious, mistrust, paranoid
thought disorders: manifested in speech and behavior
movement disorders: agitated body movement or catatonic state
Neg symptoms of Schizophrenia
flat or blunted affect
alogia: loss of verbal expression, minimal output
anhedonia: loss of pleasureable feelings
lack of self motivation, spontaneity and initiative
Cognitive symptoms of Schizophrenia
poor executive fx, concrete thoughts
diff focusing
memory deficits
Affective symptoms of Schizophrenia
blunt, odd expressions or actions that are interpreted as such and impact societal impression
stigmatization, poor self esteem
depression
increased risk for suicide
Dx criteria of Schizophrenia
two or more positive and negative symptoms present for 6 months with 1 month of characteristic symptoms
excludes other mood disorders and substance abuse
Meds that could cause Schizophrenia symptoms
Tagamet
Reglan
Dilantin
steroids
Tx for Schizophrenia
Antipsychotic meds primary tx
help alleviate pos symptoms and decrease inpt.
typical antipsychotics: effective but can have S/E
atypical antipsychotics: aim to reduce S/E
Extrapyramidial S/E antipsychotics
Akathisia
Dystonia
Pseudoparkinsonism
Tardive Dyskinesia
Akathisia
occurs few days to few weeks restlessness impaired concentration pacing foot-tapping d/c med or start benzo (lorazepam) or beta blocker
Dystonia
may occur after single dose or several days
involuntary muscle contractions of head and neck (hoarseness, laryngeal spasms)
may involve torso and extremities (torticollis, opisthotonons)
Tx with anticholinergics or antiparkison meds
Pseudoparkinsonism
after single dose or several weeks later with increase
slow pill-rolling movement of hands, cogwheel rigidity, shuffling gait, loss of arm swing
“rabbit syndrome”: tremor of lips with constant chewing
Tx with anticholinergics
Tardive Dyskinesia
Months to years after
involuntary rapid movement of face, torso, or extremities.
lip smaking
Tx: eval q 3-6 months, anticholinergics, antiparkison, remove agent
Typical antipsychotics
loxapine
chlorpromazine
photosensitivity, need CBC, TFTs and urine
Atypical antipsychotics
clozapine Olanzapine Quetiapine Risperidone weight gain common with these
Eating disorders types
anorexia bulemia unspecified 3 times higher in women ashamed, embarrassed and guilty
Eating disorder facts
biggest risk is that they die suddenly from starvation, cardiac or suicide
may have co-morbid mental probs
need inpt tx
3 types of bipolar
Bipolar I
Bipolar II
Cyclothymia
Bipolar described
can affect occupation men and women equal onset in early childhood up until 40s-50s, not older genetic degree substance abuse 25-50% lifetime suicide risk
Clinical presentation of Bipolar
triggered by adverse event or stressor
manic followed by depression
tx most often seek with depression
can have episodes lasting 3-6 months
Bipolar I dx
manic or mixed episode with one or more depressive episodes
Bipolar II dx
one hypomanic episode, no manic
hx of one or more depressive
Cylothymia dx
numerous episodes of depressed mood, do not meet full criteria for major depression and episodes of hypomania over 2 years
DIGFAST bipolar
D: distractibility I: insomnia G: gradiosity F: flight of ideas A: activities S: pressure speech T: thoughtlessness - spending sprees
Mania character
elevated or irritable mood lasting at least 1 week
psychotic features
marked impairment in occupational or social fx
Hypomania character
distinct period of elevated, expansive or irritable mood lasting at least 4 days
similar to manic episodes not severe enough to cause occupation trouble
no psychotic features
Mixed episodes character
nearly every day for 1 week criteria for manic episode and major depressive episode met simultaneously
severe occupation dysfx
sx not attributed to underlying cause
Mood disorder quest. for bipolar
score 7 or more is a mod to severe prob assess cognitive (distracted, racing thoughts, increased talking) and behavior ( less sleep, impulsive)
First line meds for mania or mixed bipolar
Lithium + antipsychotic Valporic + antipsychotic Gabapentin Topiramate Benzo
First line med for depressed
Lithium
Late life depression overview
not normal more common in LTC 80% tx in primary care depression can precede medical issues lead to alcohol and med use
Elderly depression screening
PHQ-9 or GDS
during the past month have you felt down or depressed? have you dropped any activities or interests
With depression ask for changes in
sleep interest guilt energy concentration appetite psychomotor suicide
Most reliable signs of late-life depression
insomnia low energy anorexia anhedonia guilt
Single most reliable sx of depression
anhedonia or lack of interest and pleasure
Depression vs Dementia (Depression)
short duration cog loss or dysfx communication of distress memory gaps for specific events attention and concentration preserved little effort for tasks highlights failures loss of social skills mood changes
Depression vs Dementia (Dementia)
gradual progressive few complaints of cog. loss unconcerned with changes memory gap attention and concentration faulty struggle with tasks delights in trivial accomplishments social skills retained shallow affect
Grief vs Depression
grief less likely than depression to be associated wit loss of self-esteem
symptoms should lessen in 6 months
hospice care = less depression for surviving spouse
Dementia
frontal lobe disease
apathy, lack of motivation
can be seen in Alzheimers
Dysthymia
chronic disorder of depressive symptoms most days for 2 years but not meeting MDD
“Eyore” disorder
high risk for developing MDD
Psychotic depression
more common in older adults
delusions/paranoia common
hallucination are rare
more likely to have dementia sx
Suicide in elderly
white men high risk
take seriously
asses frequently
provider does not put ideas in the minds of others
Non pharm depression tx
therapy
bright light tx
ECT therapy
Meds for depression
trial of 4-6 weeks
if SSRI’s check lab for hyponatremia
SSRIs first line (sertaline, citalopram)
avoid TCA’s (amytriptaline)
Always ask about with depression
Alcohol use
CAGE
Alzheimers
Type of dementia
progressive and fatal brain disease
7th leading cause of death
severe enough to cause probs in every day life
Areas of brain affected by AD
cortex (frontal)- thinking, planning, remembering
hippocampus- formation of memory
Average life span for AD
12 years
Other Dementias
mild cognitive impairment vascular dementia mixed dementia Lewy Body dementia Parkinson's disease dementia frontotemporal dementia creutzfeldt-jacob disease pressure hydropcephalous Hunningtons Wernicke-Korsakoff
Risk factors for AD
Age 85 or older family history apolipoprotien E-e4 (APOE-e4) pos = 50% head injury or recent fall CVD
10 warning signs of AD
memory loss affecting job difficulty with familiar tasks language problems not oriented to time or place poor or decreased judgement prob with abstract thinking misplacing things changes in mood or behavior changes in personality loss of initiative
Questions to ask family about AD
Have you observed decline in..... remember things that happened recently use the phone travel handle finances take care of personal hygiene
AD8 screen
2 or more = dementia problems with judgment reduced interest in hobbies/activities repeats self trouble learning to use something forgets month and year difficulty with finances difficulty remembering appointments
R/O causes of memory impairment
thyroid disease alcohol drug adverse effects vision hearing loss Vit B def. head injury parkinson's disease
Cognitive screening tools
MMSE
Clock test
Mini-cog
Montreal Cog test
MMSE
takes about 10 minutes and score 0-30 dementia with score 23-24/30 Orientation 10 points Registration 3 pts Attention/calculation 5 points Recall 3 pts Language 9 pts no score diagnostic just suggestive
Clock drawing test CDT
test cognitive such as:
comprehension, planning, visual memory, visuopatial ability, motor programing and concentration
could be affected by impairment with vision/writing
Mini-Cog
Memory and thinking test give 3 words to remember draw a clock put numbers on the clock set the time recall those 3 words
Other screening tools
name as many animals in 1 min (18)
alternate between letters and numbers
executive function= working memory, problem solving, sequencing, resisting distractions
Physical exam for AD
Neuro tests
lab tests
CT and MRI
Neuro exam for AD
cranial nerves motor strength tremor/myoclonus reflexes babinski sensory finger to nose praxis (show me how to...comb hair, cut bread)
Cardio exam of AD
BP supine and standing CHF PVD heart rate A fib Carotid bruits
Gait for AD eval
short steps shuffle lack of arm swing stooped posture small steps wide-based poor tandem
Lab for AD eval
CBC CMP B12 TSH RPR UA
MRI or CT for AD if
Under 60 recent head trauma/seizure NPH normal pressure hydronephrosis Hx cancer or bleeding disorder atypical presentation sudden onset or rapid progression focal neuro signs
DSM IV dx criteria for AD
memory impairment (learn new or recall old)
and 1 or more cognitive disturbances
significant impairment in social fx
gradual onset and continuing decline
Cognitive disturbances in AD for Dx
Aphasia- language
Apraxia - motor activities
Agnosia - can’t identify objects
Executive fx - planning, organizing, sequencing
Mild cognitive impairment
memory problems noticeable but not compromising independence
continue to eval for AD
Vascular Dementia
history of CVA or TIA
stepwise decline
localizing neuro signs
Lewy Body Dementia
visual hallucinations fluctuating LOC Parkinsonian motor symptoms falls executive fx worse than memory
Frontaltemporal Dementia
personality changes impulsivity disinhibition self neglect social inappropriate lower ages normally
Parkinsons disease dementia
motor symptoms first then dementia
creutzfeldt-jacob disease dementia
rapid onset and decline
myclonus
Normal pressure hydrocephalous
wet/wobbly/wacky
gait/balance disturbance, falls, incontinence
Stages of AD
1-7 (mild to very severe)
Stage 1 AD
no impairment
Stage 2 AD
very mild decline
Stage 3 AD
mild decline
Stage 4 AD
moderate decline
Stage 5 AD
mod/sev
Stage 6 AD
severe
Stage 7 AD
very severe
Assessment of those with AD
should be done every 6 months
address caregiver burden
assess fx capacity
Tx Cognitive decline with AD
cholinesterase inhibitors: Aricept, Exelon, Razadyne
NMDA antagonists: Namenda
Aricept
Donepezil
daily dosing
5mg daily x 4-6wks then 10mg daily
ODT available at 23 mg for long term dosing
S/E: n/diarrhea, vivid dreams, HA, syncope
could take in the AM to decrease dreams
Exelon
Rivastigmine 1.5-6mg 2x/day with food transdermal path avail 4.6-9.5mg S/E: n/diarrhea, GI upset, dizziness transdermal patch could have fewer GI sx but mild dermatitis often with PD and LB dementias
Razadyne
Galantamine 4mg-12mg 2x day ER 8mg daily S/E: n/v/d titrate every 4 weeks take with meals with renal disease 16mg/d is the max
Namenda
Memantine
titrate from 5mg-10mg 2x day over 4 weeks
indicated for mod to severe AD
S/E: dizziness, confusion, constipation
give with a-cholinesterase inhibitor to limit GI effects
Red flags in exam for PD
poor hygiene and grooming
difficulty with walking
difficulty with visual tasks
difficulty with attention, memory and comprehension
Tips for driving cessation
give prescription for DO NOT DRIVE
point out price of gas
have a plan for alt transportation
refer to DMV for driver evaluation
Prevention of AD
control risk factors of CVD, hyperlipidemia, DM exercise mental exercise treat depression heart healthy diet
Delirium overview
often overlooked
places a person at risk for other cog. impairment
often in ICUs, long term care
DSM V Delirium
disturbed consciousness
cognitive changes
rapid onset
Types of Delirium
Hyperactive - agitated/combative
Hypoactive - lethargic/confused
Mixed
Risk factors for Delirium
dementia
advanced age
comorbid condition
Causes of Delirium
Meds Infection - UTI, pneumonia, menningitis Metabolic probs - dehydration CV - CHF Neuro - seizure, bleed Renal - retention Endocrine - hyperthyroid, DM fecal impaction, sleep deprivation, postoperative, pain
Med leading to delirium
Antiparkinsons (carbadopa) Steroids urinary incont meds (detrol) Theophylline antihistamines (benadryl) NSAIDS Narcotics muscle relaxants seizure meds ENT meds - meclizine Abx - quinolones H2 blockers CV meds (dig)
Anticholinergic burden with delirium
growing problems with meds below
citalopram for depression then oxybutynin for urinary incont and then cyclobenzaprine
major anticholinergic effect
Eval for Delirium
CBC BNP LFTs Renal fx albumin glucose TSH ammonia UA O2 sat CT ECG
Management Delirium
safety
family help as sitters
remove meds
tx underlying causes
PREVENT acronym delirium
P: protocol for sleep, back massage, warm milk
R: replenish fluids
E: ear aids
V: visual aids
E: exercise/ambulation
N: name person place and time for orientation
T: taper or d/c unneeded meds
Pharm management for acute agitation/aggression
Haldol 0.5-1mg PO reeval in 1-2 hours IM dose would act faster 20-40 min reeval 30-60 min double dose if initial ineffective calculate total effective dose in 24 hours and divide by 1/2 give that dose BID but not if sedated QT prolongation possible
Pharm management for alcohol or benzo withdrawl
Lorazepam .5-2mg IV or PO 1-2 hrs
Add Thiamine 100mg/day IM, IV or PO if due to alcohol
Average age of veterans
60 and older
Agent orange expose
Korea and WWII
Vets of Vietnam exposure
Agent orange
Hep C
Malaria
PTST
Common war injuries
blast injuries embedded fragments TBI - traumatic brain amputations loss of vision
Behaviors risks following war
PTSD Depression Suicide High risk behavior substance abuse
Cause of depression in Vets
isolation
separation from family
continued exposure to injured and life threatening conditions
hopelessness
