Scientific Foundation & Advanced Practice 3 Flashcards

1
Q

What are the assessment tools for alcohol withdrawal, alcohol use disorder, and drug abuse?

A
  • CIWA-AR
  • AUDIT
  • DAST-10
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2
Q

What is CIWA-AR?

A
  • Clinical Institute Withdrawal Assessment - Alcohol Revised
  • Used to assess alcohol withdrawal (used to determine when to administer medications for ETOH withdrawal/detoxification)
  • Treatment starts when score is greater or equal to 8 or higher
    – If ordered PRN only – Symptom triggered method
  • Total CIWA-AR score 15 or higher if on scheduled medication (scheduled and PRN method).
    – Diazepam (Valium), Lorazepam (Ativan)
    – If patient’s liver is compromised, give them Ativan or Librium bc Valium has a LONGER HALF LIFE
  • Assess for delirium tremens
  • Withdrawal and DT usually occur within the first 24 to 72 hours afer cessation of alcohol
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3
Q

What is AUDIT?

A
  • The Alcohol Use Disorder Identification Test
  • 10 item screening tool developed by WHO
  • Assesses alcohol consumption, drinking behaviors, and alcohol related problems
  • Score of 8 or higher – indicates hazardous or harmful alcohol use
  • 3 medications approved by FDA to treat alcohol use disorder (alcohol dependence):
    Acamprosate (Campral)
    Disulfram (Antabuse)
    Naltrexone (Vivitrol)
  • Acamprosate and Naltrexone reduce alcohol consumption and increase abstinence rates
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4
Q

What is DAST-10?

A
  • Drug Abuse Screening Test
  • 10 item brief screening tool that can be administered by a clinician or self-administered
  • Assesses drug use, not including alcohol or tobacco use, in the past 12 months
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5
Q

Disulfram (Antabuse)

A
  • Used in treating cravings and maintenance of sobriety
  • Aversion treatment to avoid alcohol in alcohol dependence
  • Do not administer until the person has been alcohol free for at least 12 hours
  • Advise clients from using anything that contains alcohol (vinegar, aftershave lotion, perfumes, mouthwash, cough medication) while taking disulfiram and up to 2 weeks after discontinuing disulfiram
  • Can elevate liver function test, so monitor
  • May potentially induce mania in people with BP disorder
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6
Q

What are the signs and symptoms of alcohol withdrawal?

A
  • Nausea and vomiting
  • Tremors
  • Paroxysmal sweats
  • Tactile disturbances
  • Auditory disturbances
  • Visual disturbances
  • Headaches
  • Anxiety
  • Agitation
  • Altered sensorium
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7
Q

What is COWS?

A
  • The Clinical Opiate Withdrawal Scale
  • Tool to assess opioid withdrawal
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8
Q

What are the signs and symptoms of opiate withdrawal?

A
  • Yawning
  • Irritability/Anxiety
  • Pupillary dilation (pinpoint pupils can indicate opioid intoxication)
  • Piloerection
  • Muscle aches
  • Lacrimation
  • Rhinorrhea
  • Sweating
  • Insomnia
  • Nausea, vomiting, diarrhea
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9
Q

Depression/Anxiety Scales

A

Focus on the MODERATE scales range to help remember

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10
Q

Cannabis

A

Most active ingredient is Delta-9 THC which has psychoactive effects

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11
Q

Naltrexone

A
  • Mu opioid receptor antagonist
  • Partial agonist at Kappa receptors in the brain and spinal cord
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12
Q

Methadone

A

It can cause cardiac arrhythmia so do not use as an intervention for COWS

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13
Q

MMSE Scoring (0-30)

A
  • 25-30 = Normal
  • 21-24 = Mild Cognitive Impairment or possibly early stage/mild Alzheimer’s disease
  • 10-20 = Moderate/middle stage/moderate Alzheimer’s disease
  • 0-9 = Severe/late stage/severe Alzheimer’s disease
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14
Q

SLUM (0-30)

A
  • 27-30 = Normal
  • 21-26 = Mild
  • **0-20 = Demential **
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15
Q

What are the mental status scales?

A
  • MMSE
  • SLUM
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16
Q

What are the depression scales?

A
  • HAM-D (0-76)
  • PHQ-9 (0-27)
  • BECK (0-63)
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17
Q

HAM-D (0-76)

A

0-7 = Normal
8-13 = Mild
14-18 = Moderate
19-22 = Severe
23 < = Very Severe

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18
Q

PHQ-9 (0-27)

A

0-4 = Normal
5-9 = Mild
10-14 = Moderate
15-19 = Moderate to Severe
20-27 = Severe

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19
Q

Beck (0-63)

A

0-9 = Normal
10-18 = Mild
19-29 = Moderate
30-63 = Severe

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20
Q

What are the anxiety scales?

A
  • HAM A (0-56)
  • GAD (0-23)
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21
Q

HAM A (0-56)

A

<17 = Mild
18-24 = Moderate
25 < = Severe

22
Q

GAD (0-23)

A

0-4 = Normal
5-9 = Mild
10-14 = Moderate
15-21 = Severe

23
Q

What are the withdrawal scales?

A
  • COWS (opioid)
  • CIWA (alcohol)
24
Q

COWS (opioid) 7 > Start treatment

A

0-4 = None
5-12 = Mild – Clonidine
13-24 = Moderate
25-35 = Moderate to Severe
36 > = Severe
Moderate to severe – Buprenorphine / Suboxone (Buprenorphine and Naloxene)

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CIWA (alcohol) 8 > Start treatment
0-9 = None 10-15 = Mild 16-20 = Moderate 21 > = Severe **8 and above -- PRNs only** **15 and above -- Scheduled meds and PRN** -- **Diazepam (Valium) - Longer half life** -- **Lorazepam (Ativan) - Shorter half life**
26
When do you treat depression/anxiety based on the rating scales?
- Mild anxiety/depression: therapy/nothing - **Moderate/severe anxiety/depression: medications and/or therapy** - **Scoring on the depression scale falls on the severe range: Assess for suicidal ideation**
27
What is the screening tool for substance use disorder?
- Screening Brief Intervention Referral to Treatment (SBIRT)
28
What are the brief interventions for alcohol?
- Acronym FRAMES - **F**eedback: tell them about the risks of their current level of alcohol use - **R**esponsibility: reinforce any decision to change (or not) lies with the service user - **A**dvice: based on facts about their drinking, offer simple and direct advice to the service user, reimpact on them, and offer your advice to change - **M**enu: provide them with a menu of options for behavior change - **E**mpathic interviewing: consider their perspective, be non-non-judgemental - **S**elf-efficacy: encourage the person to believe they can change
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CAGE-AID
- Most commonly used screening tool for alcohol abuse 1. Have you ever felt like you should **cut down** on your drinking or drug use? 2. Have people **annoyed** you by criticizing your drinking or drug use? 3. Have you ever felt bad or **guilty** about your drinking or drug use? 4. Have you ever had a drink or used drugs first thing in the morning **(eye opener)** to stead your nerves or to get rid of a hangover? - 0 for no and 1 for yes - Score of 1 or above accurately detects 91% of alcohol users and 92% of drug users - Score of 2 or above is considered clinically significant
30
What are the two most common neurocognitive disorders?
- Delirium - Dementia
31
What is delirium?
- It is a syndrome and not a disease with an *acute onset* that causes short term changes in cognition. - Altered LOC, inattention - It has a poor prognosis: *1 year mortality rate of clients is up to 40%*
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What is the hallmark symptom of delirium?
**Disturbance of consciousness* accompanied by changes in cognition.
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What is dementia?
- A group of disorders characterized by *gradual development of multiple cognitive deficits* -- impaired executive functioning -- impaired global intellect with preservation of level of consciousness -- impaired problem solving -- impaired organizational skills -- altered memory
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What are the two types of dementia?
- Cortical - Subcortical
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Cortical Dementia
- Results from a disorder affecting the cerebral cortex playing a critical role in cognitive processes such as **memory and language** - **Alzheimer's and Creutzfeldt-Jakob disease are two forms** - Severe memory impairment and aphasia (inability to recall words or understand common language)
36
Subcortical Dementia
- Dysfunction in parts of the brain that are below the cortex - **Huntington's disease, Parkinson's disease, and AIDS dementia complex** - Changes in personality and attention span, with a slowing down of thinking - Early symptoms include **depression, clumsiness, irritability, or apathy.** - End stages results in the same breakdown of brain function as in cortical dementia.
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(1) Cortical vs (2) Subcortical
- (1) Alzheimer's, (2) Progressive supra-nuclear palsy - (1) Apraxia, agnosia, aphasia; (2) impaired information processing and executive functioning - (1) Poor recognition, learning deficit; (2) Recall aided by cues, retrieval deficit - (1) Depression uncommon; (2) Depression, apathy - (1) Motor symptoms uncommon; (2) EPS, dystonia, increased tone - (1) Cortical association areas and mesiotemporal limbic system; (2) Subcortical structures and fronto-sub-cortical circuitry - (1) Normal cognition; (2) slow cognition - (1) Normal speech; (2) Abnormal speech (hypophonic, mute, dysarthria) - (1) Aphasic; (2) Normal language
38
What are the various types of dementia?
- Dementia of Alzheimer's (DAT) - Vascular Dementia - Dementia due to HIV - Pick's Disease - Huntington's Disease - Creutzfeldt-Jakob - Lewy body disease
39
What are the pharmacological treatments of delirium?
- Agitation and psychotic symptoms treated with antipsychotics -- *Haloperidol (preferred treatment for agitated delirious patients)* -- Atypical antipsychotic agents -- Anxiolytic agents for insomnia
40
What are the non pharmacological treatments of delirium?
- **Monitor for safety** - Determine reality orientation frequently - **Pay attention to basic needs (hydration, nutrition)** - Client should not be sensory deprived or overstimulated - It is helpful to have in the client's room familiar people; familiar pictures or decorations; clock or calendar; and regular orientation to person, place, or time
41
Dementia of Alzheimer's (DAT)
- Most common type - Cortical dementia - **Gradual onset and progressive decline** without focal neurological deficits (problems with nerve, spinal cord, brain function) - Hallmark amyloid deposits and neurofibrillary tangles
42
Vascular Dementia
- Second most common type - **Primary caused by cardiovascular disease and characterized by step-type declines** - **Most common in men with preexisting high blood pressure and cardiovascular risk factors** - **Hallmarks: carotid bruits, fundoscopic abnormalities, and enlarged cardiac chambers**
43
Dementia due to HIV disease
- *Subcortical dementia* - Manifests by progressive *cognitive decline, motor abnormalities, and behavioral abnormalities* (lack of coordination, tremors, dsytonia, ataxia) - **Clinical signs of late stage HIV related dementia:** -- global cognitive impairment -- mutism -- seizures -- hallucinations -- delusions -- apathy -- mania - *Antiretrovirals* can interact with psychotropic medications -- prescribe with caution while monitoring for drug interactions
44
Pick's Disease
- **Also known as frontotemporal dementia/frontal lobe dementia** - More common in men - **Personality and behavioral changes in early stage, language changes (slurred)** - Cognitive changes in later stages
45
Creutzfeldt-Jakob disease
- Fatal and rapidly progressive disorder - Initial manifests with fatigue, flulike symptoms, and cognitive impairment - Later manifests with aphasia, apraxia, emotional lability, depression, mania, psychosis, marked personality changes, and dementia
46
Huntington's Disease
- **Subcortical type of dementia** - Characterized mostly by motor abnormalities - Psychomotor slowing and difficulty with complex tasks - High incidence of depression and psychosis
47
Lewy body disease
- Presents with **recurrent visual hallucinations** - **Parkinson features (bradykinesia, cogwheel rigidity, tremor)** - *Adversely react to antipsychotics (especially typical antipsychotics)*
48
Etiology of Dementia
- Diffuse cerebral atrophy and enlarged ventricles in dementia of DAT - **Decreased acetylcholine and norepinephrine in DAT** - Genetic loading -- family history of dementia in first order relative
49
Psychosis and agitation in dementia
- **Try non pharmacological therapies first** - ***Atypical antipsychotics* should be used as first line agents in patients with psychotic symptoms of dementia** - Use lowest effective dose and attempt to wean off periodically -- **Benzos should be avoided, if possible, in most patients with dementia, as they are particularly vulnerable to their adverse effects such as sedation, falls, and delirium**
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