Clinical Handbook - Old Age and Child Psychiatry

Question 1

Define delirium

Answer 1

Delirium is an acute, transient, global organic disorder of CNS functioning resulting in impaired consciousness and attention.

There are different types of delirium: hypoactive, hyperactive and mixed.

Question 2

What are the causes of delirium?

Answer 2

HE IS NOT MAD

Hypoxia
Endocrine

Infection
Stroke

Nutritional
Others - severe pain, sensory deprivation
Theatre - post-op e.g. due to anaesthetic /opioids

Metabolic - hyponatraemia, hypoglycaemia
Abdominal - faecal impaction, malnutrition, urinary retention
Alcohol
Drugs - benzos, anticholinergics

Question 3

Give some risk factors for delirium

Answer 3

Male sex
Older age ≥65
Multiple co-morbidities
Dementia
Physical frailty
Renal impairment
Severe illness
Sensory impairment
Previous episodes

Question 4

Give some key clinical features of delirium

Answer 4

DELIRIUM

Disordered thinking: Slowed, irrational, incoherent thoughts
Euphoric, fearful, depressed or angry
Language impaired: Rambling speech, repetitive and disruptive
Illusions, delusions and hallucinations (usually tactile or visual).
Reversal of sleep-wake pattern: i.e. may be tired during day and hyper-vigilant at night
Inattention: Inability to focus, clouding of consciousness.
Unaware/disoriented
Memory deficits.

Question 5

Give 6 key differences between delirium and dementia

Answer 5

conscious level is impaired in delirium versus usually not in dementia

sleep wake cycle disrupted in delirium, usually normal in dementia

attention usually markedly reduced in delirium, may be normal in dementia

duration is hours to weeks for delirium versus months to years for dementia

course is fluctuating for delirium, usually stable or slowly progressing in dementia

psychomotor activity usually abnormal in delirium, usually normal in dementia

Question 6

How would you investigate a delirious patient?

Answer 6

Routine investigations:

Urinalysis (UTI)

Bloods: FBC (infection); U&Es (electrolyte disturbance); LFTs (alcoholism, liver disease); calcium (hypercalcaemia); glucose (hypo-/hyperglycaemia); CRP (infection/inflammation); TFTs (hyperthyroidism); B12, folate, ferritin (nutritional deficiencies)

ECG (cardiac abnormalities, acute coronary syndrome)

CXR (chest infection)

Infection screen: blood culture (sepsis) and urine culture (UTI)

ABG (hypoxia)

CT head (head injury, intracranial bleed, CVA), and you may consider lumbar puncture (meningitis), EEG (epilepsy

Diagnostic questionnaire:
Abbreviated Mental Test (AMT)
Confusion Assessment Method (CAM)

Question 7

DDx for delirium?

Answer 7

Dementia
Mood disorders: depression or mania (bipolar)
Late onset schizophrenia
Dissociative disorders
Hypothyroidism and hyperthyroidism (may mimic hypo- and hyperactive delirium respectively).

Question 8

Define autism

Answer 8

Autism is a pervasive developmental disorder characterized by a triad of impairment in social interaction, impairment in communication, and restricted, stereotyped interests and behaviours.

Question 9

Give some risk factors for autism

Answer 9

male
family hx
advancing parental age
parental psych disorders
prematurity
maternal medication use esp sodium valproate

Question 10

What is the ICD-10 autism triad ?

Answer 10

ABC

Asocial (lack of eye contact, social smile, interest in others, awareness of social rules)

Behaviour restricted (stereotyped, upset at changes in routine, obsessive interests)

Communication impaired (distorted and delayed speech, echolalia)

Question 11

What is the ICD-10 diagnostic criteria for autism?

Answer 11

A. Presence of abnormal or impaired development before the age of three.
B. Qualitative abnormalities in social interaction.
C. Qualitative abnormalities in communication.
D. Restrictive, repetitive and stereotyped patterns of behaviour, interests and activities.
E. The clinical picture is not attributable to other varieties of pervasive developmental disorder.

Question 12

Ix for suspected autism?

Answer 12

Full developmental assessment including family history, pregnancy, birth, developmental milestones, daily living skills and assessment of communication, social interaction and stereotyped behaviours

Hearing tests if required

Screening tools including CHAT (CHecklist for Autism in Toddlers).

Question 13

What questions could you ask a parent in a hx of suspected ASD?

Answer 13

‘Does your child ever engage in pretend play alone or with others?’, ‘Does your child struggle to interact with others and make friends?’ (social interaction poor)

‘Have you noticed any patterns in their behaviour?’, ‘Does your child insist on the same toys, activities or foods?’, ‘Have you noticed them making any abnormal movements such as flapping their hands or walking on tiptoes?’ (repetitive, stereotypical behaviour)

‘Do they struggle to communicate with you?’, ‘Have you noticed that their speech is monotonous or repetitive?’ (impaired communication)

‘What sort of games does your child play and with what toys?’ (unimaginative play)

‘Do you have any concerns about your child’s development?’ (developmental history)

Question 14

DDx for autism?

Answer 14

Asperger’s syndrome
Rett’s syndrome
Childhood disintegrative disorder
Learning disability
Deafness

Question 15

What medical conditions are associated with autism?

Answer 15

visual / hearing impairment
sensory issues
epileptic seizures
hyperkinetic disorder
sleep disorders
constipation

Question 16

What non pharmacological mx options are available for children with autism?

Answer 16

CBT
family support
access to self-help groups such as the National Autistic Society group
special schooling
social- communication intervention (e.g. play-based strategies)

Question 17

What is hyperkinetic disorder? (ADHD)

Answer 17

characterized by an early onset, persistent pattern of inattention, hyperactivity and impulsivity that are more frequent and severe than in individuals at a comparable stage of development, and are present in more than one situation.

Question 18

Risk factors for hyperkinetic disorder?

Answer 18

male
family hx
environmental risk factors e.g. family conflict and parental cannabis and alcohol exposure

Question 19

What is the ICD-10 criteria for diagnosis of hyperkinetic disorder?

Answer 19

A. Demonstrable abnormality of attention, activity and impulsivity at home, for the age and developmental level of the child.
B. Demonstrable abnormality of attention and activity at school or nursery , for the age and developmental level
C. Directly observed abnormality of attention or activity
D. Does not meet criteria for a pervasive developmental disorder, mania, depressive or anxiety disorder.
E. Onset before the age of 7 years.
F. Duration of at least 6 months.
G. IQ above 50.

Question 20

Ix for child with suspected hyperkinetic disorder?

Answer 20

collateral hx from parents
Blood tests including TFTs (to rule out thyroid disease)
Hearing tests: Examine middle/inner ear with an otoscope and consider a pure tone audiogram
Rating scales: e.g. Conners’ rating scale and the Strengths and Difficulties questionnaire.

Question 21

DDx for hyperactivity disorder?

Answer 21

Learning disability/Dyslexia
Oppositional defiant disorder
Conduct disorder
Autism
Hearing impairment

Question 22

What questions could you ask a parent of a child with suspected hyperactivity disorder?

Answer 22

1. Inattention: ‘…is reluctant to engage in activities which need sustained mental effort, such as schoolwork?’, ‘…
   often leaves play activities unfinished?’,
   ‘…regularly loses their possessions?’, ‘…does not listen when spoken to?’
2. Hyperactivity: ‘…is constantly fidgeting, jumping or running around?’, ‘…is unable to remain still?’, ‘…is difficult to
   engage in quiet activities?’
3. Impulsivity: ‘…cannot wait their turn when playing in groups?’, ‘…blurts out answers to questions before the
   question has been completed?’

Question 23

What mx options are available for hyperkinetic disorder?

Answer 23

In severe hyperkinetic disorder in school-aged children, drug treatment is first-line with methylphenidate (Ritalin) being the usual choice.

Atomoxetine is second-line

If this fails, dexamfetamine is the alternative

Question 24

Side effects of CNS stimulants for mx of hyperkinetic disorder?

Answer 24

headache, insomnia, loss of appetite and weight loss

Question 25

Define learning disability

Answer 25

Learning disability (LD) is a state of arrested or incomplete development of the mind. It is characterized by impairment of skills manifested during the developmental period, and skills that contribute to the overall level of intelligence.

Question 26

What is the ICD-10 criteria for dx of LD?

Answer 26

Mild → IQ = 50–70 (Mental age = 9–12)

Moderate→ IQ = 35–49 (Mental age = 6–9)

Severe → IQ = 20–34 (Mental age = 3–6)

Profound → IQ = <20 (Mental age <3 years)

Question 27

Give some physical features of Down’s syndrome

Answer 27

PROBLEMS

Palpebral fissure (up slanting)
Round face
Occipital + nasal flattening
Brushfield spots (pigmented spots on iris)
Brachycephaly
Low-set small ears
Epicanthic folds
Mouth open + protruding tongue
Strabismus (squint)/Sandal gap deformity/Single palmar (Simian) crease

Question 28

Give some medical problems seen in down’s syndrome

Answer 28

heart defects (ventricular and atrial septal defects, ToF)
hearing loss
visual disturbance (cataracts, strabismus, keratoconus)
GI problems (oesophageal/duodenal atresia, Hirschsprung’s, coeliac)
hypothyroidism

Question 29

Which psychiatric conditions are more common in patients with LD?

Answer 29

Early-onset Alzheimer’s disease, schizophrenia, anxiety and depressive disorders, autism, hyperkinetic disorder, eating disorders, personality disorders

Question 30

Give some investigations for LD

Answer 30

Before birth: Amniocentesis, chorionic villus sampling, genetic testing and karyotyping

For Down’s syndrome: Two methods
(1) Serum screening (β-hCG and PAPP-A) + nuchal translucency
(2) Quad test (β-hCG, α-fetoprotein, inhibin A, estriol)

After birth:
Bloods: FBC (infection), TFTs (hypothyroidism), glucose (hypoglycaemia), serology (ToRCH infections)
Brain imaging: CT head and/or MRI
IQ (intelligence quotient) test.

Question 31

Which members of the MDT may support patients with LD?

Answer 31

psychiatrist, SLT, specialist nurses, psychologist, occupational therapist, educational support, social worker, and paediatrician