Mental Health

Question 1

What is personality?

Answer 1

Set of emotional & behavioural traits that are stable and predictable

Question 2

What is a personality disorder?

Answer 2

Severe disturbance in behavioural tendencies of the individuals personality that differs from expectations of a persons culture

Onset in adolescence & early adulthood

Question 3

What factors are linked to personality disorders?

Answer 3

Dysfunctional early environment = preventing adaptive perception/response/defence

Childhood sexual abuse ± Neglect ± Emotional abuse

Genetic link

Question 4

Why are personality disorders not diagnosed in children?

Answer 4

Because the personality is not complete, and symptomatic traits may not persist into adulthood

Question 5

What are the features of paranoid personality disorder?

Answer 5

• Pervasive distrust & suspicion
• Believe others are exploiting/decieving them
• Information confided in others will be used maliciously
• Believe there are hidden meaning in remarks or events
• Pathological jelousy (Othello syndrome)

Question 6

What are the features of Schizoid personality disorder?

Answer 6

• Withdrawal from affection/social/other contacts
• Self isolation
• Limited capacity to experience pleasure & express feelings

Question 7

What are the features of Shizotypal personality disorder?

Answer 7

• Odd behaviour - Magical thinking
• Odd perceptions/appearance
• Eccentic disorganised thought
• Lack delusions/hallucinations

Question 8

What are the features of Antisocial personality disorder?

Answer 8

• Act outside social norms
• Disregard feelings of others + Criminal behaviour
• Unable to modify behaviour in response to adverse events e.g. punishment
• Low threshold for violence - blame others for actions

Question 9

What are the features of Emotionally Unstable personality disorder/Borderline PD?

Answer 9

• Impulsive/Unpredictable
• Act w/o appreciating consequences - black & white thinking
• Outburst of emotion
• Tend to have unstable relationships - suicide attempts/self harm

Question 10

What are the features of Histrionic personality disorder?

Answer 10

• Shallow and labile affect
• Theatrical
• Lack of consideration for others/Egocentric
• Tend to be stubborn/cautious/rigid

Question 11

What are the features of Narcissistic personality disorder?

Answer 11

• Affects Males > Females
• Grandiose delusions
• Lack empathy
• Love admiration + Loathe criticism

Question 12

What are the features of Anxious/Avoidant personality disorder?

Answer 12

• Feelings of tension & apprehension
• Insecurity & Inferiority
• Yearn to be accepted and liked - Sensitive to rejection
• Exaggerate potential risks and dangers

Question 13

What are the features of Dependent personality disorder?

Answer 13

• Rely on others to take decisions - Difficulty with independence
• Fear of abandonment
• Reliance on authority figures

Question 14

If you suspect a patient has a personality disorder, what other differentials can be considered?

Answer 14

• Depression
• Schizophrenia
• Psychosis
• Delirium
• Head trauma
• Hyper/Hypothyroid

Question 15

How are personality disorders managed?

Answer 15

• Psychotherapy
• DBT
• CBT
• Crisis management - If risk of harm to self or others

Question 16

What are the topics to cover in a Psych Hx?

Answer 16

• Presenting complaint
• Past Psych Hx
• Risk assesment
• PMHx
• DHx
• FHx
• Personal & Psychosocial Hx
• Social Hx
• Forensic Hx
• Pre-morbid personality

Question 17

What are the key aspects of the presenting complaint in a psych Hx?

Answer 17

• Why did you come in today?
• When did it start?
• When did you last feel better/Different to this?
• What triggered this episode?
• Is it getting any better over time? Worse? Same?
• Does anything make it worse or better?

Question 18

When doing a psych systems review - what must you ask Q’s about?

Answer 18

• Depression
• Anxiety
• Psychosis
• Mania
• Self harm - Risk assesment

Question 19

When asking about a patients past Psych Hx, what are the key Q’s to ask?

Answer 19

• When were you last well?
• Have you ever had a mental health diagnosis?
• Did you have any treatment?
• Have you had any contact with mental health services?
• Do you have a care coordinator?
• Have you ever previously been admitted for a psychiatric condition? - Informal/Detained?
• Have you ever been detained by the police for a psychiatric condtion?

Question 20

When asking about PMHx in the Psych history, what are the key Q’s?

Answer 20

• Thyroid dysfunction?
• Epilepsy?
• Head injury - details & recovery
• Any LoC with the head injury
• Any post traumatic amnesia - How long for?
• Any post traumatic epilepsy?
• Any heart problems?
• Any high Cholesterol?
• Do you have DM?

Question 21

When asking about DHx in the psych Hx what are the key questions to be asked?

Answer 21

• What medications are you currently taking?
• Adherence?
• Any recent changes to your medications?
• Any drug allergies?
• Any Non-prescribed medications? (OTC/Herbal)
• Any ilicit drug use?
• Do you drink alcohol?

Question 22

When asking about FHx in the psych Hx what are the key Q’s?

Answer 22

• Tell me about your family - Mother/Father/Siblings
• What are their ages/occupations?
• What is your relationship to them?
• Does anyone in your family have any mental health problems?

Question 23

When asking about FHx in the personal & psychosocial Hx what are the key Q’s?

Answer 23

• Were you a planned pregnancy?
• Any birth trauma/maternal trauma or drug use?
• Gestation when born
• Who provided your childcare?
• Developmental milestones reached?
• School - Social & Academic achievement?
• Relationships - Current? Stable? Any trauma etc
• 1st sexual experience?
• Any children?
• Any abuse suffered as a child?

Question 24

When asking about SHx in the psych Hx what are the key Q’s?

Answer 24

• What are your current living arrangements?
• What is your current occupation?
• What are your relationships at work like? Performance?
• Are you financially stable?
• Are your friends and family supportive?
• ADLs

Question 25

When asking about Forensic Hx in the psych Hx what are the key Q’s?

Answer 25

• Any contact with the police?
• Have you ever been to prison?
• How do you think the contact with police has impacted you/others?

Question 26

When asking pre-morbid personality, what Qs should be asked?

Answer 26

• How do you see yourself?
• How do you think others see you?

Question 27

What are the differential diagnoses to consider for a patient presenting with anxiety?

Answer 27

• GAD
• Panic disorder
• Phobia
• PTSD
• OCD
• Depression
• ACS
• Arrythmia
• Hyperthyroidism

Question 28

What are the differential diagnoses to consider for a patient presenting with psychosis?

Answer 28

• Schizophrenia
• Bipolar disorder
• Depression
• Shizoaffective disorder
• Depression with psychosis
• Delirium
• Dementia
• Drugs/Alcohol
• Epilepsy (Temporal lobe)
• SoL
• SLE

Question 29

What are the differential diagnoses to consider for a patient presenting with Low mood?

Answer 29

• Depression
• Seasonal Affective disorder
• Bipolar disorder
• Post natal depression
• Hypothyroidism
• Anaemia
• Drug side effects
• SoL

Question 30

What are the differential diagnoses to consider for a patient presenting with memory loss?

Answer 30

• Dementia - Alzheimers/Vascular/FTD/LBD/Mixed
• Depression
• Delirium
• Degenerative CNS cause - Huntingdons/MS
• Vitamin deficiency - B12/Folate/Thiamine
• Electrolyte imbalance
• Encephalitis

Question 31

What are the differential diagnoses to consider for a patient presenting with Eating disorders?

Answer 31

• Anorexia nervosa
• Bulimia Nervosa
• Depression

Question 32

You are presented with a patient with a Hx suggestive of depression, explain to them what the diagnosis is and how it will be managed?

Answer 32

[Causes]

• Stressful events + personality + female gender
• Low levels of neurotransmitters in brain (Dopamine/NA/5-HT)

[Diagnostic criteria]

• >2wk Hx causing significant impairment in function
• Core symptoms:
  
  • Persistent sadness/low mood nearly every day
  • Anhedonia
  • Fatigue
• Other symptoms:
  
  • Nihlism/Guilt
  • Suicidal ideation
  • Decreased concentration/apetite/mood/weight
  • Increased sleep
  • Psychomotor retardation
• Psychosis -> Depression w/psychosis

[Investigations]

• TFTs - Normal
• FBC - Normal
• U&E - Normal
• PHQ9 - Positive screen
• Vitamin B12 - Normal
• ECG - Normal, for antidepressants
• BP + Pulse + BMI

[Management]

• Mild to moderate:
  
  • CBT - self help
• Moderate to severe:
  
  • SSRI - Sertraline
    
    • Children - Fluoxetine
  • High intensity CBT
• Severe:
  
  • Mental health assesment
  • ECT

Question 33

A patient is prescribed an SSRI - Citalopram/Sertraline/Fluoxetine, you are asked to explain this medication to them. How would you go about this?

Answer 33

[Indication]

• 1st line treatment for moderate to severe depression
• Panic disorder
• OCD

[How it works]

• Alters balance of some of the chemicals in your brain - NT
• Affects the uptake of 5-HT from the synaptic cleft, so increases amount of 5-HT available.
• Improves mood and physical symptoms of depression

[How to take it]

• Tablet - OD orally
  
  • Best taken on a full stomach
• Can take up to 6 weeks for effects to start
• Take for at least 6 months after symptoms stop, then taper it down slowly before stopping
• If due to recurrent depression - wait 2 years after symptoms stop to withdraw

[Side effects]

• GI Upset
• Change to apetite
• Weight Loss/Gain
• Skin rash - due to hypersensitivity
• If elderly - can lead to confusion (Due to low Na+)
• Can cause increased suicidal thoughts

[Contraindications]

• Epilepsy
• Peptic ulcer disease
• Hepatic impairment

[Withdrawal]

• Stomach upset
• Flu like symptoms
• Insomnia

[Overdose]

• Serotonin syndrome (Excess 5-HT)
  
  • Autonomic hyperactivity - HTN + Tachycardia + Hyperthermia
  • Tremor + Agitation + Irritability
  • Sweating + Diarrhoea
  • Delirium
  • Hyper-reflexia

[Monitoring]

• Before starting - ECG (QTc) + U&E
• Review symptoms after 2-6 weeks

Question 34

You are asked to take a mental health Hx from a patient presenting with x symptoms. How would you go about this?

Answer 34

[Introduction]

• Introduce self & Wash hands
• Patient name & DOB & Age
• I am here to speak to you about your current experiences in addition to your past experiences, and how they are impacting on your symptoms. The questions could be very personal, is that ok?
• Anything that you say will be kept b/w myself and your medical team.

[Presenting complaint]

• Why did you come in today?
• When did it start?
• When did you last feel better/Different to this?
• What triggered this episode?
• Is it getting any better over time? Worse? Same?
• Does anything make it worse or better?

[Systems review]

• Depression
• Anxiety
• Psychosis
• Mania
• Self harm - Risk assesment

[Past psychiatric review]

• When were you last well?
• Have you ever had a mental health diagnosis?
• Did you have any treatment?
• Have you had any contact with mental health services?
• Do you have a care coordinator?
• Have you ever previously been admitted for a psychiatric condition? - Informal/Detained?
• Have you ever been detained by the police for a psychiatric condtion?

[PMHx]

• Thyroid dysfunction?
• Epilepsy?
• Head injury - details & recovery
  
  • Any LoC with the head injury
  • Any post traumatic amnesia - How long for?
  • Any post traumatic epilepsy?
• Any heart problems?
• Any high Cholesterol?
• Do you have DM?

[DHx]

• What medications are you currently taking?
• Adherence?
• Any recent changes to your medications?
• Any drug allergies?
• Any Non-prescribed medications? (OTC/Herbal)
• Any ilicit drug use?
• Do you drink alcohol?

[Social Hx]

• What are your current living arrangements?
• What is your current occupation?
• What are your relationships at work like? Performance?
• Are you financially stable?
• Are your friends and family supportive?
• ADLs

[If any time]

• FHx - Assessing attachment
• Personal & Psychosocial Hx
• Forensic Hx

Question 35

You are asked to take a mental health Hx from a patient presenting with x symptoms, including a mental state exam. How would you go about this?

Answer 35

[Introduction]

• Introduce self & Wash hands
• Patient name & DOB & Age
• What I am going to be doing is asking you questions to assess your state of mind, is that ok?
• I just want to let you know that anything that you say will be kept b/w myself and your medical team

[Presenting complaint]

• Why did you come in today?
• When did it start?
• When did you last feel better/Different to this?
• What triggered this episode?
• Is it getting any better over time? Worse? Same?
• Does anything make it worse or better?

[Past psychiatric review]

• When were you last well?
• Have you ever had a mental health diagnosis?
• Did you have any treatment?
• Have you had any contact with mental health services?
• Do you have a care coordinator?
• Have you ever previously been admitted for a psychiatric condition? - Informal/Detained?
• Have you ever been detained by the police for a psychiatric condtion?

[PMHx]

• Thyroid dysfunction?
• Epilepsy?
• Head injury - details & recovery
  
  • Any LoC with the head injury
  • Any post traumatic amnesia - How long for?
  • Any post traumatic epilepsy?
• Any heart problems?
• Any high Cholesterol?
• Do you have DM?

[DHx]

• What medications are you currently taking?
• Adherence?
• Any recent changes to your medications?
• Any drug allergies?
• Any Non-prescribed medications? (OTC/Herbal)
• Any ilicit drug use?
• Do you drink alcohol?

[Social Hx]

• What are your current living arrangements?
• What is your current occupation?
• What are your relationships at work like? Performance?
• Are you financially stable?
• Are your friends and family supportive?
• ADLs

MSE

[General Inspection]

• Patients appearance & behaviour
  
  • Kempt/Unkempt
  • Any abnormal movements
  • Appropriate behaviour
  • Level of anxiety/restlessness/agitation
  • Assess rapport
  • Distractibility
  • Eye contact
  • Facial expressions

[Speech]

• Assess the speech of the patient - As it is an external presentation of the internal thought process
  
  • Rate
  • Rhythm
  • Volume
  • Quantity
  • Fluency
• Abnormal associations
• Any evidence of formal thought disorder? - opinion based on speech

[Mood & Affect]

• Objective based on what you see - how do they appear (Affect)
  
  • Low
  • High
  • Euthymic - Normal
• Subjective based on a scale of 1-10 -> Ask patient to describe their mood
• Enjoyment -> None/Increased
• Energy -> Increased/Decreased
• Biological symptoms - Sleep -> Increased/Decreased
• Biological symptoms - Appetite -> Increased/Decreased
• Concentration & memory -> Increased/Decreased
• Libido -> Increased/Decreased

[Suicide risk]

• Ask about thoughts of the future
  
  • Any Hopelessness?
  • Thoughts of suicide? or self harm?
• Suicide
  
  • Any thoughts of life not worth living? Hopelessness?
  • Harming yourself?
  • Wanting to kill yourself?
  • Any plans to kill yourself?
  • Any protective factors?
  • Any hope for the future?
• Risky behaviour

[Thought]

• Depression
  
  • Poverty of thought
  • Thinking is v slow & laboured (Takes patient a long time to answer)
• Mania
  
  • Pressured thought
  • Spuriously connecting words/rhyming/flight of ideas (going on lots of tangents, but there is a process)/often funny
• Psychosis
  
  • Loss of association
  • Derailment/Difficult to follow train of thought
• Cognitive impairment
  
  • Circumstantiality - Patient talking around the point, going off topic
  • Meandering speech covering up for impairment

Content of the thoughts

• Normal thoughts
  
  • Triggered by internal/external stimulus
• Obsessions
  
  • Any recurrent intrusive thoughts (Unpleasant)
  • Recognise as their own - they don’t want them
  • Generates anxiety
  • Try to resist = compulsive actions to reduce impact of the thoughts (Compulsion)
• Delusions
  
  • Fixed false belief out of keeping with Social/Cultural/Education/Religious norms or background
  • Challenge the belief to ensure it is fixed - If I told you it was due to your mood what would you say?

Specific content delusions

• Persecutory
  
  • Ask if they want to harm anyone else?/Do you feel anyone wants to harm you?
  • Do you feel the need to carry a weapon?
• Mood congruent - Delusions related to mood disorders
  
  • Depressive -> Nihilistic/Guilt (Negative)
• Manic -> Most common in grandiose
• Classic schizophrenia - Thought insertion/Thought extraction/Control/Reference

[Perception]

• Any unusual experience?
  
  • Have you heard or seen something you cant explain?
• Normal
  
  • Any sensory experience with external stimulation
• Illusion
  
  • Misinterpretation of an external stimulation
• Hallucination
  
  • Perception w/o any external stimulation
  • Look for distractibility
  • Challenge - Continues to believe it
• Auditory -> Common in psychosis
  
  • Mood disorder - talking to YOU
  • Schizophrenia - one or two talking ABOUT you
• Visual -> Organic/drugs cause but can also happen in mental illness
• Olfactory/Gustatory (Taste) -> Epileptic activity but can happen with mental health
• Somatic/Tactile -> Rare/Drug use (Amphetamines or alcohol withdrawal)

[Cognition]

• Orientation
• Time
• Place
• Person - What is your name & DOB
  
  • If not oriented -> Full cognitive assessment with Mini-ACE or MOCA

[Insight]

• Do you think you are ill?
• Do you think it is a physical or mental illness?
• Also question insight into the severity of the illness?
• What treatment do you think you need?
• Are you willing to engage in treatment/services?

Question 36

What are the possible formal thought disorders?

Answer 36

Poverty of thought (slow, decreased speech)

• depression

Pressure of thought (lots of words but makes sense)

• Mania

Total loss of association (completely disjointed, lapsed concentration)

• Schizophrenia

Circumstantiality (meandering around the point, covering up memory impairment)

• Cognitive impairment

Question 37

What biological symptoms would you expect in a MSE on a patient with depression?

Answer 37

• Enjoyment -> None + Anhedonia
• Energy -> Decreased
• Sleep -> Early morning wakening + Diurnal variation in mood
• Biological symptoms - Appetite -> Classically reduced/Can be increased in SAD
• Concentration & memory -> Decreased
• Libido -> Decreased

Question 38

What biological symptoms would you expect in a MSE on a patient with Mania?

Answer 38

• Enjoyment -> Excess
• Energy -> Increased
• Biological symptoms - Sleep -> Decreased
• Biological symptoms - Appetite -> Often decreased “Dont have time to eat”
• Concentration & memory -> Decreased (But they think its great)
• Libido -> Increased

Question 39

You are presented with taking a Hx from a patient who has recently attempted to commit suicide. How would you go about doing this?

Answer 39

[Introduction]

• Introduce self & Wash hands
• Patient name & DOB & Age
• I am here to speak to you about your current experiences in addition to your past experiences, and how they are impacting on any symptoms you are currently having.
• I just want to let you know that anything that you say will be kept b/w myself and your medical team
• How are you feeling today?
• Im really sorry that things got so bad for you that you had to do this, but I will need to ask some questions about the suicide attempt

[Before]

• Prior events/Mood – What happened before that made you feel like you had to harm yourself?
  
  • Had you been feeling this way for some time now?
  • Plan – Did you plan to harm yourself?
  • What plans did you make?
  • How long did you plan this?
  • Precautions – Did you try to make sure you wouldnt be found?
  • Did you want to be found?
• Preparation – Did you make a note or make a will in preparation?
  
  • Did you tell anyone before you did it or did you seek help afterwards?
• Did you regret it after you had harmed yourself?

[During]

• Can you talk me through exactly what happened? I know this might be difficult:
  
  • How
  • Where
  • When
  • DId you expect to die?
  • Were you under the influence of drugs?
  • Were you under the influence of alcohol?

[After]

• How were you discovered?
• Did you tell anyone?
• Did you want to be found?
• How do you feel now after what has happened? Do you feel anger/regret?
• Do you still have thoughts of wanting to harm yourself/suicide?
• What are your thoughts of the future?

[ICE]

• How has your mood affected your day to day life?
• Why do you think you feel the way you do?
• Is there anything in particular you are scared/worried about?
• Is there anything in particular you feel you need help with?

[Background]

PMHx/Psych Hx:

• Do you have any medical illness
• Do you have a diagnosis of any psychiatric illness?
• Have you ever tried to commit suicide or self harm before this?

DHx:

• Are you currently taking any medication?
• Do you have stores of medication at home?

FHx:

• Has anyone in your family ever tried to harm themselves?

SHx:

• Are you currently working? What do you do?
• How are things at work? Any problems?
• Who is at home with you?
• Do you have support from family/friends?
• Any children or dependents at home?
• Do you drink alcohol? How much in a week?
• Do you take any recreational drugs?
• Do you think you need help? Would you be prepared to accept help?

[Follow up]

• If high risk:
  
  • In light of what you have told me today, I dont think it would be safe to let you go home, however I would need to discuss this with my seniors to come up with a plan with yourself on how we can move forward
• If low risk:
  
  • I would like to see you again next week. Can we arrange a time to meet?
  • Is there anything you would like to talk about? If not now then think about it and we can discuss it next time we meet.

[Conclusion]

• Summary
• Thank you, I hope we can work together to get you feeling better.

[Management]

• Full Hx + MSE
• Collaborative Hx from family/friend
• Plan if in patient admission required
• Provide contact details for crisis team/mental health team
• Formulation

Question 40

What are the red flags for a suicide attempt?

Answer 40

• Violent method used
• Planning in place
• Ongoing suicidal intent
• Previous suicide/self harm
• Access to means
• Recent adverse life event

Question 41

You are presented with a patient with a Hx suggestive of depression in a child, explain to them what the diagnosis is and how it will be managed?

Answer 41

[Causes]

• Stressful events + personality + female gender
  
  • Bullying/Family disruption/Abuse
• Low levels of neurotransmitters in brain (Dopamine/NA/5-HT)

[Diagnostic criteria]

• >2wk Hx causing significant impairment in function
• Core symptoms:
  
  • Persistent sadness/low mood nearly every day
  • Anhedonia
  • Fatigue
• Other symptoms:
  
  • Nihlism/Guilt
  • Suicidal ideation
  • Decreased concentration/apetite/mood/weight
  • Increased sleep
  • Bad behaviour at school/home
  • Psychomotor retardation
  • Psychosis -> Depression w/psychosis

[Investigations]

• Clinical diagnosis
• TFTs - Normal
• FBC - Normal
• U&E - Normal
• PHQ9 - Positive screen
• Vitamin B12 - Normal
• ECG - Normal, for antidepressants
• BP + Pulse + BMI
• Pregnancy test is female

[Management]

• CAMHS referral
• Address sources of distress
• Remove opportunities for self harm
• CBT/Interpersonal therapy
• Family therapy

If moderate to severe:

• Fluoxetine

Question 42

A patient presents with the following Hx, what is the most likely diagnosis? What are the differential diagnosis?

A 15-year-old girl, at a private school, presents with poor concentration. She lives with her biological mother and a 13-year-old sister. Her mother describes her as an outgoing and straight-A student until about 2 months ago. Her grades have slipped from As to Cs, and she has been feeling sad and irritable. She has started avoiding her friends, and has been worrying about her appearance and her grades. She states that she feels dumb, and that her classmates don’t like her. Recently, she started to think that life was not worth living, and wished she would fall asleep and never wake up. Her boyfriend broke up with her about 3 months ago. The last time she felt this sad was 5 years ago when her parents divorced.

Answer 42

• Depression
• Bipolar disorder
• Anxiety disorder
• Bereavement
• ADHD
• Substance abuse
• PTSD

Question 43

A patient presents with the following Hx, what is the most likely diagnosis? What are the differential diagnosis?

A 9-year-old boy presents with a change in his behaviour over the past 4 weeks, from being an outgoing child who loved school to frequently complaining of stomach aches and refusing to go to school. He lives with his biological parents and a 5-year-old sister. He is attending a local school. His parents say that he has been unkind to his 5-year-old sister, and frequently screams at her. He used to like to play outside after school, but recently has stayed in his room a lot and played video games. He cannot identify any precipitants, but his parents recall that his mother was hospitalised for surgery about 3 months ago.

Answer 43

• Depression
• Bipolar disorder
• Anxiety disorder
• Bereavement
• ADHD
• Substance abuse
• PTSD

Question 44

A patient is prescribed an TCA - Amitryptiline/Imipramine/Lofepramine, you are asked to explain this medication to them. How would you go about this?

Answer 44

[Layout]

• Check what the patient knows
• Brief history
• Do they know what the drug is?
• Indication & Action of the drug
• Side effects
• How to take it
• Monitoring requirements

[Indication & Action of the drug]

• Indications:
  
  • 2nd line treatment for moderate to severe depression, after SSRI
  • Treatment for neuropathic pain

Actions:

• Inhibit the re-uptake of Serotonin (5-HT) + Noradrenaline (NA) from the synaptic cleft
• increase the availability for neurotransmission
• Improve mood & physical symptoms of moderate to severe depression
• Also help with neuropathic pain
• Block receptors - Muscarinic + Histamine (H1) + Adrenergic (Alpha) + Dopamine (D2)
  
  • Causes the side effects

[Side effects]

Blockage of antimuscarinic receptors:

• Dry mouth
• Constipation
• Urinary retention
• Blurred vision

Blockage of H1 and Alpha receptors

• Sedation
• Hypotension
• Blockage of Dopamine receptors
• Breast changes
• Sexual dysfunction

Cardiac adverse events

• Arrythmias
• ECG changes -> Prolonged QT interval & QRS duration
  
  • Risk of Torsades des Pointes

Neurological SE:

• Convulsions
• Hallucinations
• Mania

Sudden withdrawal can cause:

• GI Upset
• Neurological & flu like symptoms
• Sleep disturbance

[Overdose effects]

Very dangerous, they cause Serotonin syndrome:

• Severe hypotension
• Arrythmias
• Convulsions
• Coma
• Respiratory failure

[Complications/Contraindications]

• Caution for patients with:
  
  • Elderly - risk of fall
  • Epilepsy
  • Cardiovascular disease
  • Prostatic hypertrophy
  • Glaucoma
• C/I:
  
  • Must not be given with MOAI -> Can lead to HTN/Hyperthermia/Serotonin syndrome

[How to take it]

• Tablet/Oral solution
  
  • Take dose once a day
• Dose can be adjusted after at least 6-8wks treatment
  
  • 2 weeks supply to reduce risk of serious overdose
• Carry on for at least 6 months after they feel better
  
  • If recurrent depression -> 2yrs
• Effect time
  
  • Few weeks
  • Improves sleep and appetite

[Monitoring Requirements]

• Review symptoms 1-2 wks after starting treatment
• ECG - assess for any QT interval changes before starting treatment
  
  • Risk of Torsades des Pointes

Question 45

What is Serotonin syndrome?

How is it managed?

Answer 45

Syndrome caused by excess serotonin, from SSRI + TCA + SNRI + MOAI

• Autonomic hyperactivity - HTN + Tachycardia + Hyperthermia
• Tremor + Agitation + Irritability
• Adbominal pain
• Sweating + Diarrhoea
• Delirium/Altered Mental state
• Hyper-reflexia

[Management of Serotonin syndrome]

• Discontinue medication
• Benzodiazepines for agitation
• Severe -> Cyproheptadine - Serotonin antagonist
• Active cooling

Question 46

A patient is prescribed an SNRI - Venlafaxine/Duloxetine, you are asked to explain this medication to them. How would you go about this?

Answer 46

[Introduction]

• Check what the patient knows
• Brief history
• Do they know what the drug is?
• Indication & Action of the drug
• Side effects
• How to take it
• Monitoring requirements

[Indication & Action of the drug]

Indications

• Major depression where SSRI’s are ineffective or not tolerated
• Generalised anxiety disorder

Action:

• Serotonin (5HT) and Noradrenaline (NA) re-uptake inhibitor (SNRI)
  
  • Interferes with these NT at the synaptic cleft
  • Increases bioavailability of monoamines for NT - improve mood and physical symptoms in moderate to severe depression
• *Weaker antagonist of muscarinic & histamine receptors than TCA’s
• Fewer anti-muscarinic SE than TCAs

[How to take it]

• Orally
  
  • Take tablet every day - orally
  • Treatment started at low dose and titrated up according to response
• Continue taking it for 6 months after they stop feeling better to stop the depression from coming back
  
  • If recurrent depression -> 2 years
• Refer them for psychological therapy - long term benefits
• Effect time -> Should improve symptoms over a few weeks, particularly sleep and appetite

[Important Side Effects]

• GI upset
• Dry mouth/nausea
• Change in weight
• Diarrhoea/constipation
• Neurological effects – Headache
• abnormal dreams
• Insomnia
• Confusion
• Convulsions

Sudden withdrawal can cause:

• GI Upset
• Neurological & flu like symptoms
• Sleep disturbance

Serious SE:

• Hyponatraemia
• Serotonin syndrome
• May increase suicidal thought and behaviour
• Prolongs QT interval + Increased risk of ventricular arrhythmia
  
  • Risk of Torsades des Pointes

[Complications/Contraindications]

• Use with caution in:
  
  • Elderly
  • Patients with pre-existing arrhythmia
  • Dose reduction may be required in Hepatic/Renal impairment

[Monitoring requirements]

• Review symptoms 1-2 weeks after treatment and regularly there-after
• Dose should not be adjusted after 6-8 weeks of therapy

Question 47

A patient is prescribed Mirtzipine, you are asked to explain this medication to them. How would you go about this?

Answer 47

[Introduction]

• Check what the patient knows
• Brief history
• Do they know what the drug is?
• Indication & Action of the drug
• Side effects
• How to take it
• Monitoring requirements

[Indication & Action]

Indications

• Major depression where SSRI’s are ineffective or not tolerated

Actions

• Antagonist of inhibitory pre-synaptic alpha 2 adrenoreceptors
• Increases bioavailability of monoamines for NT - improve mood and physical symptoms in moderate to severe depression

[How to take it]

• Orally
  
  • Take at night to minimise sedative effects
  • Treatment started at low dose and titrated up according to response
• Continue taking it for 6 months after they stop feeling better to stop the depression from coming back
  
  • If recurrent depression -> 2 years
• Refer them for psychological therapy - long term benefits
• Effect time – Should improve symptoms over a few weeks, particularly sleep and appetite

[Important SE]

• GI upset
• Dry mouth/nausea
• Change in weight
• Diarrhoea/constipation
• Neurological effects – Headache
• abnormal dreams/Insomnia
• Confusion
• Convulsions

Serious SE:

• Hyponatraemia
• Serotonin syndrome
• May increase suicidal thought and behaviour

[Complications/Contraindications]

• Use with caution in:
  
  • Elderly
  • Patients with pre-existing arrhythmia
  • Dose reduction may be required in Hepatic/Renal impairment

[Monitoring requirements]

• Review symptoms 1-2 weeks after treatment and regularly there-after
• Dose should not be adjusted after 6-8 weeks of therapy

Question 48

A patient is prescribed a Monoamine Oxidase Inhibitor such as Phenelzine + Tranylcypromine, you are asked to explain this medication to them. How would you go about this?

Answer 48

[Introduction]

• Check what the patient knows
• Brief history
• Do they know what the drug is?
• Indication & Action of the drug
• Side effects
• How to take it
• Monitoring requirements

[Indication/Action]

• Bind to monoamine oxidase (Irreversible) preventing inactivation of biogenic amines such as NA, D and 5HT leading to increased synaptic levels
• Very effective

[Important side effects]

• Orthostatic hypotension
• Weight gain
• Drug mouth
• Sedation
• Sexual dysfunction
• Sleep disturbance
• Hypertensive crisis if MAOIs - taken with tyramine-rich foods - mature cheddar/broad bean pods/pickled herrings or sympathomimetics

[Important information]

• Risk of Serotonin syndrome if MAOI is combined with serotonergic medication or sympathomimetic actions - decongestants
  
  • 2 week wait to start MAOI after stopping SSRI
  • 5 week wait if Fluoxetine due to longer half life

Question 49

You are asked to explain CBT to a patient, how would you go about doing this?

Answer 49

[Introduction]

• Brief Hx
• What is CBT
• Why its being used
• How does it work
• What does it involve
• How effective is it?
• How long does it take?
• What if symptoms come back?

[Brief Hx]

• Can you bring me up to speed with the symptoms you were having?
• How do you feel today? How is your mood?
• How is it affecting your life?

[What is CBT]

• Do you know what CBT is? Have you heard of it before?
• It is a way of talking about how you think about yourself, the world and others.
  
  • Aim is to help you think about your thoughts and feelings, and change how you think and what you do
• Cognitive = What you think, Behaviour = What you do
• Focus is on the here and now, not necessarily past events

[What is it used for]

• Used for Anxiety/Depression/Phobias/OCD/PTSD

[How does it help?]

• Breaks down problems into smaller parts – Into Situation/Thoughts/Emotions/Physical feelings/Actions as this is the way we deal with scenarios
• Aim is to break the vicious circle - to stop you making yourself feel worse unconsciously

[What does it involve?]

• Either individually or with group of people, or self help
• Meet with therapist for between 5-20 weekly sessions lasting up to 1hr
• May be asked about your past life and background to understand you and what may be impacting on your actions now.
• But doesnt delve deeply into this, and it isnt the main focus
• Work with the therapist to break down each problem
• Homework – Keep diary + Practice the techniques learned on changing unhelpful thoughts & behaviours
• You decide the pace of the treatment and what you will/wont try

[Effectiveness]

• As effective as antidepressants
• May be used alongside antidepressants

[How long does it take?]

• From 6 weeks to 6 months
• Depends on the problem, and your engagement

[Recurrence of symptoms]

• Always a risk of return
• CBT should help to control the symptoms

Question 50

You are presented with a patient with a Hx suggestive of Bipolar Disorder, explain to them what the diagnosis is and how it will be managed?

Answer 50

[Cause]

• Episodic illness with behavioural disturbances
• Episodes of mania/hypomania + Depression
• Different types:
  
  • Bipolar 1 – Mania + Depression
  • Bipolar 2 – Hypomania + Depression
  • Rapid cycling – >4 episodes of MDE/Mania/Hypomania in <1yr
  • Cyclothymic – Chronic + Less severe mania & moderate depression for >2yrs

[Epidemiology]

• Males - Bipolar 1
• Females - Bipolar 2
• FHx of bipolar

[Diagnostic criteria]

At least 2 episodes of:

• Depression
• Mania/Hypomania

Mania:

• Elevated mood
• Excessively happy/irritable/easily angered
• Gradiose ideas
• Pressured speech
• Flight of ideas
• May have psychosis

Hypomania:

• Persistent mild elevation of mood
• Increased activity & Energy
• No hallucinations/Delusions

Depressive episode:

• Low mood
• Reduced mood
• Anhedonia
• Negative thoughts

[Investigations]

• Clinical diagnosis
• FBC – Normal
• TFTs – Normal
• Urine drug screen – Normal.
• ECG – QTc interval

[Management]

• Patient education
• CBT

Acute episode:

• Mania – Lithium/Valproate (Mood stabiliser)
• Depression – Olanzapine/Fluoxetine
• Refractory/Life threatening – ECT

Long term management:

• Lithium ± Valproate
• Olanzapine
• CBT

Question 51

A patient presents with the following Hx, what is the most likely diagnosis? What are the differential diagnosis?

A 20-year-old man presents to the accident and emergency department accompanied by his parents, owing to a change in mental status and behaviour, marked by uncharacteristic argumentativeness, eruptions of laughter, excessive talking, and unusual thoughts. He is being treated for depression and insomnia, and has recently been drinking more alcohol. For the past 2 weeks he has missed college classes, while staying up most nights until 4 or 5 a.m., writing feverishly in several notebooks. When asked, he reports that he is writing 2 novels at the same time and also documenting his accomplishments in an autobiography. He denies any illicit substance use while admitting to increasing alcohol consumption “like all the great novelists do”. Efforts by his family to understand his recent change in thinking and behaviour have been met with loud and rambling discourses, and he angrily accuses them of wanting him to stay “subjugated by the tyranny of depression”.

Answer 51

• Bipolar disorder
• Isolated Manic episode
• Hyperthyroidism/Hypothyroidism
• Psychosis
• Anorexia nervosa
• Cerebrovascular event
• Dementia
• Steroid use

Question 52

A patient presents with the following Hx, what is the most likely diagnosis? What are the differential diagnosis?

A 32-year-old nurse presents to her primary care provider complaining of frequent headaches, irritable bowel, insomnia, and depressed mood. She currently takes no medication and has no history of substance misuse or major medical problems beyond treatment for a single depressive episode in her first year at university. Her physical examination, routine labs, and computed tomography of the brain are all within normal limits. Her family history is notable for several ancestors who have been affected by psychiatric illness, including depression, bipolar disorder, and schizophrenia. Her paternal grandfather and a maternal aunt committed suicide. She has had 3 prior episodes of several weeks’ duration characterised by insubordinate behaviour at work, irritability, high energy, and decreased need for sleep. She regrets impulsive sexual and financial decisions that she took during these episodes, and has recently filed for personal bankruptcy. For the past month her mood has been persistently low, and she has had reductions in sleep, appetite, energy, and concentration, with some passive thoughts of suicide.

Answer 52

• Bipolar disorder
• Isolated Manic episode
• Hyperthyroidism/Hypothyroidism
• Psychosis
• Anorexia nervosa
• Cerebrovascular event
• Dementia
• Steroid use

Question 53

What are the different types of Bipolar Disorder?

Answer 53

• Bipolar 1 – Mania + Depression
• Bipolar 2 – Hypomania + Depression
• Rapid cycling – >4 episodes of MDE/Mania/Hypomania in <1yr
• Cyclothymic – Chronic + Less severe mania & moderate depression for >2yrs

Question 54

What must be asked in any patient presenting with depression?

Why?

Answer 54

If they have ever had any manic episdoes

• Why – Because prescribing antidepressants in a patient with bipolar disorder can lead to manic episodes

Question 55

When assessing risk in a manic patient what key questions need to be asked?

Answer 55

• Self harm + Suicide risk
• Financial risk
• Sexual risk
• Risk to self/others
• Drugs/Alcohol use
• Vulnerability – Neglect/Debts

Question 56

What do the following sections of the Mental health act allow for?

Section 2

Section 3

Section 4

Answer 56

[Section 2]

• Can be used up to 28 days
• Used to admit patient for assessment
• Treatment can be given for the mental disorder itself or conditions directly resulting from the disorder

Requires Application by:

• AMHP/Nearest relative

Recommendation required by:

• 1 section 12 approved Dr + 1 other Dr

Discharge/Renewal if:

• Pt appeals to tribunal/Discharge by responsible clinician, Hospital manager, or Nearest relative
• If further treatment required - Section 3 application

[Section 3]

• Can be used for 6 mo
• Used to admit patient for treatment

Treatment can be:

• Given for 3 mo THEN
• Consent required/2nd Opinion

Requires Application by:

• AMHP/Nearest relative

Recommendation required by:

• 1 section 12 approved Dr + 1 other Dr

Discharge/Renewal if:

• Patient appeal to tribunal/Responsible clinician/Hospital manager/Nearest relative

[Section 4]

• Can be used for 72hrs
• Used for emergency admission for assessment
• Treatment can only be given under common law

Requires Application by:

• AMHP/Nearest relative

Recommendation by:

• Any Dr

Discharge/Renewal if:

• Cannot appeal
• Discharge by responsible clinician

Question 57

What do the following sections of the Mental health act allow for?

Section 5(2)

Section 5(4)

Answer 57

[Section 5(2)]

• Can be used for 72hrs
• Used for emergency holding order - for pt already admitted to hospital informally
• Treatment can only be given under common law

Requires Recommendation by:

• Dr/Approved clinician in charge of pt care/Nominated deputy of responsible clinician

Discharge/Renewal if:

• Cannot appeal
• Discharge by responsible clinician

[Section 5(4)]

• Can be used for 6hrs
• Used for emergency holding order - for pt already admitted to hospital informally
• Treatment can only be given under common law

Requires Recommendation by:

• Registered nurse

Discharge/Renewal if:

• Cannot appeal
• Discharge by responsible clinician

Question 58

What do the following sections of the Mental health act allow for?

Section 135

Section 136

Answer 58

[Section 135]

• Can be used once
• Warrant to gain access to premises to remove patient to a place of safety
• Does NOT allow for treatment

Requires:

• 1 doctor
• AMHP
• Police

Can be renewed if further assessment required

[Section 136]

• Can be used once
• Allows police to remove person from public place to place of safety
• Does NOT allow for treatment

Requires

• Police - remain in attendance until further assessment arranged

Question 59

You are presented with a patient with a Hx suggestive of Psychosis explain to them what the diagnosis is and how it will be managed?

Answer 59

[Cause]

• Extreme impairment in cognitive ability – Intereferes with ability to function. There are many different causes
  
  • Mental illness – Primary v Secondary
  • Organic causes
  • Drugs + Alcohol

[Diagnostic criteria]

• Delusions
• Hallucinations – Auditory/Visual/Tactile

[Investigations]

• Referral to mental health services
• Hx + MSE
• Delirium screen:
  
  • FBC + U&E + LFTs
  • STD Screen
  • Urine drug screen
  • CT brain if focal signs
  • CXR if indicated
  • Urine dipstick ± Culture
  • B12 + Folate
  • Blood glucose

[Management]

• Treat cause of the psychosis
• May require admission under MHA

Question 60

What are the causes of psychosis?

Answer 60

Primary psychosis:

• Schizophrenia
• Depression w/psychosis
• Bipolar disorder
• Peurpural psychosis
• Delirium

Secondary psychosis:

• Drugs – OTC/Anticholinergics/Corticosteroids/Thyroid hormones/Dopamine agonists
• Recreational drugs – Cocaine/Cannabis/Amphetamines/Alcohol
• Drug/Alcohol withdrawal

Organic causes:

• Epilepsy
• MS
• Dementia
• ABI
• Encephalitis
• SoL
• Vitamin deficiency – B12/Folate/B3/Thiamine

Question 61

You are presented with a patient with a Hx suggestive of Schizophrenia explain to them what the diagnosis is and how it will be managed?

Answer 61

[Cause]

• Vulnerability to psychotic episodes
• Caused by genetic/environmental/social reasons
• Imbalance of NT in the brain, and decreased brain volume.
  
  • Increased risk of developing with cannabis use

Types:

• Paranoid
• Catatonic

[Who gets it?]

• Typically in younger ages (Adolescence/20’s)
• Men > Women
• FHx

[Diagnostic criteria]

>2 of the following for a significant period in 1 month, and continous overall for >6months:

Positive symptoms

• Delusions
• Hallucinations – Usually auditory
• Disorganised speech/catatonic behaviour
• Formal thought disorder – Echo/Withdrawal/Insertion/Broadcase/Control

Negative symptoms:

• Emotional flattening
• Avolition – Reduced ability to do goal directed behaviour
• Blunted mood
• Self neglect
• Social withdrawal
• Improverished speech & language

[Investigations]

• Full Hx + MSE
• Clinical diagnosis
• if 1st episode - Delirium screen:
  
  • FBC – Normal
  • LFTs – Normal
  • STD screen – Normal
  • Urine drug screen – Normal
  • If focal neurological signs – CT Head

[Management]

• MDT support/CAMHS if young
• Health promotion – Stop smoking/drugs/diet control
• Manage social factors
• Patient education

Medical management:

• Antipsychotics – Risperidone/Olanzapine/Quetiapine
• I/M Depot injections if non-compliant
• If treatment resistant (Used >2 antipsychotics) – Clozapine

If Acute agitation:

• Lorazepam

Resistant to drugs:

• ECT

[Prognosis]

• Suicide risk is higher than general population
• Increased risk of death from violence
• Relapse is common

Question 62

What is meant by the following terms:

Schizoaffective disorder

Schizophreniform disorder

Answer 62

Schizoaffective disorder

• Shizophrenia + Major affective disorder (Depression/Bipolar)

Schizophreniform disorder

• Symptoms that are similar to schizophrenia but do not meet the threshold for schizophrenia

Question 63

A patient presents with the following Hx, what is the most likely diagnosis? What are the differential diagnosis?

A 22-year-old unmarried white man presents to the clinic with his mother. He spends most of his time in the house and refuses to go out at night alone. He used to live independently and worked until a few months ago. The patient states he made an error on his income tax statement and is convinced that the tax authorities have hired detectives to gather information about his whereabouts. He states that, since his mistake, he uncovered an essential flaw in the taxation algorithm, which may expose the underpinning of the taxation system, and is convinced they have hired assassins disguised as bikers. After moving in with his mother, he did not see the bikers, but they are trying to trace his “mental activity”. Also, he hears them outside his house talking about how they will kill him; he reported the problem to the police and is seeking help “to defeat the tax collectors”. He appears suspicious, avoids eye contact, and his answers to questions are delayed, during which he appears internally preoccupied.

Answer 63

• Schizophrenia
• Drug induced psychosis – Amphetamine/LSD/Cannabis
• Temporal lobe epilepsy
• Alcoholic hallucinations
• Delirium
• Encephalitis
• Mania
• Depression with psychosis
• Anxiety

Question 64

A patient presents with the following Hx, what is the most likely diagnosis? What are the differential diagnosis?

A 25-year-old African-American woman is brought to the accident and emergency department by the police after being found walking in traffic at a busy city intersection. The police place her on an involuntary commitment after she states that she was instructed to kill herself by accusatory, commanding voices. On examination the patient appears dishevelled, with an indifferent and flat affect, and disorganised thought processes. She answers most questions monosyllabically. When questioned about experiencing auditory hallucinations she answers in the affirmative, but she is unable to articulate coherently the details of her experience. Throughout the examinations she appears intermittently distracted by internal stimuli; when asked what her experience is in the moment, she states: ‘They are talking to me.’ The patient’s family reports that she became increasingly withdrawn after she moved away from home to attend graduate studies at a local university. The family reports that her academic performance in college was above average, but since starting university she has struggled to complete her school work. Since moving, she has also become more isolative: she made no new friends, stopped talking to her college friends, and maintained only sporadic contact with her family. The family was unaware of the patient experiencing any hallucinatory experiences. She had no past history of drug use and her urine toxicology screen was negative, effectively ruling out a drug-induced psychosis.

Answer 64

• Schizophrenia
• Schizoaffective disorder
• Drug induced psychosis – Amphetamine/LSD/Cannabis
• Temporal lobe epilepsy
• Alcoholic hallucinations
• Delirium
• Encephalitis
• Mania
• Depression with psychosis
• Anxiety

Question 65

A patient presents with the following Hx, what is the most likely diagnosis? What are the differential diagnosis?

A 26-year-old single woman is seen in the outpatient clinic with her mother. She is dressed provocatively and states that she is Whitney Houston’s daughter and a very important person who knows many famous actors. Her thought content is significant for thought blocking. At times, she is observed to direct her attention to random parts of the room, presumably as a result of active auditory hallucinations. She also believes that everything that she thinks will, in fact, happen. The patient reports that she has always been shy, with few or no friends as she grew up. She started to experience perceptual disturbances around the age of 18, when she “saw spirits but did not hear them”. Around that time she also became aware of her ability to know the future. For example, once she looked towards the airport and knew that 2 planes would crash in the future. She wanted to call someone to report it but did not know whom to call. Days later there were 2 accidents. Despite such unusual experiences she was able to train as a dental technician and had a steady job for 5 years. During that time, she started to experience more auditory hallucinations. She described them as voices conversing, at times yelling or giving her directions, even telling her to kill herself, when under stress. She also reported that she resisted the voices by distracting herself, as she did not want to die. Last year she also had a mixed episode, during which she was manic, did not sleep for more than a week, felt “hyper”, impulsive, and “tingling”, and also depressed. At that time she decided that she could not continue to work in the same place and left; she has not since held a job. At the time of her initial evaluations she was living with her parents and brother. About 1 year ago, she started an antipsychotic medication, which decreased the intensity of the voices and the fear that other people could read her thoughts. During the past year she has had manic symptoms most of the time (including grandiosity, impulsivity, decreased sleep, and mixed mood symptoms). This culminated with an exacerbation about 6 months ago that prompted psychiatric hospitalisation. On examination, she was sitting in a somewhat provocative position on the couch. Her speech was high-pitched. She appeared relaxed, although at random times she would get tense. Her thought process was slow and tangential, with intermittent thought blocking. Her attention span was moderately diminished. No active suicidal or homicidal thoughts were present; however, she reported that the voices insisted that she should jump out of the window. Her insight and judgement were poor.

Answer 65

• Schizoaffective disorder
• Drug induced psychosis – Amphetamine/LSD/Cannabis
• Temporal lobe epilepsy
• Alcoholic hallucinations
• Delirium
• Encephalitis
• Mania
• Depression with psychosis
• Anxiety

Question 66

What is Dementia broadly?

Answer 66

Deterioration of higher levels of functioning - Progressive

Causes:

• Memory loss - Short term memory
• Decline in cognition
• Difficulties with ADLs

Types:

• Alzheimers dementia (Most common) – Degeneration of brain matter
• Vascular dementia – Brain damage due to strokes
• Dementia with Lewy Bodies – Dementia with parkinsons symptoms
• Frontotemporal dementia – Specific atrophy of the frontal + temporal lobes
• Mixed dementia – Mixture of dementia types

Question 67

What is pre-dementia?

Answer 67

Where there is:

• Mild cognitive impairment
• Decline in cognitive function - greater than expected for age/education level
• No Intereference with ADLs

Question 68

You are asked to explain Alzheimers dementia and its management to a patient/family member. How would you go about this?

Answer 68

[Introduction]

I will be explaining to you the following:

• Causes
• Who gets it?
• Symptoms/Signs
• Diagnostic criteria
• Investigations
• Management

[Causes]

• Most common cause of dementia
• Due to progressive degeneration of the cerebral cortex - impairs cognitive function
• Deposition of Amyloid plaques + neurofibrillary tangles (Deposition of material in the brain)
• Leads to inflammatory reaction that damages the brain matter
• Insidious onset + Slow progression

[Who gets it?]

• Most common form of dementia
• Genetic - FHx
• Can also be idiopathic - Due to ageing + environment
• Women > Men
• Can be initiated by head injury

[Symptoms/Signs]

• Insidious
• Short term memory lapses
• Decline in ADLs + IADLs
• Confusion
• Apathy
• May develop Depression/Hallucinations/Delusions
• May become aggressive/Disinhibited/Agitated

[Diagnostic criteria]

• Progressive short term memory impairment
• Deficits in >2 areas of cognition
• Insidious onset over months/years - Progressive worsening
• No disturbance of consciousness

[Investigations]

• Clinical diagnosis - Hx + Examination
• Cognitive assesment - MMSE + ACE
• Delerium screen:
  
  • FBC – Normal
  • U&Es – Normal
  • TSH – Normal
  • Serum B12/Folate – Normal
• MRI – Generalised atrophy. Rule out cerebral pathology.

[Management]

• Advanced care planning - LPA/Advanced statement
• Assess capacity to consent
• Patient education
• Inform DVLA for assesment
• Mild to moderate:
  
  • Structured group cognitive stimulation
  • Memory enhancement strategies
• Moderate to severe:
  
  • Donepezil/Rivastigmine/Galantamine

Question 69

A patient presents with the following Hx, what is the most likely diagnosis? What differentials should you consider?

A 76-year-old white woman is brought to her general practitioner by her children because she is becoming more forgetful. She used to pay her bills independently and enjoyed cooking but has recently received overdue notices from utility companies and found it difficult to prepare a balanced meal. She has lost 3.5 kg in the past 3 months, and left the water running in her bathtub and flooded the bathroom. When her children express their concerns, she becomes irritable and resists their help. Her house has become more cluttered and unkempt. On a past visit to her physician, she had normal laboratory tests for metabolic, haematological, and thyroid function. The current evaluation reveals no depressive symptoms and 2/15 on the Geriatric Depression Scale short-form. Her Mini-Mental State Examination score is 20/30.

Answer 69

• Alzheimers dementia
• Vascular dementia/Lewy body dementia/Fronto-temporal dementia
• Normal pressure hydrocephalus
• Delirium - Hypothyroidism/B12 deficiency

Question 70

A patient presents with the following Hx, what is the most likely diagnosis? What differentials should you consider?

A 54-year-old black woman is referred to the neurology clinic by her general practitioner for evaluation of memory problems. The patient is brought to the clinic by family members who are concerned that she has been forgetful in the past year. They report that she has difficulty in recalling birthdays and anniversaries and is not managing common household tasks such as cooking and paying bills. The patient’s sister had onset of dementia in her early 40s and was institutionalised because she was unable to care for herself. The patient was last seen by her primary care physician 3 months ago, when she had a routine work-up, which was reported to be unremarkable. Neurological examination revealed no significant abnormalities. Neuropsychological testing demonstrated severe impairment in executive function, deficits in visuo-spatial testing, and delayed speed of processing information. Mini-Mental State Examination score is 20/30.

Answer 70

• Alzheimers dementia
• Vascular dementia/Lewy body dementia/Fronto-temporal dementia
• Normal pressure hydrocephalus
• Delirium - Hypothyroidism/B12 deficiency

Question 71

If a patient with Alzheimers dementia has concurrent depression/psychotic features/agitation, what can be done to manage their co-morbidities?

Answer 71

Depression

• Avoid TCAs due to effect on cognition
• SSR – Sertraline/Citalopram

Psychotic features

• Risperidone

Agitation/Aggression

• Lorazepam/Haloperidol/Olanzapine

Question 72

What should always be discussed with regard to the prognosis in a patient with a diagnosis of dementia?

Answer 72

Due to the progressive nature of the condition, they will eventually require palliative care:

• Oral nutrition
• Consider DNAR
• Most common cause of death is infection

Vascular dementia – Prognosis worse than AZD

Question 73

What is Pseudo-dementia?

Answer 73

• Patient experiences dementia like symptoms temporarily due to severe depression
• can also appear with mania, schizophrenia, dissociative disorders or psychoactive drug use

[Diagnostic features]

• Meet all the core symptoms for depression
• Concurrent loss of short term memory +/- long term memory
• Rapid decline of cognitive function
• Temporary

[Management]

• SSR - Sertraline/Citalopram
• CBT

Question 74

You are asked to explain Vascular dementia and its management to a patient/family member. How would you go about this?

Answer 74

[Introduction]

I will be explaining to you the following:

• Causes
• Who gets it?
• Symptoms/Signs
• Diagnostic criteria
• Investigations
• Management

[Causes]

• Chronic progressive disease of brain leading to cognitive impairment secondary to cerebrovascular disease (ischaemia/haemorrhage)
• Due to stroke/small vessel disease
• Leads to loss of axons, and damage to brain matter

[Who gets it?]

• 2nd most common type of dementia
• Increased incidence with age - >65yrs
• Men > Women
• CADASIL in younger patients
• Risk in patients with Hx of stroke/TIA or HTN or DM
• All risk factors for CVD

[Symptoms/Signs]

• Progressive short term memory loss - Sudden/Gradual after a distinct decline
• Stepwise progression

[Diagnostic criteria]

• Memory loss + >2 impairments of cognition
• Intereference of ADLs due to deficits
• Concurrent cerebrovascular disease - O/E + brain imaging
• Symptoms within 3 months of stroke

[Investigations]

• Clinical diagnosis + Imaging for CVE
• CT/MRI brain – Signs of cerebrovascular lesions
• ECG – Identify if patient has AF
• Delirium screen:
  
  • FBC – Normal
  • ESR – Normal
  • Blood glucose – Normal
  • U&Es – Normal
  • LFTs – Normal
  • Vitamin B12/Folate – Normal
  • TFTs – Normal

[Management]

• Patient education
• Reduce CVD risk factors:
  
  • Antiplatelet – Aspirin/Clopidogrel
  • Statin
  • Increase physical activity
  • Antihypertensives
• Smoking cessation
• Cognitive stimulation therapy

Question 75

A patient presents with the following symptoms, what is the most likely diagnosis? What are the differentials?

A 65-year-old man presents with difficulty in decision-making and planning, which is of abrupt onset and occurs 3 months after a stroke. He has strong vascular risk factors, including smoking. Over time, there has been a fluctuating stepwise reduction in cognitive function. There is a history of nocturnal confusion and incontinence. On examination there is evidence of focal neurological deficit with pseudobulbar palsy and extrapyramidal signs. Neuroimaging indicates a probable vascular aetiology with white matter changes and infarction.

Answer 75

• Vascular dementia
• Alzheimers dementia/Frontotemporal dementia
• Depression/Pseudodementia
• Mild cognitive impairment
• Normal pressure hydrocephalus

Question 76

What are the complications that can arise from vascular dementia?

Answer 76

• Behavioural problems – Wandering/Delusions/Hallucinations
• Depression
• Falls/Gait abnormalities
• Aspiration pneumonia
• Pressure ulcers
• Caregiver burden/stress

Question 77

You are asked to explain Lewy body Dementia and its management to a patient/family member. How would you go about this?

Answer 77

[Introduction]

I will be explaining to you the following:

• Causes
• Who gets it?
• Symptoms/Signs
• Diagnostic criteria
• Investigations
• Management

[Causes]

• Progressive widespread impairment of mental function interfering with ADLs
• Proteins deposited into neurones within the area which causes Parkinsons disease

[Who gets it?]

• 3rd most common type of dementia
• Sporadic/Genetic (AD inherited)
• Older patients

[Symptoms/Signs]

• Memory loss
• Cognitive decline
• Visual hallucinations
• Mild parkinsonisms – Tremor/Rigidity/Falls
• Sleep disorders – REM sleep disorder
• Autonomic dysfunction – Fainting/Urinary incontinence/Constipation

[Diagnostic criteria]

• Fluctuating cognition + Prominent & persistent memory impairment
• Recent visual hallucinations
• REM sleep behaviour disorder
• Parkinsonism symptoms – Bradykinesia + Resting tremor + Rigidity

[Investigations]

• Clinical diagnosis
• Delirium screen:
  
  • FBC – Normal
  • ESR – Normal
  • Blood glucose – Normal
  • U&E – Normal
  • LFTs – Normal
  • Vitamin B12/Folate – Normal
  • TFTs – Normal
  • MIGB scintigraphy – Diagnostic for LBD

[Management]

• Specialist referral
• Patient education
• Risk assesment - OT & Phsyio
• Inform DVLA
• Rivastigmine - manage cognitive decline
• Lorazepam – Manage behavioural disturbances/anxiety/agitation

Question 78

A patient presents with the following Hx, what is the most likely diagnosis? What are the differentials?

A 78-year-old woman presents with confusion, agitation, and visual hallucinations. She has become progressively confused over the past 2 years and has had trouble managing her affairs, including shopping and paying bills. It is unclear when her confusion started. Initially, she was having trouble following conversations and got lost on several occasions. Her memory, which was previously good, has begun to deteriorate. At night, she sees children playing in her house and has called the police on several occasions. She gets angry easily and has been paranoid about her relatives and their intentions. Her behaviour tends to fluctuate from day to day. She started to shuffle about 6 months ago and had difficulty getting out of chairs, and getting dressed to go out seemed to take hours. On one occasion, she fell and was taken to the emergency department but was subsequently discharged with no diagnosis given.

Answer 78

• Lewy body Dementia
• Alzheimers dementia
• Vascular dementia
• Idiopathic parkinsons disease
• Intracranial tumour
• Stroke/TIA

Question 79

You are asked to explain Fronto-temporal dementia to a patient, how would you go about doing this?

Answer 79

[Introduction]

I will be explaining to you the following:

Causes

• Who gets it?
• Symptoms/Signs
• Diagnostic criteria
• Investigations
• Management

[Causes]

• Progressive dementia affecting the frontal lobe + temporal lobe
• Due to atrophy of the frontal and temporal lobes, no plaque formation
• “Holes” formed in these areas
• Picks disease – Pick bodies (Proteins in neurons) + Neurons balloon

[Who gets it?]

• Genetic component – FHx
• Typically patients <65yrs old
• Rare condition

[Symptoms/Signs]

• Gross change in social behaviour & language
• Indifferent to self care & others needs
• Loss of speech and comprehension
• Impulsive + Loss of inhibitions

[Diagnostic criteria]

• Insidious onset
• Behavioural changes
• Non fluent aphasia
• No neurological signs

[Investigations]

• Clinical diagnosis
  
  • Fulfils diagnostic features
  • MRI – Frontal & Temporal atrophy
• Delirium screen:
  
  • FBC – Normal
  • ESR – Normal
  • Blood glucose – Normal
  • U&E – Normal
  • LFTs – Normal
  • Vitamin B12/Folate – Normal
  • TFTs – Normal
  • MIGB scintigraphy – Diagnostic for LBD

[Management]

• No treatment to stop progression
• Alleviate symptoms
• Patient education
• Future planning – DNAR/Will
• OT/SALT/Physio

Question 80

A patient presents with the following Hx, what is the most likely diagnosis? What are the differentials?

A 55-year-old man who worked as a technician developed difficulty finding words 2 years earlier, which has evolved into dysfluency, frequent repetition of remarks and questions, stereotypies (purposeless behaviours or fragments of speech frequently repeated, without regard to context), and echolalia (reflexive repetition of another’s speech). In the past year, he has also become forgetful. His work efficiency deteriorated due to his poor comprehension, reasoning, planning, and completion, resulting in disability leave. He also became unfeeling, intrusive (indiscriminately approaching strangers), child-like, and impulsive. He developed rigid routines (e.g., insistence on the same TV shows) and coarse manners (e.g., eating out of serving bowls, jumping queues, and walking away from conversation). Restlessness is marked: each day he bikes, swims many laps, runs 10 km, and ‘volunteers’ at a local nursing home, making the rounds with all maintenance crews. On examination, he is pleasant and cooperative. Given opportunity, he quizzes the examiner on trivial facts (such as listing capital cities). Depression is not evident, and he does not have euphoria, psychosis, or paranoia. Speech is mildly non-fluent. Verbal fluency is impaired. Mini-mental state examination score is 29.

Answer 80

• Frontotemporal dementia
• Alzheimers dementia
• Vascular dementia
• Intracranial tumour
• Stroke/TIA
• Substance abuse

Question 81

A patient presents with the following Hx, what is the most likely diagnosis? What are the differentials?

A 58-year-old male teacher developed dysnomia, spelling errors, impaired comprehension of reading and conversation, and diminished singing ability. He also has impaired attention, planning, and organisation, along with declining self-care, child-like behaviour, and altered social habits (e.g., eating meals with his fingers). He developed anxiety. Two years into the illness, a neurologist suspected early dementia. Folstein mini-mental state examination score was 27 points and the neurological examination was normal. Brain magnetic resonance imaging showed temporal lobe atrophy, predominantly left-sided. Three years later, his partner complains about impulsive, obstinate, and gluttonous behaviour. Formal neuropsychological testing shows mini-mental state examination score of 28, impaired memory and learning, impaired word and sentence comprehension, marked dysnomia, grammatical and spelling errors, and poor copying of a complex figure.

Answer 81

• Frontotemporal dementia
• Alzheimers dementia
• Vascular dementia
• Intracranial tumour
• Stroke/TIA
• Substance abuse

Question 82

You are asked to explain autism spectrum disorder to the parents of a child, how would you go about this?

Answer 82

[Introduction]

I will be explaining to you the following:

• Causes
• Who gets it?
• Symptoms/Signs
• Diagnostic criteria
• Investigations
• Management

[Causes]

• Developmental condition where there is impairment in:
• Social interaction
• Reciprocal communication
• Stereotyped repetitive/limited behavioural repertoire

[Who gets it?]

• Genetic + Environmental influences
• Associated with Fragile X syndrome/Downs syndrome/Tuberous sclerosis
• Boys > Girls

[Symptoms/Signs]

• Hx of language delay
• Language regression
• Lack of pretend play
• Impaired verbal communication
• Unusual/repetitive movements
• Communication impairment
• Social impairment

[Diagnostic criteria]

• Abnormal or impaired development manifests <3yrs
• Abnormal functionin in ALL areas:
  
  • Reciprocal social interaction
  • Communication
  • Restricted/stereotyped/repetitive behaviour

[Investigations]

• Diagnosis after age 2/3
• Specialist diagnosis via ASD team
• Assessment by SLT + OT + Social workers + Special educators
• Screening tests, including play - ADOS2/DISCO

[Management]

• Patient mediated intervention to aid families to interact w/child
• Intensive behaviour intervention programme
• CBT
• SLT - aid with speech problems
• If challenging/aggressive behaviour – Risperidone

Question 83

A patient presents with the following Hx, what is the most likely diagnosis? What are the differentials?

A 3-year-old boy presents following concerns about language development. He started using single words at age 18 months but still doesn’t use 2 words together. He stopped using words he had previously learnt between 18 and 24 months, but has now regained most of these words. He also seems uninterested in engaging with other children. He occasionally engages with his parents but less than they think he should. He doesn’t tend to look at them much and he has difficulty maintaining eye contact with them. When he wants something he pulls them to where the object is and screams; he doesn’t point like other children. His parents have also noticed that he does not play in the same way as other children of his age; he tends to line toys up, or plays with certain aspects of them, such as the car doors. He doesn’t use the toys in the imaginative way that other children do. When his toys are moved he becomes very upset. He tends to become distressed when he thinks there is change around the house. In contrast, he is not concerned when either of his parents leaves the house. He tends to flap his hands at times and his parents report him staring at the ceiling lights for 10 to 20 minutes at a time. He is a fussy eater and hates being messy.

Answer 83

• Autism spectrum disorder
• Deafness
• Hellers disease
• General learning disability

Question 84

A patient presents with the following Hx, what is the most likely diagnosis? What are the differentials?

A 24-year-old filing clerk at the local library is referred for assessment as a result of increasing tearfulness. He has recently graduated in computer science at university and was offered this job as he knows the librarians well, having spent most weekends at the library throughout his life. He reports never having made friends throughout school or university and describes feeling lonely as a consequence. At assessment he presents as reasonably well-kempt but dressed in a somewhat old-fashioned and quirky manner, and uses eye contact only fleetingly. His speech is monotone with rapid explosive bursts making it difficult to understand what he is saying. Throughout the assessment he fails to elaborate on anything without prompting. He only becomes animated when talking about artificial intelligence in computer technology, not recognising that his assessor does not understand and is not particularly interested in this topic.

Answer 84

• Autism spectrum disorder
• Deafness
• Hellers disease
• General learning disability

Question 85

You are asked to explain anorexia nervosa to a patient/parents. How would you go about this?

Answer 85

[Introduction]

I will be explaining to you the following:

• Causes
• Who gets it?
• Symptoms/Signs
• Diagnostic criteria
• Investigations
• Management

[Causes]

• Patients maintain low body weight due to pre-occupation with weight
• Fear of fatness/pursuit of thinness - pts believe they are fat and terrified of normal weight/shape

[Who gets it?]

• Females > Males
• Early/mid adolescents
• FHx of eating disorder/depression
• Pre-morbid experiences – Sexual abuse/Dieting behaviour in family

[Symptoms/Signs]

• Low body weight - BMI <18.5kg/m2 or <5th centile in child
• Rapid weight loss
• Weight loss measures – Extreme dieting
• Amenorrhea >3 months
• Purging behaviour – Over-exercise/Laxative use/diuretics
• Lanugo hair

[Diagnostic criteria]

• Restriction of energy intake to significantly lower weight below minimum for age/height
• Intense fear of gaining weight/persistent behaviour interfering with weight gain
• Disturbance of body image
  
  • Restricting sub-type – Weight loss by dieting/fasting/excessive exercise
  • Binge eating sub-type – Recurrent episodes of Binge eating in preceeding 3 months
  • Purging sub-type – Recurrent episodes of purging in preceeding 3 months

[Investigations]

• Clinical diagnosis
• FBC – Normal. May have normocytic normochronic anaemia + Mild leukopenia + thrombocytopenia
• TFTs – Normal
• U&Es – Normal. May have electrolyte imbalance from purging behaviour
• LFTs – Normal. May have elevated ALT/AST/Cholesterol
• Urine dipstick – Normal. May have ketonuria (Starvation)
• DEXA – If 1 yr underweight due to risk of osteopenia/osteoporosis
• ECG – Assess for Bradycardia/Prolonged QTc interval

[Management]

• Assess physical risk with MARSIPAN (Determine if severe anorexia)
• Refer to eating disorder service – Further assesment/treatment
• If child – Anorexia focused family therapy (Control to parents, then independence, then maintenance)
• Dentist assesment if purging
• If severe – Refeeding under MHA sectioning

Question 86

A patient presents with the following Hx, what is the most likely diagnosis? What are the differentials?

A 15-year-old girl, accompanied by her mother, presents to her primary care physician complaining of fatigue and sleeplessness for 6 months’ duration. The doctor notes the patient is quite petite and is wearing an oversized, baggy dress. There are no physical findings, but, during the examination, the patient is reluctant to step on the scale, mentioning that she is sure she has gained too much weight since her last visit, and that she ought to spend more time exercising at the gym. She is weighed and is found to be 88% of the minimum weight requirements for her age and height. Her mother is concerned as her daughter has been eating little and exercising daily, and seems disinterested in her friends.

Answer 86

• Anorexia nervosa
• Bulimia nervosa
• Depression
• Hyperthyroidism
• T1DM
• Crohns/UC
• Systemic illness

Question 87

What are the complications of Anorexia Nervosa?

Answer 87

• Osteoporosis
• Hypokalaemia – Fatal arrythmia
• Hypotension
• Anaemia + Thrombocytopenia
• Hypoglycaemia
• Infertility
• Stunting of growth + Delayed puberty
• AKI/CKD
• Anxiety & Mood disorders

Question 88

You are asked to explain Bulimia nervosa to a patient/family member. How would you go about this?

Answer 88

[Introduction]

• I will be explaining to you the following:
  
  • Causes
  • Who gets it?
  • Symptoms/Signs
  • Diagnostic criteria
  • Investigations
  • Management

[Causes]

• Eating disorder with repeated uncontrolled excessive eating (Binges)
• Compensatory weight loss behaviours

[Who gets it?]

• Genetic/Environmental
• Women > Men
• All socio-economic groups
• Adolescents & young adults

[Symptoms/Signs]

• Regular binge eating for at least 3 months - with loss of control
• Compensatory weight loss - Vomitting/Fasting/Exercise/Medication use
• Physical symptoms:
  
  • Bloating/Fullness
  • Abdominal pain
  • Sore throat
  • Dental problems due to vomiting
  • Swollen parotid glands
  • Calluses on back of hand due to teeth abrasions (Russels sign)

[Diagnostic criteria]

• Excessive preoccupation with body weight and shape
• Regular binge eating for at least 3 months - with loss of control
• Lack of control over eating
• Compensatory weight loss - Vomitting/Fasting/Exercise/Medication use

[Investigations]

• Clinical diagnosis
• U&E – Normal
• Urine pregnancy test – Negative

[Management]

• Referral to eating disorder service
• Focused family therapy
• Individual CBT
• Regular dental review & Dental hygeine
• Fluoxetine – to decrease purging behaviour

Question 89

A patient presents with the following Hx, what is the most likely diagnosis? What are the differentials?

A 30-year-old woman presents with marked weight fluctuations. She says that her weight has changed by just over 3 kg over a few days, unrelated to menstruation. Physical examination is normal except for bilateral parotid hypertrophy.

Answer 89

• Bulimia Nervosa
• Binge eating
• Depression
• Anorexia nervosa with bulimic features

Question 90

A patient presents with the following Hx, what is the most likely diagnosis? What are the differentials?

A 25-year-old woman complains that she is obsessed with eating and weight. She has tried unsuccessfully to lose weight. She becomes so hungry that she overeats to the point of regurgitating.

Answer 90

• Bulimia Nervosa
• Binge eating
• Depression
• Anorexia nervosa with bulimic features

Question 91

What are the complications of bulimia nervosa?

Answer 91

• Haematemesis
• Metabolic complications (Hypokalaemia)
• Dental erosions
• Painless enlargement of salivary glands
• Tetany
• Seizures

Question 92

You are asked to explain a diagnosis of conduct disorder to a parent of a young child. How would you do this?

Answer 92

[Introduction]

• I will be explaining to you the following:
  
  • Causes
  • Who gets it?
  • Symptoms/Signs
  • Diagnostic criteria
  • Investigations
  • Management

[Causes]

• Recurrent persistent pattern of behaviour - violates rights of others and societal norms
• May develop into antisocial personality disorder as adult

[Who gets it?]

• Late childhood/Early adolescence
• Boys > Girls
• Parents may be involved with substance abuse or antisocial behaviour

[Symptoms/Signs]

• Lack sensitivity to feelings and well being of others/Little remorse
• Mispercieve others behaviour as threatening
• Act aggressively or bully
• Use weapons/act against the rules
• May harm animals/Destroy property

[Diagnostic criteria]

• Child/Adolescent with >3 behaviours in past 12 mo + at least in last 6 mo
  
  • Aggression towards people/animals
  • Destruction of property
  • Deceitfulness/Lying/Stealing
  • Serious violations of parental rules
• Impairs functioning in relationships at school/work

[Investigations]

• Clinical diagnosis

[Management]

• Psychotherapy - Improve self esteem + self control
• Behviour modification
• CBT
• Risperidone (Short term - rarely used)

Question 93

You are asked to explain a diagnosis of oppositional defiant disorder to a parent of a young child. How would you do this?

Answer 93

[Introduction]

• I will be explaining to you the following:
  
  • Causes
  • Who gets it?
  • Symptoms/Signs
  • Diagnostic criteria
  • Investigations
  • Management

[Causes]

• Recurrent persistent pattern of negative/defiant/hostile behaviour directed at authority figures
• Mild version of conduct disorder
• Dont lack remorse/conscience

[Who gets it?]

• Common in children from argumentative families
• Boys > Girls

[Symptoms/Signs]

• Loses temper easily and repeatedly
• Argue with adults
• Refuse to obey rules
• Blame others for own mistakes/misbehaviour
• Spiteful/Vindictive

[Diagnostic criteria]

• Child with >4 symptoms for at least 6/12
  
  • Loses temper easily and repeatedly
  • Argue with adults
  • Refuse to obey rules
  • Blame others for own mistakes/misbehaviour
  • Spiteful/Vindictive
  • Severe + Disruptive
  • [Investigations]
  • Clincal diagnosis

[Management]

• Behvaiour modification therapy - reward based

Question 94

You are asked to explain Dialectical behavioural therapy, how would you do this?

Answer 94

What does it mean?

• Therapy to try to balance contradictory positions - work with therapist to find a good balance b/w acceptance v change
  
  • Acceptance – Accepting yourself
  • Change – Making positive changes in your life
• Aim is that by understanding yourself you can learn to deal with your feelings in a different way

Who is it used for?

• To treat Borderline personality disorder
• Can also be used for people with drug/alcohol problems, eating disorders, offending behaviour

What does it involve?

• Talking with therapist to help patient gain control over their behaviour
• Stop suicidal and self harming behaviour
• Reduce behaviour that intereferes with therapy
• Improve quality of life by addressing things that interefere with this

Question 95

You are asked to explain a diagnosis of Attention Deficit Hyperactivity disorder, how would you go about doing this?

Answer 95

[Introduction]

• I will be explaining to you the following:
  
  • Causes
  • Who gets it?
  • Symptoms/Signs
  • Diagnostic criteria
  • Investigations
  • Management

[Causes]

• Persistent pattern of inattention + Hyperactivity & Impulsivity
• May be due to dysregulation of dopamine + Noradrenaline
• Commonly occurs in children with low birth weight/Maternal smoking

[Who gets it?]

• Genetic + Environmental
• One of the most common disorders in childhood
• Boys > Girls
• FHx

[Symptoms/Signs]

• Inattention:
  
  • Fails to give close attention to details
  • Trouble holding attention
  • Does not listen when spoken to
  • Easily distracted
• Hyperactivity & Impulsivity:
  
  • Figeting/Tapping
  • Unable to remain seated
  • Run about/climbs in inappropriate situations
  • Interrupts often

[Diagnostic criteria]

• Persistent pattern of inattention + Hyperactivity & Impulsivity
  
  • Inattention – >6 symptoms for at least 6/12
  • Hyperactivity & Impulsivity – >6 symptoms for at least 6/12
• Symptoms start in childhood <7yrs
• Functional impairment across 2 domains at school + home

[Investigations]

• Clinical diagnosis:
  
  • Diagnostic symptoms
  • Conners assesment scale
• Full clinical & Psychosocial assesment – Observer/School reports

[Management]

• Specialist referall to CAMHS
• If adult –> Psychiatrist
• Patient & Parent education
• Balanced diet & good nutrition & Regular exercise
• If severe – Methylphenidate (Stimulants)

Question 96

A patient presents with the following Hx, what is the most likely diagnosis? What are the differentials?

A 7-year-old boy is brought to the doctor because of academic difficulty at school and behavioural problems that first came to attention in preschool when the teacher was concerned about impulsive aggression. His mother reports that at home he runs around all day, needs multiple requests to pick up his toys, and can only sit still for a few seconds before ‘growing bored’. A teacher’s note states that he jumps queues, distracts his classmates, and loses his homework assignments, but appears bright and is able to finish his work when he is given individual supervision. His mother is concerned because other children are teasing him for being stupid. However, she reports that he is a sweet and motivated boy who does not talk back to teachers or adults and does not bully anybody. In the surgery, he is jumping up and down in the chair despite multiple requests by his mother to sit still. She notes that his 15-year-old brother was also hyperactive when he was younger and has persistent academic problems.

Answer 96

• ADHD
• Thyroid disease
• Depression
• Anxiety
• Substance abuse

Question 97

A patient presents with the following Hx, what is the most likely diagnosis? What are the differentials?

A 12-year-old girl presents to her general practitioner because of problems with school performance. She attends a large school, and her teacher has reported that she has not been turning in her homework and she is falling behind in maths. Her father hired a tutor and she seems to respond well to individual instruction, but cannot apply the lessons learned at school. In the surgery, it is noted that she is sitting calmly but is constantly fiddling with her mobile phone and is distracted by the toys in the room. She says that she does fine on tests but has difficulty focusing on homework. She still maintains an active social life and reports that her mood is fine.

Answer 97

• ADHD
• Thyroid disease
• Depression
• Anxiety
• Substance abuse

Question 98

What are the criteria for dependence?

Answer 98

At least 3 in the last 12 months:

1. Increased tolerance
2. Loss of control of substance use
3. Narrowing of drinking repertoire
4. Reinstatement despire knowing its harmful
5. Difficulty/Failure of abstinence
6. Withdrawal leads to - Sweats/Nausea/Tremor
7. Often aware of compulsion to use drug

Question 99

What is alcohol abuse?

You are asked to take a Hx from a patient with a Hx of alcohol abuse, how would you go about this?

Answer 99

Repeated drinking that harms the persons work/social life

Signs of dependence:

• Increased tolerance
• Loss of control of substance use
• Narrowing of drinking repertoire
• Reinstatement despire knowing its harmful
• Difficulty/Failure of abstinence
• Withdrawal leads to - Sweats/Nausea/Tremor
• Often aware of compulsion to use drug

[Screening tools]

• CAGE
  
  • Have you felt the need to CUT down on your drinking?
  • Have people ANNOYED you by critisizing your drinking?
  • Have you ever felt bad/GUILTY about your drinking?
  • Have you ever had a drink 1st thing in the morning to steady your nerves/get over the hangover (EYE OPENER)
• >2 considered clinically significant

Question 100

How is alcohol abuse managed?

Answer 100

• Ask patient if they want to change
• Treat coexisting depression if present
• Self help/Group therapy

Question 101

What are the effects of alcohol abuse?

Answer 101

• Liver – AFLD/Hepatitis/Liver failure
• CNS – Poor memory/cognition/Wernickes/Korsakoffs
• Gut – D&V/Peptic ulcer/Varices/Pancreatitis
• Hear – Arrythmia/HTN/Cardiomyopathy
• MSK – Osteoporosis risk due to disrupted Ca metabolism

Question 102

What are the effects of alcohol withdrawal?

How is this managed?

Answer 102

Delirium tremens:

• Increased pulse
• Decreased BP
• Tremor
• Fits/Seizures
• Visual/Tactile hallucinations

[Management]

• Monitor observations
• Diazepam for 3 days then wean – To prevent seziures
• Pabrinex - Thiamine

Question 103

What is Wernickes encephalopathy?

What is Korsakoffs syndrome?

Answer 103

[Wernickes]

• Thiamine B1 deficiency - due to:
• Deceased dietary intake of thiamine
• Decreased absorption of thiamine from GIT + Utilisation in cells

Symptoms:

• Confusion
• Wide based gait ataxia
• Opthalmoplegia – Nystagmus + Bilateral Lateral rectus palsy

Management:

• High dose Pabrinex for 1 week IV/IM
• Followed by oral supplementation
• Glucose

[Korsakoffs syndrome]

• Complication of untreated wernickes encephalopathy
• Leads to Hypothalamus damage + Cerebral atrophy

Symptoms:

• Inability to acquire new memories
• Confabulation - invented memory due to retrograde amnesia
• Lack of insight + apathy

Management:

• May be reversible with supplemental thiamine
• May be permanent requiring institutional care

Question 104

You are asked to explain generalised anxiety disorder to a patient, how would you do this?

Answer 104

[Introduction]

• I will be explaining to you the following:
  
  • Causes
  • Who gets it?
  • Symptoms/Signs
  • Diagnostic criteria
  • Investigations
  • Management

[Causes]

• Syndrome of ongoing anxiety + worry about thoughts/events - No identifiable trigger
• Patient recognises that the worry & anxiety is inappropriate
• Can be chronic & disabling
• Can be due to:
  
  • Increased minor stressors in life
  • Presence of physical/emotional trauma
  • Genetic factors
  • Bullying/peer victimisation

[Who gets it?]

• Women > Men
• May have onset in childhood/adolsecence
• FHx of anxiety
• Hx of physical/emotional trauma
• Co-morbid depression

[Diagnostic criteria]

• At least 3 symptoms for 6/12:
  
  • Excess anxiety + worry more days than not - Concerns wide range of events/activities
  • Difficulty controlling worry
  • Poor concentration
  • Irritability
  • Sleep disturbance
  • Restless/Nervous
• AND at least 4 of the following:
  
  • Autonomic arousal symptoms
  • Chest/abdominal symptoms
  • Symptoms involving mental state
  • General symptoms

[Investigations]

• Clinical diagnosis
• TFTs – Normal
• Urine drug screen – Negative
• ECG – Normal
• BP – Normal

[Management]

• Patient education
• Low intensity psychological support
• CBT
• Drug treatment:
  
  • SSRI – Escitalopram/Paroxetine
  • SNRI – Venlafaxine
• If immediate management – Clonazapam/Diazepam
• If complex/Treatment refractory:
  
  • Medication
  • Psychological treatment
  • Crisis intervention

Question 105

A patient presents with the following Hx, what is the most likely diagnosis? What are the differentials?

A 25-year-old woman presents to her general practitioner with complaints of muscle tension, especially in her shoulders and neck, contributing to tension headaches. She describes decreased sleep, chronic fatigue and constant restlessness in addition to poor concentration at work, with repeated run-ins with her co-workers. She has been a worrier since childhood, with worsening bouts when under stress; currently she reports having a hard time controlling her worry, which extends into several topics. Physical examination reveals a healthy, tense woman with normal vital signs and generalised muscular tension. She does not abuse substances, and medical history is unremarkable.

Answer 105

• Generalised Anxiety disorder
• Panic disorder
• PTSD
• OCD
• Social phobia

Question 106

You are asked to explain a diagnosis of PTSD to a patient, how would you go about doing this?

Answer 106

[Introduction]

• I will be explaining to you the following:
  
  • Causes
  • Who gets it?
  • Symptoms/Signs
  • Diagnostic criteria
  • Investigations
  • Management

[Causes]

• Develops folloing a stressful event/situation of exceptionally threatening/catastrophic naure
• Likely to cause pervasive stress in anyone
• Anterior cingulate area fails to inhibit the amygdala, so there is decreased amygdala threshold to fearful stimuli
• Increased adrenaline produced in HPA axis

[Who gets it?]

• Increased in inner cities/disaster zones
• Military personnel/Emergency services/Police
• Can also occur in post natal period
• Female > Males

[Symptoms/Signs]

• Intrusions – Flashbacks/dreams & nightmares/Intrusive images
• Avoidance – People/situations/circumstances that resemble the event
• Negative alteration to mood & cognition – Feeling alienated/diminished interest in activities
• Altered arousal & reactivity – Hypervigilance/Exaggerated startle response
• Emotional detachment from others
• Amnesia regarding important aspects of the trauma

[Diagnostic criteria]

4 symptoms present for at least 4 weeks:

• Intrusions – Flashbacks/dreams & nightmares/Intrusive images
• Avoidance – People/situations/circumstances that resemble the event
• Negative alteration to mood & cognition – Feeling alienated/diminished interest in activities
• Altered arousal & reactivity – Hypervigilance/Exaggerated startle response
• Emotional detachment from others
• Amnesia regarding important aspects of the trauma

[Investigations]

• Clinical diagnosis

[Management]

• Manage anxiety
  
  • Beta blockers
  • Clonidine (Alpha antagonist)
• Long term management:
  
  • CBT
  • EMDR (Eye movement desensitisation & reprocessing)
  • SSRI
  • TCA

Question 107

A patient presents with the following Hx, what is the most likely diagnosis? What are the differentials?

A 25-year-old woman presents to the accident and emergency department complaining of sad mood, nervousness, difficulty falling asleep, and disinterest in her friends for the past 2 months. She notes these symptoms started following a rape by a former male friend after a party. She appears visibly uncomfortable when asked further questions about the attack. The patient has disclosed the incident to some of her peers, but did not report it to authorities. She reports nightmares about the rape, concerns for her safety, difficulties in intimate relationships with men, and repeated avoidance of non-dangerous situations reminding her of the assault.

Answer 107

• PTSD
• Depression
• Specific phobia
• Acute stress reaction (Symptoms <1month)
• Psychosis
• personality disorder

Question 108

A patient presents with the following Hx, what is the most likely diagnosis? What are the differentials?

A 35-year-old male combat veteran presents with symptoms of poor sleep, crying episodes, flashbacks, and nightmares. He also reports that his marriage and friendships have been suffering, in addition to poor work performance. When in a bad mood, he tends to smoke cigarettes and drink alcohol. He has tried to overcome these symptoms on his own, but has been largely unsuccessful and now recognises a need for formal help. He speaks openly about his experiences and recognises a direct connection between his combat exposure and current symptoms.

Answer 108

• PTSD
• Depression
• Specific phobia
• Acute stress reaction (Symptoms <1month)
• Psychosis
• personality disorder

Question 109

You are asked to explain to a patient the drug Lithium, how will you go about doing this?

Answer 109

Layout:

• Check what the patient knows
• Brief history
• Do they know what the drug is?
• Indication & Action of the drug
• Side effects
• How to take it
• Monitoring requirements

[Indication & Action of the drug]

• Indication
  
  • Bipolar affective disorder
  • Schizoaffective disorder
  • Cyclothymia
  • Impulse control & Intermittent explosive disorders
• Action:
  
  • The precise mechanism of action of Li+ as a mood-stabilizing agent is currently unknown.
  • Lithium has been found to exert a dual effect on glutamate receptors, acting to keep the amount of glutamate active between cells at a stable, healthy level, neither too much nor too little.
  • It is postulated that too much glutamate in the space between neurons causes mania, and too little, depression
  • Effective in long term prophylaxis of both mania + depressive episodes

[Side effects]

• GI distress
• Reduced appetite
• Nausea & Vomiting
• Diarrhoea
• Fine tremor - intention tremor
• Hair loss
• Acne
• Polydipsia
• Polyuria -> Secondary to ADH antagonism

Long term effects:

• Chronic renal failure
• Clinical/subclinical hypothyroidism
• Diabetes insipidus
• Cardiac arrhythmia
• Leukocytosis - elevated WCC count
• Reduced seizure threshold
• Cognitive slowing

Toxicity

• Moderate - Blurred vision/Clonic limb movements/Anorexia/Delirium.Syncope
• Severe - Generalised convulsions/Oliguria/Renal failure

[How to take it]

• Tablet

[Monitoring requirements]

• Before starting
  
  • FBC - Increase WCC
  • U&E - gradual increase in creatinine (Kidney function affected)
  • TFTs
  • Weight + BMI
  • ECG
  • Check for pregnancy
    
    • Teratogenic in 1st trimester
• Monitoring Lithium levels
  
  • Steady state achieved after 5 days
  • Blood sample taken 12hrs after last dose (Trough level)
  • Therapeutic range - 0.6-1.2 mmol/L
• Once stable check:
  
  • Weekly for 1/12
  • Monthly for 6/12
  • 3 monthly
  • TSH and Creatinine levels every 6 months

Question 110

You are asked to explain to a patient the drug Sodium Valproate (Depakote), how will you go about doing this?

Answer 110

Layout:

• Check what the patient knows
• Brief history
• Do they know what the drug is?
• Indication & Action of the drug
• Side effects
• How to take it
• Monitoring requirements

[Indication & Action]

Indications

• Seizure prophylaxis in epilepsy
• Status epilepticus not responding to benzodiazepines
• Bipolar disorder - acute treatment of manic episodes and prophylaxis against recurrence

Action

• Weak inhibitor of neuronal Na channels - stabilising resting membrane potentials & reducing neuronal excitability
• Increases brain content of GABA - inhibitory NT (Involved in regulation of neuronal excitability

[How to take it]

• Take in 1-3 divided doses
• Comes as tablet/granules/oral solutions/IV infusion
• Reduce GI upset by taking it with food

[Important SE]

• GI Upset
• Nausea/Gastric irritation/diarrhoea
• Neurological & psychiatric effects
• Tremor/ataxia/behavioural disturbances
• Thrombocytopenia + platelet dysfunction
• Transient increase in liver enzymes

Severe rare SE:

• Severe liver injury - chemical hepatitis
• Pancreatitis
• Bone marrow failure
• Anti-epileptic hypersensitivity syndrome

Complications/Contraindications

• Avoid in:Women of childbearing age - conception & 1st trimester
• Increased risk of foetal abnormalities - NT defects/Craniofacial/Cardiac & limb abnormalities
• Also risk of developmental disorders - ADHD/ASD
• Note: If pregnancy can not be avoided - Folic acid 5mg daily
• Hepatic impairment
• Severe renal impairment

Special info

• Signpost to seek urgent medical advice, for unexpected symptoms
• Lethargy/Loss of appetite/vomiting/abdominal pain - Signs of liver poisoning
• Bruising/high temperature/mouth ulcers - Indicates blood abnormalities

[Monitoring requirements]

• Monitor by comparing seizure frequency before + after starting treatment
• Monitor safety
• Measure LFTs + PT time
• Pregnancy test
• Before starting
• During first 6 mo of treatment
• Measure Plasma valproate levels
• Check for adherence/toxicity

Question 111

You are asked to explain to a patient the drug Typical Antipsychotics (Haloperidol/Chlorpromazine/Fluphenazine), how will you go about doing this?

Answer 111

Layout:

• Check what the patient knows
• Brief history
• Do they know what the drug is?
• Indication & Action of the drug
• Side effects
• How to take it
• Monitoring requirements

[Indication & Action of the drug]

Indication

• Psychomotor agitation - causing dangerous/violent behaviour/calm patients to permit assessment
• Schizophrenia
• Bipolar disorder - Mania/Hypomania
• Nausea & vomiting

Actions:

• Blocks post synaptic D2 (Dopamine) receptors
• Note: Dopaminergic pathways:Mesolimbic (Positive symptoms) Midbrain -> Limbic system
  
  • Where positive symptoms come from - Hallucinations/Delusions/Thought disorders
  • Too much dopamine
• Mesocortical pathways (Negative symptoms)Midbrain -> Frontal cortex
  
  • Where Negative symptoms & cognitive disorders come from
  • Too little dopamine
• Nigrostriatal pathway
  
  • Substantia nigra -> Corpus striatum of basal ganglia
  • Involved in movement regulation
  • Dopamine hyperactivity -> Parkinsonian movements
• Tuberohypophysial pathway Hypothalamus -> Pituitary gland
  
  • Dopamine inhibits/regulates Prolactin release
  • Blocking dopamine here -> Predisposed to hyperprolactinemia (Gynecomastia/galactorrhoea/decreased libido/menstrual dysfunction)

[Side effects]

• Extrapyramidal SE Movement abnormalities from D2 blockage of Nigrostriatal pathway
• Acute dystonic reactions - involuntary parkinsonisms/muscle spasms
• Akathisia - state of inner restlessness
• Neuroleptic malignant syndrome* (Rare but life threatening)
  
  • Muscle Rigidity
  • Confusion
  • Autonomic dysregulation
  • Hypethermia
  • HTN + Tachycardia
  • Hyper-reflexia
  • Tremor
  • Agitation & irritability
  • Sweating
  • Pyrexia
  • Confusion
  • Elevated FBC & LFTs
• Tardive dyskinesia (Late effect)
  
  • Pointless movements
  • Involuntary & repetitive movements (Lip smacking)
• Drowsiness
• Hypotension
• Prolonged QT interval - Risk of Torsades des Pointes
• Erectile dysfunction
• Weight gain
• Hyperprolactinemia
• Menstrual disturbance
• Galactorrhoea
• Breast pain

Complications/Contraindications

• Neuroleptic malignant syndrome
• C/I:
  
  • Dementia - increased risk of stroke & death
  • Parkinsons disease - EP effects

[How to take it]

• Tablet or Depot injection (Every 2-4wks)
  
  • Oral (Tablet/Liquid)
• Slow release IM depot injection
• Long term treatment - to stop symptoms from returning
• If aggression (Psychomotor agitation) - Single dose to manage patient
  
  • Takes several days/weeks for the effects to take place

[Monitoring requirements]

• Regular review of symptoms & signs
• ECG - before starting, assess QT interval

Question 112

What is Neuroleptic malignant syndrome?

How is it managed?

Answer 112

Neuroleptic malignant syndrome* (Rare but life threatening S/E of antipsychotics)

• Muscle Rigidity
• Confusion
• Autonomic dysregulation
• Hypethermia
• HTN + Tachycardia
• Hyper-reflexia
• Tremor
• Agitation & irritability
• Sweating
• Pyrexia
• Confusion
• Elevated FBC & LFTs

Complications:

• Rhabdomyolysis
• Hyperkalaemia
• Kidney failure
• Seizures
• Potentially fatal

Management

• Discontinue medication
• ICU - may require circulatory/ventilator support
• Active cooling
• Dantrolene/Bromicriptine/Amantadine for rigidity
• Benzodiazepines for agitation
• May require aggressive IV hydration with Diuresis

Question 113

You are asked to explain to a patient the drug Atypical Antipsychotics (Quetiapine/Olanzepine/Risperidone/Aripiprazole/Clozapine), how will you go about doing this?

Answer 113

Layout:

• Check what the patient knows
• Brief history
• Do they know what the drug is?
• Indication & Action of the drug
• Side effects
• How to take it
• Monitoring requirements

[Indication & Action of the drug]

• Urgent management of psychomotor agitation
• Schizophrenia
• When EP symptoms are a problem on 1st generation medications
• If negative symptoms are prominent
• Bipolar disorder - Mania & Hypomania

Actions:

• Blocks post synaptic D2 receptors
• Main effects are on the mesolithic & mesocortiyal pathways
• Note: Dopaminergic pathways:Mesolimbic + Mesocortical pathways
• Midbrain -> Limbic system/frontal cortex
• Antipsychotics block the D2 pathway here
• Nigrostriatal pathway
• Substantia nigra -> Corpus striatum of basal ganglia
• Tuberohypophysial pathway Hypothalamus -> Pituitary gland
• activity in these pathways cause the SE of the antipsychotics
• Also Serotonin antagonists
• More effective in treating treatment resistant schizophrenia & against the negative symptoms
• Decreased risk of EP symptoms - Due to higher affinity for other receptors

[Side effects]

• Extrapyramidal SE (Lesser degree than typical) Movement abnormalities from D2 blockage of Nigrostriatal pathway
• Acute dystonic reactions - involuntary parkinsonisms/muscle spasms
• Akathisia - state of inner restlessness
• Neuroleptic malignant syndrome* (Rare but life threatening)
• Muscle Rigidity
• Confusion
• Autonomic dysregulation
• Hypethermia
• HTN + Tachycardia
• Hyper-reflexia
• Tremor
• Agitation & irritability
• Sweating
• Pyrexia
• Confusion
• Elevated FBC & LFTs
• Tardive dyskinesia (Late effect)
• Pointless movements
• Involuntary & repetitive movements (Lip smacking)
• Sedation
• Metabolic disturbance
• Increased weight - BMI/Waist circumference
• Increased lipids
• DM
• Prolonged QTc interval
• Risk of Torsades des Pointes

[Complications/Contraindications]

Use with caution in patients with:

• Cardiovascular disease
• Severe heart disease

Avoid Clozapine in patients with:

• Severe heart disease
• Neutropenia - Agranulocytosis

[How to take it]

• Tablet daily
• Depot injections every 2-4 weeks, slow release
• Best taken at bed time
• Start with small doses - titrate up over 1-2wks depending on response
• Long term treatment to stop symptoms from returning
• Effects take several days/weeks to manifest

[Monitoring requirements]

• Assessment of symptoms & signs
• Testing at start of treatment & Periodically after
  
  • FBC
  • U&E
  • LFTs
  • Serum Prolactin
• Note if patient is on Clozapine:Monitoring is weekly
• Due to risk of Agranulocytosis (Decreased WCC - neutrophils)
• Risk of Myocarditis

Monitor for metabolic and Cardiovascular SE:

• Fasting blood glucose & HbA1c
• Lipid profile
• Weight & BMI
• ECG - assess QT interval
• Risk of Torsades des Pointes

Question 114

You are asked to explain to a patient the drug Anti-dementia drugs (Donepezil + Rivastigmine + Galantamine), how will you go about doing this?

Answer 114

Layout:

• Check what the patient knows
• Brief history
• Do they know what the drug is?
• Indication & Action of the drug
• Side effects
• How to take it
• Monitoring requirements

[Indications & Action]

Indications:

• Mild to moderate Alzheimers disease
• Mild to moderate dementia with PD (RIVASTIGMINE)

Actions:

• Acetylcholine is important NT in the CNS - essential for learning & memory
• Decrease in activity of the brains cholinergic system seen in AZD and Dementia associated with PD
• Drugs inhibit the cholinesterase enzymes (Enzyme that breaks down ACh) in the CNS
• Increased availability of ACh for neurotransmission - improves cognitive function & reduces rate of cognitive decline
• Recovery of function is not guaranteed however - aim is to improve memory and brain function, but may only slow decline

[How to take it]

• Available as tablet/capsule/liquid
• Rivastigmine available as a patch - if swallowing difficulties
• Donepezil - to be taken at night before bed
• If patient experiences vivid dreams - best taken in the morning

[Important SE]

• Nausea & Diarrhoea
• vomiting
• Due to increased cholinergic activity in PNS
• Patients with asthma or COPD - may have exacerbation of symptoms

Serious SE:

• Peptic ulcers & bleeding
• Bradycardia & Heart block
• Central cholinergic effects
• Hallucinations
• Altered/aggressive behaviour
• Extrapyramidal symptoms & Neuroleptic malignant syndrome

[Complications/Contraindications]

Use with caution in:

• Asthma & COPD
• Risk of developing peptic ulcers

Avoid in:

• Heart block
• Sick sinus syndrome
• Rivastigmine can worsen tremor in PD

[Monitoring requirements]

• Reviewed for adverse effects 2-4 weeks after starting treatment
• 3 months later - repeat cognitive assessment to assess efficacy
• Continue treatment only where there is improvement in symptoms (Cognitive/functional/behavioural

Special info

• Signpost to see doctor if:
  
  • Abnormal movements
  • Agitated or aggressive behaviour
  • Reversible SE by reducing dose or stopping treatment
  • Rivastigmine is best for patients with poly pharmacy as it has no drug interactions

Question 115

You are asked to explain to a patient the drug Anti-dementia drugs (Memantine), how will you go about doing this?

Answer 115

[Indication & Action of the drug]

• Moderate to severe dementia in alzheimers disease

Action

• In AD there is increased Glutaminergic neurotransmission
• Causing hyper excitation of neurons - leading to toxicity
• Memantine acts as an antagonist to the glutamate receptors
• Binds to the receptors and inhibits excessive neuronal excitation
• Therefore stopping the excitotoxicity

[Side effects]

Anticholinergic drugs decrease the effect of the AChE-Inhibitors

e.g. Benzodiazepines/Antipsychotics/Warfarin/TCAs

SE are due to increased cholinergic activity

• Nausea/vomiting/diarrhoea
• Insomnia/Dizziness
• Urinary incontinence
• Can cause bradycardia

Note: Donepezil is thought to have lower SE frequency

• In patients with CVD/Polypharmacy -> Rivastigmine