Psychiatric Disorders

Question 1

Anxiety Disorders

Answer 1

• Generalized anxiety
  
  • Persistent, excessive anxiety regarding general life events that lasts for 6 months or more
  • Often present to providers complaining of fatigue or muscle tension
  • Diagnostic criteria à at least 3 of the following
    
    • Restlessness or hypervigilance, easy fatiguability, irritability, sleep disturbance, muscle tension, and difficulty concentrating
  • Treatment
    
    • SSRIs
    • SNRIs
    • Avoid benzos if possible; if they must be used, shorter acting agents are preferable
      
      • But both shorter acting and long-acting agents are associated w/ increased fall risk
    • Avoid antihistamines and buspirone.

Question 2

Depression

Answer 2

• Sadness, withdrawal from previously enjoyed activities, and anhedonia but the elderly concentrate on somatic complaints more than on mood
• Typical presentations include = memory impairment, agitation, anxiety, and displaced anger
• Diagnosis = clinical suspicion and Yesavage Geriatrics Depression Scale
• Management
  
  • Older adults may be reluctant to participate in psychotherapy so pharmaceuticals are the usual therapy
  • SSRIs – fewer side effects
  • Occasionally, stimulates in low doses, such as methylphenidate, are useful for a short time
  • Avoid TCAs
  • Patients that are resistant to meds à electroconvulsive therapy is very effective and safe even in frail elderly patients.

Question 3

Insomnia

Answer 3

• Difficulty falling asleep or staying asleep, intermittent wakefulness during the night, early morning awakenings
  
  • Depression is associated w/ fragmented sleep, decreased total sleep time, quicker onset of REM sleep, and a shift of REM to earlier in the night
• Diagnosis
  
  • Polysomnography (sleep studies) assesses EEG activity, heart rate, respiratory movement, and oxygen saturation
• Treatment
  
  • Meds should be avoided if possible
  • Rapidly acting hypnotics (Zolpidem) may be used for short periods if necessary

Question 4

Alcohol Dependency and Abuse

Answer 4

• Alcohol withdrawal
  
  • Clinical manifestations
    
    • Uncomplicated alcohol withdrawal à 6-24 hours after last drink
      
      • Increased CNS activity = tremors, anxiety, diaphoresis, palpitations, insomnia, GI issues
    • Withdrawal seizures à 6-48 hours after last drink
      
      • Usually generalized tonic-clonic type
    • Alcoholic hallucinosis à 12-48 hours after last drink
      
      • Delirium (altered sensorium), hallucinations, agitation
      • Abnormal vital signs (tachycardia, HTN, fever), diaphoretic
  • Management
    
    • IV Benzos
    • IVF and supplementation
      
      • IV thiamine and magnesium
• Alcohol dependence
  
  • Alcohol abuse becomes dependence when withdrawal symptoms develop or tolerance
  • CAGE questions
  • Management
    
    • Supportive: psychotherapy
    • Disulfram (Antabuse) can be deterrent to alcohol abuse
    • Naltrexone