Neurocognitive d/o and psychiatric emergencies Flashcards
Neurocognitive disorders definition
Primary cognitive deficit is ACQUIRED, not developmental
Delerium definition
Disturbance (different from baseline) in attention, awareness, develops over hrs to days, may have additional disturbances to memory, orientation, language, perception, etc.
Not explained by another condition.
Most common cause of delerium
Infection -
Clinical pearl for you - If you see altered mental state in a senior - GET A URINALYSIS - UTI is a VERY common cause.
Delerium epidemiology - who is at risk?
> 85 years - nursing homes, end of life.
10-30% in older ED pts - represents a medical illness.
Hospitalized patients - associated with worse outcomes.
Kinds of delerium (specifiers)
Substance intox
Substance withdrawl (delerium tremens)
acute
persistent (wks to months)
Evaluation of a delerious patient
Interview family/caregiver to assess baseline.
CBC, CMP, UA, tox screen, cardiac enzymes, ABG, CXR, EKG.
Consider CT/MRI and LP to evaluate for medical causes.
Dementia - how is it different from delerium and normal age-related changes?
Dementia is CHRONIC, IRREVERSIBLE, and distinctly different (worse) than normal age-related changes.
What do we call dementia-like disorder in younger adults?
Neurocognitive Disorder
Most common form of dementia
Alzheimer’s
Goal of treatment in dementia
Once function is lost, it’s not coming back. You want to maintain function, not cure.
Major neurocognitive disorder
Significant cognitive deficits that interfere with DEPENDENCE IN EVERYDAY ACTIVITIES.
As always, not attributable to any other cause.
Mild, moderate, and severe Neurocognitive D/O definitions.
Mild: IADLs affected
Moderate: ADLS affected
Severe: Completely dependent
Alzheimer’s symptoms
Progressive memory loss, despite being alter. Inattention, language difficulties.
Alzheimer’s pathophysiology
Neurofibrillary tangles form due to neuron supportive tau protein failure leading to microtubule collapse. Changes may be visible on CT/MRI.
Alzheimer’s treatment
Cholinesterase inhibitors provide some benefit temporarily. Memantine, CAREGIVER SUPPORT.
If a patient has already attempted suicide, what should you do before treating their suicidal ideation?
Treat the mechanism of injury
Suicide epidemiology
Men use guns and rope. Women use drugs. Risk factors - Major psychiatric disorders, substance abuse, previous suicide attempts, impulsivity, living alone, unemployed or employed as a doctor, chronic illness, family hx of suicide.
Suicidal ideation presentation
Variable. “People would be better off if I was gone.” “I just wish I could go to sleep and never wake up,” Or may have a plan.
Assessment of a suicidal patient
Be direct.
Ask if they have a plan. Is it realistic? Have they prepared?
Management of a suicidal patient.
Admit. They can be held involuntarily for 72 hours. Constant 1:1 monitoring. Start antidepressents and treat medical complaints. Plan the discharge immediately.
“Contract for safety”
Not a legal document - the patient and you agree on a plan for what they will do if they get suicidal and sign it. It should be simple and have numbers to call (911, suicide hotline, relatives). If they won’t sign, try to get a verbal agreement.
Who should you ask about homicidal ideation?
Anyone with depression, schizophrenia, personality disorder, or suicidality. DOCUMENT THE CONVERSATION.
Tarasoff Ruling
Health professionals have a duty to warn the intended victim. This supercedes practitioner-patient confidentiality.
Treatment of the homicidal patient.
Common sense -
Immediate hospitalization. Treat underlying psych/medical conditions. Work with law enforcement to warn the victim.
Psychosis definition
A psychiatric emergency - Disturbance in the perception of reality, evidenced by hallucination, delusion, or thought disorganization - high risk for behavioral dysfunction.
Evaluation of a psychotic patient.
Stay safe!
Calm the patient. Give them time if they need it. Give them Haldol if you have to . Assess for hallucinations, delusions, thought content, etc.
Acute Psychosis Treatment
Immediate secure hospitalization. Long term, they will need a diagnosis of their true psychiatric condition and medication.
A couple of points on personal safety when you’re in the room with an acutely psychotic patient.
Stay calm. Don’t close the door. If they have a weapon, ask them to put it down instead of reaching for it. Most importantly - call security (or James).
Remember - “Be polite. Be professional, but have a plan to kill everyone you meet.”
