Pyschiatry Flashcards
What are the 7 stages of addiction?
1) craving
2) dependance
3) withdrawal
4) salience
5) narrowing of repitoire
6) loss of control
7) relapse
Regarding the 7 stages of addiction, how many do you need to have at one time in a 12 month period to be classified as addicted?
3 stages
What are the the different parts of the mental state exam?
Appearance and behaviour
Speech (look for formal thought disorder)
Mood (3 core, 4 biological, psychological and risk)
Thought (obsessive or delusional thoughts)
Perception (illusion or hallucinations)
Cognition - are they orientated in time, person and place
Insight and capacity
What are the 3 core elements of mood?
Energy
Enjoyment
Mood scale (1-10)
- objective and subjective
What are the 4 biological elements of mood?
Sleep
Appetite
Concentration
Libido
What are the 5 stepwise questions to ask regarding risk assessment in a psychiatric history?
1) Thoughts of life not worth living
2) thoughts of self harm
3) thoughts of killing
4) plans to kill
5) Protective factors
Apart from risk of self harm what else do you need to assess in a psychiatric risk assessment?
Risk to self - neglect, vulnerability
Risk to others
What is the difference between thought form and thought content?
Thought form - the form of the speech (this is abnormal in formal thought disorders)
Thought content - what they are speaking about
What are the 4 types of formal thought disorder?
Poverty - depression
Pressure - manic phase of bipolar
Loss of association - schizophrenia
Circumstantiality - dementia
What are the hallmarks of an obsessive thought?
Recurrent
Intrusive
Unpleasant
What is the definition of a delusional thought?
Fixed, false and out of keeping
What are the different types of delusional thoughts?
Persecutory (most common and non-specific) Mood congerent (nilhilistic or grandiose) Schizophrenic delusions
What are the different types of delusional thoughts which are specific to schizophrenia?
Thought insertion
Thought extraction
Control - like someone is moving arms and legs like puppet
Reference - like the TV is talking to you
What is the difference between an illusion and a hallucination?
Illusion - incorrect image in the presence of a stimulus
Hallucination - no stimulus present, but all the qualities of a true perception
What are the different types of hallucinations?
Which is most common?
Based on senses: Auditory (most common) Visual Touch Smell Taste
What is a pseudohallucination?
Eg, hearing a voice in your head
Doesn’t have all the qualities of a true perception
What is formulation in psychiatry?
What are the components?
Formulations are used to communicate a hypothesis from the history and provide a framework for treatment approach
3 P’s (predisposing, precipitating, perpetuating) 3 components (biological, psychological and social)
What does the accrynom SADMOPP stand for regarding differentials in psychiatry?
Substance abuse Anxiety Developmental disorder Mood disorder (unipolar or bipolar) Organic (ALWAYS CONSIDER UNTIL RULED OUT) Psychosis Personality Disorder
What is the ICD-10 Diagnosis Criteria for Depression?
Symptoms need to be present for a minimum of 2 weeks
Must contain at least 2 of the core symptoms
Must contain at least 2 of the other symptoms
What are the 3 core symptoms for depression?
Depressed mood - that doesn’t improve to positive events
Anhedonia (loss of pleasure and enjoyment)
Anergia (loss of energy, fatigue)
What are the other non core depressive symptoms?
Impaired concentration
Reduced self a stem
Sleep disturbance
Loss of appetite
Psychomotor changes - retardation and agitation
Psychotic symptoms - delusions and auditory hallucinations
What are the classic sleep disturbances seen in a patient with depression?
Early morning awakening - 2 hours before usual time
Middle insomnia - waking up during the night and having difficulty falling asleep again
Initial insomnia - problems falling asleep initially
If you suspected someone had depression, how could you confirm this?
Using a PHQ-9 Questionnaire
What are the important differentials when thinking about depression?
Bipolar - ask about manic phases
Bereavement - ask about recent family death
Chronic medical conditions - increase risk
Medications - some increase risk
Which medications increase the risk of depression?
Corticosteroids Beta blockers Stains Oral contraception Isotretinoin Topiromate
What initial investigations should you do when investigating depression?
BP, pulse, BMI - good baseline for medications
FBC, U&Es, LFTs, TFTs HbA1C - look for underlying chronic conditions
ECG - useful for some antidepressant meds can increase QT interval
What are the different grading of depression?
Mild, moderate, severe
Graded on severity of symptoms and functional impairment
How is depression managed?
Mild - watchful waiting and supportive consultation, review in 2 weeks
Moderate/severe - trial antidepressant
What lifestyle management is important in depression?
Time off work - especially if stress is impacting mood
Stop drinking/smoking
Exercise - 30 mins 3x a week
Encourage social support
What guidance should you give to someone before starting an antidepressant medication?
Can take 3-6 weeks before they start to work
Tend to feel worse initially - because side effects kick in before therapeutic effect of drug
Need to trial antidepressant for at least 2 months before switching
Must continue on drug even once they feel better to decrease risk of relapse
Little benefit switching between classes - unless for side effect reasons
What are the different classes of antidepressants?
TCAs (tricyclic antidepressants)
SSRIs (selective serotonin reuptake inhibitors)
SNRIs (serotonin and noradrenaline reuptake inhibitors)
MOIs (Monoamine oxidase inhibitors)
5HT2A Antagonists
How do tricyclic antidepressants work?
Block reuptake of noradrenaline, serotonin and dopamine
Give examples of TCAs
Disipramine
Amitriptyline
Clomipramine
What are the main side effects of TCAs?
Lower seizure threshold
Cardiotoxic - can prolong QT interval
Lethal in overdose
Anticholinergic effects - dry mouth, blurred vision, constipation, urinary retention, confusion
Antiadrenergic effects - postural hypotension, sexual dysfunction
Antihistamine effects - sedation, weight gain
How to SSRIs work?
Block serotonin reuptake by SERT (Serotonin transporter)
This prolongs the actions of released serotonin
However this takes weeks to come into affect as initially the 5HT neurons decrease the firing in response to increased serotonin and autoreceptors on the neurons. Over time these autoreceptors desensitise
Give examples of the common SSRIs used?
Sertraline
Citalopram
Paroxetine
Fluoxetine
What are the common SSRI side effects?
GI disturbance - nausea and diarrhoea Sexual dysfunction Restlessness, nervousness, agitation, sweating (note that these initial symptoms can make the patient feel worse) Dry mouth Loss of appetite Insomnia
How do SNRIs work?
Inhibit the reuptake of serotonin and noradrenaline
Act like TCAs but without the anticholingergic, antiadrenergic and antihistamic side effects - this is because they don’t inhibit dopamine reuptake
Give examples of the commonly used SNRIs
Venlafaxine
Duloxetine
How do MOIs (Monoamine oxidase inhibitors)
Monoamine oxidase is an enzyme that breaks down serotonin, noradrenaline and dopamine
MOIs bind to monoamine oxidase and prevent its action
What is the main side effect of MOIs?
Why are they not used anymore in treating depression?
Hypertensive crisis
This is because monoamine oxidase is also needed to metabolise other monoamines - such as dietary tyramine (which is found in red wine, cheese)
If you block activity then this will lead to a build up of these foods which will cause a hypertensive crisis
Give an example of a MAOIs
Why is this famous?
Iproniazid
First antidepressant ever licensed, originally a TB drug
What s serotonin syndrome?
Major side effect of antidepressant
Caused by excessive serotonin
Presents with extreme sympathetic nervous system response (hyperthermia, hypertension, hyperreflexia, tachycardia, tremor, agitation, irritability, sweating, diarrhoea, dilated pupils)
Many patients with depression relapse after their first episode. How is the risk of relapse determined?
Low risk of relapse - in first episode patients with no risk factors
Moderate risk of relapse - any risk factors present e.g, (residual symptoms, previous depressive episodes, severe depression)
High risk of relapse - patients with >5 lifetime episodes or 2 episodes in the last year
How long should patients stay on antidepressants for?
This depends on their risk of relapse:
- Low risk of relapse - 6-9 months
- moderate risk of relapse - at least 1 year
- high risk of relapse - at least 2 years
What is the process for coming off antidepressant medication
Need to consider withdrawal symptoms and reccurance of symptoms
Come off slowly over a course of 4 weeks - several months depending on dose and severity of depression
Only come off medication at an appropriate time - not during a time of stress e.g, moving house, new job, wedding, exam
What options are there for treatment resistant depression?
Lithium
ECT
When would you refer a patient with depression to psychiatric services?
If the patient doesn’t respond to multiple treatments
If there is significant risk of suicide, self harm, self neglect or harm to others
If there are any psychotic symptoms present
If you suspect bipolar disorder
If the patient is a child/adolescent with severe major depression
What are the important questions to ask someone after a suicide attempt?
What precipitated the event Was it planned or impulse Did they plan to kill themselves or was it a cry for help Did they leave a note Were they intoxicated Previous attempts Current risk assessment
Which pathway in the brain is associated with excessive dopamine in schizophrenia?
Associative striatum of the nigrostriatal pathway
What is psychosis?
A mental disorder in which thoughts and emotions are impaired so the person loses contact with reality
Note that psychosis is not a diagnosis - but recognising it is the first step towards making a diagnosis
How does psychosis commonly present?
Delusions and/or hallucinations - these often drive a disturbance of behaviour
Paranoid thinking
What are the causes of psychosis?
Organic cause - important to rule out Schizophrenia Drug induced psychosis Bipolar - manic phase Severe depression Dementia
What other features may be present if psychosis is caused by an underlying physical disease?
Disorientation
Memory problems
Neurological features
What initial investigations would be done for a patient presenting with psychosis?
Need to investigate to rule out organic cause:
Bloods - FBC, LFTs, TFTs, bone profile, U&Es
ECG - as some antipsychotics prolong QT interval
MRI scan - rule out organic cause (done if there are other neurological findings)
In a patient presenting with a 1st episode psychosis, what is the management?
Referral to the EIS (Early intervention service) mental health team
Trial of oral antipsychotic
Physiological interventions e.g, CBT
What is the EIS (Early intervention service)?
Mental health team which help people aged 14-35 with early psychosis
Help to reduce the duration of untreated psychosis (DUP) to help improve outcomes
Help improve access to effective treatment particularly in the ‘critical period’ (3-5 years following onset)
Who can initiate antipsychotic treatment?
Only a qualified psychiatrist
GP can not initiate but can continue treatment in community with consent from psychiatry team
What are the 4 main dopamine pathways in the brain?
Nigrostriatal - involved in motor control, and emotion
Mesolimbic - involved in feelings of reward/pleasure
Mesocortical - inovled in cognition and memory
Tuberoinfundibular - involved in inhibiting prolactin production
What is the main mechanism of antipsychotics?
Act on the 4 main dopamine pathways in the brain
Majority act on D2 receptors (inhibitory receptors)
What are the main side effects of antipsychotics?
Metabolic side effects (weight gain, diabetes, metabolic syndrome, Hyperlipidemia) Sedation Extrapyramidal (movement disorders) Cardiovascular (prolong QT interval) Hormonal (increase prolactin)
What monitoring would you do before starting a patient on an antipsychotic?
Need to check baseline due to side effect profile
Weight
Pulse, BP, ECG
Bloods - glucose, HbA1c, lipid profile, prolactin
Assess for movement disorders
Assess nutritional status, diet and exercise level
What is the difference between typical and atypical antipsychotics?
Typical - act to reduce dopamine by acting as D2 receptor antagonists (because of this they have a high EPS side effect profile)
Atypical - have lower D2 receptor affinity and higher serotonin 5-HT2A receptor affinity (serotonin-dopamine 2 antagonists). They affect dopamine and serotonin neurotransmission in the 4 main dopamine pathways
Give examples of typical antipsychotics used?
Haloperidol
Sulpiride
Fluphenazine
Amisulpiride
How is amisulpiride different to the other typical antipsychotics used?
Highly selective for D2 and D3 Limbic subtypes
Reduces EPS side effects e.g, parkinsonism
Has favourable outcomes for weight gain
Side effect - may cause hyperprolactinaemia
Give some examples of atypical antipsychotics used?
Risperidone Olanzapine Quetiapine Aripiprazole Clozapine
Which of the atypical antipsychotics is most likely to cause extrapyramidal side effects?
Risperidone
Which of the atypical antipsychotics is most associated with weight gain?
Olanzapine
Which atypical antipsychotic can also be used as an antidepressant at lower doses?
Quetiapine
Which atypical antipsychotic is most likely to prolong the QT interval?
Quetiapine
Which atypical antipsychotic has a unique mechanism in that is acts as a D2 agonist?
Aripiprazole
Which atypical antipsychotic is reserved for treatment resistant psychosis?
(Must have tried 2 previous antipsychotics, one being atypical)
Clozapine
What is the major side effect of clozapine to be aware of?
How is this monitored for?
Agranulocytosis (0.5-2% risk)
Requires weekly blood monitoring for first 6 months
Requires 2 weekly blood monitoring for next 6 months
Apart from agranulocytosis, what are the other main side effects of clozapine?
Increased risk of seizures - especially if taken with lithium
Sedation
Weight gain
Deranged LFTs
What is neuroleptic malignant syndrome?
Major side effect of antipsychotics
Results in autonomic dysfunction - like serotonin syndrome
Can have severe muscle breakdown and increased CK which can cause rhabdomyolysis
How does neuroleptic malignant syndrome present?
Hyperthermia Hypertension Hyperreflexia Tachycardia Tremor, agitation, sweating Dilated pupils
How is neuroleptic malignant syndrome managed?
Discontinue antipsychotic medication Transfer to ICU Benzodiazepines for agitation May need active cooling Aggressive IV hydration
What are the 3 symptom categories in schizophrenia?
Positive symptoms (delusions, hallucination) Negative symptoms (blunted emotions, anhedonia, lack of motivation) Cognitive impairments (memory problems)
What type of hallucinations are commonly seen in schizophrenia?
Auditory hallucinations
What does catatonic behaviour mean?
Marked psychomotor movements
- generally movements are rigid
- can present as bizzare and inappropriate movements
- wavy flexibility (the limbs remain in the position they are placed)
What are the risk factors for developing schizophrenia?
Genetic link?
Prenatal exposure to infections
Heavy canabis use - particularly if used before the age of 16
Obstetric complications
How does schizophrenia commonly present? (3 phases)
Prodromal phase - patient becomes withdrawn
Active phase - positive symptoms occur e.g, delusions, hallucinations, catatonic behaviour
Residual - patients show cognitive symptoms
Hyperprolactinaemia is a major side effect of antipsychotic medication. What can it lead to?
Sexual dysfunction Reproductive dysfunction Breast pathology - e.g, enlargement Hypogondism - decreased BMD (leading to hip fractures) Acne and hirsutism
What is section 2 of the mental health act?
Detained in hospital for assessment of mental health and to get any treatment needed
Requires 2 doctors + approved mental health worker
Length is up to 28 days
What is section 3 of the mental health act?
detained in hospital for treatment
Either follows from section 2 OR if patient is known mental illness
Length is up to 6 months
Requires 2 doctors + mental health worker
What is section 4 of the mental health act?
Used in emergency situations
Detained in hospital for assessment
Lasts up to 72 hours
Requires one doctor + one mental health worker
Should move to section 2 as soon as possible
What is section 5 of the mental health act?
Detained by doctor or nurse holding power Section 5(2) - doctor holding power up to 72 hours Section 5(4) - nurse holding power up to 6 hours
What is section 136 of the mental health act?
Detained under police officer for up to 72 hours
How is schizophrenia managed?
Antipsychotic use
CBT if this helps
Assigned care coordinator (key worker) in the community to follow up patient
How many patients with schizophrenia will have a repeated episode in the 5 years following their first episode?
80%
What is the care programme approach (CPA)?
Package of care for patients with mental health problems (severe mental disorder, risk of subsided, recently sectioned)
Patients will get a written care plan and support
Provides help in emergencies
Provides a CPA care coordinator to manage care plan and review yearly
How does delirium tremens present?
Alcohol withdrawal
Altered consciousness
Fluctuating motor cavities
Autonomic hyperactivity - raised temp, raised BP, tachycardia
Hallucinations - auditory, visual, tactile
How is delirium tremens managed?
Benzodiazepines - usually chlordiazepoxide
Pabrinex (thiamine) - to prevent wenicke’s encephalopathy
IV fluids - for dehydration
How is alcohol withdrawal managed long term?
Vitamin B and thiamine
Psychosocial support
What is the difference between Wernicke’s encephalopathy and Korsakoff’s syndrome?
Wernicke’s - neurological deficit relating to thiamine deficiency
Korsacoffs - brain damage when Wernicke’s is not treated, results in irreversible damage to thalamus and hypothalamus and neuronal loss. Short term memory is diminished (presents with cognitive impairment and significant deficit in anterograde and retrograde memory)
What is the typical triad of Wernicke’s encephalopathy?
Ophthalmoplegia (eye movements disorders e.g, nystagmus)
Ataxia
Confusion
How is Wernicke’s managed?
Thiamine replacement - this is the only way to stop the damage
Cardiovascular stabilisation
Long term support for alcohol cessation
What medications can be given to recovering alcoholics to help reduce cravings?
Acamprosate
Naltrexone
What is disulfiram and how does it work?
Used in alcohol recovery
Produces acute sensitivity to drinking alcohol
Inhibits the enzyme acetaldehyde dehydrogenase
So it makes the effects of a hangover to be felt immediately following alcohol consumption - feeling sick
What are the difference types of bipolar disorder?
Type 1 - cycles of mania episodes and depressive episodes
Type 2 - cycles of severe depression with hypomania
Cyclothymia - hypomania an depressive mood states cycles. Symptoms less severe than type 1 and 2
What are the symptoms of mania?
DIG FAST acronym
Distractability Impulsivity - e.g, spending lots of money Grandiosity Flight of ideas Activity increase Sleep deficit Talkative - pressured speech
What is the difference between mania and hypomania?
Hypomania is shorter lived and is not accompanied by psychotic symptoms. Hypomania episodes are less severe and don’t cause marked impairment in social or occupational functioning
Manic episodes must last for a minimum of a week
Hypomania episodes should last for at least 4 days
How are acute episodes of mania in bipolar disorder managed?
With antipsychotics
E.g olanzapine, risperidone
What blood monitoring needs to be done with patients on lithium?
U&Es
Lithium is excreted by the kidneys so can effect renal function
What are the the contraindications for taking lithium?
Renal failure patients
Cardiovascular insufficiency patients
Addison’s disease
Untreated hypothyroidism
Which medications should not be used alongside lithium?
Any medications which can reduce renal function:
- NSAIDs
- ACEi
- Certain antibiotics
What is the risk of taking lithium in pregnancy
Risk of congenital heart defects
What is the risk of sodium valproate (depakote) in pregnancy?
Risk of neural tube defects
How many hours after abrupt cessation of alcohol consumption do delirium tremens usually occur?
Can occurs within 72 hours of cessation
Which medications are used as maintenance treatment in bipolar disorder?
Lithium - mood stabiliser
Sodium valproate (depokate) - epilepsy treatment used in bipolar
What are the 3 key features of dementia?
Decline in memory
Decline in cognitive domains (planning, organising, thinking, recognition)
Functional impairment
How many months do symptoms of dementia need to be present for a diagnosis to be suspected?
6 months
With NO clouding of consciousness
What are the 4 primary degenerative causes of dementia?
Alzheimer’s
Vascular dementia
Lewy body dementia
Fronto-temporal dementia
What is the most common primary degenerative cause of dementia?
Alzheimer’s disease
What is the difference between early and late onset Alzheimer’s disease?
Early onset <65 years
Late onset >65 years
What is the usual presentation of Alzheimer’s disease?
Slow and gradual memory loss
Signs usually noticed by carers/family rather than patient
Normally attributed initially as normal ageing
Disease usually well established by the time of presentation to health service
What are the signs of Alzheimer’s disease?
Determination in self care Repetitive phone calls Episodes of wandering Missed appointments Dangerous lapses of memory
What are the 5 A’s of Alzheimer’s?
Amnesia - slow but progressive
Agnostic - inability to recognise objects and people
Apraxia - decreased motor coordination
Aphasia - difficulty speaking (this is a late symptom)
Associated behaviour - personality change, psychotic symptoms, challenging behaviour
What are the risk factors for Alzheimer’s disease?
Increasing age Family history - 1st degree relative increases risk by 3-4x CVD history Parkinson’s disease Down’s syndrome Hypothyroidism Significant head injury
What genes have been linked to Alzheimer’s?
APOE (E4 allele of apolipoprotein E gene) - around 40-80% of AD patients have at least one of these alleles
Amyloid precursor protein (APP) - present in Down’s syndrome
What is the pathophysiology of Alzheimer’s?
Accumulation of beta amyloid plaques - these interfere with neuronal function
Neurofibrillary tangles - due to abnormal tau protein which tangles. Tau is responsible for internal cell transport. Without this neurons die
What are the risk factors for vascular dementia?
Ischaemic disease - HTN, heart disease, vascular disease
AF
Diabetes
FH of stroke or vascular disease
Ethnicity - Indian, Bangladesh, Pakistani, Sri Lanka
Male sex
What are the different causes of vascular dementia?
Stroke - results in single onset
Multi infarct dementia - multiple mini strokes causing sudden decline in function every time
Subcoritcal vascular dementia - damage to smaller blood vessels in the brain results in gradual decline in function
What is Lewy body dementia?
Less common type of dementia - related to Parkinson’s disease
Results from clumps of Lewy body proteins accumulating inside nerve cells and causing them to die
How does Lewy body dementia differ in its presentation to other types of dementia?
Onset slightly earlier (50’s-60’s)
Features of Parkinsonism- bradykinesia, difficulty moving, falls
Fluctuation in symptoms - symptoms vary day to day. Variation in orientation and alter Tess
Visual Hallucinations may be present
Sleep disturbances - patients can have vivid dreams
40-50% of patients can have depressive episodes
How is Lewy body dementia diagnosed?
Using a DaTSCAN - dopamine imaging
Will show specific cell death related to Lewy body dementia
How does the presentation of fronto-temporal dementia differ to other types of dementia?
Often younger onset (50-60) Predominance of frontal lobe involvement: - emotional blunting - coarsening of social behaviour - disinhibition - apathy or restlessness
What are pick bodies? How does this relate to fronto-temporal dementia?
Pick bodies are composed of tau fibrils - usually accumulate in the frontal and temporal lobes of the brain
A build up of these can cause picks disease
Fronto-temporal dementia used to be known as picks disease - however now known only 20-30% of patients have pick bodies present
Apart from the 4 primary progressive causes of dementia, what are the other organic causes?
Brain tumours
Normal pressure hydrocephalus
Subdural haemotoma
Alcohol dementia
What diseases are linked to causing dementia?
Creutzfeldt Jakob disease Huntington’s disease Parkinson’s disease HIV Down’s syndrome
What is the difference between delirium and dementia?
Delirium is an acute cause of cognitive impairment
Duration of delirium will be hours-weeks long
Patients will have clouding of consciousness - reduced clarity of the environment
Patients can be agitated and psychotic
Delirium is usually reversible
How is delirium managed?
Identity the underlying cause - usually infection
Treat cause - this should treat delirium state
What are the differentials for dementia?
Delirium
Pseudo-dementia
Mild cognitive impairment
How does pseudo dementia present?
Depression related cognitive impairment
Patients will not feel fine and will be distressed by their cognitive impairment (compared to dementia where they will be unaware or unconcerned by impairment)
What investigations should you do in a patient presenting with suspected dementia?
Need to rule out any underlying cause for symptoms and any treatable causes of dementia:
Urinalysis - UTI can cause confusion
Bloods - FBC, U&E, HbA1c, B12, folate, TFTs, CRP, syphillis serology (if suspected)
CT/MRI scan - look for SOL, or areas of atrophy
What screening tools are used to help aid dementia diagnosis?
ACE III (Addenbrokes cognitive examination)
MOCA (Montreal cognitive assessment)
MMSE (mini mental state exam)
What ACE III score is highly suggestive of possible dementia?
ACE III <82
How would you assess a patients functional impairment in a patient presenting with dementia symptoms?
Activities of daily living questionnaire
What are the two types of medications used to help manage cognitive symptoms in dementia?
Acetylcholinesterase inhibitors (AChE inhibitors) Glutamate receptor antagonist
Name the common AChE inhibitors used in Alzheimer’s disease?
Donepezil
Galantamine
Rivastigmine
Which AChE inhibitor is also licences for use in Lewy body dementia and Parkinson’s disease?
Rivastigmine
Name the common Glutamate receptor antagonist use in moderate/severe dementia?
Memantine
What investigation must you do before starting a patient on an acetylcholinesterase inhibitor and why?
ECG
AChE inhibitors are contraindicated for patients with bradykinesia, LBBB and prolonged QT interval
In which patients should memantine be avoided?
Which blood test is done before use?
Patients with renal failure
Important to check renal function before starting
Which Alzheimer’s medications is the safest choice in patients with cardiovascular disease?
Rivastigmine
Which antipsychotic medication can be used to help patients with Alzheimer’s who experience symptoms of agitation or hallucinations?
Why should antipsychotics be used with caution in dementia?
Quetiapine
Antipsychotics are associated with increased mortality in dementia
What other teams are involved in the care for dementia patients?
Physiotherapy - assess fall risk
Occupational therapist - assess home risks e.g, fires, self neglect, wandering
Care coordinator - dementia patients may have a CPA involved in care
What are the two different types of lasting power of attorney?
LPA for health and welfare
LPA for property and affairs
What is a lasting power of attorney (LPA)
Where you nominate someone to make decisions on your behalf when you lose the capacity to do so
What is DoLs?
Deprivation of liberty safeguarding
Where you restrict someone’s free will and independence in their best interest
E.g, keeping them in a hospital or care home for their wellbeing
What is the duration of restriction of a DoLs
12 months
Must be reviewed after this to be extended
What is triad of symptoms for normal pressure hydrocephalus?
Memory problems
Ataxia
Urinary incontinence
What is REM sleep behaviour disorder and how is it managed?
Where people act out their dreams
Patients are not confused when they wake up
Can co exist with narcolepsy leading to day time sleepiness
Seen in patients suffering from neurological disorders
Managed with Clonazepem
What is the criteria for diagnosing a personality disorder?
Deeply ingrained maladaptive patterns of behaviour
Patterns must arise in childhood and continue into adulthood
Patterns must cause stress to themselves and to people around them
What are the 3 clusters of personality disorder?
A - odd/eccentric cluster
B - dramatic/emotional/erratic cluster
C - anxious/fearful
What are the different types of personality disorder in cluster A?
Paranoid
Schizoid
Schizotypal
What type of personality does someone with a schizoid personality disorder have?
Detached emotionally
Finds it difficult to form close relationships
What type of personality does a person with a schizotypical personality disorder have?
Disorientated thoughts or perceptions e.g, think they are able to read minds
May express themselves in an odd way
What are the different personality disorders in cluster B?
Antisocial
Borderline (emotionally unstable)
Histrionic
Narcissistic
What kind of personality does someone with an antisocial personality disorder have?
Act impulsively
Has little regard for others
Lacks empathy
What kind of personality does someone with emotionally unstable personality disorder have?
Has unstable relationships
Has unstable emotions - switches from happy to sad
Problems with self image
May have suicidal or self harm thoughts
What kind of personality does someone with a histrionic personality disorder have?
Enjoys being the centre of attention
May flirt or act provocatively to ensure this
What kind of personality does someone with a narcissistic personality disorder have?
Someone who thinks highly of themselves (big ego)
Puts their own needs before others
What are the different personality disorders in cluster C?
Avoidant
Dependant
Obsessive compulsive
How are personality disorders managed?
Biological - treat any anxiety/depression/psychosis with meds
Psychosocial - dialectic behavioural therapy
Social - support, crisis management
What is DBT (dialectic behavioural therapy)?
Treatment specifically for personality disorders such as EUPD (emotionally unstable personality disorder)
Works in a similar way to CBT
Incorporates mindfulness
Helps with coping mechanisms
What are the different Extrapyamidal side effects (EPSEs) that can be seen on typical antipsychotics?
Parkinsonism
Acute dystonia: sustained muscle contraction (oculogyric crisis)
Akathisia (severe restlessness)
Tardive dyskinesia (abnormal involuntary movements, most common is chewing and pouting of the jaw)
What medication can be used to treat drug induced extra pyramidal side effects?
What is its MOA?
Procyclidine
Anticholinergic drug
Which antidepressant is most commonly used in bipolar disorder?
Fluoxetine
Which chronic health conditions does bipolar disorder increase your risk of?
Diabetes
Cardiovascular disease
COPD
What is a oculogyric crisis?
Dystocia reaction to certain drugs (usually typical antipsychotics)
Cause prolonged involuntary upward deviation of the eyes
What class of drugs does mirtazapine belong to?
What is the MOA?
It is its own class of antidepressant Noradrenergic and specific serotonergic antidepressant
Works by blocking alpha2 adrenoreceptors to increase the release of neurotransmitters
What are the side effects of mirtazapine?
What can this be good for?
Sedation and weight gain
Good for patients with depression who have trouble with sleep and poor appetite
What are the indications for ECT (electroconvulsive therapy)
Treatment resistant severe depression
Manic episodes
Moderate depression known to respond to ECT in the past
Life threatening Catatonia
What are the short term side effects of ECT?
Headache Nausea Short term memory impairment Memory loss of events prior to ECT Cardiac arrhythmia
What is the only absolute contraindication to ECT?
Raised intracranial pressure
What are the most common causes for acute delirium in the elderly?
Pain Infection Constipation Urinary retention Metabolic - hyperglycaemia, hypoglycaemia, dehydration Medications - e.g, opoids Hypoxia
Which medications should be avoided in patients with Lewy body dementia and why?
Typical antipsychotics e.g risperidone and haloperidol
D2 antagonists can lead to irreversible parkinsonism
How is REM sleep behaviour disturbances managed?
Clonazepam
Given at a low dose 30 mins before bedtime
