Acute psychiatric assessment

Question 1

What are some organic causes of an altered mental state?

ILO: Describe organic and psychiatric causes of acute confusional st

Answer 1

Structural abnormalities – space-occupying lesions
Biochemical changes – electrolyte imbalances
Physiological changes – hypotension
Multi-factorial conditions – sepsis

(Psych conditions may in part be due to genetic, biochemical and structural abnormalities.)

Question 2

Delirium is often misdiagnosed as schizophrenia, depression, or dementia.

What features are more suggestive of physical illness?

ILO Describe the organic and psychiatric causes of acute confusional st

Answer 2

• Non-auditory hallucinations.
• Dysarthria.
• Ataxia.
• Gait disturbance.
• Incontinence.
• Focal neurological signs.

Question 3

What are causes of an acute confusional state - Surgical seive loads!

Answer 3

• Prescribed meds: digoxin, cimetidine, steroids, analgesics, diuretics, anticholinergics, antiparkinsonian drugs.
• Drugs of abuse: opioids, benzodiazepines, ecstasy, amphetamines, hallucinogens.
• Withdrawal: from alcohol, opioids, hypnotics, or anxiolytics.
• Infection: pneumonia, UTI, septicaemia, meningitis, encephalitis.
• Metabolic: hypoxia, hypercapnia, hypoglycaemia, acidosis, hyponat-raemia, hypercalcaemia.
• Cardiac: acute MI, cardiac failure, endocarditis.
• Neurological: head injury, chronic subdural haematoma, meningitis, post-ictal state.
• Organ failure: respiratory, renal, and hepatic failure.
• Endocrine: myxoedema, thyrotoxicosis, diabetes, Addison’s diseas

ILO Describe the organic and psychiatric causes of acute confusional sta

Question 4

mnemonic for Mental state exam…

Answer 4

A - Appearance/Behaviour
S - Speech
E - Emotion (Mood and Affect)
P - Perception (Auditory/Visual Hallucinations)
T - Thought Content (Suicidal/Homicidal Ideation) and Process
I - Insight and Judgement
C - Cognition

Question 5

Common features of acute confusion

Answer 5

• Rapid onset.
• Fluctuation.
• Clouding of consciousness.
• Impaired recent and immediate memory.
• Disorientation.
• Perceptual disturbance, especially in visual or tactile modalities.
• Psychomotor disturbance (agitation or movements).
• Altered sleep–wake cycle.
• Evidence of underlying cause.

Question 6

MSE : A- appearance and mood. What to cover…

Answer 6

• Is the patient appropriately dressed?
• Are they clean and tidy, or neglected?
• Does general posture, body movement, and facial expression suggest fear, anxiety, aggression, withdrawal, detachment, or low mood?
• Do they maintain eye contact?
• Do they respond appropriately to external stimuli or is he easily distracted?
• Do they appear to be hallucinating or responding to no obvious stimuli?
• Any abnormal movements, tics, grimaces, or dystonic movements?
• Note whether behaviour is steady and consistent, or labile and unpredictable.

Question 7

How to detect Acute confusion in terms of tests

Answer 7

• The 10-point Abbreviated Mental Test Score
• 30-point Mini Mental State Examination (MMSE),
• Montreal Cognitive Assessment (MoCA),
• Confusion Assessment Method (short version)
• all give a rapid estimate of key cognitive functions.

Question 8

Outline domains covered in MMSE

Answer 8

Question 9

MSE: S- Speech what to cover

Answer 9

• Describe: rate, volume, intonation, and spontaneity of speech.
• Dysarthria or dysphasia?
• Examples of invented new words (neologisms), unusual phrases, perseveration, or garbled speech verbatim.
• vagueness? over-preciseness? or sudden switching to new themes or subjects (flight of ideas).

Question 10

MSE: E - emotion (mood and affect) what to cover…

Answer 10

• Ask about the patient’s prevailing mood, opinion of himself, and view of the future
• are mood and affect congurous?
• suicidal thoughts and thoughts of harm to others?
• sleep disturbance, appetite, libido, concentration, and mood variations during a typical day.
• Ask about irritability or memory disturbance (particularly of short-term memory).

Question 11

MSE: P- Perception what to cover?

Answer 11

• Hallucinations, including their nature and specific content.
• Visual, olfactory, gustatory, and tactile hallucinations should prompt suspicion of organic, rather than psychiatric, disease

Question 12

MSE: T- Thoughts form and content what to cover….

Answer 12

• Form e.g. insertion, withdrawal, broadcast, blocking, flight of ideas.
• Ideas of reference or persecutory delusions may require direct enquiry to be revealed (eg asking about neighbours, electrical devices).
• passivity phenomena eg ‘Is anyone making you think or move without you wanting to?’.

Question 13

MSE: I Insight…. what to cover

Answer 13

• Does the patient believe they are ill?
• Do they think they need treatment, and would they be willing to accept it?
• Doe they have mental capacity?

Question 14

MSE: Cognitive Assessment what to cover?

Answer 14

• Level of consciousness (eg alert, hyperalert, withdrawn, or comatose).
• Orientation.
• Attention and concentration.
• Registration of new information.
• Recall of recent and distant memories.
• Ability to interpret instructions and carry out tasks.

Question 15

What is the mini-mental state exam?
what is it used for?

Answer 15

Designed as a screening tool for the assessment of cognitive function in the elderly

Question 16

Assessing risk of self harm and suicide

Key questions to ask about a current episode of self harm: THINK headings of questions for now

Answer 16

Before
During
After

Question 17

Assessing risk of self harm and suicide

Key questions to ask about a current episode of self harm: Before

Answer 17

• Was there a precipitant?
  e.g. argument with spouse/ bereavement.
  Was the self-harm planned, or impulsive?
• Did the patient carry out any final acts?
  Write a suicide note
  Leaving a will
  Terminating contracts (e.g. mobile phone, gas and electricity)
• Precautions taken against discovery?
  Closing curtains
  Locking doors
  Waiting until they knew everyone would be out of the house and not be back for several hours
  Going somewhere very remote
• Was alcohol used?
  Ask about the amount and type used
  Ask about previous alcohol use

Question 18

Assessing risk of self harm and suicide

Key questions to ask about a current episode of self harm: During

Answer 18

• What method of self-harm was involved?
• Was the patient alone?
• Where were they when they self-harmed?
• What was going through their mind at the time?
• Did they think their self-harm would end their life?
• What did they do straight after the self-harm?

Question 19

Assessing risk of self harm and suicide

Key questions to ask about a current episode of self harm: After

Answer 19

• Did the patient call anyone? How did they get to A&E? Who were they found by?
• How did they feel when help arrived?
• How does the patient feel about the attempt now? Do they regret it?
• What is the patient’s current mood?
• Does the patient still feel suicidal?
• If the patient were to go home today, what would they do? (make sure you cover the next few days)
• If the patient were to feel like this again, what might they do differently?
• What does the patient think might prevent them from doing this again in the future?
• Does the patient feel there is anything to live for? (i.e. protective factors)
• Will the patient accept treatment?

Question 20

What are some specific questions to ask about cutting as a form of self harm?

Answer 20

Where are the cuts?

How many cuts are there?

How deep are the cuts?

How did the patient feel whilst they were cutting?

How did the patient feel when they saw blood?

What was the patient hoping the cutting would do?

Question 21

What are some specific questions to ask about overdose?

Answer 21

What medication or medications did the patient take?

Where did the patient get the medication from?

How much of the medication did the patient take?

What did the patient take the medication with?

What did the patient think that amount of medication would do?

What made the patient decide to take the medication/how long had they been thinking about taking an overdose for?

What did the patient do after taking the medication?

How did the patient get to the hospital?

Question 22

What other mental health conditions should you screen for which increase the risk of suicide?

Answer 22

Depression
* ask about anhedonia, low mood, fatigue

Psychosis
* ask about thought insertion, auditory hallucinatins

Anorexia
* ask about eating habits, appeptite, have the lost weight, are they satisfied with their current weight, do they think they are eating enough

Question 23

Abbreviated mental test score (AMTS) is a 10-point assessment …what questions

Answer 23

1. “What is your age?”
2. “What is the time to the nearest hour?”
3. Give the patient an address, and ask them to repeat it at the end of the test (e.g. “42 West Street”)
4. “What is the year?”
5. “What is the name of this place?” or “What is your house number?”
6. Can the patient recognise two persons (e.g. doctor, nurse)?
7. “What is your date of birth?” (day and month sufficient)
8. “In what year did World War 1 begin?”
9. “Name the present monarch/prime minister/president”
10. “Count backwards from 20 down to 1”

A score of 6 or less suggests delirium or dementia, although further tests are necessary to confirm the diagnosis.

Question 24

Risks of emergency tranquilisation

Answer 24

• sedatives may mask important signs of underlying illness, eg an intracranial haematoma requiring urgent treatment.
• Normal protective reflexes (including airway reflexes such as gag and cough response) will be suppressed.
• Respiratory depression and the need for tracheal intubation and IPPV may develop.
• Adverse cardiovascular events (eg hypotension and arrhythmias) may be provoked, particularly in a struggling, hypoxic individual

Question 25

oral tranquilisation - oral, name, dose

Answer 25

* Give lorazepam (1–2 mg PO) if there is no psychotic context. * Give lorazepam (1–2 mg PO) + antipsychotic (eg haloperidol 1.5–3mg PO) if there is a psychotic context.

Question 26

why use IM rapid tranquilisation? what are options (name of drugs only)

Answer 26

* If PO therapy is inappropriate (refused, failed, or not indicated) * choose between IM lorazepam OR IM haloperidol + promethazine. In most instances, IM lorazepam is the most appropriate first choice

Question 27

IM rapid tranquilisation: drug names and dose

Answer 27

* Give lorazepam (2–4 mg IM) and allow sufficient time for it to work. Consider giving a further dose of IM lorazepam if there is a partial response, but if there is no response: * consider IM haloperidol (5–10mg) + IM promethazine hydrochloride (25–50mg) .

Question 28

In who should you not use IM haloperidol + promethazine for rapid tranquilisation?

Answer 28

If there is any history of cardiovascular disease (including long QTc) or if there is no normal ECG recorded. Pts with parkinsons

Question 29

What monitoring after IM tranquilisation?

Answer 29

Record vital signs e.g. HR, BP, RR every 15min if the patient: * Is asleep/sedated. * Has taken illicit drugs or alcohol. * Has any pre-existing physical health problem. * Has experienced any injury from restrictive intervention. * If the BNF’s maximum dose has been exceeded.

Question 30

Stepped approach for rapid tranquilisation for acutely disturbed or violent pts..

Answer 30

1. Verbal and situational descalation 2. Offer oral treatment 3. ir oral refused / ineffective and pt is putting themselves or others at risk - IM treatment

Question 31

What to have on hand if using benzodiazepines for sedation?

Answer 31

Flumazenil - in case of respiratory depression.

Question 32

A patient wants to leave before they are assessed by a mental health professional...what to do..... ## Footnote OX handbook

Answer 32

* try to persuade them to stay. * If they refuse, consider their capacity to decide to leave under the MCA framework and whether you can use this to keep them from leaving, or consider detaining them under common law, pending an urgent psychiatric assessment. * If you are satisfied that the ongoing risk is not of a magnitude that requires them to be detained, then allow them to be discharged, but ensure that the GP is informed.

Question 33

The mental health act allows for what treatment...

Answer 33

the Mental Health Act only allows treatment for mental health disorders against the wishes of patients, and not physical health problems.

Question 34

What to remember if you want to treat a patient without their consent?

Answer 34

* You are assessing capacity for a specific decision (e.g. does the patient have capacity to refuse NAC treatment for paracetamol OD?). there is no overall/global capacity which a patient has or lacks. * Patients may have the capacity to make some decisions and not others. * Capacity in the same patient may 􀂀uctuate over time. * Disagreeing with medical advice does not automatically constitute incapacity. * If a patient does not have capacity and requires emergency treatment, then this may be given against their will under the Mental Capacity Act 2005 or under common law, depending on which is more appropriate.

Question 35

5 principals of mental capacity act?

Answer 35

1. A person must be assumed to have capacity, unless it is established that he lacks capacity. 2. A person is not to be treated as unable to make a decision, unless all practicable steps to help him to do so have been taken without success. 3. A person is not to be treated as unable to make a decision merely because he makes an unwise decision. 4. An act done, or decision made, under this Act for, or on behalf of, a person who lacks capacity must be done, or made, in his best interests. 5. Before the act is done, or the decision is made, regard must be had to whether the purpose for which it is needed can be done in the least restrictive way.

Question 36

Following an episode of self-harm/ overdose, a rapid initial assessment (triage) to establish the degree of urgency of the situation is done. NICE recommends the Australian Mental Health Triage Scale... a combined physical and mental health triage scale....can think of points on it?

Answer 36

Question 37

What domains should you focus on when assessing a pt with self harm?

Answer 37

Involve family/carers with the patient’s consent. Focus upon: * Events and circumstances leading up to the episode of self-harm. * Preparation, concealment, and true intention of a self-harm act. * Outcome of the act (eg unintended danger or accidental discovery). * Current stresses and financial, legal, or interpersonal problems. * Alcohol or substance misuse. * Previous self-harm or psychiatric illness.

Question 38

How to decide when to refer for self harm? ## Footnote Ox handbook of emergency medicine

Answer 38

* Use assessment (earlier card) * if in doubt - refer * immediately refer child / adolescent * Some EDs- patients who are not at immediate risk can come back the next day for an appt with a psychiatric liaison nurse/specialist for psychosocial assessment * Ensure that the patient’s GP receives written communication about the patient’s ED attendance and discharge.

Question 39

Factors suggesting suicidal intent

Answer 39

Careful preparation (eg saving tablets) and/or significant premeditation. Final acts (eg organizing finances, insurance, or a will). Performing self-harm alone, secretly, or when unlikely to be discovered. Not seeking help following self-harm. A definite, sustained wish to die.

Question 40

Factors that increase the risk of self-harm

Answer 40

* Recurrence * singe / separated * 25-45yrs * unemployed/ lower socioeconomic group * drug / alcohol dependence * hx of criminal behaviour * previous psych treatment * personality disorder

Question 41

Certain factors are common amongst completed suicides and are significant if found in a patient who self-harms...what are some>

Answer 41

* male * Elderly (particularly ♀). * Living alone. * Separated, divorced, or widowed. * Unemployed or retired. * Physical illness (eg painful, debilitating, or terminal conditions). * Psychiatric illness (especially schizophrenia and depression). * Alcoholism. * Sociopathic personality disorder. * Violent method of deliberate self-harm (eg hanging, shooting, drowning, or high fall).