Psychiatry Flashcards
1
Q
Define delirium
A
- Acute confusion
- Inattention
- Cognitive impairment
- Reduced awareness
2
Q
Describe the symptoms and signs of delirium
A
- Inattentive
- Drowsy/ hyperalert
- Picking at clothes/sheets (carphologia)
- Not getting out of bed
- Not interacting with others
- Unwell
- Fluctuates
- Loss of appetitie
- No lucid conversations
- Paranoid, disturbed, overzealous affection.
3
Q
List causes of delirium
A
- Hypoxia
- Anticholinergic drugs (dementia drugs are cholinesterase inhibitors and increase ACh)
- Constipation
- Urosepsis
- Change of environment
- Sedatives
- Withdrawal from sedatives
- Electrolyte disturbances
4
Q
Describe management of delirium
A
- Treat underlying cause
- Supportive care
- Orientation
- Appropriate environment
5
Q
List the types of dementia and define them
A
- Alzheimer’s disease (AD) is a chronic neurodegenerative disease with an insidious onset and progressive but slow decline. AD is the most common type of dementia
- Frontotemporal dementias (FTDs) are the second most frequent primary neurodegenerative brain diseases (after Alzheimer’s disease) in adults <65 years of age. Dementia with atrophy of the frontotemporal lobes
- Vascular dementia is a chronic progressive disease of the brain bringing about cognitive impairment.
- Lewy body dementia is memory impairment with fluctuating cognition, hallucinations and parkinsons symptoms
6
Q
Describe epidemiology of Alzheimers dementia
A
- Most common dementia
- 60-70% of dementia
- 5% population below 70
- 30% population over 80
- More common in women and black people
- Early onset 1% of cases, autosomal dominant inheritence
- Predicted 17 mil dementia patients in 2050
7
Q
Describe epidemiology of frontotemporal dementia
A
- 15 cases per 100000 in age 45-64
- Higher prevalence in men
- 8-17% of all dementia cases
8
Q
Describe epidemiology of vascular dementia
A
- 17% of dementia cases
- Significant overlap with alzheimers
- 3.8 per 100 000
Highest in those age over 90 - Men more affected than women
- Higher rates in asian and black populations
9
Q
Describe epidemiology of lewy body dementia
A
- 10% of dementia
- 0.1% per year
- Increases with increasing age
10
Q
List risk factors for Lewy body dementia
A
- Older age
- Male sex
- Familial occurence
11
Q
Describe aetiology of lewy body dementia
A
- Toxic protein aggregation
- Abnormal phosphorylation
- Nitration, inflammation, oxidative stress, lysosomal dysfunction
12
Q
Describe aetiology of vascular dementia
A
- Infarction
- Lekoaraiosis (disease of white matter)
- Haemorrhage
- AD
13
Q
List risk factors for vascular dementia
A
- Over 60
- Obesity
- Hypertension
- Smoking
- Diabetes mellitus
- High cholesterolaemia
- Alcohol abuse
14
Q
List risk factors of frontotemporal dementia
A
- Mutations in MAPT gene
- Mutations in PGRN gene
- Head trauma
- Thyroid disease
15
Q
Describe aetiology of alzheimers dementia
A
- Amyloid hypothesis (excess of A beta peptoids)
- Tau aggregation (microtubule-associated protein)
- Late onset associated with alphalipoprotein E4
16
Q
Describe risk factors of alzheimers dementia
A
- Advanced age
- Family history
- Genetics
- Down’s syndrome
- Cerebrovascular disease
- Hyperlipidaemia
- Lifestyle (smoking, obesity, diet high in saturated fats, and alcohol consumption)
- Less than secondary school education
- Low IQ
- Traumatic brain injury
- Depression
- Female sex
- Elevated plasma homocysteine level
- Artificially sweetened soft drink consumption
17
Q
List symptoms and signs of alzheimers dementia
A
- Memory loss
- Disorientation
- Nominal dysphasia
- Misplacing items/getting lost
- Apathy
- ADLs decline
- Personality change
- Unremarkable initial physical exam
- Mood changes
- Poor abstract thinking
- Prospagonosia and autoprosopagnosia
18
Q
List symptoms and signs of frontotemporal dementia
A
Picks disease
- Coarsening of personality, social behaviour and habits - disinhibition
- Loss of language fluency or comprehension
- Memory impairment, disorientation, apraxias
- Progressive self neglect and abandonment of work, activities and social contacts
- Altered eating habits
- Inattentiveness, impulsive responding
- Signs of ALS (progressive asymmetrical weakness)
- Fasciculations, atrophy, hyperreflexia, MND
- Glabellar, snout, sucking, rooting, grasp reflex
- Loss of bladder and bowel control
19
Q
List signs and symptoms of vascular dementia
A
- Difficulty solving problems
- Apathy
- Disinhibition
- Slowed processing of information
- Poor attention
- Retrieval memory deficit
- Frontal release reflexes (glabella tap, jaw jerk)
- Focal neurological signs
- Impaired gait and balance
20
Q
List signs and symptoms of dementia with lewy bodies
A
- Cognitive fluctuations, progressive insidious onset
- Visual hallucinations
- Motor symptoms (shuffling gait, trmor, increased tone)
- REM sleep behavioural disturbance
- Severe antipsychotic sensitivity
- Depression
- Repeated falls and syncope
- Orthostatic hypotension
- Urinary incontinence
- Constipation
- Attention and visuospatial abnormalities
- Delusions
- Hypersomnia
- Hyposmia
- Auditory hallucinations
21
Q
List investigations for alzheimers dementia
A
- Bedside cognitive testing
- FBC
- Metabolic panel
- TSH
- B12
- Urine drug screen
- CT
- MRI (generalised atrophy, beta amyloid plaque, neurfibrillary tangles)
- CSF analysis, HIV
- Neuropsychological testing
- EEG
22
Q
List investigations for frontotemporal dementia
A
- Cognitive testing
- MRI and CT (atrophy of frontal and anterior temporal lobes, pick cells and pick bodies in the cortex)
- FBC
- ESR
- CRP
- TSH
- T4
- Metabolic panel
- Urea
- Creatinine
- LFTs
- B12
- Folate
- Syphilis
- ## HIV testing
23
Q
List investigations for vascular dementia
A
- FBC
- ESR
- Glucose
- Renal and LFTs
- Syphilis serology
- B12
- Folate
- Thyroid function
- CT MRI brain (cerebrovascular lesion)
- ECG
24
Q
List investigations for lewy body dementia
A
- FBC
- Metabolic panel
- TSH
- B12
- Folate
- VDRL (rule out syphilis)
- Urine drug screen
- Urinalysis
- HIV testing
- CT/ MRI (generalised cortical atrophy, lewy bodies in cortex and midbrain)
- EEG
- CSF
- Neuropsychological testing
- PET, decreased basal ganglia dopamine transporter uptake
- Eosinophilic cytoplasmic inclusions of alpha-synuclein proteins
25
Q
Define alcohol withdrawal
A
Physical and psychological symptoms associated with a sudden decrease in alcohol consumption
26
Q
Describe epidemiology of alcohol withdrawal
A
- 43% worlds population consumes alcohol
- 20% of patients admitted for illnesses not related to alcohol drink to hazardous levels
- 25% of alcohol withdrawal experience hallucinations, seizures occur in 10%
27
Q
Describe aetiology/risks of alcohol withdrawal
A
- Chronic alcohol use up regulation of NMDA receptors, downregulation of GABA. decrease in alcohol causes imbalance between NMDA and GABA
- Caused by abstinance from alcohol
- History of alcohol withdrawal, past history of seizures and/or DT
28
Q
List symptoms and signs of alcohol withdrawal
A
- Minor within 6 hours anxiety, agitation, palpitations, GI upset, sweating and tremor N and V
- Major within 12 hours visual/tactile hallucinations
- Major 36 hours short generalised tonic clonic seizures
- 48-72 hours delerium tremens - delerium , severe tremor, fever, high BP and HR
- 3% develop status epilepticus
29
Q
List investigations for alcohol withdrawal
A
- CAGE questionnaire
- AUDIT questionnaire
- CIWA Ar scale (clinical institute withdrawal assessment from alcohol)
- Tachycardia/temp
- FBC
- U&E
- LFT INR
- Glucose
30
Q
Describe management of alochol withdrawal
A
- Benzodiazepines (chlordiazepoxide to prevent withdrawal, diazepam for seizures)
- Pabrinex (B vits)
- Glucose if hypo
- Manage alcohol dependence with drug and alcohol liaison specialist, alcoholics anonymous, therapy
31
Q
List complications of alcohol withdrawal
A
- Over sedation
- Status epilepticus
- Prolonged autonomic symptoms and insomia 6 months
32
Q
Describe prognosis of alcohol withdrawal
A
- Delerium tremens fatal 15-20% if untreated, 1% with early management
33
Q
Define depression
A
- Major depressive disorder is characterised by the presence of at least five symptoms and can be classified along a spectrum of mild to severe.
- Severe episodes may include psychotic symptoms such as paranoia, hallucinations, or functional incapacitation.
- Subthreshold (minor) depression is characterised by the presence of two to four depressive symptoms, including depressed mood or anhedonia, lasting longer than 2 weeks.
- Persistent depressive disorder (dysthymic disorder) is characterised by at least 2 years of three or four dysthymic symptoms for more days than not. Dysthymic symptoms include depressed mood, appetite change, sleep disturbance, low energy, low self-esteem, poor concentration, and hopelessness.
34
Q
Describe epidemiology of depressive disorder
A
- 18-44, leading cause of diability and prematire death
- 2nd leading cause of disability in people of all ages by the year 2020
- 1 in 5 patients in primary care had some depressive symptoms between 2005 and 2008. 10% depression serious enough to warrant treatment but only 1/3 treated
- 20% affected in life
- Women 2 times more than men
- Increases 2 to 3 fold if first degree relative
- First onset most commonly age 12-24 or over 65
35
Q
Describe aetiology of depressive disorder
A
- Genetic component
- Stressful life events, personality, sex
- Postnatal
- Corticosteroids, interferon, COCP, isotretinoin
36
Q
Describe symptoms and signs of depressive disorder
A
- Depressed mood most of the day nearly every day for 2 weeks
- Anhedonia
- Functional impairment
- Weight change
- Loss of libido
- Psychomotor problems
- Low energy
- Guilt
- Poor concentration
- Suicidal ideation
37
Q
Describe investigations for depressive disorder
A
- Clinical diagnosis (more than 5 symptoms for 2 weeks is major depression)
- Metabolic panel
- FBC
- TFT
- Patient health questionnaire 2 (have you felt down, depressed, hopeless over the past 2 weeks + have you felt little pleasure) and 9 (classifies symptoms from 0-4)
- Edinburgh postnatal depression scale
- Geriatric depression scale
- Cornell scale for depression in dementia
38
Q
Define substance abuse disorder: smoking
A
Substance-related disorders are a class of psychiatric disorders characterized by a craving for, the development of a tolerance to, and difficulties in controlling the use of a particular substance or a set of substances, as well as withdrawal symptoms upon abrupt cessation of substance use
39
Q
Describe epidemiology of substance abuse: smoking
A
- 14.1% of people age 18 and above have smoked cigarettes
- In UK half a mill admissions annually attributable to smoking
40
Q
Describe aetiology of substance abuse: smoking
A
- Nicotine from the tobacco plant
- Stimulates nicotinic receptors in autonomic ganglia
- High rates in HIV/AIDS patients, low socioeconomic status, and genetic influence
41
Q
Describe symptoms and signs of substance abuse: smoking
A
Intoxication
- Euphoria
- Tachycardia, hypertension, weight loss
- Restlessness, anxiety
- Increased GI motility
- Insomnia
- Tar staining
Withdrawal
- Irritability, frustration, anger, restlessness, anxiety
- Dysphoria, depressed mood
- Insomnia
- Impaired concentration
- Increased appetite, weight gain
42
Q
Describe investigations for substance abuse: smoking
A
- Pack years
43
Q
Describe the management for substance abuse: smoking
A
- Counselling and support
- Local service
- Behavioural support, nicotine replacement therapy (transdermal, lozenge, gym), varenicline, bupropion, e-cigarettes
- Combination drug and behavioural
44
Q
Describe prognosis of substance abuse: smoking
A
- 8000 fatalities annually
- 70% want to quit and 40% make an attempt each year
- 3-4% successful on their own
- Highest relapse first 8 days after stopping
45
Q
Describe complications of substance abuse: smoking
A
- Relapse
- COPD
- Cardiovascular disease
- Cancer (eg. lung)
- Fetal complications
- Effect on glycaemic control
- Depressive disorder
46
Q
List symptoms of dependence
A
Three or more once in the last year:
- Strong desire for consumption
- Difficulty controlling use/amount/recidivism
- Tolerance
- Neglect of other activities/primacy
- Persistent use despite adverse consequences
- Withdrawal symptoms
- Narrowing of repertoire
47
Q
Describe epidemiology of delerium
A
- 20% patients on general wards
- 30% of elderly medical patients
- One year mortality 30%
48
Q
List risks for delirium
A
- Co-exsiting medical condition
- Cognitive status
- Decreased oral intake
- Age over 65
- Metabolic abnormalities
- Functional status
- Sensory impairment
- Drugs.
49
Q
Describe investigations for confusion
A
- Pulse oximetry
- BP
- Urinalysis
- FBC
- CRP
- Renal profile
- Calcium
- LFT
- Glucose
- Blood culture
- ABG
- ECG
- CXR
- AMTS and MMSE
- GCS
50
Q
Describe the mental state exam
A
- Appearance of the patient (weight, tattoos, scars, stigmata of disease, personal hygiene, clothing)
- Behaviour (engagement in the conversation, rapport, hallucinations. Eye contact, facial expression, body language threatening or withdrawn, psychomotor activity (paucity of movement and delayed responses to questions, restlessnes)
- Abnormal movements or postures (involuntary, tremors, ticks, lip-smacking, akathisias, rocking)
- Speech (rapid or slow, quantity- less in depression, more in mania or schizophrenia, tone of speech (monotonus in depression, schizophrenia and autism, tremolous in anxiety)
- Volume of speech
- Stammering or stuttering
- Mood and affect (mood is predominant subjective internal state as described by the patient, while affect is an observed emotion)
- Thought (form ie. organisation, speed, coherence - loose associations (jumping between topics), circumstantial thoughts (extra info), tangential thoughts (digressions), flights of ideas (pressure of speech), thought blocking (sudden cessation of thought), perseveration (repetition), neologisms (made up))
- Thought content (delusions, obsessions, compulsions, overvalued ideas, suicidal or violent thoughts)
- Thought possession (insertion ie. thoughts can be inserted into pts mind, withdrawal ie thoughts can be removed, broadcasting ie others can hear the patients thoughts)
- Perception (hallucinations, pseudo-hallucinations, illusions, depersonalisation, derealisation)
- Cognition (oriented in time, place person, attention span and concentration levels, short term memory)
- Insidht (ability to understand the problem they are experiencing is abnormal)
- Judgement is inability to make considered ideas
51
Q
Describe the abrieviated mental test score
A
- Age
- Current time
- Ask to recall an address (42 west street)
- Current year
- Current location
- Recognise 2 people
- Date of birth
- Year the second world war finished
- Name of current prime minister
- Count backwards from 20 to 1
Less than 8 cognitive impairment
52
Q
Describe the mini mental state examination
A
30 point test
- Orientation (year, season, month, date, time, country, town, district, hospital, ward, floor)
- Registration (ask pt to learn 2 objects, see how long it takes to learn
- Attention and calculation (subtract 7 from 100 and repeat)
- Ask for names of 3 objects
- Language (name 2 objects, repeat ‘no ifs, ands or buts’ 3 stage command ‘place index finger of right hand on your nose then on your left ear’ ask patient to obey written command on a piece of paper, ask patient to write a sentence)
- Ask patient to copy a pair of intersecting pentagons
Scoring 24-30 normal, 18-23 mild impairment, 0-17 severe impairment
53
Q
Describe korsakoff
A
- Chronic
- Alert (no longer confused)
- Amnesia (reterograde and anterograde) and confabulation
- Irreversible
