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Year 5 Core Conditions > Psychiatry - Level 1 > Flashcards

Psychiatry - Level 1 Flashcards

1
Q

Epidemiology of DSH?

A
  • More common in young adults 15-24

- Girls more than boys

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2
Q

Risk factors of DSH/suicide attempt?

A

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

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3
Q

Types of DSH/suicide attempt?

A 
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
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4
Q

Signs pointing towards type of drug - tachycardia?

A

salbutamol, antimuscarinics, TCAs, quinine, phenothiazide

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5
Q

Signs pointing towards type of drug - respiratory depression?

A

opiates, benzodiazepines

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6
Q

Signs pointing towards type of drug - hypothermia?

A

phenothiazides, barbituates

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7
Q

Signs pointing towards type of drug - hyperthermia?

A

amphetamines, MAOIs, cocaine, ecstasy

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8
Q

Signs pointing towards type of drug - coma?

A

benzodiazepines, alcohol, opiates, TCAs, barbiturate

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9
Q

Signs pointing towards type of drug - seizures

A

recreational drugs, hypoglycaemics, TCAs, phenothiazides, theophylline

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10
Q

Signs pointing towards type of drug - constricted pupil?

A

opiates, insecticides

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11
Q

Signs pointing towards type of drug - dilated pupils?

A

Amphetamines, cocaine, TCAs, quinine

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12
Q

Signs pointing towards type of drug - hyperglycaemia?

A

theophylline, MAOIs

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13
Q

Signs pointing towards type of drug - hypoglycaemia?

A

Insulin, OHA, alcohol, salicylate

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14
Q

Signs pointing towards type of drug - renal impairment?

A

salicylate, paracetamol

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15
Q

Signs pointing towards type of drug - metabolic acidosis?

A

alcohol, methanol, paracetamol, CO poisoning

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16
Q

Management of DSH or suicide attempt - initial management?

A

o Use TOXBASE
o ABCDE, clear airway
o Assess patient and take history from patient, family and friends
• Risk assessment

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17
Q

Management of DSH or suicide attempt - investigations?

A
  • Bloods – FBC, LFT, U&E, INR, paracetamol and salicylate levels
  • ABG
  • ECG
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18
Q

Management of DSH or suicide attempt - monitoring?

A

• Temperature, HR, RR, BP, O2 sats, urine output + ECG

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19
Q

Management of DSH or suicide attempt - treatments?

A
  • Activated charcoal 50g if within 1 hour of presenting

* Specific antidotes and measures

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20
Q

Management of DSH or suicide attempt - psychiatric assessments?

A

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

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21
Q

Management of DSH or suicide attempt - if person at risk of DSH and in primary care?

A

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

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22
Q

Management of DSH or suicide attempt - advice follow DSH episode?

A

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

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23
Q

Prognosis of DSH/suicide?

A
  • Suicide risk increased by 50-100x

- Repetitive self-harm – 1 in 6 self-harm within 1 year

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24
Q

Definition of Alzheimer’s Disease?

A
  • 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
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25
Q

Epidemiology of Alzheimer’s Disease?

A
  • Most common dementia in over 65s

- Prevalence increasing – 50-75% of dementias

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26
Q

Risk factors of Alzheimer’s Disease?

A 
o	Advancing age
o	Genetic (trisomy 21, APOE4)
o	Lifestyle risk factors
o	Social interaction
o	Head injury
o	Parkinson’s disease
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27
Q

Protective factors of Alzheimer’s Disease?

A

o Smoking
o Oestrogen
o NSAIDs
o Vit E

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28
Q

Pathology of Alzheimer’s Disease?

A

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

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29
Q

Symptoms of Alzheimer’s Disease?

A

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

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30
Q

Criteria of Alzheimer’s Disease diagnosis?

A

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)

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31
Q

Assessment of Alzheimer’s Disease?

A
  • Mental State Examination
  • Cognitive Testing – AMTS, MMSE, ACE-3
  • Physical Examination
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32
Q

Investigations of Alzheimer’s Disease?

A
  • Blood tests
    o FBC, ESR, U&Es, creatinine, HbA1c, LFTs, TFTs, B12 and folate
  • EEG – exclude delirium, CJD
  • Brain imaging – CT/MRI
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33
Q

Management of Alzheimer’s Disease - general principles?

A

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)

34
Q

Management of Alzheimer’s Disease - non-pharmacological?

A

o Group cognitive stimulation programme
o Memory enhancement strategies (Reminder notes, lists, reorganisation of possessions)
o CBT for underlying anxiety, depression

35
Q

Management of Alzheimer’s Disease - pharmacological?

A

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

36
Q

Management of Alzheimer’s Disease - follow up?

A

o Assessment every 6 months to see if drug effective and should only be continued if having benefit on cognition, global, functional

37
Q

Management of Alzheimers - when to refer?

A

Refer all patients to memory clinic if suspected dementia and all reversible causes ruled out

38
Q

Tests to perform if Alzheimer’s suspected but uncertain?

A

PET scan

CSF for tau proteins

39
Q

Definition of vascular dementia?

A
  • Results from thromboembolic or hypertensive infarction of small and medium-sized vessels
  • Extent of cerebral infarction being related to degree of cognitive impairment
40
Q

Epidemiology of vascular dementia?

A
  • 20%
  • 2nd most common cause of dementia
  • Men > Females
  • Peak 60-70
41
Q

Risk factors of vascular dementia?

A 
o	Family history of CVD
o	Smoking
o	Diabetes
o	Hyperlipidaemia
o	Coagulopathies
o	Valvular disease
o	Hypertension
o	Arteriosclerosis
42
Q

Pathology of vascular dementia?

A

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

43
Q

Types of vascular dementia?

A

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

44
Q

Symptoms of vascular dementia?

A
  • 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
45
Q

Signs of vascular dementia?

A

o Features of arteriovascular disease together with neurological impairments (e.g. rigidity, akinesia, brisk reflexes, pseudobulbar palsy)

46
Q

Assessment of vascular dementia?

A
  • Mental State Examination
  • Cognitive Testing – AMTS, 6-CIT, MOCA, ACE-3
  • Physical Examination
47
Q

Investigations of vascular dementia?

A

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

48
Q

Management of vascular dementia - referral?

A

Refer to memory clinic when dementia suspected and all reversible causes ruled out

o Regular follow-up 6 months

49
Q

Management of vascular dementia - general advice?

A

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

50
Q

Management of vascular dementia - non-pharmacological?

A

o Group cognitive stimulation programme
o Memory enhancement strategies
• Reminder notes, lists, reorganisation of possessions
o CBT for underlying anxiety, depression

51
Q

Management of vascular dementia - pharmacological?

A

o Daily aspirin/anticoagulants

o ACEi’s or memantine only considered if co-morbid AD or LBD

52
Q

Prognosis of vascular dementia?

A
  • Prognosis poor and average 5 years survival

- Death by CVA, IHD, renal failure

53
Q

Definition of Lewy Body Dementia?

A
  • 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
54
Q

Epidemiology of Lewy Body Dementia?

A
  • 2nd most common degenerative dementia (10-15%)
  • Age of onset 50-80
  • Males > Females
55
Q

Pathology of Lewy Body Dementia?

A

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%

56
Q

Symptoms of Lewy Body Dementia?

A
  • 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
57
Q

Assessment of Lewy Body Dementia?

A
  • Mental State Examination
  • Cognitive Testing – AMTS, MOCA, ACE-3
  • Physical Examination
58
Q

Investigations of Lewy Body Dementia?

A
  • 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
59
Q

Criteria for diagnosis of Lewy Body Dementia?

A

o Progressive cognitive decline to interfere with normal functioning
o Two of the following:
• Fluctuating cognition
• Recurrent visual hallucinations
• Spontaneous motor features of Parkinsonism

60
Q

Management of Lewy Body Dementia - referral?

A
  • Referral to memory clinic

o Regular follow-up 6 months

61
Q

Management of Lewy Body Dementia - general advice?

A

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

62
Q

Management of Lewy Body Dementia - drug therapy?

A

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

63
Q

Management of Lewy Body Dementia - non-pharmacological?

A

o Group cognitive stimulation programme
o Memory enhancement strategies
o Reminder notes, lists, reorganisation of possessions
o CBT for underlying anxiety, depression

64
Q

Definition of Fronto-Temporal Dementia (Pick’s disease)?

A
  • 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
65
Q

Epidemiology of Fronto-Temporal Dementia (Pick’s disease)?

A
  • 2% of cases
  • Middle age presentation – 45-65, can occur in <30
  • Associated with Motor Neuron Disease
66
Q

Risk factors of Fronto-Temporal Dementia (Pick’s disease)?

A

o Family history

o Genetic

67
Q

Pathology of Fronto-Temporal Dementia (Pick’s disease) - macroscopic?

A

• Bilateral atrophy of frontal and anterior temporal lobes, degeneration of striatum

68
Q

Pathology of Fronto-Temporal Dementia (Pick’s disease) - microscopic?

A

• 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

69
Q

Types of Fronto-Temporal Dementia (Pick’s disease)?

A

o Disinhibited
• Orbito-medial frontal and anterior temporal pathology

o Apathetic
• Extensive frontal lobe pathology

o Stereotypic
• Often temporal>frontal with striatal involvement

70
Q

Symptoms of Fronto-Temporal Dementia (Pick’s disease)?

A

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

71
Q

Diagnostic criteria of Fronto-Temporal Dementia (Pick’s disease) - core features?

A

 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

72
Q

Diagnostic criteria of Fronto-Temporal Dementia (Pick’s disease) - supportive features - behavioural?

A

 Decline in personal hygiene and grooming
 Mental rigidity and inflexibility
 Distractibility and impersistence
 Hyperorality and dietary changes
 Perseverative and stereotyped behaviour
 Utilisation behaviour

73
Q

Diagnostic criteria of Fronto-Temporal Dementia (Pick’s disease) - supportive features - speech and language?

A 
	Altered speech output (pressured speech- i.e. hard to interrupt)
	Stereotypy of speech 
	Echolalia
	Perseveration
	Mutism
74
Q

Diagnostic criteria of Fronto-Temporal Dementia (Pick’s disease) - supportive features - physical signs?

A

 Primitive reflexes
 Incontinence
 Akinesia, rigidity and tremor (parkinsonism)
 Low and labile BP

75
Q

Assessment in Diagnostic criteria of Fronto-Temporal Dementia (Pick’s disease)?

A
  • Mental State Examination
  • Cognitive Testing – AMTS, MOCA, ACE-3
    o Impairments in frontal and temporal testing
76
Q

Investigations of Fronto-Temporal Dementia (Pick’s disease)?

A 
-	Blood Tests
o	FBC, ESR, U&amp;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
77
Q

Management of Fronto-Temporal Dementia (Pick’s disease) - referral?

A
  • Referral to memory clinic

o Regular follow-up 6 months

78
Q

Management of Fronto-Temporal Dementia (Pick’s disease) - general advice?

A

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

79
Q

Management of Fronto-Temporal Dementia (Pick’s disease) - drug treatment?

A

o No specific treatment

80
Q

Management of Fronto-Temporal Dementia (Pick’s disease) - non-pharmacological?

A

o Group cognitive stimulation programme
o Memory enhancement strategies
o Reminder notes, lists, reorganisation of possessions
o CBT for underlying anxiety, depression

Year 5 Core Conditions (55 decks)

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