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The Patient (Y3-2) > Mental health + Parkinsons > Flashcards

Mental health + Parkinsons Flashcards

1
Q

How is schizophrenia seen in an MRI scan of the brain?

A

Ventricular dilation due to loss of brain tissue

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2
Q

What are the three main types of symptoms in schizophrenia?

A

Cognitive
Positive
Negative

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3
Q

State some positive symptoms of schizophrenia

A

Hallucinations
Delusions
Disorganised speech

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4
Q

State some negative symptoms of schizophrenia

A

Reduced motivation
Reduced emotion
Lack of interest
Lack of pleasure

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5
Q

State some cognitive symptoms of schizophrenia

A

Lack of attention

Lack of working and verbal memory

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6
Q

What are the four dopaminergic pathways in the brain?

A

Mesolimbic
Mesocortical
Nigrostriatal
Tuberoinfundibular

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7
Q

What is the mesolimbic pathway associated with?

A

Mediates pleasure, reward, motivation
Hyperactivity of dopamine mediates positive psychotic symptoms
D2 antagonists treat positive symptoms

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8
Q

What is the mesocortical pathway associated with?

A

Cognitive function, emotion

Decreased dopamine responsive for negative symtpoms

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9
Q

What is the nigrostriatal pathway associated with?

A

Motor control

Parkinsonian symptoms

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10
Q

What is the tuberoinfundibular pathway associated with?

A

Inhibition of prolactin release

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11
Q

Malfunction in which brain circuit are cognitive symptoms associated with?

A

Dorsolateral prefrontal cortex

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12
Q

What is the dopamine theory for schizophrenia?

A

Increased dopamine in subcortical pathways -> psychotic symptoms
Agonists of dopamine e.g. amphetamine induce psychotic symptoms

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13
Q

What is the glutamate theory of schizophrenia?

A

NMDA hypofunction is induced by genetic and non-genetic factors instilled in the brain in early development triggers psychosis in adulthood.
NMDA antagonist phencyclidine lead to positive, negative, cognitive and affective symptoms

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14
Q

Which of the two classes of antipsychotics causes most EPS?

A

Typicals

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15
Q

Name a typical antipsychotic

A

Haloperidol

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16
Q

Name an atypical antipsychotic

A

Clozapine

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17
Q

What are the major side effects of atypicals?

A

Weight gain
CVD
Diabetes

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18
Q

Which class of antipsychotics is ineffective at managing negative symptoms?

A

Typical

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19
Q

Which class of antipsychotics is associated with motor side effects and why?

A

Typicals because they have high affinity for dopamine D2 receptors not only in areas needed but else where so can affect motor function and cause tardive dyskinesia

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20
Q

What percentage of receptor occupancy is required for effective antipsychotic effect?

A

> 65%

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21
Q

What is the effect of >78% D2 receptor occupancy?

A

EPS

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22
Q

What is the effect of over 70% D2 receptor occupancy?

A

Hyperprolactinaemia

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23
Q

Which antipsychotic is associated with most weight gain?

A

Olanzapine

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24
Q

What are the treatment options for a schizophrenic patient in the prodromal phase?

A

Offer CBT +/- family intervention. Do not offer antipsychotic

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25
Q

What are the treatment options for patient with first episode of schizophrenia?

A

Offer antispsychotic in conjunction with CBT after ruling out other causes of symptoms

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26
Q

How is a subsequent actue episode of schizophrenia treated?

A

Treated as first episode schizophrenia. May need to switch therapy e.g. from typical to atypical

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27
Q

What is “treatment resistant schizophrenia” defined as and how is it treated?

A

Schizophrenia resistant to treatment with two different antipsychotics, one of which being an atypical

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28
Q

What are the 4 different types of EPSE?

A

Pseudo-parkinsonism
Akathisia
Dystonia
Tardive dyskinesia

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29
Q

Which type of EPSE are anticholinergics not useful for?

A

Akathisia and tardive dyskinesia

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30
Q

What side effects are associated with clozapine?

A 
VTE
Constipation 
Sedation 
Hypersalivation 
Myocarditis and cardiomyopathy 
neutropenia and agranulocytosis 
Metabolic syndrome
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31
Q

Describe the pathophysiology of Parkinson’s disease

A

Chronic, progressive neurodegenerative disease
Degeneration of dopaminergic neurones in the nigro-striatal pathway
Presence of Lewy bodies in neurones
Changes in GABA glutamate pathway

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32
Q

What are the motor symptoms associated with Parkinson’s disease?

A

Tremor
Rigidity
Bradykinesia

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33
Q

List some non-motor symptoms associated with Parkinson’s

A 
Swallowing and speech problems 
Constipation 
Urinary problems 
Drooling, loss of smell
Lewy body dementia
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34
Q

When should drug treatment be initiated in Parkinson’s?

A

When motor symptoms affect patients ability to function on a daily basis

35
Q

What does drug treatment for Parkinson’s aim to do?

A

Increase dopamine levels in the brain

36
Q

What are the main 3 initial treatment options for parkinson’s disease?

A

Levodopa - most effective
MAO-B inhibitor
Dopamine agonists

37
Q

Why does levodopa need to be combined with dopa-decarboxylase?

A

To prevent the peripheral metabolism of levodopa to dopamine

38
Q

Name a MAO-B inhibitor

A

Rasagiline

39
Q

How do MOA-B inhibitors work?

A

Inhibit the metabolism of dopamine -> increase of dopamine at receptors

40
Q

What are the two classes of dopamine agonists used in Parkinson’s?

A

Ergot and non-ergot

41
Q

What are some of the side effects associated with dopamine agonists?

A

Sudden sleep onset
N + V
rarely, dopamine dysregulation syndrome (gambling, hypersexuality, binge eating)

42
Q

Which drug are COMT inhibitors used in combination with and how do they work?

A

Levodopa. They prevent the metabolism of levodopa to 3-O-methyldopa

43
Q

Name a COMT inhibitor

A

Entacapone

44
Q

Which class of drugs in Parkinson’s disease is avoided in elderly due to risk of falls

A

Anticholinergics

45
Q

In which circumstances is duodopa used?

A

For PD with severe motor fluctuations and dyskinesia

46
Q

How is duodopa administered?

A

It is an intestinal gel administered using pump via PEG tube i.e. invasive

47
Q

Which dopamine agonist can be given as a subcut injection?

A

Apomorphine - useful for on-off fluctuations

48
Q

How can early morning bradykinesia in PD be treated?

A

Dispersible levodopa taken on wakening or night-time dose of dopamine agonist or MR levodopa

49
Q

How can dyskinesia be treated in PD?

A

Reduce levodopa dose

Add amantadine

50
Q

What is amantadine used for in PD?

A

Treatment of dyskinesia in late disease. It is a glutamate antagonist at NMDA receptor

51
Q

Which drug in the treatment of bipolar disorder can’t be used in mania?

A

Lamotrigine

52
Q

Which drug in the treatment of bipolar disorder can’t be used in women of child-bearing potential?

A

Valproate

53
Q

Can lithium be used in pregnancy?

A

Yes - sometimes taking pregnant woman off lithium can lead to them becoming manic during pregnancy so plan needs to be made

54
Q

How often do lithium levels need to be taken?

A

12hrs post dose, check weekly until stable then 3 monthly for first year

55
Q

How is lithium cleared?

A

Kidneys so can lead to nephrotoxicity

56
Q

What is the maximum level of lithium that should be given?

A

1mmol/l

Ideally range of 0.4-0.8mmol/l

57
Q

Which class of antidepressants interacts with tyramine (found in cheese)?

A

Monamine oxidase inhibitors

58
Q

What is the monoamine hypothesis in depression?

A

Depressive disorders are due to a depletion and mania to an excess provision of monoamine neurotransmitters at one or more CNS sites
Antidepressants correct this depletion by increasing the availability of monoamines at post-synaptic receptors

59
Q

When taking antidepressants, the effects on transmitters are immediate and antidepressant effects take several weeks to arise. Why?

A

Because when you first start taking antidepressants, transporters are blocked. This increases serotonin around the cell body which increases the activation of autoreceptors. This then reduces cell firing and reduces the release of serotonin. This is the opposite to what you want. However, after taking antidepressants for a few weeks, there is chronic activation of the autoreceptors and they become downregulated.
Inhibition on cell-firing is lost so cell-firing is increased

60
Q

What is the first line class of antidepressants?

A

SSRIs

61
Q

Name a SSRI

A

Sertraline
Citalopram
Fluoxetine

62
Q

Name a SNRI

A

Venlafaxine

63
Q

Which antidepressant drug can be used if first-line doesn’t work?

A

Mirtazapine - considered to be a better tolerated antidepressant

64
Q

Which two side effects are linked to mirtazapine?

A

Sedation

Weight gain

65
Q

Which class of antidepressants does amitriptyline belong to?

A

Tricyclics

66
Q

Which class of antidepressants requires strict dietary requirements?

A

Monoamine oxidase inhibitors - cannot eat food containing tyramine

67
Q

How long does it take for improvement in depressive symptoms to take place after starting an antidepressant?

A

4 weeks for full effect, 6 weeks in the elderly

68
Q

What is the most common combination of antidepressants?

A

mirtazapine and venlafaxine

69
Q

Antipsychotics can be used on their own in depression. True or false?

A

False

70
Q

What is meant by augmentation in depression?

A

Adding lithium or an antipsychotic e.g. olanzapine

71
Q

Is St John’s Wort recommended in depression?

A

No

72
Q

How is antidepressant treatment stopped?

A

Continued for 6 months after patient gets better at the dose they got better at. May need to continue for longer depending on history, side effects and risk of relapse. Then gradual reduction needed to prevent discontinuation symptoms

73
Q

What are the 7 adverse effects of clozapine?

A 
VTE 
Sedation 
Hypersalivation 
Constipation 
Myocarditis and cardiomyopathy
Metabolic syndrome
Neutropenia and agranulocytosis
74
Q

How are myocarditis and cardiomyopathy treated?

A

Stop treatment and refer

75
Q

How are myocarditis and cardiomyopathy monitored?

A

Daily RR, pulse, BP and temp

Weekly FBC, CRP, ECG

76
Q

How are neutropenia and agranulocytosis monitored?

A

Flu-like symptoms

77
Q

How many brands of clozapine are there and can the patient switch between them?

A

3 brands - bioequivalent so yes can switch without dose adjustment

78
Q

Does the risk of agranulocytosis increase or decrease with prolonged clozapine use?

A

Decreases

79
Q

Describe the traffic light system for dispensing clozapine

A

Red - stop, FBC daily until stable
Amber - continue but monitor FBC twice weekly
Green - dispense

80
Q

How often are FBC needed for clozapine?

A

1 weely for first 18 weeks, fortnightley for 34 weeks. Monthly until stopped

81
Q

How much clozapine can be dispensed in weekly FBC monitoring?

A

10 days from last blood count

82
Q

How much clozapine can be dispensed in fortnightly FBC monitoring?

A

21 days from last blood count

83
Q

How much clozapine can be dispensed in monthly FBC monitoring

A

42 days from last blood count

84
Q

What does the patient need to be told if they miss a dose of clozapine?

A

If missed for more than 48hrs, re-titrate dose, can’t continue maintenance
If missed more than 3 days, blood test frequency may need to be changed

The Patient (Y3-2) (8 decks)

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