Psychiatry - Level 1 Flashcards
Epidemiology of DSH?
- More common in young adults 15-24
- Girls more than boys
Risk factors of DSH/suicide attempt?
o Socioeconomic disadvantage
o Isolated – single, divorced, living alone, single parents
o Stressful life event – divorce, army veteran
o Mental health problems – depression, psychosis, schizophrenia, bipolar, PTSD, PD
o Chronic physical health problems
o Alcohol/Drug misuse
o Child maltreatment
Types of DSH/suicide attempt?
o Self-poisoning: • OTC, prescription or ilicit drug overdoses o Self-injury • Cutting • Burning • Hanging • Stabbing • Insertion • Shooting • Jumping from heights or in front of vehicles
Signs pointing towards type of drug - tachycardia?
salbutamol, antimuscarinics, TCAs, quinine, phenothiazide
Signs pointing towards type of drug - respiratory depression?
opiates, benzodiazepines
Signs pointing towards type of drug - hypothermia?
phenothiazides, barbituates
Signs pointing towards type of drug - hyperthermia?
amphetamines, MAOIs, cocaine, ecstasy
Signs pointing towards type of drug - coma?
benzodiazepines, alcohol, opiates, TCAs, barbiturate
Signs pointing towards type of drug - seizures
recreational drugs, hypoglycaemics, TCAs, phenothiazides, theophylline
Signs pointing towards type of drug - constricted pupil?
opiates, insecticides
Signs pointing towards type of drug - dilated pupils?
Amphetamines, cocaine, TCAs, quinine
Signs pointing towards type of drug - hyperglycaemia?
theophylline, MAOIs
Signs pointing towards type of drug - hypoglycaemia?
Insulin, OHA, alcohol, salicylate
Signs pointing towards type of drug - renal impairment?
salicylate, paracetamol
Signs pointing towards type of drug - metabolic acidosis?
alcohol, methanol, paracetamol, CO poisoning
Management of DSH or suicide attempt - initial management?
o Use TOXBASE
o ABCDE, clear airway
o Assess patient and take history from patient, family and friends
• Risk assessment
Management of DSH or suicide attempt - investigations?
- Bloods – FBC, LFT, U&E, INR, paracetamol and salicylate levels
- ABG
- ECG
Management of DSH or suicide attempt - monitoring?
• Temperature, HR, RR, BP, O2 sats, urine output + ECG
Management of DSH or suicide attempt - treatments?
- Activated charcoal 50g if within 1 hour of presenting
* Specific antidotes and measures
Management of DSH or suicide attempt - psychiatric assessments?
o Psychiatric Assessment by PLN once medically optimised
• Risk assessment in A&E or on ward prior to discharge
• Refer to psychiatry if psychiatric disorder or high-risk
Management of DSH or suicide attempt - if person at risk of DSH and in primary care?
o Assessment of psychosocial needs and risk assessment
o Referral:
• CRISIS if immediate risk of self-harm or suicide
• CMHT if significant psychiatric disorder needing specialist management
o Follow up depending on severity
Management of DSH or suicide attempt - advice follow DSH episode?
o Risk assessment
o Physical risks
o Follow up within 48 hours of discharge from hospital
o Harm reduction advice
• Use pinching, ice cubes, rubber bands
• Reinforce coping strategies
• Do not prescribe a large amount of medications
Prognosis of DSH/suicide?
- Suicide risk increased by 50-100x
- Repetitive self-harm – 1 in 6 self-harm within 1 year
Definition of Alzheimer’s Disease?
- Primary degenerative cerebral disease of unknown aetiology which results in prominent cognitive and behavioural impairment
- Beta-amyloid precursor protein (APP) accumulates in brain parenchyma to form typical lesions
Epidemiology of Alzheimer’s Disease?
- Most common dementia in over 65s
- Prevalence increasing – 50-75% of dementias
Risk factors of Alzheimer’s Disease?
o Advancing age o Genetic (trisomy 21, APOE4) o Lifestyle risk factors o Social interaction o Head injury o Parkinson’s disease
Protective factors of Alzheimer’s Disease?
o Smoking
o Oestrogen
o NSAIDs
o Vit E
Pathology of Alzheimer’s Disease?
o Cerebral atrophy (medial temporal lobe atrophy)
o Beta-amyloid deposition
o Senile plaques
o Neuro-fibrillary tangles (Tau proteins)
o Acetyl-choline levels reduced
Symptoms of Alzheimer’s Disease?
Insidious onset, progressive decline
Early symptoms
o Forgetfulness, deterioration of self-care, changes in behaviour
5 A’s of Alzheimer’s
o Amnesia (recent events)
o Aphasia (difficulty with speech)
o Agnosia (inability to recognise objects/people)
o Apraxia (difficulty performing tasks)
o Associated behavioural and psychological symptoms of dementia (BPSD)
• Aggression, restlessness, agitation, disinhibition
• Wandering, pacing, screaming, crying, swearing
• Lack of drive, shadowing
• Anxiety, depression, sleeplessness, delusions, hallucinations
Criteria of Alzheimer’s Disease diagnosis?
o Deficits in at least two areas of cognition, progressive and non-fluctuating, no clouding of consciousness
o Impaired ADLs, CT features evident of Alzheimer’s
o Histological evidence of disorder (post-mortem)
Assessment of Alzheimer’s Disease?
- Mental State Examination
- Cognitive Testing – AMTS, MMSE, ACE-3
- Physical Examination
Investigations of Alzheimer’s Disease?
- Blood tests
o FBC, ESR, U&Es, creatinine, HbA1c, LFTs, TFTs, B12 and folate - EEG – exclude delirium, CJD
- Brain imaging – CT/MRI
Management of Alzheimer’s Disease - general principles?
o Brain activities such as regular activities, word games, socialisation
o Inform DVLA
o Treat modifiable risk factors
o Manage carers, financial support, legal (lasting powers of attorney)
Management of Alzheimer’s Disease - non-pharmacological?
o Group cognitive stimulation programme
o Memory enhancement strategies (Reminder notes, lists, reorganisation of possessions)
o CBT for underlying anxiety, depression
Management of Alzheimer’s Disease - pharmacological?
If mild-to-moderate AD:
o AChEIs monotherapy
• 2nd generation – donepezil, rivastigmine, galantamine (longer half-life and commonly used)
In moderate-to-severe AD - add on:
o NMDA-receptor partial antagonists
• Protects from glutamate excitotoxicity
• Memantine
Management of Alzheimer’s Disease - follow up?
o Assessment every 6 months to see if drug effective and should only be continued if having benefit on cognition, global, functional
Management of Alzheimers - when to refer?
Refer all patients to memory clinic if suspected dementia and all reversible causes ruled out
Tests to perform if Alzheimer’s suspected but uncertain?
PET scan
CSF for tau proteins
Definition of vascular dementia?
- Results from thromboembolic or hypertensive infarction of small and medium-sized vessels
- Extent of cerebral infarction being related to degree of cognitive impairment
Epidemiology of vascular dementia?
- 20%
- 2nd most common cause of dementia
- Men > Females
- Peak 60-70
Risk factors of vascular dementia?
o Family history of CVD o Smoking o Diabetes o Hyperlipidaemia o Coagulopathies o Valvular disease o Hypertension o Arteriosclerosis
Pathology of vascular dementia?
o Multiple cerebral infarcts, local or general atrophy of brain
o Secondary ventricular dilatation and evidence of arteriosclerosis changes in major arteries
o Histological changes of infarction and ischaemia
Types of vascular dementia?
o Cognitive defects in single stroke
• Particularly severe with midbrain and thalamic strokes
• May remain fixed or recover partially/completely
o Multi-infarct dementia (MID)
• Stepwise deterioration in cognitive functions
• Between strokes there are periods of instability
• Think risk factors
o Progressive small-vessel disease (Binswanger)
• Multiple microinfarcts leads to progressive lacunae formation and white matter leukoariosis on MRI
• Gradual intellectual decline, generalised slowing and motor problems (gait, dysarthria)
• Depression
Symptoms of vascular dementia?
- Sudden-onset stepwise deterioration and risk factors for cardiovascular disease
- CVA/TIA associations
- Course:
o Emotional and personality defects early
o Followed by cognitive deficits which fluctuate
o Depression with episodic affective lability and confusion
o Behavioural slowing, anxiety
Signs of vascular dementia?
o Features of arteriovascular disease together with neurological impairments (e.g. rigidity, akinesia, brisk reflexes, pseudobulbar palsy)
Assessment of vascular dementia?
- Mental State Examination
- Cognitive Testing – AMTS, 6-CIT, MOCA, ACE-3
- Physical Examination
Investigations of vascular dementia?
Blood tests
o FBC, ESR, U&Es, creatinine, HbA1c, LFTs, TFTs, B12 and folate
o CRP, ANF, RF, cholesterol
Echocardiogram/Doppler
Brain imaging
o MRI if suspected vascular dementia
Management of vascular dementia - referral?
Refer to memory clinic when dementia suspected and all reversible causes ruled out
o Regular follow-up 6 months
Management of vascular dementia - general advice?
o Brain activities such as regular activities, word games, socialisation
o Inform DVLA
o Treat modifiable risk factors
• Changing diet, stop smoking, normotension, increase exercise
o Manage carers, financial support, legal (preferred place of care, advanced statement, lasting powers of attorney)
o OT, physiotherapy, SALT
Management of vascular dementia - non-pharmacological?
o Group cognitive stimulation programme
o Memory enhancement strategies
• Reminder notes, lists, reorganisation of possessions
o CBT for underlying anxiety, depression
Management of vascular dementia - pharmacological?
o ACEi’s or memantine only considered if co-morbid AD or LBD
Prognosis of vascular dementia?
- Prognosis poor and average 5 years survival
- Death by CVA, IHD, renal failure
Definition of Lewy Body Dementia?
- Dementia that shares clinical findings of both Alzheimer’s and Parkinson’s disease
- Lewy bodies found in brainstem nuclei (esp. basal ganglia), paralimbic and neuro-cortical structures.
- Development of cognitive symptoms and motor features of Parkinson’s within 1 year
Epidemiology of Lewy Body Dementia?
- 2nd most common degenerative dementia (10-15%)
- Age of onset 50-80
- Males > Females
Pathology of Lewy Body Dementia?
o Lewy bodies
• Eosinophilic intracytoplasmic neuronal inclusion bodies
o Neurofilaments aggregated with ubiquitin and alpha-synuclein found in basal ganglia, paralimbic and neocortical structures
o Neuronal loss with decreased ACh
o Senile plaques
o Vascular disease in 30%
Symptoms of Lewy Body Dementia?
- Fluctuating cognition (attention & alertness)
- Spontaneous motor features of Parkinsonism (70%)
o Bradykinesia, cogwheel-limb rigidity, gait disorder - Visual hallucinations
o Often animals and people - Recurrent falls and syncope
- Depression episodes
- Sleep disorder
- Disturbances of sensitivity
Assessment of Lewy Body Dementia?
- Mental State Examination
- Cognitive Testing – AMTS, MOCA, ACE-3
- Physical Examination
Investigations of Lewy Body Dementia?
- Blood tests
o FBC, ESR, U&Es, creatinine, HbA1c, LFTs, TFTs, B12 and folate
o EEG – exclude delirium, CJD - Brain imaging
o CT/MRI – generalised atrophy
o SPECT scan – reduced striatal uptake of FP-CIT in DLB
Criteria for diagnosis of Lewy Body Dementia?
o Progressive cognitive decline to interfere with normal functioning
o Two of the following:
• Fluctuating cognition
• Recurrent visual hallucinations
• Spontaneous motor features of Parkinsonism
Management of Lewy Body Dementia - referral?
- Referral to memory clinic
o Regular follow-up 6 months
Management of Lewy Body Dementia - general advice?
o Brain activities such as regular activities, word games, socialisation
o Inform DVLA
o Treat modifiable risk factors
o Manage carers, financial support, legal (preferred place of care, advanced statement, lasting powers of attorney)
o OT, physiotherapy, SALT
Management of Lewy Body Dementia - drug therapy?
o AChEIs
• Donepezil & Rivastigmine can be used in mild-to-moderate LBD
o Memantine only used if ACEi’s CI or not tolerated
o Antipsychotics (Avoid/use with great caution) • Severe sensitivity reactions with irreversible Parkinsonism
o L-dopa may worsen psychiatric symptoms
Management of Lewy Body Dementia - non-pharmacological?
o Group cognitive stimulation programme
o Memory enhancement strategies
o Reminder notes, lists, reorganisation of possessions
o CBT for underlying anxiety, depression
Definition of Fronto-Temporal Dementia (Pick’s disease)?
- Form of dementia characterised by preferential atrophy of fronto-temporal regions with usually early onset
- Early symptoms include personality change and social disinhibition, preceding cognitive impairments
Epidemiology of Fronto-Temporal Dementia (Pick’s disease)?
- 2% of cases
- Middle age presentation – 45-65, can occur in <30
- Associated with Motor Neuron Disease
Risk factors of Fronto-Temporal Dementia (Pick’s disease)?
o Family history
o Genetic
Pathology of Fronto-Temporal Dementia (Pick’s disease) - macroscopic?
• Bilateral atrophy of frontal and anterior temporal lobes, degeneration of striatum
Pathology of Fronto-Temporal Dementia (Pick’s disease) - microscopic?
• Microvascular type
Loss of large cortical nerve cells, spongiform degeneration, minimal gliosis, no swellings or inclusions
• Pick type
Loss of large cortical nerve cells, widespread gliosis, no spongiform, inclusions (tau and ubiquitin)
Knife-blade atrophy of gyri
• Associated with MND
Types of Fronto-Temporal Dementia (Pick’s disease)?
o Disinhibited
• Orbito-medial frontal and anterior temporal pathology
o Apathetic
• Extensive frontal lobe pathology
o Stereotypic
• Often temporal>frontal with striatal involvement
Symptoms of Fronto-Temporal Dementia (Pick’s disease)?
o Decline of social conduct - Breaches of etiquette, tactlessness, disinhibition, changes in usual behaviour, overactive
o Emotional blunting - Primary emotions (happiness, sadness, fear) and secondary emotions (embarrassment, sympathy)
o Impaired insight
o Dietary changes - Overeating, preference of sweet foods
o Perseverative behaviours - Drinking from empty cup
o Speech - Echolalia, perseveration, mutism
o Cognitive decline - Impaired attention, ineffective retrieval, poor organisation, lack of self-monitoring
o MND in minority
Diagnostic criteria of Fronto-Temporal Dementia (Pick’s disease) - core features?
Insidious onset and gradual progression
Early decline in social interpersonal conduct
Early impairment in regulation of personal conduct
Early emotional blunting aka apathy
Early loss of insight
Diagnostic criteria of Fronto-Temporal Dementia (Pick’s disease) - supportive features - behavioural?
Decline in personal hygiene and grooming
Mental rigidity and inflexibility
Distractibility and impersistence
Hyperorality and dietary changes
Perseverative and stereotyped behaviour
Utilisation behaviour
Diagnostic criteria of Fronto-Temporal Dementia (Pick’s disease) - supportive features - speech and language?
Altered speech output (pressured speech- i.e. hard to interrupt) Stereotypy of speech Echolalia Perseveration Mutism
Diagnostic criteria of Fronto-Temporal Dementia (Pick’s disease) - supportive features - physical signs?
Primitive reflexes
Incontinence
Akinesia, rigidity and tremor (parkinsonism)
Low and labile BP
Assessment in Diagnostic criteria of Fronto-Temporal Dementia (Pick’s disease)?
- Mental State Examination
- Cognitive Testing – AMTS, MOCA, ACE-3
o Impairments in frontal and temporal testing
Investigations of Fronto-Temporal Dementia (Pick’s disease)?
- Blood Tests o FBC, ESR, U&Es, creatinine, HbA1c, LFTs, TFTs, B12 and folate - EEG – exclude delirium, CJD - Brain imaging o CT/MRI o If uncertain - use PET scan or SPECT
Management of Fronto-Temporal Dementia (Pick’s disease) - referral?
- Referral to memory clinic
o Regular follow-up 6 months
Management of Fronto-Temporal Dementia (Pick’s disease) - general advice?
o Brain activities such as regular activities, word games, socialisation
o Inform DVLA
o Treat modifiable risk factors
o Manage carers, financial support, legal (preferred place of care, advanced statement, lasting powers of attorney)
o OT, physiotherapy, SALT
Management of Fronto-Temporal Dementia (Pick’s disease) - drug treatment?
o No specific treatment
Management of Fronto-Temporal Dementia (Pick’s disease) - non-pharmacological?
o Group cognitive stimulation programme
o Memory enhancement strategies
o Reminder notes, lists, reorganisation of possessions
o CBT for underlying anxiety, depression
Antidote for paracetamol
N-Acetylcysteine
Antidote for anticholinergics
Neostigmine
Antidote of benzodiazepines
Flumazenil
Antidote of beta blockers
Glucagon
Antidote of ethylene glycol (antifreeze)
Ethanol
Antidote of heparin
Protamine
Antidote of iron
Desferroxime
Antidote of lead
Dimercapol, EDTA
Antidote of methanol
Ethanol
Antidote of methemoglobinaemia
Methylene blue
Antidote of organophosphorus
Atropine
