Schizophrenia and Delirium Flashcards
Summary of Schizophrenia:
Common chronic relapsing condition often presenting in early adulthood with negative symptoms, disorganisation symptoms, psychotic symptoms and cognitive impairment. Most common form of psychosis.
Risk factors for schizophrenia?
1) Family history (strong RF)
2) PMH of maternal pregnancy complications or problems with cognitive/NM development.
3) Environmental factors: Disturbed childhood/family problems, social isolation
4) Teenage cannabis use
Clinical presentation of schizophrenia?
1) Prodromal phase preceding episodes of psychosis by 18 months - gradual deteriorating of functioning: transient psychotic symptoms, odd out of character thoughts beliefs and actions, concentration problems.
2) Main symptoms must be present for at least a month, with 1 first rank symptom and 2 others.
3) First rank symptoms: a) delusions of thought interference (withdrawal, insertion and broadcasting),
b) delusions of control (thoughts, feelings, emotions and actions controlled by external forces),
c) persistent delusions (implausible/inappropriate),
d) 3rd person auditory hallucinations (running commentary, thought echo, voices arguing).
4) Other symptoms: a) persistent hallucinations in any modality every day for weeks,
b) Breaks in train of thought resulting in incoherent, irrelevant speech or neologisms.
c) Catatonic Behaviours: waxy flexibility, mutism, stupor, negativism, purposeless behaviour.
d) Negativism: Anhedonia, apathy, paucity of speech, blunting or incongruity of affect.
Differential diagnosis of Schizophrenia?
1) Dementia
2) Delirium due to infection, neurological disease
3) Drug induces psychosis - amphetamine, LSD, cannabis
4) Mania/Bipolar
5) Alcohol hallucinosis
Diagnosing Schizophrenia?
1) CT/MRI to rule out other cerebral pathology
2) Alcohol and drug screen
3) LFT’s and FBC - abnormal + macrocytosis - alcohol abuse
4) History and exam (MMSE) - 1 1st rank symptom and 2 other symptom. Must only be diagnosed after 6 months of symptoms, with symptoms lasting most of the month.
Types of schizophrenia?
1) Paranoid schizophrenia (most common) - delusions and hallucinations, more prominent
2) Hebephrenic schizophrenia - poor prognosis, disorganised speech, fluctuating delusions and hallucinations.
3) Catatonic schizophrenia - psychomotor disturbance with stupor, waxy flexibility, mutism, negativism.
How do you treat schizophrenia?
1st line: SGA - Olanzapine, Quetiapine, Risperidone. (5HT2A and D2 antagonists) associated with hyperglycaemia, ED and weight gain.
2nd line: FGA - Haloperidol, Chlorpromazine (D2 antagonists) associated with extrapyramidal side effects: Parkinsonism (stiffness and movement issues), acute dystonia, akathisia (restlessness), dyskinesia (twitching).
Treatment resistant schizophrenia: SGA - Clozapine (failure to respond to 2 or more antipsychotics given for over 6 weeks). Requires FBC monitoring as agranulocytosis/leukopenia risk.
Other treatment - CBT, advice, reassurance, patient and family education.
Delirium summary:
Acute onset of fluctuating cognitive impairment (or deteriorating in pre-existing cognitive impairment) associated with behavioural abnormalities. (Acute confusional state)
Risk factors: Elderly, dementia, blind/deaf, post-op (common in medical and surgical inpatients), alcohol/benzo dependent.
Aetiology of Delirium?
1) Pain
2) Infection - UTI, cellulitis
3) Nutrition
4) Constipation
5) Hydration - electrolyte disturbance, anaemia
6) Medicine - Lithium, steroids, benzos, alcohol
7) Environment - Hypoxia
Clinical Presentation of delirium?
1) Acute/rapid onset fluctuations in severity
2) Impaired cognition, consciousness and concentration
3) Memory loss (recent)
4) Abnormal sleep-wake cycle - hypersomnia
5) Hallucinations and illusions
6) Emotion lability
7) Speech incoherent and rambling
8) Psychomotor agitation
9) Neurological signs
Hyperactive/agitated delirium - psychomotor agitation, increased arousal, inappropriate behaviour, delusions and hallucinations
Hypoactive delirium - psychomotor retardation, lethargy
Mixed delirium - both
Diagnosis of delirium?
DSM criteria:
(FBC - elevated WCC), U&E’s, ESR/CRP, LFT, TFT, glucose, B12/folate/ferritin.
MSU.
Imaging - AXR, CXR, Head CT
1) Impaired attention and awareness
2) Disturbance develops over a short period of time and fluctuates
3) Additional disturbance in cognition (memory, speech, perception, disorientation)
4) Disturbance is a result of a general medical condition/substance intoxication
5) Not a result of previous/evolving dementia
Treating Delirium?
1) Identify and treat cause
2) Optimise patient condition - hydration, nutrition, pain control
3) Environment and supportive measures - family education, safe environment with lighting, reduced noise and mobilise patient, reality orientation technique with clocks and calendars.
4) Avoid sedation unless severely agitated or necessary to minimise risk or facilitate treatment/investigation: consider haloperidol or risperidone, if alcohol related - Benzodiazapene (Lorazepam). Sedating antihistamine - Primethazine.
5) Regular clinical review and follow up (MMSE useful)
