Week 6 Neuro Flashcards
Parkinson
cardinal features
- bradykinesia
- resting tremor suppressed by movement
- lead pipe rigidity with passive movement
Parkinson
motor features
- resting tremor
- lead pipe rigidity
- bradykinesia
- postural instability
- gait: shuffling
- freezing (initiating, turns, obstacles)
Parkinson
non-motor features
- autonomic dysfunction (bladder, bowels, postural instability)
- dementia
- depression
- sensory (anosmia, paresthesia, pain)
- sleep disturbance (nocturia, stiffness at night, RLS)
Treatment of anxiety in elderly
SSRIs and SNRIs recommended
- which one is well tolerated?
- common side effects?
- increased risk in elderly?
escitalopram, citalopram
SERTRALINE
side effects: GI upset, insomnia, sexual dysfunction, sedation
INCREASE risk GIB if on concurrent NSAIDs
INCREASE risk bone density loss, hip fracture, SIADH
Treatment of anxiety in elderly
SNRI
-venlafaxine side effects
-duloxetine side effects:
venlafaxine: sexual dysfunction, sweating, increase in SBP and DBP
duloxetine: BP not as affected
monitor for urinary retention, sweating
Treatment of anxiety in elderly
TCA - why avoid?
MAOI - why avoid?
TCA: anticholinergic: orthostatic hypotension, falls, urinary retention, confusion, cardiac effects
MAOI: orthostatic hypotension, falls, HTN crisis
are benzos recommended for treatment of anxiety in elderly?
risks»_space;»> benefits
recommend lorazepam, oxazepam or temazepam if MUST be used (metabolized by conjugation)
RISK of falls, hip fracture, cognitive impairment, dementia
treatment of anxiety in elderly
are antipyschotics recommended?
black box warning!
increased mortality esp in elderly with dementia
Quetiapine is effective for GAD
Risk long term use: increase osteopenia, bone loss
features of delirium
AIDA
AIDA
- acute, fluctuating
- inattention
- disorganized thinking
- altered LOC
what neurotransmitters are imbalanced in delirium?
cholinergic deficiency
dopaminergic excess
what drug class is implicated as precipitator and predisposing factor in delirium?
anticholinergics!
esp oxybutynin and diphenhydramine
**think of anticholinergic burden
for hospitalized patients, what are the common modifiable triggers for delirium?
- fluid and electrolyte imbalance
- infection
- drug toxicity
- metabolic d/o
- sensory and environmental problems (eg untreated pain, missing hearing aids or glasses, poor sleep)
Dementia
MMSE ratings:
mild:
moderate:
severe:
mild: 20-26
moderate: 12-29
severe: <12
Death from severe dementia is often a result of what processes?
malnutrition
infections (aspiration pneumonia, pressure ulcers)
Pathophysiology of Alzheimer’s
amyloid beta (ABeta) plaques and tau fibrillary tangles Plaques and tangles cause "downstream" effects: synaptic dysfunction, mitochondrial damage, vascular damage, and inflammation
Alzheimer’s non-modifiable risk factors
- genetics
- family hx
- Down syndrome (APP gene carried on chromosome 21)
- low education
- CKD
- afib
- depression
Dementia modifiable risk factors
what class of meds?
HTN
- CVD
- obesity
- DM
- sedentary lifestyle
- OSA
- social isolation
- ETOH, smoking
- anticholinergic meds, benzo, PPI
- environmental pollutants
- brain trauma
- hearing impairment
Workup of cognitive impairment
Labwork?
B12 level, TSH, HIV, syphilis, metabolic screen, liver enzyme, CBC, lytes
*identify reversible causes
Components of HISTORY differentiating between:
- MCI
- Alzheimer’s
MCI: cognitive deficits across one or more domains
Alzheimer’s progressive memory loss and other cognitive deficits
-impact on ADL and IADL
Components of HISTORY differentiating between:
Vascular dementia
Lewy Body dementia
vascular: hx vascular risk factors: eg hx of stroke/TIA
* executive function as prominent early symptom
* can commonly present WITH Alzheimer’s (Mixed dementia)
Lewy body:
-well formed visual hallucinations, REM sleep disorder, falls, fluctuating cognition
Dementia DDX
- depression
- OSA
- NPH
- subclinical seizures
- SDH
- untreated hearing and vision impairment
- side effect of anticholinergic meds
Treatment of Dementia
NO disease modifying or curative drug therapies for MCI, AD or other dementia
goal is to improve QoL
support autonomy
Person-Centered Care Framework
Informed decision making and self-determination
side effects associated with cholinesterase inhibitors (donepezil, galantamine, rivastigmine)
GI distress wt loss urinary urgency BRADYCARDIA, syncope sleep disturbances (vivid dreams)
side effects associated with NDMA receptor inhibitors (memantine)
Fewer s/e but can be dizzy, hallucinations, and increased agitation
what type of dementia should NOT be treated with cholinesterase inhibitors or NDMA receptor inhibitors?
frontal-temporal dementia (may worsen symptoms)
What is the DICE approach to BPSD ?
describe
investigate
create
evaluate
risk factors for late life depression?
chronic medical illness loss of loved one relocation disability social isolation
older adults with depression are more likely to present with what symptoms?
may deny depression or mood symptoms
may have more physical/somatic symptoms
suspect depression if somatic complaints out of proportion to medical illness
how is depression differentiated from normal grief and bereavement?
grief does not impact functioning (or at least very minimal)
typically does not have active suicidal ideation or florid psychosis
grief generally recovers 1 year after loss
what co-morbidities have strong correlation with depression?
stroke arthritis heart disease (MI and heart failure) cancer substance use iatrogenic (meds: benzos, opiates, steroids)
symptoms of manic episode
(DIGFAST)
duration?
Distractibility
Impulsitivity / Indiscretion (excessive involvement in pleasurable activities
Grandiosity – Inflated self-esteem
Flight of ideas / Racing thoughts
Activity increase / Increase goal-directed behavior (socially, sexually, at work, etc)
Sleep deficit (decreased need for sleep)
Talkativeness (pressured speech)
distinct period of at least 7 days of persistently elevated, expansive, irritable behaviour
-at least 3 of following
depression screening
Geriatric Depression Scale
PHQ-9
Beck
suicidal ideation
**always test cognitive functioning
(MMSE, MoCA, mini-cog)
SSRI common side effects
GI upset
Diarrhea (sertraline)
constipation (paroxetine)
Insomnia, jitteriness
Hyponatremia
GIB
Extrapyramidal (tremors, parkinsons, bruxism)
SSRI prescribing precautions in elderly
CYP450 – watch drug interactions
*choose escitalopram, citalopram or sertraline (little effect on CYP450)
SIADH: risk factors age, female, low weight, use of diuretics, NSAIDs
*symptoms: fatigue, anorexia, confusion
GIB: risk factors use of NSAIDs, ASA, anticoagulants
Prolonged QT: citalopram, dose dependent
- max dose 20 mg if age >65
- max dose 40 mg up to age 65
Balance
3 main sensory inputs to maintain balance
Proprioception (muscle spindles, golgi tendon)
Vestibular: position and acceleration of head in space, CN VIII to vestibular nuclei
Vision
Screening for falls risk: 3 questions
Have you fallen in the last year?
Do you worry about falling?
Do you feel unsteady when standing or walking?
Symptoms often seen with falls?
syncope/presyncope
vision
cognition impairment
urinary urgency/impairment
Components of physical assessment for frequent falls
Cognition: MMSE, miniCOG MOCA
*even in absence of reported cognitive changes
CNS: neuro exam
*sensation in feet
CV: orthostatic hypotension
MSK: strength, resting muscle tone, tremors
Vision
Gait exam
Balance: tandem gait, Romberg
TUG (over 12 sec is positive for falls risk)
Get up from chair
Gait assessment: 4 S’s
Sit to stand
Speed (slow speed predicts falls, functional decline, death)
Stance (wide vs narrow)
Step (clearance, shuffling, symmetry, antalgic Trendelenberg)
Medication culprits linked to falls
antidepressants anticonvulsants BENZOS*** sleep aids anticholinergic meds opiates
Dizziness is a broad term used to describe different sensations including:
- vertigo (spinning)
- disequilibrium (unsteadiness, only when erect, disappears when sitting/lying)
- presyncope (lightheadedness, about to faint)
How is orthostatic hypotension defined?
SBP drop of 20+ mm Hg
DBP drop of 10+ mm HG
within 3 minutes of standing
How is postprandial hypotension defined?
SBP drop of 20+ mm Hg within 1-2 hours of eating
Acoustic neuroma
symptoms?
unilateral SNHL
- high frequency
- poor word recognition
Unilateral and rapid progression
Disequilibrium not related to position
Tinnitus
Nystagmus with peripheral lesions?
central lesions?
peripheral: unidirectional horizontal/rotational nystagmus
central: easily seen in light, vertical or gaze-evoked
Modifiable risk factors for stroke
Which one is most important?
HTN ***most important** DM Hyperlipidemia Afib OSA Smoking ETOH (light to mod associated with DECREASED risk, heavy use associated with INCREASED risk) Inactivity
Sequence of assessment for suspected stroke
- initial survey (LOC, speech, following instructions, weakness)
- gaze deviation, pupils, facial weakness, tone
- VS and capillary glucose
- imaging
- NIHSS assessment
- *only finger stick glucose is needed before starting IV alteplase
- INR if on warfarin
Other labs can wait
timeframe for IV alteplase
Treatment window: within 3-4.5 hours
ideally before 3 hours
TIA
why is rapid recognition important?
symptoms usually last 15-20 min with complete recovery
TIA is a notable risk factor for subsequent stroke
**especially high in first 90 days after TIA
what is the single most important treatable risk factor for stroke?
BP control
goal of SBP <140, DBP <90
Secondary ischemic stroke prevention
ANTIPLATELET agent for all pts after first stroke
ASA (50-100 mg daily), clopidogrel (75 mg)
*depends on underlying etiology
*DAPT (dual antiplatelet therapy) if TIA and minor stroke
Duration should not be > 3 months
STATINS for hyperlipidemia
- HIGH DOSE atorvastatin 80 mg daily
- diet has NO effect on stroke incidence
- shared decision making if limited life expectancy (<5 years)
ANTICOAGULATION for pts with afib
- DOAC preferred over warfarin *consider renal function
- ASA 325 mg if unable to take po anticoagulant
- left atrial appendage (LAA) occlusion device eg Watchman if nonvalvular AF
SMOKING CESSATION
DIABETES glycemic control
PHYSICAL ACTIVITY
What is the most common underlying etiology of seizures in older adults?
STROKE
- early seizures: within 2 weeks of stroke
- late onset: >2 weeks after stroke
post-stroke seizures associated with poor functional recovery and outcomes
Complications seen in post-stroke survivors?
falls *hip fractures dysphagia --> weight loss, apathy fatigue pain (1-3 months after stroke) seizures sleep disorders: OSA, central sleep apnea, cheyne-stokes breathing depression urinary and fecal incontinence spasticity cognitive impairment
Idiopathic normal pressure hydrocephalus
Symptoms?
gait and balance impairment
cognitive impairment
urinary incontinence
insidious onset over 3 months
Giant cell arteritis (temporal arteritis) is a type of _____ vessel arteritis
large vessel
*typically also involves medium and small arteries esp superficial temporal arteries
Complications of untreated giant cell arteritis?
BLINDNESS
vision loss is often irreversible - abrupt and painless
CVA, MI, death, dissecting aortic aneurysm
Risk factors for giant cell arteritis?
Age > 50 peak onset 70-80
F > M
Genetic (HLA-DR4 haplotype)
Infection
PMR (15% develop GCA, conversely, 50% people with GCA have PMR)
Northern European descent
Smoking
Characteristics of headaches in giant cell arteritis?
New-onset or new pattern
Localized to temporal or occipital area
Characteristics: Throbbing, continuous, dull, boring, burning
Focal tenderness, scalp tenderness with combing hair
Giant cell arteritis
symptoms?
new onset headache (temporal or occipital) blurred vision diplopia jaw claudication neck/shoulder/pelvic girdle pain fatigue fever
Giant cell arteritis
most common cause of vision loss?
anterior ischemic optic neuropathy (AION)
- pale edematous optic disc
- edema resolves within 10 days
- retinal artery occlusion –> diffuse retinal edema
Features of polymyalgia rheumatica?
Aching and morning stiffness last >30 min, worse with exertion, may be severe
Neck, shoulder girdle, hip girdle
At least 1 month
Age 50+
gold standard diagnostic test for temporal arteritis?
temporal artery biopsy
Giant cell arteritis:
5 criteria for diagnosis
ESR > 50
(CRP often elevated, higher sensitivity and specificity than ESR)
Age > 50
New-onset HA
Temporal artery tenderness to palpate or decreased palpation
Abnormalities of artery on biopsy (multinucleated giant cells)
Treatment of GCA
start on oral prednisone 40-60 mg/day
*temporal artery biopsy within 1 week
higher doses if visual or neurological symptoms
F/U within 72 hours
ASA 81 mg
PPI
Calcium and vit D
Headache red flags SNOOP4
systemic symptoms: fever, chills, myalgia, weight loss Neurologic symptoms (focal) Older age at onset (>50 years) Onset: thunderclap (peak intensity 60 seconds) P1: papilledema P2: positional P3: precipitated by Valsalva or exertion P4: progressive headache, pattern change
Headache red flags to suspect giant cell arteritis?
- older age at onset
- progressive
- systemic symptoms
- polymyalgia rheumatica
Labwork for suspected giant cell arteritis?
ESR or CRP
CBC: normochromic anemia, thrombocytosis
Characteristics of cardiac cephalgia headache?
headache triggered by exertion
relieved with rest
Relieved by nitro (in migraine, nitro will make migraines worse)
**diagnosis: stress test
Characteristics of headaches from subacute glaucoma?
headache with duration <4 hours
visual blurring triggered by LOW LIGHT (causing mydriasis that increases IOP)
Definition of medication overuse headache
headache occurring 15+ days per month with overuse of medication
Overuse: >10 or 15 days per month
diagnostic evaluation of new onset headache in older adults?
neuroimaging: CT
CBC, CRP/ESR
Symptoms of cluster headache
unilateral pain
severe, stabbing, short duration
orbit, temple, cheek
Tearing
ptosis
nasal congestion, rhinorrhea
what does clock drawing test assess?
executive functioning
what are modifiable causes of cognitive impairment?
- delirium
- depression
- hyponatremia
- thyroid d/o
- hypercalcemia
- B12 deficiency
- ETOH
- polypharmacy
- comorbidities
Diagnosis of dementia:
2 or more of the following cognitive domains:
memory language visuospatial executive function behavior
causing significant FUNCTIONAL DECLINE in daily life activities/work
core features of Lewy Body dementia
fluctuating cognition, variation in attention and alertness
- recurrent visual hallucinations (well formed, detailed)
- spontaneous motor features of Parkinsonism
- REM sleep disorder
dementia occurs BEFORE or CONCURRENTLY with onset of Parkinsonism
core features of frontotemporal dementia
- early personality changes: apathy, disinhibition, executive function failure
- decline in hygiene, mental rigidity, distractibility, perseveration
- prominent language changes
relatively preserved memory, spatial skills, praxis
PRISME: modifiable factors that can contribute to onset of delirium
P: pain, poor nutrition
R: retention, restraints
I: infection, illness, immobility
S: sleep, skin, sensory deficits (hearing, glasses)
M: mental status, meds, metabolic (abnormal labs)
E: environment (change)
primary vs secondary vs tertiary prevention
Primary prevention: Prevent it from happening
Secondary intervention: Prevent recurrence
Tertiary: Managing consequences
ETOH guidelines for older adults age 65+?
Adults age ≥65 years should not consume more than seven drinks in a week and should not consume more than three drinks on a given day
Contraindications to outpatient ETOH withdrawal management?
PAWSS score >4
Severe or uncontrolled comorbidities (DM, COPD, heart disease)
-acute confusion/cognitive impairment
-acute illness/infection
-concurrent active MH suicidal ideation/psychosis
-concurrent severe drug use
-pregnancy
-hx of withdrawal seizure
-multiple failed attempts at outpatient withdrawal
-sign of liver compromise
-failure to respond to meds after 24-48 hours
- inability to attend daily medical visits for first 3-5 days, alternating days after
- inability to take po meds
- no reliable family member who can monitor symptoms
- any serious risk deemed by clinician’s best judgment
symptoms of alcohol withdrawal
tachycardia pyrexia tremor nausea, vomiting sweating agitation, anxiety insomnia
what are the two options for pharm management of ETOH use disorder?
if goal is reduced drinking: naltrexone
if goal is abstinence: acamprosate or naltrexone
Naltrexone for AUD
contraindications?
side effects?
contraindicated:
- current opioid use (must be opioid free for 7-10 days)
- acute opioid withdrawal
- acute hepatitis/liver failure
side effects:
nausea, headache, dizziness
Naltrexone for AUD
monitoring
LFT at start and 1, 3, 6 months
Acamprosate for AUD
contraindications?
side effects?
contraindicated:
-severe renal impairment
-breastfeeding
CAUTION geriatric
side effects:
diarrhea, vomiting, abdo pain
Acamprosate for AUD
monitoring
dosing
no safety risk with mild renal impairment, hepatic toxicity
moderate renal impairment: dose reduction
2x 333 mg TID
Multivitamin supplementation in AUD
thiamine (100mg)
folic acid (1mg)
vitamin B6 (2mg)
Max drinking limits
men
women
how often should screening occur?
men up to age 65:
- 3 drinks or less in a day AND
- 15 drinks or less in a week
healthy women AND healthy men over 65:
- 2 drinks or less in a day AND
- 10 drinks or less in a week
*annual screening
Mallampati score
Class I
Class II
Class III
Class IV
Mallampati Score
Class I: soft palate, uvula, and tonsillar pillars are visible
Class II: Soft palate and Uvula are visible
Class III: Only Soft palate and base of the uvula are visible
Class IV: Only hard palate is visible
STOP BANG for sleep apnea
The mnemonic STOP is helpful and includes the following:
S: “Do you snore loudly, loud enough to be heard through a closed door?”
T: “Do you feel tired or fatigued during the daytime almost every day?”
O: “Has anyone observed that you stop breathing during sleep?”
P: “Do you have a history of high blood pressure with or without treatment?”
ALSO»>The mnemonic BANG is also useful, as follows:
B: BMI greater than 35
A: Age older than 50 years
N: Neck circumference greater than 40 cm (16 in)
G: Gender, male
signs and symptoms of obstructive sleep apnea? central sleep apnea?
both:
- sleep deprivation, excess daytime fatigue
- headache, difficulty concentrating
- morning headache
CSA:
-nocturia, stress induced insomnia, nocturnal anigna chest pain
OSA:
-snoring, hypopnea, repeated arousals from sleep, decreased libido
Insomnia diagnostic criteria
difficulty falling asleep, or waking up throughout the night or in the early-morning and then struggling to fall back asleep.
The second criteria is that the disturbance must be present for more than three times a week for at least three months.
The third criteria is that the sleep pattern must affect the individual’s life - like their performance at work or their relationships, and the symptoms shouldn’t be better explained by other sleep conditions.
TIA
secondary ischemic stroke prevention:
BP control target?
Treat if SBP 140+
DBP 90+
Bells palsy
affects which CN?
Symptoms?
CN VII
Common findings
Unilateral facial weakness w/ inability to close one eye
Sagging of one eyelid
Ipsilateral retroauricular pain w/ or preceding paralysis
Mouth drawn to affected side
Loss of nasolabial fold Hyperacusis or hypersensitivity to sound Dysgeusia or perversion of taste Facial paraesthesia Drooling Decreased tearing
Bells palsy
first line pharm tx?
Prednisone: for all patients
60 to 80 mg po once a day x 1 week
Take with food in the morning
Monitor mood and sleep, may cause hyperglycemia if DM
valacyclovir: not to be used as monotherapy, only given in conjunction with steroid for severe cases
1000 mg three times daily for one week
for patients with severe facial palsy at presentation
in older adults, headache is more common in strokes in _____ vs _____ circulation
-more common in POSTERIOR circulation
secondary headaches in older adults:
Red flags for:
- CVA
- ICH
- neoplasm
CVA: neuro deficits
ICH: thunderclap headache, neuro deficit, decreased LOC, anticoagulated
neoplasm:
-subacute neuro deficit, papilledema
secondary headaches in older adults:
Red flags for:
- cardiac cephalgia
- sleep apnea
- subacute glaucoma
cardiac cephalgia:
-precipitated by exertion, relieved by rest and nitro
sleep apnea: morning headache
subacute glaucoma: lasts <4 hours, with visual blurring, triggered by dim light
medication overuse headache
definition of overuse?
other meds that cause headaches?
10-15 days/month
other meds:
- nitro
- nifedipine
- dipyimadole
- PPI
- SSRI
contraindications to triptan use?
hx of TIA, CVA, CAD
trigeminal neuralgia
symptoms?
which cranial nerve involved?
electric shock along trigeminal nerve
CN V
V1 ophthalmic
V2 maxillary
V3 mandibular
**most often affects V2 and V3
Symptoms: unilateral severe electric shock facial pain
- seconds to 2 min
- 0-50x/day
- does not wake up at night
Trigeminal neuralgia
first line treatment?
carbemazepine (tegretol)
100-200 mg BID initially, slow titration until pain relief
treat for 6+ months
side effects: nausea, vomiting, diarrhea, hyponatremia, SJS/TEN
CYP and test for HLA-B*15:02 in Asians (high risk SJS/TEN)
difference between MCI and dementia?
MCI: functional ability preserved
dementia: across multiple domains, interferes with ADLs
MMSE cut off
mild dementia
mod dementia
severe dementia
mild: 20-26
mod: 12-19
severe: <12
Lab workup for cognitive impairment?
CBC, lytes, B12, TSH, HIV, syphilis, LFTs
lewy body dementia and parkinson dementia is associated with what symptoms?
what sleep disorder?
fluctuating cognition
well formed hallucinations
REM sleep disorder
What is a prominent early symptom in vascular dementia?
executive dysfunction
what portion of brain is affected in Alzheimers?
median temporal,
parietal, and/or
hippocampal atrophy
what neurotransmitters are involved in patho of delirium?
cholinergic deficiency
dopamine excess
Lewy body dementia
vs
Parkinson disease dementia
Parkinson Disease Dementia (PPD): if PD symptoms for 1 year before onset of dementia
Lewy Body Dementia (LBD): if onset of dementia precedes or at same time as onset of PD symptoms
parkinson disease
patient counselling re: taking sinemet (levodopa/carbidopa)?
common side effect is nausea, vomiting, hypotension
nausea is due to inadequate carbidopa
Take on empty stomach (protein interferes with absorption)
LDL target if atherosclerotic CVD (ASCVD)?
ie stable angina, MI, ACS
stroke, TIA
AAA
PAD
LDL <1.8
non-HDL <2.4
apoB <0.7
what is the pre-screening question if someone has AUD and is interested in treatment?
has pt consumed alcohol in the last 30 days?
if yes—> do PAWSS
Alcohol use disorder:
if PAWSS is <4, first line option for alcohol withdrawal management?
carbamazepine
gabapentin
clonidine
benzo is NOT preferred, prescribe fixed dose and short course (monitor frequently for relapse)
common medications that cause dizziness?
anticonvulsants anxiolytics antidepressants NSAIDs antiarrhythmics diuretics anti-HTN antihistamines
what is the quick 2 question screen for depressive disorders?
- in the last month, have you been
- bothered by little interest or pleasure in doing things
- feeling down, depressed or hopeless
risk factors for chronic depression?
- early age onset
- high number previous episodes
- severity of initial episode
- disruption in sleep/wake cycle
- presence MH comorbidities
- family hx MH
- negative cognitions
- highly neurotic
- poor social support
- stressful life
what is the DSM criteria for dysthymia aka persistent depressive disorder?
Depressed mood for most of the day, for more days than not, for at least 2 years
Presence, while depressed, of ≥2 of the following:
Poor appetite or overeating
Insomnia or hypersomnia
Low energy or fatigue
Low self-esteem
Poor concentration or difficulty making decisions
Feelings of hopelessness
During 2 year period, individual has never been without symptoms in A or B for more than 2 months at a time
what are some non-modifiable risk factors for high risk suicide?
Non-modifiable • Old age • Male Gender • Being widowed or divorced • Previous attempt • Losses (e.g., health, status, role, independence, significant relations)
- family hx suicide
- hx legal problems
- sexual minority
SADPERSONS for suicide risk
Sex (male)
Age <19 or >45
Depression or hopelessness
Previous suicide attempts of psychiatric hospitalization
Excessive alcohol or drug use
Rational thinking loss
Single, divorced or widowed
Organized serious attempt
No social support
Stated future intent
first line psychological treatment for acute MDD?
CBT
**group therapy less effective than individual therapy but improves access
CBT as effective as antidepressant for MDD
combo CBT and rx more effective than either alone
first line treatment for MDD
mild?
moderate to severe?
mild: psychoeducation, self management, counselling
consider pharm if pt preference, previous response to rx, lack of response to non-pharm
moderate to severe: start rx
how often to reassess a patient after starting antidepressant?
within 2 weeks
- *lack of early improvement at 2-4 weeks is predictor of later non-response or non-remission
- *increase dose at 2-4 weeks if no improvement and tolerating s/e
f/u again every 2-4 weeks
review at 6-8 weeks
if well, continue on rx for 6-9 months
3 examples of antidepressants that cause more sedation (helpful with agitation or insomnia)?
TCA
trazodone
mirtazapine
what class of antidepressant is linked with SIADH and hyponatremia?
SSRI
risks associated with ST John’s Wort
**CYP inducer
**MANY medication interactions including warfarin, oral contraceptives, SSRIs, digoxin, anticonvulsants. very long list
**risk of serotonin syndrome and hypomania with SSRIs and triptans
how long do anxiety symptoms have to be present to meet DSM criteria for GAD?
6 or more months
two questions screen for GAD?
over last two weeks, how often have you felt:
- nervous/anxious/on edge
- not able to stop/control worrying
FINISH mnemonic for SSRI withdrawal syndrome
flu insomnia nausea imbalance sensory change hyper (agitation)
