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
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
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
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
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
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
7
Q
What is COWS?
A
- The Clinical Opiate Withdrawal Scale
- Tool to assess opioid withdrawal
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
9
Q
Depression/Anxiety Scales
A
Focus on the MODERATE scales range to help remember
10
Q
Cannabis
A
Most active ingredient is Delta-9 THC which has psychoactive effects
11
Q
Naltrexone
A
- Mu opioid receptor antagonist
- Partial agonist at Kappa receptors in the brain and spinal cord
12
Q
Methadone
A
It can cause cardiac arrhythmia so do not use as an intervention for COWS
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
14
Q
SLUM (0-30)
A
- 27-30 = Normal
- 21-26 = Mild
- **0-20 = Demential **
15
Q
What are the mental status scales?
A
- MMSE
- SLUM
16
Q
What are the depression scales?
A
- HAM-D (0-76)
- PHQ-9 (0-27)
- BECK (0-63)
17
Q
HAM-D (0-76)
A
0-7 = Normal
8-13 = Mild
14-18 = Moderate
19-22 = Severe
23 < = Very Severe
18
Q
PHQ-9 (0-27)
A
0-4 = Normal
5-9 = Mild
10-14 = Moderate
15-19 = Moderate to Severe
20-27 = Severe
19
Q
Beck (0-63)
A
0-9 = Normal
10-18 = Mild
19-29 = Moderate
30-63 = Severe
20
Q
What are the anxiety scales?
A
- HAM A (0-56)
- GAD (0-23)
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)
25
Q
CIWA (alcohol) 8 > Start treatment
A
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
Q
When do you treat depression/anxiety based on the rating scales?
A
- 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
Q
What is the screening tool for substance use disorder?
A
- Screening Brief Intervention Referral to Treatment (SBIRT)
28
Q
What are the brief interventions for alcohol?
A
- Acronym FRAMES
- Feedback: tell them about the risks of their current level of alcohol use
- Responsibility: reinforce any decision to change (or not) lies with the service user
- Advice: based on facts about their drinking, offer simple and direct advice to the service user, reimpact on them, and offer your advice to change
- Menu: provide them with a menu of options for behavior change
- Empathic interviewing: consider their perspective, be non-non-judgemental
- Self-efficacy: encourage the person to believe they can change
29
Q
CAGE-AID
A
- 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
Q
What are the two most common neurocognitive disorders?
A
- Delirium
- Dementia
31
Q
What is delirium?
A
- 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%
32
Q
What is the hallmark symptom of delirium?
A
**Disturbance of consciousness* accompanied by changes in cognition.
33
Q
What is dementia?
A
- 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
34
Q
What are the two types of dementia?
A
- Cortical
- Subcortical
35
Q
Cortical Dementia
A
- 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
Q
Subcortical Dementia
A
- 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.
37
Q
(1) Cortical vs
(2) Subcortical
A
- (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
Q
What are the various types of dementia?
A
- Dementia of Alzheimer’s (DAT)
- Vascular Dementia
- Dementia due to HIV
- Pick’s Disease
- Huntington’s Disease
- Creutzfeldt-Jakob
- Lewy body disease
39
Q
What are the pharmacological treatments of delirium?
A
- Agitation and psychotic symptoms treated with antipsychotics
– Haloperidol (preferred treatment for agitated delirious patients)
– Atypical antipsychotic agents
– Anxiolytic agents for insomnia
40
Q
What are the non pharmacological treatments of delirium?
A
- 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
Q
Dementia of Alzheimer’s (DAT)
A
- 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
Q
Vascular Dementia
A
- 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
Q
Dementia due to HIV disease
A
- 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
Q
Pick’s Disease
A
- 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
Q
Creutzfeldt-Jakob disease
A
- 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
Q
Huntington’s Disease
A
- Subcortical type of dementia
- Characterized mostly by motor abnormalities
- Psychomotor slowing and difficulty with complex tasks
- High incidence of depression and psychosis
47
Q
Lewy body disease
A
- Presents with recurrent visual hallucinations
- Parkinson features (bradykinesia, cogwheel rigidity, tremor)
- Adversely react to antipsychotics (especially typical antipsychotics)
48
Q
Etiology of Dementia
A
- 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
Q
Psychosis and agitation in dementia
A
- 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
50
Q
A
51
Q
A
