Psychosis and Dementia/Delirium Flashcards
Define psychosis and a psychotic episode
What are the common symptoms
What diagnosis must be considered
No accepted definition
An individual is experiencing a reality different to everyone else. “the dreamer awake”
A psychotic episode can begin quite suddenly, or gradually. It can last days, weeks, or months
The individual does not (usually) realise they are psychotic i.e. they have no insight
The symptoms of psychosis
- Hallucinations
- Delusions
- Formal Thought Disorder
- Fragmentation of the boundries of the self
Psychotic patients do not usually present to a psychiatrist but behaviour may become obvious to the police, family or friends
Describe hallucinations
- A hallucination is the perception of an object in the absence of an external stimulus
- Can be any of the 5 modalities
- Auditory commonest in psychosis—can be 2nd or 3rd person
- Visual more likely to be delirium
- Olfactory indicates possible frontal lobe pathology pressing on 1st nerve e.g. meningeoma
• ‘Hearing voices in my head’ is not psychosis ( pseudohallucioation)
Describe delusions
What is an encapsulated delusion?
- A delusion is a fixed, firmly held belief that is (usually) false, that cannot be reasoned away, that is held despite evidence to the contrary and is out of keeping with a person’s sociocultural norms
- Can have different content e.g. persecutory , grandiose, reference (everything about you), erotomanic (someone is in love with you), hypochondriacal etc
- The key feature is the degree to which the person is convinced that the belief is true - regardless of evidence to the contrary.
- Delusions can be difficult to distinguish from overvalued ideas, which are unreasonable ideas that a person holds, but the affected person has at least some level of doubt as to its truthfulness.
• “what makes you think that…couldn’t it just be…” Interested scepticism
“Encapsulated delusion: a delusion that usually relates to one specific topic or belief but does not pervade a person’s life or level of functioning. Ususally one must dig in order to uncover it. A primary delusion is a delusion which arises “out of the blue” with no morbid antecedents.
Describe formal thought disorder and give examples
A problem of speech (and flow of thought?) whch means that each sentance (or phrase or work) does not follow on from the next
— Circumstantiality - organized but over inclusive, eventually gets to the point in a painstakingly slow manner
— Tangential - occasional lapses in organization such that the patient suddenly changes the subject and never returns to it; if a question is asked, it isn’t answered
— Loosening of associations - frequent lapses in connection between thoughts
— Word salad - incomprehensible speech due to lapses in connections even within a single sentence
— Neologisms - words that are created by the patient and have their own idiosyncratic meaning
— Flight of ideas - flow of thoughts is extremely rapid but connections remain intact , often with pressured speech, uninterruptable. Tends to occur in mania.
Describe disorders of the self
The self v other, the self through time, the unity of experience, the self as agent
So the individual can no longer distinguish betwen themselves and the world.
Includes
Thought broadcast - the belief that others can hear or are aware of an individual’s thoughts
Passivity phenomena - the belief that one is no longer in control of one’s own body, feelings or thoughts. The individual feels that some external agent is controlling them to feel emotions, to desire to do things, to perform actions or to experience bodily sensations.
Thought insertion - feeling as if one’s thoughts are not one’s own, but rather belong to someone else and have been inserted into one’s mind.
- *Depersonalisation_:_** feeling disconnected or detached from one’s self
- *Derealisation**: detachment from one’s surroundings
What are the types of functional psychosis and what is the DDx
Schizophrenic
Bizarre
Persecutor
3rd Person
Manic
Grandiose
2nd Person
Depressive
Guilt, poverty, nihilism
2nd Person
DDx
- Delerium
- Dementia
- Infection e.g. Syphillis
- Endocrine e.g. hyperthyroid
- Temporal Lobe Epilepsy
What is Schizophrenia
Schizo = split phrenia = mind
There is an initial psychotic episode. But:
Some people recover and have no other episodes
Some people have recurent episodes
Some people have a personality change after the initial episode and then go on to have recurrent episodes
A disorder (or group of disorders) characterised by psychotic episodes (positive symptoms) and negative symptoms
- Autism, asocality (as in self absorbed, fantasy dominates over reality)
- Flat Affect (or incongruous)
- Ambivalence (holding two contradictory ideas)
- Loosening of associations (formal thought disorder)
- Amotivation or apathy
1% prevalence. Late teens and early 20s onset.
Higher in certain groups e.g. afro-caribbean, migrants
No one knows cause but ?role of family, ?upbringing.
Illicit drugs definite link esp. amphetamines
Increased mortality 10-20 years
What are Schneider’s First-Rank Symptoms of schizophrenia?
Auditory hallucinations
- Hearing voices conversing with one another
- Voices heard commenting on one’s actions (hallucination of running commentary)
- Thought echo (a form of auditory hallucination in which the patient hears his/her thoughts spoken aloud)
Passivity experiences
The individual has the experience of the mind or body being under the influence or control of some kind of external force or agency; delusions of control or of being controlled
Thought withdrawal
the delusional belief that thoughts have been ‘taken out’ of the patient’s mind
Thought insertion
thoughts are ascribed to other people who are intruding into the patient’s mind
Thought broadcasting
The belief that others can hear or are aware of an individual’s thoughts. This differs from telepathy in that the thoughts beingbroadcast are thought to be available to anybody.
Delusional perception
linking a normal sensory perception to a bizarre conclusion, e.g. seeing an aeroplane means the patient is the president
ICD-10 core symptoms
The most important psychopathological phenomena include thought echo; thought insertion or withdrawal; thought broadcasting; delusional perception and delusions of control; influence or passivity; hallucinatory voices commenting or discussing the patient in the third person; thought disorders and negative symptoms.
How do you manage schizophrenia?
Can they be managed in the community or in hospital?
How risky are they to themselves and others?
Do they have insight?
Assessment
- *Bio:** blood tests, drug test, CT, compliance with meds
- *Psyco**: Mental state examination, collateral history
- *Social**: Talk to cares etc.
Treatment
- *Bio:** Antipsychotics
- *Psycho:** Suppotive counsellng, family therapy
- *Social:** Debts, benefits, housing
Define dementia and delerium
- Cognitive impairment: disturbance of higher cortical functions including memory, thinking, judgement, language, perception and awareness
- Cognitive impairments may be single or multiple, and may be static or progressive
- It is not a specific illness but is a description of someone’s condition
Dementia: persistent disabling cognitive impairment
–Cognitive impairment: decline in both memory and thinking sufficient to impair personal ADLs
–Problems with the processing of incoming information - problems with maintaining and directing attention
–Clear consciousness
Delirium: acute onset of cognitive deterioration
–Impairment of cognition; disturbances of attention and conscious level; abnormal psychomotor behaviour and affect; disturbed sleep-wake cycle
–Onset is usually acute (hours/days)
–All symptoms fluctuate during daytime and are typically worst at night
–2 behavioural subtypes:
•Hyperactive – heightened arousal, restlessness, irritability, wandering, carphologia (picking at clothing)
•Hypoactive – quiet, sleepy, inactive, unmotivated and EASILY OVERLOOKED
•Earliest stage = clouding of consciousness, characterised by attentional deficits e.g. vague rambling conversation, drifting off the point, undue distractibility
•perceptual disturbance usually in the visual modality (c.f. auditory in schizophrenia). Likely to fluctuate. Visual hallucinations when present tend to be fragmentary and/or transient
Describe the symptoms of dementia, early, mid and late stage?
Early stage
–Forgetfulness and other memory symptoms may the most prominent cognitive abnormality, especially in AD
–There may be subtle changes in mood and behaviour e.g. loss of motivation/interest
–There may be minimal intrusion into day to day activities if these are not too demanding
Mid stage
–Memory problems become more prominent and other cognitive difficulties may start to emerge e.g. difficulty with language and executive function
–Changes in behaviour will usually be more marked
–Disability starts to become more obvious: simple personal ADLs may be OK but complex activities e.g. finance, planning activities, dealing with unexpected events becomes a problem. People usually require frequent but not continuous support and assistance
–Often, awareness of disability starts to diverge from reality
Late stage
–Severe and pervasive memory problems accompany other major cognitive disabilities e.g. severe disorientation, failure to recognise familiar people
–Marked (positive and negative) changes in behaviour e.g. agitation or restlessness, irritability, disinhibition, severe apathy
–Disability is severe, even basic aspects of personal functioning are failing and people generally require more or less continuous supervision
Describe the subtypes of dementia according to these catagories
Course and onset
Early presenting symptoms
Neurological features
Mood and behavioural changes
Structural Brain Imaging
Alzheimer’s disease
- Course and onset:* Gradual insidious onset and slow progression
- Early presenting symptoms:* Memory impairment (usually)
- Neurological features:* Nil
- Mood and behavioural changes:* May be minimal initially but pre-existing anxiety etc may worsen
- Structural Brain Imaging:* Volume loss esp. in medial temp lobe, posterior cingulate, precuneus. Neurofibrillary tangles of tau and amyloid deposits
Vascular Dementia
- Course and onset:* May be gradual or more abrupt onset with erratic course
- Early presenting symptoms:* Variable – may be prominent dysexecutive features
- Neurological features:* +/- (highly variable)
- Mood and behavioural changes:* Depression common after stroke; emotional lability
- Structural Brain Imaging:* Maybe evidence of infarcts, bleeds, white matter ischaemia
Frontotemporal Dementia
- Course and onset:* Gradual onset but may progress quickly (esp in younger patients)
- Early presenting symptoms:* Loss of executive ability and impaired social behaviours
- Neurological features:* + (frontal release signs)
- Mood and behavioural changes:* Apathy, loss of volition and disinhibition may be early features
- Structural Brain Imaging:* Frontotemporal atrophy
Lewy Body
- Course and onset:* Fluctuating episodic course; may initially look like delirium
- Early presenting symptoms:* Perceptual disturbance (hallucinosis) and Parkinsonism
- Neurological features:* ++ (Parkinsonism)
- Mood and behavioural changes:* May be paranoia and suspiciousness arising from psychotic symx
- Structural Brain Imaging:* No specific abnormalities. Clumps of alpha-synuclein protein in neurons
Alcoholic Dementia
- Course and onset:* Onset may be gradual but cognitive status fluctuates with drinking and withdrawal episodes
- Early presenting symptoms:* Memory problems and dysexecutive (frontal) features
- Neurological features:* Nil
- Mood and behavioural changes:* Depression commonly associated with alcohol misuse problems
- Structural Brain Imaging:* Age-disproportionate cortical and WM atrophy
Describe the assessment of dementia
History
•What is the course of symptoms over time? This is the single most important bit of diagnostic information and the patient almost certainly won’t be able to tell you
•Is there evidence of disability or impact on day to day life?
•Why have they come now? – Has anything happened recently?
•Any changes in general health?
Examination
•Cognitive screening assessment (GPCOG, AMT, 6-CIT , MMSE, MOCA etc)
•Check for new Physical findings if prompted by Hx
Investigation
–‘Dementia screen’ bloods
•Not screening for dementia per se but screening out other active problems which may contribute
–Structural brain imaging
•CT or preferably MRI
–Functional brain imaging
•Perfusion, glucose metabolism, dopamine transporter turnover
–Specialised tests for special situations
•EEG, lumbar puncture etc
Describe management of dementia
•For patients with Alzheimer’s disease
–Donepezil, rivastigmine, galantamine (cholinesterase inhibitors)
–for mild to maderate AD.
–Predicated on the ‘cholinergic hypothesis’.
–Memantine (NMDA receptor antagonist)
•Predicated on the glutamate overactivity hypothesis in AD
•Licensed for moderate and severe stages of AD
•Impact on cognition may not be great in severe AD
•Impact on behavioural symptoms may be more useful however
•For Parkinson’s disease dementia/DLB –Rivastigmine
•Avoid anticholinergic drugs
–Cognitive deterioration
–Hallucinosis and other psychotic symptoms may arise
•Benzodiazepines
–Use sparingly due to risk of falls, cognitive decline etc
•Antipsychotic tranquilisers
–Avoid where possible due to risks of stroke, falls, movement disorders and cognitive deterioration
What are the risks important risks for delerium?
What drugs are implicated?
- Vision impairment 1.7
- Infection 2.96
- >65 3.03
- Illness severity / multiple co-morbidities 3.5
- >80 5.22
- Cognitive Impairment 6.30
- Fracture on Admission 6.57
Within 24hrs assess people for factors which may precipitate delirium
- Polypharmacy
- Infection
- Hypoxia
- Immobility
- Dehydration, constipation or both
- Pain
- Poor nutrition
- Catheters
- Sensory impairment
- Sleep disturbance
- Environment
Drug induced delirium
•Psychotropic drugs: Antidepressants, Antipsychotics, Benzodiazepines
•Antiparkinsonian drugs
•Anticholinergic drugs
•Opiates
•Diuretics
•(recreational drug intoxication and withdrawal)
How do you screen for and assess delerium?
What is the process for management?
AMT4 (for quick assessment)
- Age
- Birthday or DOB - need day and month (not the year)
- Place (name hospital)
- Year
Confusion Assessment Method
BOTH features A and B. One of C or D
A. Acute onset and Fluctuating course
B. Innattentionfor example, being easily distractible or having difficulty keeping track of what was being said?
C. Disorganized thinking such as rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable, switching from subject to subject?
D. Altered level of consciousness
Collateral History
- Onset and course of confusion
- Previous intellectual function
- Any previous cognitive problems
- Functional status
- Care package
- Safety at home
- Alcohol / Benzodiazepines
- Previous delirium
- Education
How do you manage delerium?
- FBC •CRP •Urea and Electrolytes •LFT’s •Blood cultures
- Glucose
- Calcium
Sedatives
- Only if patient distressed or dangerous behavior. Often has an underlying cause e.g. pain, constipation, frustration or fear
- Sedative drugs themselves can precipitate delirium. Go low and slow
Drug__Oral Dose__IM Dose__Max in 24hrs
Haloperidol 0.5mg PO 1-2mg IM 5mg
Lorazepam 0.5-1mg PO 0.5-1mgIM 3mg
Treat Potential Underlying causes
- Hypoxia / electrolytes
- Infection
- Constipation: PR to exclude impaction, ensure good hydration, laxatives and enemas if required.
- Retention: Treat the underlying cause; catheterise
- Pain: Non-verbal pain scores, utilise other routes e.g. patches
- Avoid moves: Avoid multiple ward and bed moves
- ‘Know Me Better’: Complete a profile with the help of the family/ carers
- Vision / Hearing: Ensure patient has their glasses and hearing aids if appropriate.
- Avoid distress: Avoid constraints, unnecessary or repeated interventions that can cause distress
- SoGo: Sit out, Get out; encourage mobilisation
- Sleep: Engage in activities during day, classical music; avoid excess noise
- DOLS: Complete DoLS assessment if patient at risk of Deprivation of Liberty
- Orientation: Use calendars/ clocks, photos (family/ familiar objects); signpost to toilets
- Staff: Aim for continuity with ward staff
- Nutrition: Promote nutrition — offer regular drinks, snacks and “finger foods”.
What is the difference between second person and third person auditory hallucination?
Third person hallucinations are when patients hear voices talking about themselves, referring to them in the third person, for example “he is an evil person”.
This type is particularly associated with schizophrenia, but can occur in affective disorders. Such voices may be experienced as commenting on the patient’s intended actions - “he wants to kill her”, or describing his current actions - “he is trying to sleep now”. A running commentary by voices is most suggestive of schizophrenia.
Second order hallucinations occur when the voice is talking directly to the patient - “You are going to die” - or the voice tells the patient to do some action - “kill him”. These types of auditory hallucinations are not diagnostic in the same way as third person auditory hallucinations, but the content of the hallucination, and the patient’s reaction to it, may help in diagnosis.
In a depressive psychosis the comments from the auditory hallucination may be derisory (“you are useless”), and the patient may accept them as being justified. A schizophrenic may experience second person hallucinations but may resent the comments that the voice makes. These interpretations of the content of the hallucination and the patient’s reaction are only indicators to the possible psychiatric diagnosis.
What is paraphrenia?
A term that is sometimes used to describe late-onset schizophrenia.
It is not coded for in the ICD-10. Hallucinations and delusions (particularly paranoid) are prominent, whereas thought disorders and catatonic symptoms are rare.
It lacks the negative symptoms, such as the deterioration of intellect or personality.
This disorder is also distinguished from schizophrenia by a lower hereditary occurrence, less premorbid maladjustment, and a slower rate of progression. Onset of symptoms generally occurs later in life, near the age of 60 and is more common in women
What investigations may be organised for a presentation of
Depression
Psychosis
Cognative Decline
Depression
screening tools: Patient Health Questionnaire-9, Beck’s depression inventory
Laboratory analyses: FBC (anaemia); hypothyroidism testing [TSH]; U&E, LFT, (biochemical abnormalities); urine or serum drug screen; glucose (diabetes can cause anergia)
Imaging: When features suspicious of intracranial lesion e.g. headache or personality change.
Psychosis
Lab tests: FBC (B12 / folate deficiency and porphyria); urine or serum drug screen; infection screen (syphilis, HIV, UTI, leporasy, malaris; ANA (SLE); U&E/LFT (cushing’s); TFT (thyroid)
Imaging: CT for SOL; Consider chest x-ray (rule out sarcoid); EEG (temporal lobe epilepsy)
Genetic test for Huntington’s
Cognitive decline
MMS exam; AME; ACE; MOCA
Lab tests: FBC, CRP (anaemia, infection, B12/folate); U&E (electrolyte distubrance) LFT (liver disease / alcohol); glucose; TFT; Urinalysis, CXR, cultures (infection); syphillis/HIV serology; genetic for huntingtions and familial dementia
ABG - hypoxia
CT head - intracrainal bleed / oedema, dementia, SOL,
MRI - identifies posterior circulation vascular pathology better
LP - meningitis, CJD
EEG - epilepsy, fronto-temporal lobe dementia, CJD
ECG - cardiac disease
What are the possible causes of a change in behaviour?
Mental disorders
- Bipolar disorder
- Depression
- Schizophrenia
- Posttraumatic stress disorder
Drugs
- Intoxication: alcohol, amphetamines, cocaine, hallucinogens (such as LSD), and phencyclidine(PCP)
- Withdrawal: Alcohol, barbiturates, benzodiazepines, and opioids
- Side effects of neurological drugs, anticholinergic effects, opioids
Medical disorders that mainly affect the brain
- Alzheimer disease
- Brain infections, such as meningitis, encephalitis, HIV-associated encephalopathy
- Brain tumors
- Head injuries, such as a concussion and postconcussion syndrome
- Multiple sclerosis
- Parkinson disease
- Seizure disorders
- Stroke
Bodywide disorders that also affect the brain
- Kidney failure
- Liver failure
- hypoglycemia
- Systemic lupus erythematosus
- Thyroid dysfuntion
How does frontal lobe dementia present? How do we test for it at the bedside?
- Usuall occurs between the ages of 50 and 60 and develops insidiously
- family history in 50%
- Early personality changes e.g. disinhibition (reduced control over one’s behaviour), apathy/restlessness
- worsening of social behaviour
- Repetative behaviour
- Language problems e.g. Anomic aphasia
- memory is preserved in early stages whereas insight is lost early
Verbal fluency and initiation
Recall as many words beginning with a letter. >10 abnormal
Cognitive estimates
Educated guesses about thigns they are unlikely to know the anser
Clock drawing test
Tests executive funtion.
Similarities (conceptulisation)
Ask in what way two objects are alike
_Motor sequencing (Luria's 3 step test)_ Tell the patient you are goign to show them a series of hand movements - fist, edge, palm, - 5 times and then repeat
