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
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
29
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%*
32
What is the hallmark symptom of delirium?
**Disturbance of consciousness* accompanied by changes in cognition.
33
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
34
What are the two types of dementia?
- Cortical
- Subcortical
35
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.
37
(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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