Psych - Part 2 Flashcards
Dementia vs delirium
Dementia
- Slow and progressive
- Alert
- Thought poverty
- Non-reversible
Delirium
- Rapid
- Fluctuating
- Clouded consciousness
- Hallucinations
- Reversible
What is dementia
Global
Progressive
Intellectual deterioration
Without impaired consciousness
Alzheimer’s RFs
Family history Smoking Increasing age Head injuries Downs Hypercholesterolaemia
Alzheimer’s prognosis
8-10 years
Alzheimer’s S/S
Short-term memory impairment
Difficulty decision making
Less flexible
Inability to learn new information
Confusion
Personality changes
Mood changes
Sleep disturbances
Severe Alzheimer’s
Dysphagia
Weight loss
Urinary incontinence
Loss of speech
Dementia DDx
Depression Delirium Hypothyroidism Infection B12 and thiamine deficiency Drugs and alcohol Hypercalcaemia
Dementia screening tools
MMSE - Mini mental state exam 10-CS - 10-point cognitive screen 6CIT - 6-item cognitive impairment test GPCOG - General practitioner assessment of cognition AMTS - Abbreviated mental test score MoCA - Montreal cognitive assessment ACE-R - Addenbrooks cognitive test
Alzheimer’s diagnosis in secondary care
MRI - Cerebral atrophy
Biopsy
Alzheimer’s
Non-pharmacological management
Group cognitive stimulation therapy
Group reminiscence therapy
Dementia
Pharmacological management
Ach-esterase inhibitors
- Donepezil
- Galantamine
- Rivastigmine
NMDA receptor antagonist - Memantine
Consider antipsychotics
Vascular dementia presentation
3 FACTORS
- Associated RFs
- Stepwise progression
- FND
Vascular dementia management
Mixed - Ach-esterase inhibitor and NMDA receptor antagonist
Pure vascular
- Control BP - ACE-I
- Lower cholesterol - Statin
- Control BM
- Control BMI
- Aspirin
Vascular dementia prognosis
Likely death from MI or stroke
Fronto-temporal dementia cause
Pick’s disease
Fronto-temporal dementia syndromes
- Fronto-temporal dementia - Behavioural changes with preserved memory and visa-spatial skills
- Progressive non-fluent aphasia - Understanding intact but struggle with fluency
- Semantic dementia - Loss of vocabulary
Fronto-temporal dementia presentation
Insidious
Onset < 65
Personality changes
Intellectually functional
Preservation of memory and visuospatial skills
Memory loss occurs later
Fronto-temporal dementia investigations
MRI
- Knife blade atrophy
- Pick bodies
Fronto-temporal dementia management
S/L therapy
SSRIs for behavioural problems
Fronto-temporal dementia prognosis
8-10 years
Lewy body dementia pathophysiology
Cytoplasmic inclusions consisting of alpha synuclein
- Substantia nigra - Parkinson’s
- Paralimbic areas - Memory impairment
- Neocortical areas
Insidious onset
Progressive
Lewy body dementia presentation
TRIAD!!!
- Parkinson’s
- Hallucinations
- Fluctuating consciousness
REM sleep disorder
Frequent falls
Lewy body dementia investigations
BLOODS
ECG - Heart block
SPECT - 123-I-FP-CIT
Lewy body dementia prognosis
8-10 years
Lewy body dementia management
NO HALOPERIDOL
Ach-esterase inhibitors
- Donepezil
- Rivastigmine
NMDA receptor antagonist - Memantine
Reversible causes of dementia
HHHHHHHHHHHHHHs
Haematoma Hydrocephalus Hypothyroidism Halcohol Hinfection
Dementia bloods
FBC LFT U/E TFT B12 Thiamine Ca Glucose Na Tox screen
Dementia practical aids
Start a routine Post-it notes Big clock Avoid stress Sleep hygiene Newspaper with date
Other dementia investigations
Not bloods
MSU - RULE OUT DELIRIUM
ECG
Neuroradiology
- Atrophy
- Enlarged ventricles
Alzheimer’s microscopic changes
Beta-amyloid plaques
Neurofibrillary tangles
Alzheimer’s mAcroscopic changes
Cortical atrophy
Hippocampal atrophy
Enlarged ventricles
Increased sulcal swelling
Alzheimer’s neurotransmitter defects
Noradrenaline
5-HydroxyTriptamine
Ach
Frontal lobe dementia features
Emotional blunting Personality changes Apathy Disinhibition Taking things literally
Temporal lobe dementia features
Language changes
Behavioural and psychological symptoms of dementia
PADDA-1
Psychosis Anxiety Depression Disinhibition Agitation
…
1
What is delirium
Acute confusional state
Can be hyperactive, hypoactive or mixed
Delirium diagnosis
- Impaired consciousness
- Perceptual and Cognitive disturbance
- Rapid onset and fluctuating
- Evidence it may be related to a physical cause
Delirium causes
PINCH ME!!
Pain/post-op Infection - UTI/pneumonia Nutrition - B12 Constipation Hypoxia/hydration decreased Medications/metabolic Environmental
VT
Vascular - Stroke
Trauma - Head
Drugs causing delirium
SSAAALLAD
Steroids Statins Anticonvulsants Anticholinergic Antihistamine Lithium Levodopa Antispasmodics Digoxin
Delirium investigations
Bloods bloods and more bloods
CXR - Pneumonia
CT head
- Trauma
- Bleed
- Infection
- Tumour
Delirium management
ABC
Treat cause
Antipsychotic - Unless LBD
Benzos for alcohol related
Alcohol screening aids
CAGE
TWEAK
FAST
AUDIT
CAGE questionnaire
2 = Problemo
Have you considered cutting down?
Have people annoyed you by criticising you?
Have you ever felt guilty?
Eye opener?
TWEAK questionnaire
3 = Problemo
Tolerance - How many drinks can you have? Worried - Are people worried about you? Eye-opener? Amnesia? Considered cutting down?
ICD-10 addiction criteria
TRAM WC
Tolerance increased
Repertoire narrowing
Abstinence difficult
Maintaining intake is priority
Withdrawal symptoms
Compulsion awareness
Long-term alcohol problems - BIOLOGICAL
Wernicke’s
Memory loss
Pancreatitis
Arrhythmia’s
HTN
Fatty liver
Hepatitis
Cirrhosis
Osteoporosis
Malignancy - GI and breast
Pregnancy - CHD
Alcohol dependence management
Disulfiram - Blocks alcohol
Acamprostate - Acts on GABA, decreases cravings
Naltrexone - Opioid antagonist
Alcohol dependence
When to admit
Previous delirium Autonomic activity < 18 Safeguarding Failure of home detox Wernicke's
Wernicke’s encephalopathy cause and presentation
Thiamine B1 deficiency!!
COW TRIAD
- Confusion
- Ophthalmoplegia
- Ataxia - WOBBLY
Wernicke’s findings
Decreased red cell transketolase
MRI
Muscular atrophy
Wernicke’s management
PABRINEX
Wernicke’s Korsakoff
Confabulation
Anterograde amnesia
Irreversible
Hippocampal involvement
Delirium tremens BASIC CAUSE
Alcohol withdrawal
48-72 hours post-withdrawal
Worse at night
DT pathophysiology
Alcohol = Increased GABA + Decreased NMDA
Withdrawal = Decreased GABA + Increased NMDA
Jittery and hyper AF
Alcohol withdrawal presentation
6-12 hours - FASTT
- Formication
- Anxiety
- Sweating
- Tremor
- Tachycardia
36 hours - Seizures
48-72 hours - DELIRIUM TREMENS
- Coarse tremor
- Ataxia
- Confusion
- Seizures
- Delusions
- Hallucinations
Alcohol withdrawal imbalances
Metabolic acidosis
Hypoglycaemia
Alcohol withdrawal management
ABCDE
Chlordiazepoxide
PABRINEX
Dextrose
Carbamazepine - Seizures
Magnesium - Seizures and arrhythmias
Opioid misuse presentation
Rhinorrhoea Lacrimation Drowsiness PIN POINT PUPILS Track marks
Opioid misuse management
Naloxone
Dependence
- Methadone
- Buprenorphine
- Naltrexone
Opioid misuse complications
Infection
- Site
- Endocarditis
- Hep B/C
- HIV
Social
- Depression
- Homelessness
- Unemployment
VTE
Respiratory depression
Dependence syndrome criteria
- Strong desire to take substance
- Difficulty controlling use
- Physiological withdrawal state
- Tolerance
- Neglect of activities
- Persistent use despite negative effects
Anorexia causes
Genetics
Childhood - Trauma/bullying?
Depression
OCD
Anorexia diagnostic criteria
Restricted intake
Intense fear of gaining weight
Body dysmorphia or denial of low body weight
Anorexia symptoms
Underweight
Lanugo hair
Dental caries
Swollen tender abdomen due to constipation
Amenorrhoea and sub fertility
Libido changes
Sleep disturbances
Cold intolerance
Dizziness
Anorexia investigations
SCOFF questionnaire
Sit-up test
Squat test
LFT
Amylase
Bicarb - Alkalosis
Hormones - Gs/Cs are HIGH, everything else is LOW
Decreased - LH, FSH, Oestrogen
Increased - GH, Cortisol, Glucose, Cholesterol, Carotin
ECG - Bradycardia and prolonged QT
DEXA
SCOFF questionnaire
Sick - Have you ever made yourself sick? Control - Have you lost control? One stone lost in 3 months? Fat - Ever thought you're fat? Food - Does food control your life?
Anorexia management
Family therapy
CBT-ED
Pharmacological
- Chlorpromazine
- SSRI - Fluoxetine
Anorexia complications
Amenorrhoea and sub fertility
Psychological
- Depression
- OCD
Refeeding syndrome
Constipation
Peripheral neuropathy
Osteoporosis
AKI and renal calculi
Pancytopenia
Cardiac
Cardiac complications of anorexia
Prolonged QT
T wave changes
Bradycardia
ST elevation
Anorexia risk assessment
Rapid weight loss
Not responding to treatment
Electrolyte imbalance
Physiological changes
- Temp < 35
- Brady < 45
- Cardiac changes
Psychosis
Risk of suicide
Refeeding syndrome
Rapid introduction of food after > 10 days of malnutrition
HYPO HYPO HYPO
Hypokalaemia
Hypophosphataemia
Hypomagnesaemia - TREAT FIRST!
Impaired glucose sensitivity = ^ Insulin = hypokalaemia
How to avoid refeeding syndrome
U+Es
Increasing calories slowly
Thiamine
Malingering
Making up symptoms for the intention of financial or other gain
Somatisation disorder
Multiple physical symptoms persistent for at least 2 years
Multi-organ
Hypochondriasis
Persistent belief in the presence of underlying disease
Refusal to believe medical results
Conversion disorder
Loss of motor/sensory function
No conscious faking
Personality disorders categories
MAD
BAD
SAD
Personality disorders - MAD
Paranoid
Schizoid - Detached and cold
Schizotypal - Eccentric and odd beliefs
Antisocial - Aggressive, lack of consciousness, criminal behaviour
Personality disorders - BAD
Histrionic - Attention seeking, seductive, manipulative, exhibitionist
Borderline - Self-harm, intense relationships, ashamed, impulsive
Narcissistic - Grandiose thoughts, seeking power
Personality disorders - SAD
OCPD - Worrying, perfectionist, controlling
Anxious - Timid, desire to be liked, anxious
Dependent - Excessive need for care, feels abandoned, helpless when single
