Neurocognitive d/o and psychiatric emergencies

Question 1

Neurocognitive disorders definition

Answer 1

Primary cognitive deficit is ACQUIRED, not developmental

Question 2

Delerium definition

Answer 2

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.

Question 3

Most common cause of delerium

Answer 3

Infection -

Clinical pearl for you - If you see altered mental state in a senior - GET A URINALYSIS - UTI is a VERY common cause.

Question 4

Delerium epidemiology - who is at risk?

Answer 4

> 85 years - nursing homes, end of life.

10-30% in older ED pts - represents a medical illness.

Hospitalized patients - associated with worse outcomes.

Question 5

Kinds of delerium (specifiers)

Answer 5

Substance intox
Substance withdrawl (delerium tremens)
acute
persistent (wks to months)

Question 6

Evaluation of a delerious patient

Answer 6

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.

Question 7

Dementia - how is it different from delerium and normal age-related changes?

Answer 7

Dementia is CHRONIC, IRREVERSIBLE, and distinctly different (worse) than normal age-related changes.

Question 8

What do we call dementia-like disorder in younger adults?

Answer 8

Neurocognitive Disorder

Question 9

Most common form of dementia

Answer 9

Alzheimer’s

Question 10

Goal of treatment in dementia

Answer 10

Once function is lost, it’s not coming back. You want to maintain function, not cure.

Question 11

Major neurocognitive disorder

Answer 11

Significant cognitive deficits that interfere with DEPENDENCE IN EVERYDAY ACTIVITIES.

As always, not attributable to any other cause.

Question 12

Mild, moderate, and severe Neurocognitive D/O definitions.

Answer 12

Mild: IADLs affected
Moderate: ADLS affected
Severe: Completely dependent

Question 13

Alzheimer’s symptoms

Answer 13

Progressive memory loss, despite being alter. Inattention, language difficulties.

Question 14

Alzheimer’s pathophysiology

Answer 14

Neurofibrillary tangles form due to neuron supportive tau protein failure leading to microtubule collapse. Changes may be visible on CT/MRI.

Question 15

Alzheimer’s treatment

Answer 15

Cholinesterase inhibitors provide some benefit temporarily. Memantine, CAREGIVER SUPPORT.

Question 16

If a patient has already attempted suicide, what should you do before treating their suicidal ideation?

Answer 16

Treat the mechanism of injury

Question 17

Suicide epidemiology

Answer 17

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.

Question 18

Suicidal ideation presentation

Answer 18

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.

Question 19

Assessment of a suicidal patient

Answer 19

Be direct.

Ask if they have a plan. Is it realistic? Have they prepared?

Question 20

Management of a suicidal patient.

Answer 20

Admit. They can be held involuntarily for 72 hours. Constant 1:1 monitoring. Start antidepressents and treat medical complaints. Plan the discharge immediately.

Question 21

“Contract for safety”

Answer 21

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.

Question 22

Who should you ask about homicidal ideation?

Answer 22

Anyone with depression, schizophrenia, personality disorder, or suicidality. DOCUMENT THE CONVERSATION.

Question 23

Tarasoff Ruling

Answer 23

Health professionals have a duty to warn the intended victim. This supercedes practitioner-patient confidentiality.

Question 24

Treatment of the homicidal patient.

Answer 24

Common sense -

Immediate hospitalization. Treat underlying psych/medical conditions. Work with law enforcement to warn the victim.

Question 25

Psychosis definition

Answer 25

A psychiatric emergency - Disturbance in the perception of reality, evidenced by hallucination, delusion, or thought disorganization - high risk for behavioral dysfunction.

Question 26

Evaluation of a psychotic patient.

Answer 26

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.

Question 27

Acute Psychosis Treatment

Answer 27

Immediate secure hospitalization. Long term, they will need a diagnosis of their true psychiatric condition and medication.

Question 28

A couple of points on personal safety when you’re in the room with an acutely psychotic patient.

Answer 28

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.”