Week 4 Flashcards
What anatomical landmark on the back can be used to help guide insertion for a lumbar puncture or epidural?
The spinous process of the L4 vertebra
What layers does a needle have to pass through when performing a lumbar puncture?
Skin
Superficial fascia
Supraspinous ligament
Interspinous ligament
Ligamentum flavum
Epidural space
Dura
Arachnoid
Subarachnoid space (site of CSF sampling)
What are the extrinsic muscles of the back?
Trapezius
Latissimus dorsi
Levator scapulae
Rhomboid major and Rhomboid minor
What are the intrinsic muscles of the back (collectively known as the erector spinae)?
Spinalis
Longissimus
Iliocostalis
Describe the features of a vertebra
Body
x2 pedicles
x2 laminae
Spinous process
x2 transverse processes
What are the names of the laterally positioned sheets of pia mater that anchor the spinal cord to the arachnoid mater, located between the anterior and posterior roots?
Denticulate ligaments
What is the name of the screening questionnaire used to screen for potential alcohol problems?
What are the 4 parts of it?
CAGE questionnaire
- have you ever felt the need to cut down on your drinking?
]2. have people annoyed you by criticising your drinking?
- have you ever felt guilty about drinking?
- have you ever felt like you needed a drink in the morning (eye opener) to steady your nerves or get rid of a hangover?
2 “yes” responses warrants further investigation
What is the name of the full alcohol use disorders identification test?
What is the name of the subset of questions from this test that was developed for speedy use in emergency departments?
Alcohol Use Disorders Identification Test (AUDIT)
Quick version used in emergency departments - FAST screening tool
What would be the best treatment for this patient?
2 month history of paranoid delusions about neighbour using bluetooth device to poison the food in his fridge, auditory hallucination of his neighbour’s voice threatening to kill him, some formal thought disorder, no mood disturbance.
- no past psychiatric history and no previous treatment for this episode
- well-controlled type 2 DM, no acute physical illness
1. Lithium Carbonate
2. Risperidone
3. Olanzapine
4. Clozapine
5. Mirtazapine
- Lithium carbonate is a mood stabiliser for BPD, not appropriate here
- Risperidone is an atypical antipsychotic and would be first line
- Olanzapine is another atypical but has a higher rate of weight gain
- Clozapine is a third line option used in treatment-resistant cases
- Mirtazapine is a MAOI used to treat depression
What is the best description of this woman’s current mental state?
“I felt great a few weeks ago, couldn’t have been better, I’m still very restless but now feeling ill-at-ease. I’m worried that there’s something terrible wrong with me, cancer or a stroke, something like that. I can’t get the thoughts of dying a painful death out of my mind. At first I enjoyed being able to think so quickly, I had so many great ideas, now I’m still thinking fast but it’s all horrible thoughts. I can’t sit still, the nurses keep telling me to stop fidgetting and pacing about the ward but I can’t. Then I get annoyed with them and shout, which makes things worse.”
- Depression
- Mania without psychotic symptoms
- Hypomania
- Mixed affective state
- Cyclothymia
- Mixed affective state is symptoms of both mania/hypomania at the same time as depression, but neither predominate
She has been hospitalised, so cannot be Hypomania by definition
Cyclothymia is basically a much milder form of BPD
When taking a patient history from someone with suspected Dementia, what important questions should you not forget to ask about?
Do you drive?
Do you have a source of money/income? - risk of being exploited
What test is used (in practice) to assess someone for Dementia?
Montreal Cognitive Assessment (MOCA) - in practice the Addenbrooke’s Cognitive Exam is used but isn’t free
What is the most common form of mental health problem in hospitalised patients over the age of 65?
Delirium - mean prevalence of 20% and lots of cases are missed
In a patient with delirium, how might their consciousness be impaired?
Clouding
Drowsiness
Sopor (abnormally deep sleep)
Coma
In a patient with delirium, how might their cognition be disturbed?
Disorientation of time but also sometimes of place and person
Impaired memory and attention
Impaired thinking
Perceptual disturbance, hallucinations and delusions (commonly visual)
In a patient with delirium, how might they experience psychomotor disturbance?
Hyperactive/hyperalert - agitation, disorientation, hallucinations and delusions
Hypoactive/hypoalert - confusion, sedation, misdiagnosed as depression
In a patient with delirium, how might their sleep-wake cycle be disturbed?
Insomnia
Sleep loss
Reversal of sleep cycle
Nocturnal worsening of symptoms - sundowning
Disturbing dreams and nightmares
Delirium is slow/rapid onset and has a steady and predictable/transient and fluctuating course
Rapid onset
transient and fluctuating course
What investigation is used to assess if a patient has likely Delirum? What are the 4 components of this test?
4AT
- alertness (normal/mild sleepiness/clearly abnormal)
- AMT4 - age, DoB, place, current year
- attention - “starting at December, work backwards”
- acute change or fluctuating course
How should a patient with delirium be managed?
- Identify and treat the cause
- Manage the environment and provide support
- Prescribe - sedating drugs can worsen delirium. Alcohol withdrawal requires benzodiazepines, commonly Chlordiazepoxide or Diazepam. Otherwise, antipsychotics are standard treatment e.g. Haloperidol 1-10mg
- Review
How long does delirium last for?
Mean duration is 1-4 weeks, often longer in the elderly
Minority can become chronic
What is the most common neuropsychiatric complication of a stroke, seen in up to 1/3 of patients?
Post stroke depression
This is also seen post-MI, with 65% of patients developing depressive symptoms after heart attack
How does dementia compare to delirium and depression in terms of onset, duration, course, alertness, orientation, memory, thinking, perception, emotions and sleep?
Onset - insidious
Duration - months/years
Course - stable, progressive, step-wise
Alertness - normal
Orientation - normal, or impaired to place/time
Memory - recent and remote impaired
Thinking - slowed, reduced interest
Perception - hallucinations seen in 30-40%
Emotions - shallow, labile, irritable
Sleep - nocturnal wandering and confusion
When taking a history from a patient with suspected dementia, it can be useful to take a corroborative history from a family member. What questions might you ask?
Functional abilities at home?
Help required to support them when at home?
Any significant cognitive, physical or emotional changes in recent weeks?
Rate and pattern of cognitive decline?
According to SIGN guidelines on Dementia, what test should be used in individuals with suspected cognitive impairment to diagnose dementia?
How does SIGN say this initial cognitive testing can be improved?
SIGN states that the MMSE should be used, and to improve the initial assessment the Addenbrooke’s Cognitive Exam can also be used
What is the MMSE?
What is the cut off?
Mini Mental State Examination
Scored out of 30, with any score greater than or equal to 24 being normal
Under 24 = cognitive impairment
Mild = 19-23
Moderate = 10-18
Severe = 9 or less
What bedside tests can be used to determine someone’s cognitive function?
GPCOG
6-CIT (tests orientation, memory and corroborative history)
Clock drawing test (tests executive function, visuospatial ability, abstraction and correlates well with overall cognitive functioning)
How is the Addenbrooke’s Cognitive Assessment (ACE) III scored?
Scored out of 100 with 5 domains
- orientation and attention
- memory
- fluency
- language
- visuospatial functioning
Cut-off 88/100 = sensitivity 1.0 and specificity 0.96
Cut-off 82/100 = sensitivity 0.93 and specificity 1.0
What test is used to differentiate between the different types of dementia?
Frontal Assessment Battery (FAB)
What are the main symptoms of Alzheimer’s Disease?
Which part of memory is first affected?
Memory loss, particularly short term
Dysphasia
Dyspraxia
Agnosia (difficulty recognising objects)
What are the main symptoms in Vascular Dementia?
Dysphasia
Dyscalculia
Frontal lobe symptoms and affective symptoms (i.e. personality changes) are more common in Alzheimer’s
May have focal neurological signs
May have vascular risk factors
May have a stepwise decline
What would a CT/MRI show in a patient with Alzheimer’s Disease?
Normal, or possibly medial temporal lobe atrophy or temporoparietal atrophy
Variants - frontal (more visual and proprioception problems), posterior cortical atrophy (v. rare)
What would a CT/MRI show in a patient with Vascular Dementia?
How about a SPECT scan?
CT/MRI - moderate-severe small vessel disease or multiple lacunar infarcts
SPECT - patchy reduction in tracer uptake throughout the brain
What are main symptoms in Frontotemporal Dementia (Pick’s Disease)?
3 syndromes…
- behavioural variant (most common), behaviour changes, executive dysfunction, disinhibition, impulsivity, loss of social skills, apathy, obsessions, change in diet
- primary progressive aphasia - effortful non-fluent speech, speech sound/articulatory errors, lack of grammar and words
- semantic dementia - impaired understanding of meaning of words, fluent but empty speech, difficulty retreiving names
What is the best type of investigation for identifying frontotemporal dementia?
SPECT - shows frontotemporal reduction in tracer uptake
What ar ethe main symptoms in Lewy Body Dementia?
Dementia - common early involvement of reduced attention, executive function and visuospatial skills
Two of the following…
- visual hallucinations
- fluctuating cognition (delirium-like)
- REM sleep behaviour disorder
- Parkinsonism
- Positive DAT scan
What % of patients with Parkinson’s Disease develop dementia after 15-20 years?
80%
When would you use the following scans in a patient with suspected dementia?
- CT
- MRI
- SPECT
- DAT
CT - currently standard
MRI - if young, fast progression or other atypical features
SPECT - most useful for identifying frontotemporal dementia
DAT - if needing to clarify Parkinson’s Plus syndromes (group of conditions that cause symptoms like Parkinson’s as well as other symptoms)
Which family of medications can be given in dementia?
Which would you give in Alzheimer’s Disease?
Cholinesterase inhibitors
In AD, donepezil, rivastigmine, galantamine
Which family of medications can be given in dementia and how do they work?
Which would you give in Dementia with Lewy Bodies and Parkinsons Dementia?
Cholinesterase inhibitors - slows cognitive decline, more effective in DLB/DPD than in Alzheimer’s, work by increasing amount of ACh in the synapse but don’t affect the underlying disease process
Rivastigmine, donepezil
What are some of the side effects of cholinesterase inhibitors?
Are they more effective in Alzheimer’s disease or DLB/DPD?
Side effects - GI (nausea and diarrhoea most common), headache, muscle cramps, bradycardias, worsen COPD/asthma
More effective in treating DLB/DPD
When are cholinesterase inhibitors contraindicated?
Not with an active peptic ulcer or severe asthma/COPD
What drug is specifically licensed for Alzheimer’s to slow cognitive decline?
What side effects might it cause?
Memantine - acts on NMDA receptors to prevent glutamate from binding
Start in moderate dementia
Largely well-tolerated, but may cause hypertension, sedation, dizziness, headache, constipation
How is the issue of driving managed in patients with dementia?
Who gets to decide if the patient can drive while the investigations are ongoing?
Always need to discuss the issue of driving at diagnosis in patients with dementia
Must be reported to the DVLA, patient fills in a CG1 form
DVLA request a report from the doctor - doctor decides if the patient can still drive during investigation
The Rookwood Driving Battery is used (more specific version of the ACE)
Other than cholinesterase inhibitors, what other medication should be considered in all patients with dementia?
Antidepressants +/- adjuncts
What are the triad of impairments seen in autistic spectrum disorders?
1. Qualitative impairments in reciprocal social interaction
- may find relationships difficult to establish
- may not be motivated by the need for social approval
- may show no interest in the needs of others
- may show little awareness of the feelings of others
2. Language and impairment deficits
- may have no speech
- may have difficulty using pronouns, interpreting similies and metaphors
- stress, pitch, rhythm and intonation of speech may be odd
- may have difficulty interpreting non-verbal communication
- may have a peculiar stiff-eyed gaze, or no eye contact at all
3. Thought and behaviour
- restricted, repetitive and stereotyped patterns of behaviour, interests and activities
- resistance to change
- lack of social imagination/theory of mind
- concrete and inflexible thinking
- ritualistic behaviours ‘stereotypes’
What comorbidities may be seen in someone with an autistic spectrum disorder?
Learning disabilities
Depression and social anxiety
OCD
ADHD
Dyspraxia
Managing an individual with an ASD requires multiagency input. Which AHPs might be involved in their care?
SLT - language disorders/impairment
Psychology (educational/clinical)
Psychiatry - ADHD, complex or late presentations etc.
Occupational therapy - if dyspraxic or sensory defensiveness
Paediatrics - if globally delayed
Social work - if abusive or struggling families
What assessment methods are there for detecting autism?
Screeners (Social Responsiveness Scale), used in people aged 4-18
Semi-structured interviews (3di - Developmental, Dimensional and Diagnostic Interview)
DISCO - Diagnostic Interview for Social and Communication Disorders
Standardised assessment tools (Autism Diagnostic Observation Schedule, ADOS)
According to the DSM-IV-TR, how many symptoms must be present for an ASD to be diagnosed?
At least 6 symptoms
Including at least 2 symptoms of qualitative impairment in social interaction, at least one symptom of qualitative impairment in communicaiton, and at least one symptom of restricted and repetitive behaviour
What are the main pharmacological mechanisms of managing an ASD?
Principles - agree on the symptoms to target, monitor side effects and duration
Risperidone - used in the short term to manage significant aggression, tantrums or self-injury
Methylphenidate - treats symptoms of ADHD
Melatonin - endogenous hormone that is secreted by the pineal gland and may be considered in case of sleep problems
What is the diagnostic triad of ADHD?
Inattention
Hyperactivity
Impulsivity
What comorbidities may be seen alongside ADHD?
Social communication difficulties
Learning disabilities
Attachment difficulties
Mood and anxiety problems
Behavioural disorders
Substance abuse
What is the rough prevalence of ADHD?
Somewhere between 4 and 6%
So its very common, but still underdiagnosed
What questionnaires may be used to aid in diagnosing ADHD?
Screening questionnaires (SDQ - strength and difficulties questionnaire, part of the development and well-being assessment DAWBA family of mental health measures)
Structured diagnostic questionnaires (Conners Rating Scale, ADHD rating scale)
ADHD can be treated with both Psychological and Pharmacological therapies.
What are the 1st and 2nd line Psychological treatments?
1st line - parent training (New Forest Parenting Programme), behavioural classroom management strategies
2nd line - social skills training, sleep and diet: elimination and supplements
ADHD can be treated with both Psychological and Pharmacological therapies.
What are the 1st, 2nd, 3rd and 4th line Pharmacological treatments?
1st line (stimulants) - methylphenidate (Ritalin), dexamfetamine, lisdexamfetamine
2nd line (SNRIs) - atomoxetine (noradrenaline reuptake inhibitor)
3rd line (alpha agonists) - clonidine, guanfacine
4th line - antidepressants, antihypertensives, antipsychotics
How does methylphenidate (Ritalin) work?
Is medication effective in managing ADHD?
Improves the actions of catecholamines in the brain by blocking dopamine and noradrenaline reuptake
Medication is unusually effective (numbers needed to treat for methylphenidate, amfetamine and atomoxetine are only 4)
