Psychiatric Disorders in Children + Geriatrics + Cognitive Disorders Flashcards
1
Q
Selective mutism
A
Usually 2-5 yo
Children have fear of situations that call for them to speak
Social phobia is often co-morbid condition
Criteria:
- consistent failure to speak in some specific situations, but not others in which a person is expected to speak
- duration > 1 mo
- not attributable to lack of knowledge or comfort w/ spoken language
- other communication or autism spectrum d/o or psychosis do not account for the presentation
2
Q
Separation anxiety disorder
A
Usually > 6 years old
3 or more of following need to be present for >=4 wks:
excessive distress when separated from home
excessive worry about losing major attachment figures
refusal to go out because of fear of separation
nightmares about separation
physical complaints (HA, nausea, ab pain) when separation from attachment figure is anticipated
3
Q
Stranger anxiety is normal finding until
A
age 3
After that, fear of strangers usually due to other causes
Autistic children lack this developmental marker
4
Q
1 cause of suicide deaths in adolescents
A
Firearms
OD is #1 method of suicide ATTEMPT
5
Q
When does sleep terror occur?
A
Stage 3-4 of sleep
6
Q
1st line tx MDD in children
A
SSRI
7
Q
Expressive language disorder
A
Interfere with academic functioning
Limited vocab
errors in tense
difficulty recalling words or making sentences
IQ test most helpful to confirm - need to r/p MR
8
Q
Rumination disorder
A
Repeated regurg and rechewing of food for >= 1 mo following period of nl functioning
Often seen in infants w/ many caretakers in unstable environment
To confirm, need to r/o reflux via esophageal pH measurement
9
Q
1 cause of visual hallucinations in child
A
substance induced psychotic disorder
10
Q
1 psych emergency in kids and adolescents
A
Suicidal behavior
11
Q
What is more commonly seen in kids w/ MDD compared to adoslecents w/ MDD
A
Psychomotor agitation
12
Q
1 method CHILDREN use when attempting suicide
A
Substance ingestion
13
Q
1 reason for MR
A
early alterations in embryo dev (eg chromosomal changes, prenatal damage 2/2 toxins)
14
Q
What axis is MR?
A
2
15
Q
Enuresis usually occurs in
A
Otherwise nl boys
16
Q
Development milestones
A
2 yo - copy circle
3 yo - tell age and gender, ride tricycle
5 yo - copy square, ID L hand
17
Q
ADHD children often suffer from
A
Low self esteem
Manic children more likely ot be euphoric
18
Q
Children are what age when begin to understand irreversibility of death
A
7 or 8 yo
19
Q
Delirium
- clinical features
A
Acute change from baseline
Impairment in cognition with fluctuating course
Change in level of consciousness
Inability to sustain attention
Can be hypo or hyperactive or mixed delirium
20
Q
Highest risk factor for delirium
A
Amount of cognitive reserve you have (eg higher risk if you have dementia)
21
Q
Highest risk surgery causing delirium
A
Cardio thoracic
22
Q
Confusion assessment method
A
Acute onset, fluctuating course
In attention (serial 7s)
Disorganized thinking
Altered level of consciousness
+ if 3-4 of above are present
Do not use MMSE to dx delirium. Use this.
23
Q
Tx delirium
A
Tx underlying condition
1:1
Antipsychotics (Haloperidol #1) prn
Benzo for withdrawal. Only time benzos used for delirium! Otherwise, can prolong/cause delirium
24
Q
Dementia
A
Acquired persistent impairment in various cognitive domains
Deficit in memory in one or more of the following: Language Calculation Visual spatial skills Praxis Recognition Executive functioning
No impairment in consciousness
Orientation often impaired
Hallucinations less common vs delirium
Sx stable throughout day
Awareness clear
No EEG changes
25
Multi infarct dementia vs alzheimer's disease - how do you tell the difference?
Multi infarct dementia usually has focal neuro signs
26
#1 finding in delirium
Impairment in recent memory
Visual hallucinations + short attention span are typical sx
27
Hallmark of delirium
Waxing + waning sx
Lucid intervals --- then change in mental status
28
Delirium dx - dsm criteria
- disturbance of consciousness + attention altered
- change in cognition or dev of perceptual disturbance
Disturbance develops over short period of time, waxes and wanes
29
Delirium + hemiparesis or other focal neuro sign + sx
What could it be?
Confirm/dx tests?
CVA or mass lesion
Brain CT/MRI
30
Delirium + HTN + papilledema
What could it be?
Confirm/dx tests?
Hypertensive encephalopathy
Brain CT/MRI
31
Delirium + dilated pupils + tachy
What could it be?
Confirm/dx tests?
Drug intoxication
UDS
32
Delirium + fever + nuchal rigidity + photophobia
What could it be?
Confirm/dx tests?
Meningitis
LP
33
Delirium + tachy + tremor + thyromegaly
What could it be?
Confirm/dx tests?
Thyrotoxicosis
T4
TSH
34
#1 dementia type
Alzheimers
Vascular (#2)
35
Pt presents with dementia
Nl CT
What do you do next?
CMP
MRI
36
Workup for reversible causes of dementia
```
CBC
Electolytes
TFTs (HYPOthyroidism)
VDRL
B12 folate
Brain CT or MRI
```
37
Dementia + stepwise increase in severity + focal neuro signs
What could it be?
Confirm/dx tests?
Multi infarct dementia
CT/MRI
38
Dementia + cogwheel rigidity + resting tremor
What could it be?
Confirm/dx tests?
LBD
Parkinson disease
Clinical
39
Dementia + gait apraxia + urinary incontinence + dilated cerebral ventricles
What could it be?
Confirm/dx tests?
NPH
CT/MRI
40
Dementia + obesity + coarse hair + constipation + cold intolerance
What could it be?
Confirm/dx tests?
HYPOthyroidism
TSH
T4
41
Dementia + diminished position and vibration sensation + megaloblasts on CBC
What could it be?
Confirm/dx tests?
Vit B12 deficiency
Serum B12
42
Dementia + tremor + abnormal LFTs + Kayser Fleischer rings
What could it be?
Confirm/dx tests?
Wilsons disease
Ceruloplasmin
43
Dementia + diminished position and vibration sensation + argyll robertson pupils
What could it be?
Confirm/dx tests?
Neurosyphillia
CSF FTA-ABS or CSF VDRL
44
Syphillis tests
- sensitive
- specific
Screen with VDRL (more sensitive)
Confirm with FTA ABS (more specific)
45
Alzheimer's disease
- epi
- pathophys
Women > men
Dec acethylcholine b/c loss of NE neurons in basal ceruleus and decreased choline acetyltransferase (need for Ach synthesis)
AB peptides excess
46
Alzheimer genes
Presenelin I
Presenielin II
APP
Major susceptibility gene: APOe4
47
AD autopsy
Diffuse arophy w/ large ventricles and flattened sulci
Senile plaques + neurofibrillary tangles
Neruritic plaques (not neurofibrillary tangles) correlate w/ severity of dementia
48
Pharm tx Alzheimer's disease
Cholinesterase inhibitors (want more ACh)
- Tacrine
- Donepezil
- Rivastigmine
- Galantamine
NMDA antagonists
- Memantine
49
Classic finding with vascular dementia
2nd most common dementia
Stepwise loss of function as microinfarcts add up
Both this and AD can have similar neuropsych testing
50
Lewy body dimentia
- clinical manifestations
- Vs parkinson
3rd most common dementia
caused by lewy bodies + lewy neurites in brain, esp basal ganglia
```
Waxing + waning of cognition is core feature
Visual hallucinations
Paranoid delusions
Parkinsomism is core feature
Sensitivity to neuroleptics
```
Vs Parkinson - onset of dementia within 12 months of parkinsonism sx. If dementia onset > 12 mo, that is more Parkinson disease dementia
51
Tx lewy body dementia
Cholinesterase inhibitors for visual hallucinations
Levadopa/carbidopa, dopamine agonists for cognition, apathy, motor sx
Atypical neuroleptics to stop delusions and agitation
Clonazepam for REM sleep behavior disorder
52
Pick Disease
- clinical manifestations
- path
Usually start 45-65 yo
Lots familial
4-6 years usually (rapidly progressive)
Lots of changes in personality and social conduct
Disinhibited
Echolalia, overeating, (frontal lobe signs)
NO emotional warmth, empathy
Poor insight
Cognitive deficits
Memory, language, and spatial functions usually OK
Path:
- marked atrophy of frontal and temporal lobes
- loss of cortical layer II
53
Tx Pick Disease
Anticholinergic meds
Antidepressants
Improve behavior but not cognition
54
HIV associated dementia
- clinical manifestations
- tx
Rapid decline cognition, behavior, memory, concentration
Apathy
Depression
Language OK
Tx - HAART as dec viral load often improves dementia
55
Huntington disease
- clinical
- dx
- path
- tx
Autosomal dominant
trinucleotide repeat on short arm chromosome 4
30-50 years onset
Progressive dementia (1 year within onse of chorea)
Pts aware of deteriorating mentation
Choreiform mvmts
Muscular hypertonicity
Assoc w/ depression, psychosis, alcoholism
Inc rate of suicide
MRI --> caudate atrophy
56
Parkinson disease
- epi
- clinical manifestations
- path
- Loss of neurons in substantia nigra (which gives dopamine to basal ganglia)
- Senile plaques, neurofibrillary tangles, loss of neurons, decreased choline acetyltransferase
- 30-40% ppl w/ PD get dementia
- 50% suffer depression
- Men > Women
Parkinsonism
- bradykinesia
- cogwheel rigidity
- resting tremor
- mask life facies
- shuffling gait
- dysarthria
Dementia 2/2 PD made worse by antipsychotics
57
Crutzfeldt Jakob Disease
- Clinical
- Dx
Progressive, degen dz of CNS 2/2 abnormal prions
Small % got infected through corneal transplants!
- Progressive dememtia -- 6 - 12 mo after onset of sx
- > 90% with myoclonus
- basal ganglia + cerebellar dysfunction common
- personality changes, paranoia
Dx:
- path --> spongiform changes of brain tissue
- Rapidly progressive dementia + periodic generalized sharp waves on EEG + 2 of the following:
- myoclonus
- cortical blindness
- ataxia or EPS signs
- muscle atrophy
- mutism
58
Normal pressure hydrocephalus
- clinical
- tx
Enlarged ventricles w/ increased CSF pressure
Etiology: idiopathic or 2/2 obstruction of CSF reabsorption sites
Gait disturbance
Urinary incontinence
Dementia
Tx:
- relieve w/ shunt
- dementia is least likely to improve out of the triad
59
Suicide rate of elderly > 85
2x national average
60
Pseudodementia
Cognitive deficits + major depression
Sx are 2/2 underlying depression
vs. dementia pts, pseudodementia more likely to say I don't know and can actually answer questions; dementia pts more likely to confabulate when don't know answer
61
Tx Pseudodementia
Psychotherapy
Involve in senior groups
Low dose SSRI
If need to use TCA --> nortriptyline b/c least amt of antiCh SE
Mirtazapine
Methylphenidate for psychomotor retardation
ECT
62
Dementia vs pseudodementia
Dementia
- insidious onset
- sundowning common
- confabulation
- unaware of problems
- cognitive deficits don't improve w/ antidepressants
Pseudodementia
- acute onset
- sundowning uncommon
- answers I don't know often
- pt aware of problems
- cognitive deficits improve w/ antidepressants
63
Stages of bereavement
```
Denial
Anger
Bargaining
Depression
Acceptance
```
64
Normal grief
```
intense feelings (guilt, sadness, sleep distrubances)
Usually stop within 6 mos
function is preserved
```
65
Complicated/prolonged grief
```
At least 6 mos
4/8 sx:
- difficult move on with life
- numbness/detachment
- bitterness
- feeling that life is empty
- trouble accepting the loss
- feeling the future holds no meaning without deceased
- agitation
- difficulty trusting others since loss
```
66
Bereavement-associated depression
Major depression beginning with concrete death or loss in pt's life
If have depressive sx for 2 wks, 6-8 weeks after precipitating loss, may need SSRIs
67
Most common psych disorder in elderly
MDD
68
Who has highest rate of successful suicide
White elderly males
69
Meds and result of concurrent EtOH use
H2 blockers --> higher BAL
Benzos, TCAs, narcotics, barbs, anti-H --> inc sedation
ASA, NSAIDs --> long bleeding time, GI irrtation
Metronidazole, sulfas, long acting hypoglycemics --> N/V
Acetaminophen, INH, Phenylbutazone --> hepatotoxicity
Anti-HTN, anti-diabetes, ulcer drus, gout meds --> worsen underlying disease
70
In setting of dementia, what kind of hallucinations do you get?
Visual
Suggest LBD --> don't give antipsychotics!
71
When do you tx w/ pharm for hallucinations?
If do not bother pt or interfere with caring for pt , pharm NOT necessary
72
Normal sleep changes in geriatric pts
Dec REM latency and total REM sleep
Inc stage 1& 2 sleep
Dec stage 3&4 sleep
Freq nocturnal awakenings
Dec total amt of sleep
Earlier to bed, earlier to rise
73
What can you use to help with sleep in elderly?
Hydroxyzine
| Trazodone
74
KAUFFMAN ASSESMENT Battery for children
Intelligence test ages 2-12
75
Weschler Intelligence Scale for Children - Revivsed
IQ ages 6-16
76
Mental retardation
IQ < 70, subaverage intellectual functioning
Deficits in adaptive skills ok for age group
Onset < 18 yo
Mild 55-70
Mod 40-55
Severe 25-40
Profound < 25
77
Causes metnal retardation
Genetics - Down, Fragile X (MOST COMMON), Prader willi, Williams, angelman
Prenatal - TORCH (toxo, Other - syphilis, AIDS, EtOH, Rubella, CMV, Herpes)
Perinatal - anoxia, prematurity, meningitis
Postnatal - hypothyroid, malnutrition, toxins, trauma
78
Prader Willi syndrome
MR
Obesity
Hypogonadism
Almond shaped eyes
79
Fragile X syndrome
Most common inherited form of MR
FMR-1 gene defect
Autistic characteristics
Delayed speech
Motor delay
Sensory deficits
Males w/ large testicles
80
What do you always want to r/o before diagnosing learning disorders?
Sensory deficits
81
Oppositional defiant disorder
- traits
- tx
Usually onset age = 8
>= 6 mo negative, hostile, defiant behavior
No difficulties getting along with peers but won't comply with authority figures
Vs. conduct disorder, ODD does not have physical aggression or violation of basic rights of others
Tx: psychotherapy
82
Conuduct disorder
persistent behavior: basic rights of others or social norms violated
- aggression towards ppl and animals
- destruction of property
- deceitfulness
- serious violation of rules
Boys vs girls
- boys = high risk fighting, stealing, fires, vandals
- girls = higher risk lying, running away, sex acting out
Boys > girls
83
ADHD
- categories
- criteria
Inattentiveness, hyperactivity or both that...
- persist >=6 mo
- maladaptive at age
- onset < 7 yo
Inattentive sx: Careless mistakes, losing things, forgetful, easily distracted
Hperactivity-impulsivity sx: Restlessness, can't keep quiet, lots of talking, blurt out answer, interrupts
84
How many kids w/ ADHD have comorbid psych dx?
> 50%
85
Encoporesis
voluntary or involuntary passage of stools in a child who has been toilet trained (typically over age 4), which causes the soiling of clothes
Therefore, person has to be > 5yo and toilet trained
86
Tx ADHD
CNS stimulants 1st line
- methylphenidate (ritalin, concerta)
- dextroamphetamine
amphetamine esalts (adderal)
Atomoxetine = selective NE reuptake ---|
Alpha 2 agonists (clonidine, guanfacine)
Non-pharm:
- family, individual, group psychotherapy
- edu interventions
87
Autism spectrum disorder
Must be present by age 3
Problems with social interaction
Impairments in communication
Repetitive and stereotyped patterns of behavior and activities
ALWAYS GET HEARING TEST BEFORE DX AUTISM
Boys > girls
88
Most important predictors of adult outcome in autistic children
Level of intellectual functioning
Communicative competence
89
Tx autism
No cure
Help manage sx:
- remedial ed
- behavioral tx
- antipsychotics
- antidepressants
90
Asperger Disorder
Impairment in social interaction
Restricted or stereotyped interests and behaviors
Vs. autism - NO clinically significant delay in spoken or receptive language, cognitive dev, curiosity about environment
Boys > girls
91
Rett disorder
Nl physical + psychomotor development in first 5 months
Decrease rate of head growth, loss of prev learned purposeful hand skills between ages 5-30 months
Stereotyped hand mvmts (hand wringing), impaired language, psychomotor retardation
Coagnitive dev never progressed beyond that of the 1st yr of life
Only girls --> boys lethal in utero
Genetic testing available
Assoc w/ MECP2 gene mutation on X chromosome
Tx = supportive
92
Childhood disintegrative disorder
Normal dev in 1st 2 yrs of life -->
loss of prev acquired skills before age 10 yrs in language, social skills, adaptive behaviors, bowel/bladder control, or play motor skills
Boys > girls
Vs Rett --> head growth does not slow and hand mvmts not present in CDD
93
Out of Autism, Rett, and childhood disintegrative disorder, which has abnormal EEG?
ALL!
94
Tourette disorder
Tics many times / day, every day for > 1 year (no tic free period > 3 mo)
--> will have change in anatomic location and character of tics over time
Need both motor + vocal tics to dx tourette
Onset < 18 yo, avg onset = 7yo
Motor tics usually before vocal tics
Motor tics that are most common = face and head, eg blinking eyes
Vocal tics
- coprolalia = repetitive speaking of obscene words
- echolalia = exact repeat of words
95
Possible etiologies of Tourette
Genetics
Impaired regulation of dopamine
Group A beta hemolytic strep infection --> OCD or Tourette?
96
Tx Tourette disorder
Education + supporive interventions
Pharm if tics impair life:
- atypical neuroleptics (risperidone)
- alpha 2 agonists (clonidine, guanfacine)
- typical neuroleptics for severe
Stimulants can exacerbate tics
97
Elimination disorders
Urinary continence usually est by age 4
Enuresis = involuntary wetting of bed after age 5; 2x/wk for 3 mo consecutive)
---> most resolve by age 7
Encopresis = involuntary passage feces by age 4 (1x/mo for at least 3 mo
Boys > girls
98
Causes of elimination disorders
Eneuresis --> small bladder, low nocturnal levels ADH
Encopresis --> no sphincter control, constipation with overflow incontinence
99
Tx enuresis
Behavior modification
DDAVP
TCAs (imipramine)
100
Tx encopresis
Inital bowel catharsis, then stool softeners if etiology is constipation
101
Most common drug of abuse by adolescents
EtOH
2 - Cannabis
102
Most common reason to see kid in ER setting for psych reason
suicidal behavior
