core conditions - 2 Flashcards

Question

MANAGEMENT of LEWY-BODY dementia: - BIO balance between? - other BIO option? 1 - psych? 3 - social? 3

Answer 1

fine balance between PARKINSONSIM and PSYCHOSIS - A/Ps increase parkinsonsim - L-Dopa increase psychosis ^so both could be used symptomatically - but notoriously difficult to treat Acetyl Cholinesterase Inhibitors can help e.g. RIVASTIGMINE emphasis on psychosocial PSYCH - emotional support - cognitive stimulation / rehabilitation - treat co-morbid conditions (eg CBT for anxiety) SOCIAL - carer support - occupational therapy - social care interventions nb the psych + social is same for all dementias - is only the bio that changes depending on diagnosis

Answer 2

- MI - stroke / TIA - HTN - diabetes - thyroid disease - epilepsy - past traumatic head injury - mental health problems (particularly depression)

Answer 3

- Meals on wheels - Respite care - Day centers - Sitting services - Financial assessment - Home assessment

Answer 4

MIRROR SIGN - pt start talking to themselves in the mirror SUNDOWNING - pt becomes aggresive around tea time (4-5:30), often settles as evening progresses

Answer 5

ACUTE CONFUSIONAL STATE 1) acute CONFUSION - or acute-on-chronic - important to know a baseline (get collateral) 2) impaired CONSCIOUSNESS - may be transient, fluctuating GCS/AVPU - reduced awareness of environment 3) impaired COGNITION - impairment in short-term memory and attention - assess with AMTS - almost always disorientated to time + place 4) PERCEPTUAL disturbance - eg hallucinations, norm visual or misinterpretation - may ave thought disorder 5) MOOD disturbance - eg agitation or aggression - emotional lability 6) SLEEP-WAKE cycle disturbance 7) PSYCHOMOTOR abnormalities course often FLUCTUATES throughout the day! - worse at night! TYPES - hyperactive - hypoactive (often undiagnosed)

Answer 6

AGE - elderly (20-30%) - very young REASON IN HOSP - post-op pts - burns victims COMORBIDITIES - dementia - blind or deaf - alcohol dependence IATROGENIC - many medications increase risk basically anything that reduces your cognitive 'reserves'

Answer 7

``` INFECTIONS = UTI = chest infection = wound abscess / cellulitis - meningitis / encephalitis - endocarditis ``` INTRA-CRANIAL = stroke / TIA / bleed = traumatic head injury - raised ICP (incl tumour) ``` METABOLIC = electrolyte disturbances (esp low sodium + low calcium) = liver failure / hepatic encephalopathy = uraemia / kidney failure - anaemia - heart failure - hypothermia ``` ``` ENDOCRINE = hypoglycaemia = thyroid (hypo/hyper) - pituatory disease - parathyroid - adrenal (cushings/addisons) - porphyria ``` MEDICATIONS / SUBSTANCES = alcohol intoxication / withdrawal (wernickes - thiamine) = illegal/psychoactive drugs = carbon monoxide posioning (see other flashcard for prescribed drugs that can cause/worsen) OTHER - terminal medical condition - severe asthma (or other lung/heart problems) nb may be a combination of things

Answer 8

nb this excludes illegal / non prescribed (eg alcohol, carbon monoxide, legal highs etc) ``` PSYCH / NEUROACTVE = benzos (use + withdrawal) - antipsychotics - lithium - anticonvulsants - antiparkinsonian - antidepressants (esp TCAs) ``` CARDIOVASCULAR - antihypertensives - diuretics - digoxin - betablockers PAIN / INFLAM = opioids - NSAIDs - steroids ``` OTHER = anticholinergics (incl TCAs) - insulin - salicylates - ketamine (used in anaesthetics) - old/sedating antihistamines ``` POLYPHARMACY = independent risk factor (ie regardless of which meds on, if on a lot then increased risk) nb many drugs have an anti-cholinergic effect so be careful when prescribing

Answer 9

- establish timeline (Qs to identify cause) - recent interventions - baseline cognition (from collateral) - full physical (to look for signs of infection etc) - MSE REVIEW DRUG CHART (before do any investigations) - MSU (urine dip useless in elderly) - urine drug screen (if suspect) - blood glucose - blood gas - ECG (can show metabolic signs) - bloods (norm ones +/- bone profile + cultures) - drug levels (eg if on digoxin/lithium etc) - CXR (if any chest signs) - CT head (if any neurology)

Answer 10

- treat underlying cause - manage other comorbidities - consider stopping any meds that may be contributing (eg benzos) - Nurse him in a SIDE ROOM (with fam member if poss) - Ensure GLASSES and HEARING AIDS are within reach and are working - KEEP pt ORIENTATED to time place and person (give him a clock and talk to him regularly) - COMMUNICATE clearly and frequently - Avoid INFECTION or CONSTIPATION - Control PAIN - ensure HYDRATION + NUTRITION nb DOLS sometimes appropriate

Answer 11

Gradual reduction of symptoms with effective treatment of cause Symptom resolution may be much slower in elderly Often patchy amnesia following recovery High mortality May be marker for subsequent development of dementia

Answer 12

Psychological or behavioral abnormalities associated with a dysfunction of the brain. History and physical examination or laboratory tests demonstrate the presence of a specific organic factor judged to be etiologically related to the abnormal mental state and loss of previously acquired functional abilities nb delirium and dementias are examples, as are space occupying lesions, drug-induced psychosis etc MANAGEMENT: 1) treat underlying cause 2) treat symptoms (eg antipsychotics)

Answer 13

1) WHICH drugs used (ask about each one directly: alcohol, cannabis, heroin, benzo, prescription etc) 2) AMOUNT and FREQUENCY used - bags, cost, ask if they think it's strong or weak 3) ROUTE of use (IV, snort, smoke) 4) DURATION - of most recent episode - also when start intially - try and establish a timeline 5) when LAST USED and how much 6) WHO do they use with? 7) WHY do they use 8) how FUNDING use 9) any TREATMENT or periods of REMISSION? - what happened? 10) any evidence of DEPENDENCE? (see other flashcard) also in PMHx ask about any physical complications: groin abscess, endocarditis, BBV and do very thorough risk assessment!!! - and FORENSIC HX

Answer 14

- overdose - medical complications - psychosis from cocaine/cannabis - DSH/suicide - financial overspending - risk to others (violence, neglect to dependents) - risk from others (relationships, drug dealers)

Answer 15

- signs of acute INTOXICATION / WITHDRAWAL - COMPLICATIONS (DVT, cellulitis, groin abscess, femoral aneurysm, liver disease) - COMORBIDITIES (liver disease, COPD, BBV) - signs of SELF-NEGLECT / malnutrition

Answer 16

- URINE DRUG SCREEN (even if they admit, they may miss some out) - ECG (esp for cocaine but, eg need one before start methadone as can lengthen QTc) BLOODS - FBC - U+E - LFT - BBV screen (blood cultures if symptomatic) nb if head injury, have lower threshold for CT scan as alcohol etc increases risk of bleeds

Answer 17

PHYSICAL - experience WITHDRAWAL symptoms if don't use - use of substance RELIEVES withdrawal symptoms - TOLERANCE (need to escalate dose in order to achieve same effect) PSYCH - CRAVING: intense desire to use - DIFFICULTY CONTROLLING onset, termination + amount used SOCIAL - SALIENCE (neglecting alternate forms of leisure or pleasure in life) - persistent use despite clear evidence of HARM (physical, psych and social) need AT LEAST 3 features in past 12 months! NARROWING of REPERTOIRE of substance use is also commonly seen but not essential for diagnosis nb there is a broader, less-severe condition of 'harmful use of substances' which covers majority of problem drinking and drug use = 'a pattern of psychactive substance use causing damage to health - physical +/or psychological'

Answer 18

STAGES OF CHANGE MODEL 1) PRE-CONTEMPLATION - no intention on changing behaviour = HARM REDUCTION techniques (incl education about risks + how to reduce) 2) CONTEMPLATION - aware a problem exists but with no commitment to action = use MOTIVATIONAL INTERVIEWING 3) PREPERATION - intent on taking action to address the problem = use MI and get on TREATMENT and SUPPORT 4) ACTION - active modification of behaviour = TREATMENT and SUPPORT 5) MAINTENANCE - sustaine change, new behaviours replaces old = continued SUPPORT + may still be on TREATMENT 6) RELAPSE - fall back into previous pattern of behaviour = SUPPORT + MI people do relapse frequently - but never give up on them!! - every time may be the time they quit for good! upward spiral - learn from each relapse

Answer 19

PREVENT DEATHS - not injecting or injecting more safely (teach safe injecting techniques - eg anatomy of groin) - not using drugs alone - call an ambulance if necessary - dispense naloxone pens - education on reducing amount taken after intervals where tolerance is lost (eg after release from prison) PREVENT BBV - not sharing needles - needle exchange programmes - safer sex (condoms) - give Heb A + B vaccine - BBV screening, incl hep C REFER WHEN APPROPRIATE - specialist drug services - voluntary sector services - infectious disease services

Answer 20

BIO for ALCOHOL 1) chlordiazapoxide (acute detox) 2) thiamine (prevent wernicke's) 3) ACAMPROSATE (reduces cravings + pleasurable effect) 4) DISULFARIM (makes you throw up, used less) nb can also use naltrexone (see bio management of opioids flashcard) with alcohol ALSO treat any other comrbidities - eg depression

Answer 21

METHADONE - easier to start in hospital OR use if do need to use opioids in addition BUPRENORPHINE - starting to be used more frequently - partially agonist, at high quantities have a blockade effect - so if they try to use heropin on top of it then don’t get a high - but people have to be withdrawal in order to start NALTREXONE - opioid blocker - so can use so they don't get high when they take opioids - can also use with alcohol ^nb different to naloxone!!! ALSO treat any other comrbidities - eg depression

Answer 22

PSYCH - motivational interviewing - CBT - group therapy SOCIAL - 12 steps programme - alcoholics / narcotics anonymous - rehab programme also sort out finances, employment, housing etc

Answer 23

SSRIs - sertraline (good for co-morbid anxiety - norm 1st line) - fluoxetine (long half life so good if poor compliance, only one for <18yo) - citalopram (can lengthen QTc) - paroxetine (discontinuation problems) SNRIs - duloXetine - venlafaXine TCAs - amitryptilline - clomIPRAMINE - imIPRAMINE NaSSA - mirtazapine MAOIs - Phenelzine - Isocarboxazid - Moclobemide "mirtazapine, like NASA, can send people to sleep"

Answer 24

- SERTRALINE (good for co-morbid anxiety - norm 1st line) - FLUOXETINE (long half life so good if poor compliance, only one for <18yo) - CITALOPRAM (can lengthen QTc) - PAROXETINE (discontinuation problems) inhibit SEROTONIN reuptake -> increase in conc

Answer 25

- SERTRALINE (good for co-morbid anxiety - norm 1st line) - FLUOXETINE (long half life so good if poor compliance, only one for <18yo) - CITALOPRAM (can lengthen QTc) - PAROXETINE (discontinuation problems) 1) 1st line for moderate-severe DEPRESSION (mild depression, if psych therapies insufficient) 2) ANXIETY disorders (GAD, OCD, PTSD) 3) BULIMIA NERVOSA (fluoxetine only)

Answer 26

- SERTRALINE (good for co-morbid anxiety - norm 1st line) - FLUOXETINE (long half life so good if poor compliance, only one for <18yo) - CITALOPRAM (can lengthen QTc) - PAROXETINE (discontinuation problems) COMMON - agitation / anxiety - sexual dysfunction = nausea = diarrhoea - headaches - dizziness - insomnia RARE - hyponatraemia (esp in elderly) - platelet dysfunction (GI bleeds - PPI in elderly) - initital increase in suicide risk (first 1-4months) - esp in <30yo also warn about discontinuation syndrome with abrupt withdrawal PREGNANCY 1st trimester = risk of cardiac abnormalities 3rd Trimester = perinatal problems e.g. RDS, irritability, feeding problems. RISK/BENEFIT - AVOID if POSS

Answer 27

- dizziness - headaches - gait instability - diarrhoea - abdo pain - fatigue

Answer 28

- duloXetine (good if comorbid pain or incontinence) - venlafaXine inhibit reuptake or serotonin AND noradrenaline

Answer 29

- duloXetine (good if comorbid pain or incontinence) - venlafaXine 1) 2nd line MAJOR DEPRESSION, when ssris are ineffective/not tolerated 2) GAD - venlafaxine only 3) MENOPAUSAL symptoms - venlafaxine only

Answer 30

- duloXetine (good if comorbid pain or incontinence) - venlafaXine COMMON = nausea - constipation - dizziness - sedation - insomnia = dry mouth - headache - sexual dysfunction RARE - can increase BP - QTc prolongation -> arrythmias - suicidal ideation - hyponatraemia (esp elderly) nb tend to get more side effects with SNRIs than with SSRIs (as targetting >1 receptor) MONITORING - monitor BP in pts on high doses

Answer 31

- amitryptilline - clomIPRAMINE - imIPRAMINE INHIBIT REUPTAKE of sertraline and noradrenaline. also BLOCK several other neurotransmitter receptors e.g muscarinic, alpha1 and H1.

Answer 32

- amitryptilline - clomIPRAMINE - imIPRAMINE 1) 2nd line moderate-severe DEPRESSION 2) neuropathic PAIN (not licensed) 3) prophylaxis of tension/migraine HEADACHES (low dose amitryptilline) 4) OCD - clomipramine only

Answer 33

- amitryptilline - clomIPRAMINE - imIPRAMINE ANTICHOLINERGIC - blurred vision - dry mouth - constipation - urinary retention HISTAMINE + A1/2 - sedation - postural hypotension CARDIAC - tachycardia - arrythmias + ECG changes OTHER - weight gain - excessive sweating (esp at night) nb can worsen glaucoma monitoring = ECG avoid prescribing if high chance of OD - AS VERY DANGEROUS!!!

Answer 34

CNS - sedation + coma (tend to precede cardiotoxicity) - seizures CARDIOVASCULAR - sinus TACHY (anti-cholin) - HYPOtension (mild hypertesion initially) - broad complex tachy-dysrhythmias -> broad complex brady pre-arrest ANTICHOLIBNERGIC - agitation / restlessness / delirium - dry, warm flushed skin - mydriasis (pupil dilation) - myoclonic jerks - urinary retention - ileus ECG - normal initially - TACHY (brady is pre-terminal) - widening QRS - dysrhythmias - also RBBB MANAGEMENT - supportive (incl activated charcoal if early) - SODIUM BICARB (nb don't get too hung up on learn specifc - know cardiac + neuro effects + management)

Answer 35

mirtazepine = only one used Potent agonist at several serotonin receptor subtypes, competitive agonist of H1 α1 and α2

Answer 36

mirtazepine = only one used 1) DEPRESSION 2) ANXIETY (incl OCD)

Answer 37

mirtazepine = only one used COMMON = drowsiness = increased appetite + weight - dry mouth - headaches - constipation RARE - hyponatraemia (although rarer than in other anti-Ds) - pancreatitis - agitation - suicidal ideation used for people with insomnia / appetite loss to help! "mirtazapine, like NASA, can send people to sleep"

Answer 38

- Phenelzine - Isocarboxazid - Moclobemide RARELY USED now dt dietary restrictions! Inactivate enzymes (monoamine oxidase) that oxidise noradrenaline, serotonin, dopamine, tyramine and other amines. 1) refractory depression 2) refractory anxiety MILD SEs - dry mouth - postural hypotension - headaches - confusion - constipation SERIOUS SE = HYPERTENSIVE CRISIS - food containing tyramine causes accumulation of tyramine which cannot be broken down -> hypertensive crisis - Avoid all cheeses, red wine, beer, smoked fish, Marmite, liver, salami, pepperoni amongst others. - Also interact with local anaesthetics, some opiates, cocaine

Answer 39

combo of ANTI-DEPRESSANTS, plus: - st john's wart - ecstasy (aka MDMA) - cocaine SYMPTOMS - rapid onset! - restlessness - fever + diaphoresis - tremor - myoclonus - increased reflexes - mydriasis (dilation of pupils) - confusion - fits - arrythmias MANAGEMENT - stop anti-depressants - supportive (incl intubation if necessary) nb most mild + better within 24hrs

Answer 40

CAUSES - combo of serotonin agents (incl cocaine, ecstasy) in serotonin syndrome - A/Ps in NMS ONSET + COURSE - SS = abrupt (6 hours of taking) + quick to resolbe - NMS = gradual onset + prolonged recovery NEUROMUSCULAR - SS = myoclonus + tremour - NMS = diffuse rigidity (w CK risk) REFLEXES - SS = increased - NMS = decreased PUPILS - SS = dilated - NMS = normal

Answer 41

Both are dopamine D2-receptor blockers - but also act on histamine + serotonin receptors (varies with drug) - FGAs (typical) are non-selective - SGAs (atypical) are more selective MESOCORTICAL pathway = cognition + executive function - low levels cause negative symptoms (A/Ps may worsen these) MESOLIMBIC pathway = motivation, emotion, reward - high levels cause positive symptoms (A/Ps work here!) NIGROSTRIATAL pathway = stimulation of movement - (A/Ps can cause EPSEs here) TUBERINFUNDIBULAR pathway = DA functions as prolactin inhibitory hormone (PIH) - (A/Ps can cause high prolactin levels)

Answer 42

- ORAL (1st line - least restrictive) - IM (fast-acting, eg for quick sedation) - DEPO* 1-3months (long acting IM, for poor compliance - need oral until stable plasma levels) FGA - haloperidOL* - fluphenaZINE* - flupentixOL* - zuclopenthixOL* - chlorpromaZINE - pimoZIDE ``` SGA - olanzaPINE* - risperiDONE* - quetiaPINE - aripipraZOLE = clozaPINE ``` * = available as depo "FGA are OLd and still reading ZINEs" "SGA are what people PINE over now"

Answer 43

INDICATIONS 1) acute psychosis 2) schizophrenia 3) schizoaffective disorder 4) mania 5) sedation 6) anti-emetic (eg haloperidol for palliative care) 1) sedation = within hours 2) SEs = hours-days 3) anti-psychotic = days-weeks FGA - haloperidOL* - fluphenaZINE* - flupentixOL* - zuclopenthixOL* - chlorpromaZINE - pimoZIDE ``` SGA - olanzaPINE* - risperiDONE* - quetiaPINE - aripipraZOLE = clozaPINE ``` * = available as depo "FGA are OLd and still reading ZINEs" "SGA are what people PINE over now"

Answer 44

FGA ONLY - increased prolactin - galactorrhoea + amenorrhoea - EPSEs BOTH - long QTc - lower seizure threshold - sedation - anti-cholinergic SEs - apathy - weight gain SGA ONLY - metabolic syndrome (olanzapine / clozapine) (olanzapine not used in pts w diabetes or obesity) CLOZAPINE - constipation (kills more than agranulocytosis) - neutropenia (4%) - agranulcytosis (1%) - myocarditis - reduced seizure threshold RARE, BUT SERIOUS = neuroleptic malignant syndrome nb can also get postural hypotension + impotence in men! ANOTHER WAY OF CATEGORISING SE's: ANTI-DOPAMINERGIC - EPSEs - Raised prolactin (galactorrhoea and amenorrhoea in women. Sexual dysfunction, osteoporosis) ANTI-ADRENERGIC - Sedation - Postural hypotension - Inability to ejaculate ANTI-CHOLINERGIC - Dry mouth - Constipation - Blurred vision ANTI-HISTAMINIC - Sedation - Weight gain OTHER - Cardiac conduction defects– prolongation of QT interval, rarely Torsades de Pointes and sudden death - Diabetes and metabolic syndrome – weight gain, raised triglycerides, raised fasting glucose. RARE – Neuroleptic malignant syndrome.

Answer 45

ADAPT - Acute Dystonia - Akasthesia - Parkinsonism - Tardive dyskinesia increasing time of onset as you go down list (days - years) ``` ACUTE DYSTONIA = torticolis (spasms) = grimacing = oculogyric crisis - acute onset === anti-cholinergics (eg procyclidine) ``` AKASTHESIA = feeling of physical restlessness === procyclidine, propranolol, benzos, dose change PARKINSONISM = expressionless face, rigidity, tremor === anti-cholinergics (eg procyclidine) TARDIVE DYSKINESIA - aka choreoathetoid movements = involuntary chewing, sucking, grimacing, eye blinking - onset a few years after start medication === dose reduce or change drug, hard to treat (anti-cholinergics make it worse)

Answer 46

- blurred vision - dry mouth - constipation - urinary retention

Answer 47

RARE SE of A/Ps norm after first starting A/Ps but can be insidious onset a few months after initiation / dose change MEDICAL EMERGENCY - variable BP - tachycardia - high fever - sweating - altered mental state - rigid muscles / hypertonicity BLOODS - raised CK - raised WCC MANAGEMENT - stop offending agent - supportive treatment (may need ITU) mortality = 10%

Answer 48

'atypical atypical' better efficacy than other A/Ps can only use if: - TWO A/Ps tried for at least 6 weeks - at least one being a SGA - agranulocytosis (1%) - leucopenia (5%) - constipation -> paralytic ileus (kills most) - myocarditis - reduced seizure threshold registered with national monitoring service - FBC weekly initially, then fortnightly, then monthly - also loads of obs + ECG when titrating up if stop for >48 hours then have to retitrate dose up again

Answer 49

drugs affecting DOPAMINE - L-dopa (will cancel out effect) - metoclopramide (will increase EPSEs) drugs affecting CPY450 PATHWAY - esp antiepileptics + abx (eg clarithromycin) drugs that PROLONG QTc

Answer 50

Large studies have found the efficacy of all antipsychotics to be equal (except Clozapine), so choose based on other factors TO TAKE INTO ACCOUNT - prev A/P tried - age, gender - co-morbidities - preference wrt formulation - pt views - carer views norm start an ORAL SGA at lowest effective dose try for 2-3 weeks - if SE or poor response, change - if some effect, continue for 4 wks compliance is really important - risk of relapse if stop in first 6 months is huge! (concordance is 25-75% day 10 post-discharge) offer healthy eating + physical exercise programme to reduce risk of metabolic syndrome continue for 1-2 years, monitor + stop gradually (if multiple relapses. then may be life-long)

Answer 51

OBS - BP - HR BEDSIDE - BMI - ECG BLOODS - FBC - U+E - LFT - TFT - Prolactin - HbA1c - Lipids basically do the same for monitoring??? not sure of frequency though... *** - think most stuff is annually and when dose change etc FBC weekly then less frequently for CLOZAPINE

Answer 52

- lithium - sodium valproate - carbamazepine - lamotrigine can use A/Ps too if psychotic symptoms / severe mania nb can use anti-depressants for bipolar to augment but rarely used as can trigger mania other indications 1) schizoaffective disorder 2) severe unipolar depression 3) prevention of aggression in pts with learning disability (also obvs anti-epileptics can be used for seizures etc too!)

Answer 53

LITHIUM - reduces excitatory neurotransmitters (ie dopamine + glutamate) - increases inhibitory neurotransmitters (ie GABA) SODIUM VALPROATE - inhibits neuronal Na+ channels + increases GABA - reduces neuronal excitability -> reduces electrical 'kindling' in the temporal lobe + limbic system CARBAMAZEPINE - inhibit neuronal Na+ channels -> stabilises resting membrane potential -> reduces electrical 'kindling' in the temporal lobe + limbic system LAMOTRIGINE - inhibit neuronal Na+ channels -> stabilises resting membrane potential -> reduces electrical 'kindling' in the temporal lobe + limbic system

Answer 54

EARLY - dry mouth - metallic taste - polydipsia - polyuria - FINE tremor - nausea / GI upset - fatigue / drowsiness LATE - neuro effects (ataxia, dysarthria) - nephrogenic diabetes insipidus (monitor kidneys) - hypothyroidism - 20% (TFTs) - hypercalcaemia (Ca2+) - arrythmias (ECG) - weight gain (BMI) ^monitor these every 6 months - a year monitor lithium levels a week after initiation + dose changes - once steady state - monitor every 3 month (level taken 12 hours post dose) is also teratogenic - epstein's anomaly more common (although not as much as valproate)

Answer 55

SODIUM VALPROATE - GI upset - neuro effects (tremor, ataxia, behavioural disturbances - weight gain (monitor BMI) - thrombocytopenia (monitor FBCs) - transient increase in liver enzymes (monitor LFTs) = very teratogenic!!! CARBAMAZEPINE - GI upset - Neuro effects (dizziness and ataxia) - Hypersensitivity → rash - Oedema - Hyponatraemia (U+Es) LAMOTRIGINE - GI upset - Neuro effects (tremor, dizziness, insomnia, aggression) - Dry mouth - Skin rash → SJS (rare) "all mood stabilisers have GI upset + some form of neuro effects"

Answer 56

- diuretics - NSAIDs - ACEi - ARBs - metronidazole can all INCREASE lithium levels (nb other interactions too) - basically anything that affects renal excretion -> build up of lithium be aware of CYP450 drugs with anti-epileptics as may induce, inhibit +/or be affected by this! - ie they interact with a lot of meds!!!

Answer 57

therapeutic = 0.5-1 toxicity >1.5 (but treat symptoms) EARLY - blurred vision - dysarthria (slurred speech) - COARSE tremor - ataxia - anorexia - nausea + vomiting - diarrhoea LATE - hyper-reflexia - confusion / delirium - renal failure - convulsions - coma -> death nb fine tremor is normal SE of lithium, coarse tremor is a sign of toxicity!!

Answer 58

therapeutic = 0.5-1 toxicity >1.5 (but treat symptoms) COMMON CAUSES - UTI - renal failure - dehydration - drugs (NSAIDs, diuretics) (basically anything that reduces renal functioning can cause!) MANAGEMENT - stop lithium - treat cause (eg abx for UTI) - fluids - dialysis (if bad)

Answer 59

BEDSIDE - BMI - ECG BLOODS - U+E - lithium levels - TFTs - Ca2+ do every 3 months?? nb must stay on the same drug BRAND of lithium - concentrations vary between brands

Answer 60

dangerous in OD = lithium (although tbh all are but lithium has a very narrow therapeutic range) best for depressive phase of BPD = lamotrigine avoided in WCBA = sodium valproate

Answer 61

Benzodiazepines facilitate and binding of neurotransmitter GABA to the GABAA receptor, resulting in sedative, hypnotic (sleep-inducing), anxiolytic (anti-anxiety) and anticonvulsive effects - oral - sublingual - rectally - IM - IV ``` SHORT ACTING = half life < 10hrs - midazolam - loprazolam - lorazepam - lormetazepam - temazepam ``` ``` LONG ACTING = half life > 15hrs - diazepam - chlordiazepoxide - nitrazepam - flurazepam - alprazolam - clobazam ``` (don't bother learning all these drug names)

Answer 62

1) SEIZURES + status epilepticus = buccal midazolam, IV lorazapam 2) ALCOHOL WITHDRAWAL = chlordiazepoxide 3) sedation for INTERVENTIONS = midazolam 4) sedation for AGITATION / aggression = lorazepam 5) severe, disabling or distressing ANXIETY = diazepam 6) severe, disabling or distressing INSOMNIA = temazepam only use short term (2-4 wks) as tolerance and addiction common generally use short-acting for insomnia and long-acting for anxiety

Answer 63

COMMON - drowsiness / sedation - unsteadiness (^falls in elderly) - confusion / memory problems - muscle weakness - slurred speech - paradoxical increase in aggression (5-10%) SERIOUS - dependence (-> withdrawal) - resp depresison in OD (-> coma + death)

Answer 64

- elderly (^risk falls, confusion etc) - respiratory impairment - neuromuscular disease - liver failure (may precipitate hepatic impairment)

Answer 65

FLUMAZENIL = BZD receptor antagonist, for acute toxicity.

Answer 66

Withdrawal syndrome - anxiety - insomnia - tremor - nausea - perceptual disturbances ^very similar to alcohol withdrawal Occurs within 2-3/7 of stopping short-acting, or 7/7 long-acting BZD. Short-acting BZDs more likely to be associated with dependence and withdrawal. MANAGEMENT - switch to diazepam (long-acting) and then taper - additional psych / social support too!

Answer 67

- other sedating drugs - opioids - alcohol - CYP450 (inhibitors may increase effects) all increase risks of sedation, resp depression etc

Answer 68

- zopiclone - zolpidem - zaleplon act at, or close to, the BZD receptor site oral route

Answer 69

INSOMNIA (short-term use only) - zopiclone - zolpidem - zaleplon

Answer 70

- bitter aftertaste / dry mouth - residual drowsiness the next day biggest risk = tolerance + rebound insomnia on withdrawal interact with other sedatives (incl alcohol) to increase effect nb risk in eldery of confusion + falls

Answer 71

OLD / 1ST GEN ANTI-HISTAMINES - diphenhydramine - doxylamine MIRTAZEPINE - esp for depression w insomnia MELATONIN - aka circadin nb, aside from mirtazepine, these should all be used short term as build tolerance nb also opioids may help with insomnia but should not be used purely for this indication

Answer 72

- mild insomnia (use sleep hygiene instead) - energy drinks / excess caffeine (counteract activity, reduce these) - over 65s (risk excessive sedation, falls + confusion) - excessive alcohol use (both CNS depressors) - severe hepatic impairment (as can increase accumulation dt lowered metabolism)

Answer 73

Inhibits acetylcholine breakdown – increased cholinergic neurotransmission - Both muscarinic and nicotinic - In the brain cholinergic NT increases. Other: - Stimulates smooth muscle of bowel - Relaxes sphincter of bladder and bowel - Constrict pupils - Increases secretions e.g. sweat, saliva, bronchial think of it as doing the opposite to an anti-cholinergic drug (like a TCA) oral route - Donepezil - Galantamine - Rivastigmine

Answer 74

- Donepezil - Galantamine - Rivastigmine 1) mild-moderate ALZHEIMERS (incl mixed alzheimers-vascular) 2) LEWY BODY dementia (Rivastigmine only) don't use for fronto-temporal demnetia - makes worse! nb also used for: - myasthenia gravis - relief of post-op urinary retention

Answer 75

- Donepezil - Galantamine - Rivastigmine basically the OPPOSITE of anti-cholinergic side effects! - nausea - vomiting - abdo cramps - diarrhoea - bradycardia - muscle cramps - hypersalivation - excess sweating - insomnia monitor pulse

Answer 76

Memantine increase levels of acetylcholine oral route

Answer 77

Memantanine 1) moderate-severe ALZHEIMERS (use after acetylcholinesterase inhibitors failed / stopped working)

Answer 78

Memantanine - dizziness - sedation - constipation

Answer 79

OPEN Qs could you tell me about your usual drinking habits? could you take me through a typical day of drinking for you? when did you first start drinking? what did you drink then? how have things changed since you first started drinking? SPECIFIC Qs - time of first drink of the day? - any days off? - alone or socially? - efforts to control?

Answer 80

- fine intention tremour (also tongue - harder to feign!) - high HR - high BP - GI upset - nausea / vomiting - diaphoresis - headache (incl photosensitivity) - anxiety / agitation - loss of orientation - hallucinations (norm visual) COMPLICATIONS - delirium tremens - seizures - wernicke's encephalopathy (see my ED notes for time scales of these**)

Answer 81

- chlordiazepoxide (reducing or PRN dosing) - thiamine - fluids refer to drug + alcohol services in community!

Answer 82

weed, maijuana, herb, hash, grass, ganja, dope, bud, puff, pot (legal class B) - smoke w tobacco - vape - ingest Binds to cannabinoid receptor CB1. Indirectly increases dopamine release. Lipid soluble so stays in body for weeks - useful for drug testing! THC – psychoactive component CBD – non-psychoactive, thought to reduce negative psychological experiences nb ‘skunk’ = higher THC content and lower CBD content nb CBD thought to be beneficial for pain, epilepsy and others, although not sufficient evidence. CBD recently recognised as a medicine in the UK, but not licensed.

Answer 83

ACUTE PSYCH - relaxation - euphoria - altered perceptions (could be illusions or hallucinations) - short-term memory loss - irritability - paranoia - drowsy ACUTE PHYSICAL - increased HR - increased appetite - dry mouth - dry eyes - bloodshot eyes

Answer 84

- all risks of smoking tobacco - low motivation - depression - anxiety - psychosis / schizophrenia (5x baseline risk)

Answer 85

nb although rarer than most other drugs - 10-20% of people who use every day develop a physical dependence on cannabis (more likely if start using when younger age) - anxiety / irritability - insomnia - loss of appetite - abdo pains - nausea - sweating - chills - depression / anxiety / modd swings - loss of concentration physical symptoms within first 48hrs, subside by a week then psych symptoms increase from 7-14 days and can last for weeks

Answer 86

MDMA, MD, mandy, molly, pills, crystal (legal class A) - swallowed - 'dabbing' onto gums Blocks serotonin reuptake, increasing serotonin in the synapse (so is like a super-SSRI), also has a lesser effect on increasing dopamine and noradrenaline

Answer 87

ACUTE PSYCH - euphoria - empathy towards others - increased energy - reduced tiredness - altered sensual experiences (eg music, anxiety, panic attacks, confusion) ACUTE PHYSICAL - high HR - high BP - dry mouth (so they drink) - hyperthermia - dilation of pupils - loss of appetite - tightening / repetitive movement of jaw (bruxism/'gurning')

Answer 88

- lethargic - increased need for sleep - low mood - anxiety

Answer 89

- pills (unaware of dose or what cut with = danger of overdose / poisoning) - water intoxication / hyponatraemia - memory problems - depression - anxiety

Answer 90

speed, whizz, billy, sulph, base (legal class B, A if injected) - snort - dab - swallowed ('bomb) - injected binds to transporter proteins for monoamines such as dopamine, noradrenaline, serotonin and taken up into neurons. Once inside, disrupts the storage of monoamines in synaptic vesicles. More neurotransmitters in neuron. Then, by unknown mechanism, makes transporters run in reverse, leading to increased release of monoamines, esp. dopamine and noradrenaline. May also inhibit reuptake and inhibit monamine oxidase.

Answer 91

ACUTE PSYCH - alert / wide awake - excited / chatty - increased focus / concentration - panicked - agitated / aggressive - delusions + hallucinations ACUTE PHYSICAL - high HR - high BP - high temp - high RR - arrythmias - insomnia - LOW appetite (opposite to cannabis) (almost manic symptoms without the psychosis and flight of ideas) COME DOWN - lethargic - low mood

Answer 92

- dependency - pscyhosis - depression - anxiety OTHER USES - treatment for ADHD - 'study drug'

Answer 93

- cravings - anhedonia - depression - anxiety - increased need for sleep - increased appetite

Answer 94

yaba, christine, tina, meth, ice, glass, crystal meth, crank (legal class B, A if injected) Chemically very similar to amphetamines. However, extra methyl group means crosses blood brain barrier more readily as it is highly lipophillic, therefore more of it reaches brain, it reaches it faster, and it stays for longer as it resists breakdown from MAO more - swallowed - snorted - smoked - injected

Answer 95

- highly addictive! - affect on cognition - risk of MI all the risks of amphetamine, but more so

Answer 96

blow, coke, crack, charlie, white, wash, toot, flake, stones, sniff, snow, rocks, percy, pebbles, freebase, ching, change, C - snort - smoke (crack) - inject Mainly unknown. Thought to be inhibition of monoamine reuptake and blocking monoamine transporters. Dopamine, noradrenaline and serotonin. Dopamine thought to be most important in causing the desired effects as well as dependency

Answer 97

ACUTE PSYCH - elated mood - increased confidence - feelings of having great mental capacities - increased energy HIGHER DOSES: - anxiety / panic - hallucinations PHYSICAL - high HR - sweating - dry mouth - loss of appetite - vasoconstriction - dilated pupils COME DOWN - low mood - poor concentration - runny nose - tremours

Answer 98

RISKS - stroke - MI / arrest - bowel gangrene - ENT complications (epistaxis, chronic rhinorrhoea, septum damage) (also dependence) nb if a young person comes in with chest pain, always ask about cocaine use! EFFECT OF EVERYDAY USE - restlessness / hyperactivity - 'wired' + paranoid - insomnia -> exhaustion - nausea - weight loss

Answer 99

- tired, exhausted + unable to sleep - extreme emotional + physical distress - anorexia - sweating

Answer 100

benzos, downers, valium, vallies, roofies, rohypnol, jellies (legal class C) - swallowed - injected binds to GABA receptor and increases effect of GABA (more chloride ions in post-synaptic neuron, hyperpolarises, less excitable)

Answer 101

ACUTE PSYCH - sedation - reduction in anxiety ACUTE PHYSICAL - reduced RR - reduced HR - reduced temp

Answer 102

- addiction | - overdose

Answer 103

- decreased concentrations - depression - anxiety / panic attacks - tremours - headaches - seizures - nausea - vomiting

Answer 104

smack, skag, horse, brown, gear legal class A - smoked - snorted - injected crosses blood brain barrier and is converted to morphine, whereby it binds to mu-opioid receptors - reduces excitability of neurons, reduces GABA (an inhibitory neurotransmitter, therefore increased dopamine- high)

Answer 105

PSYCH - happy / euphoric - relaxed - sleepy PHYSICAL - reduced RR - reduced HR - low temp - constricted pupils

Answer 106

HR + BP - opioid DOWN - sympathomimetics UP - sedatives DOWN RR - opioid DOWN - sympathomimetics UP - sedatives DOWN TEMP - opioid DOWN - sympathomimetics UP - sedatives DOWN PUPILS - opioid SMALL - sympathomimetics LARGE - sedatives NO CHANGE BOWEL SOUNDS - opioid REDUCED - sympathomimetics LOUD - sedatives REDUCED DIAPHORESIS - opioid LESS - sympathomimetics YES - sedatives LESS SYMPATHOMIMETICS - cocaine - amphetamines & meth SEDATIVE / HYPNOTICS - benzos + barbs - Z drugs - antihistamines

Answer 107

offence to SUPPLY (or OFFER to suppy) any PSYCHOACTIVE substance, regardless of its potential for harm possession is not an offense - but production + supply is! psychoactive substance = any substance which is capable of producing a psychoactive effect in a person who consumes it (+ is not an exempted substance) EXEMPTIONS - caffeine - alcohol - nictoine - nutmeg - poppers nb this acts includes nitrous oxide

Answer 108

METHADONE - once a day, take supervised in pharmacy - liquid, tablet, injection - long half life (24+hr, may reduce to 8hrs in pregnancy) BUPRENORPHINE - semi-synthetic opioid - agonist / antagonist opioid receptor modulator - norm sub-lingual tablet NALTREXONE - long acting opiate antagonist - oral, depot, implant - blocks euphoric effects, little effct on cravings - also used in alcohol dependency (better evidence base) LOFEXIDINE - alpha2-adrenergic receptor agonist - used to relieve withdrawal symptoms, particularly those caused by noradrenaline - can be used in conjunction with naltrexone for detox

Answer 109

``` B complex vitamins (B-l (thiamin), vitamin B-3 (niacin)) AND folacin (folic acid) ``` B vitamins to prevent wernickes encephalopathy + sub-acute degeneration of cord check for loads of others, incl Vit D, norm electrolytes etc - do full blood panel

Answer 110

``` COMPLEMENTARY = therapies used alongside treatments offered by your doctor - yoga - meditation - acupuncture - massage ``` ``` ALTERNATIVE = approaches which are generally meant to replace the treatments offered by your doctor - traditional chinese medicine - ayurvedic medicine - St John's Wart ```

Answer 111

- DON'T WANT treatment from dr (eg psych meds or talking therapies) - ALREADY TRIED treatment from dr + didn't work or had unacceptable side effects - on WAITING LIST for treatment but need help now - want more options for treatment IN ADDITION to treatment from dr

Answer 112

1) they are not evidence-based (except maybe accupuncture) and so may not produce desired benefit 2) alternative medications may INTERACT with prescribed meds 3) also may not be what they say on packet, market is UNREGULATED

Answer 113

never recommend directly BUT if they ask you, say: As with all medicines and therapies, different things work for different people, and it’s not easy to predict which therapy you would find most useful or effective. Most of the evidence for complementary and alternative therapies is based on traditional use rather than modern scientific studies. This means it's really difficult to know whether they are an effective treatment for mental health problems. However, many people do say they find them helpful in managing or relieving the symptoms they experience. BUT be careful as many medications can cause harm 1) dt INTERACTIONS (also pregnancy) and 2) dt lack of REGULATION - so talk to dr first But no harm at all to trying complementary methods (acupuncture, massage etc) 'complementary + alternative therapies' leaflet produced by MIND

Answer 114

1) LEAST RESTRICTIVE OPTION and maximising independence 2) EMPOWERMENT and INVOLVEMENT (of pts and family) 3) Respect and DIGNITY 4) PURPOSE and effectiveness (clear therapeutic aim to admission) 5) EFFICIENCY + EQUITY.

Answer 115

Informal = admitted to hospital voluntarily (must have capacity to consent to admission formal / detained = pt admitted under MHA (aka sectioned)

Answer 116

1) must be suffering from MENTAL DISORDER (any disorder or disability of mind), of a nature or degree which warrants detention in hospital AND 2) must be at RISK to own health +/or own safety +/or risk to others AND 3) must be UNWILLING to be admitted voluntarily OR LACK the CAPACITY to make this decision so always assess capacity - because even if they agree to admission, they may lack the capacity to make that decision - and so may have to section even if they appear to want to go voluntarily

Answer 117

A diagnosis of learning disability isn’t sufficient for detention in its own right Their presentation must be associated with abnormally aggressive or seriously irresponsible conduct in order to detain

Answer 118

A specific relative of the pt who is organised through a hierarchy system - Not the same as next of kin - They can apply for a section - Ability to request a pt to be discharged from the section - Can apply for a review of the section - Duty to inform this relative when the pt is detained

Answer 119

2 = ASSESSMENT - up to 28 days - 2 doctors + 1 AHMP (MH assessment) 3 = TREATMENT - up to 6 months (initially) - 2 doctors + 1 AHMP (MH assessment) 5(2) = DOCTORS HOLDING - up to 72 hours - fully registered DR (FY2 +) 5(4) = NURSES HOLDING - up to 6 hours - mental health nurse

Answer 120

``` 135 - POLICE POWERS = warrant to search + remove pt from PRIVATE property + take to a 'place of safety' for assessment = requires a magistrate warrant - duration n/a - not renewed - triggers 136 ``` 136 - POLICE POWERS = allows police to remove pt from PUBLIC area to 'place of safety' for assessment - up to 24hrs - not renewed (can be extended by 12 hrs) - triggers MHA assessment (for section 2/3) nb don't need warrant for 136 BOTH - police - no right to treat - no right to appeal

Answer 121

2 = admission for ASSESSMENT - up to 28 days - can't renew - 2 doctors + 1 AHMP (MH assessment) - can treat - can appeal (within 1st 14 days) ENDS: - revoked - detain under section 3 (need another assessment)

Answer 122

3 = admission for TREATMENT - up to 6 months (initially) - can be renewed for another 6m and then annually - 2 doctors + 1 AHMP (MH assessment) - can treat - can appeal (twice in first 6m then annually) ENDS: - revoked - renewed

Answer 123

5(2) = DOCTORS HOLDING powers - up to 72 hours - can't be renewed - fully registered DR (FY2 +) - must be INPATIENT (not A&E) - can't treat (but can under MCA if lack capacity!!) - can't appeal END: - triggers MHA assessment - (or just revoke)

Answer 124

5(4) = NURSES HOLDING - up to 6 hours - mental health nurse - up to 6 hours - can't be renewed - mental health nurse - must be INPATIENT (not A&E) - can't treat (but can under MCA if lack capacity!!) - can't appeal END: - triggers 5(2) assessment by FY2+ - (or just revoke)

Answer 125

can treat under: - section 2 (assessment) - section 3 (treatment) can treat: 1) the CAUSE of the mental disorder: - causes of delirium - acute intoxication 2) the MENTAL DISORDER - anti-depressants, anti-psychotics - includes ECT 3) DIRECT CONSEQUENCES of mental disorder: - self-neglect - overdose (eg parvolex) - self-injury - feeding in ED (incl NG tubes) If need to treat: A) under a section which doesn’t cover treatment OR B) a physical health condition unrelated to MH condition then ASSESS CAPACITY and treat under MCA (if lack)

Answer 126

aka CTO allows treatment for MH condition in community (instead of hospital) legal order for supervised community treatment, with specific criteria (eg attend appts, let nurses give A/Ps depo) can be recalled to hospital if criteria not met (don't have to do any) initially for 6 months, renewed for further 6m then annually (basically section 3) can only be used under section 3! go on section 3 first then it's converted into a CTO

Answer 127

1) WHY detaining - Eg ”Mr smith is 46 yo gentleman who is suffering from auditory hallucinations which are telling him to go and jump of a bridge. He has a prior diagnosis of paranoid schizophrenia and appears to be suffering a relapse of symptoms” 2) WHO the RISK is to - eg “Mr smith is at risk to himself if he listens to the auditory hallucinations and jumps of a bridge, he is also unlikely to consent to treatment as he lacks insight and also lacks capacity to make that decision” 3) brief CAPACITY assessment OR that they are REFUSING treatment 4) that you have considered a LESS RESTRICTIVE option - “eg I have considered allowing mr smith to remain as an informal patient, but it is likely that he would leave the ward and prove a risk to himself” 5) POTENTIAL BENEFITS of detainment - eg for assessment and diagnosis, to get to therapeutic dose of A/Ps etc

Answer 128

1) A person is ASSUMED to have capacity (thumb) 2) YOU have taken all practicable steps must be taken to ENABLE DECISION MAKING. (index) 3) People are able to make UNWISE decisions (middle) 4) Any actions or decisions made on behalf of a person who lacks capacity must be in that person’s BEST INTERESTS (ring) 5) Decisions made on behalf of someone lacking capacity must be LEAST RESTRICTIVE (little)

Answer 129

DIAGNOSTIC TEST - at the time of the decision the person has an impairment of, or disturbance in functioning of, the mind or brain (incl learning disability etc)? if no, person has capacity! if yes: FUNCTIONAL TEST - is pt able to: 1) UNDERSTAND the info relevant to the decision 2) RETAIN this info 3) WEIGH UP information as part of making the decision 4) COMMUNICATE their decision Info relevant to decision = eg what procedure involves, risks, intended benefits length of retention depends on decision (eg endoscopy retain for several hours-days, what want for dinner - only need to do for secs/mins) Ability to weigh up information may be impaired in an overdose due to depression because of underlying suicidal ideations - so can say they lack capacity to refuse treatment for OD - so can give the treatment against their will Communication doesn’t have to be verbal - can be written or shake head etc

Answer 130

Decision specific. Time specific say: pt doesn’t have capacity for this procedure at this time - NOT the person doesn’t have capacity capacity should be assessed by the person who will be then making the decision, if they do lack capacity over 16 years (under 16 is gillick competence)

Answer 131

ADVANCED DIRECTIVE - (advanced decision and living will are outdated terms for same thing) - Allows REFUSAL of specific treatments under the law - must be SPECIFIC - specific scenario and specifically what you are refusing - Valid for ECT under MHA - Need to have capacity when made - Needs to be witnessed - Always check if someone has one - In an emergency - provide treatment and then consider options later once see directive ADVANCED STATEMENT - Again, written down when pt has capacity - GENERAL statement which GUIDES Drs if need to make DECISIONS in best interests of pts - eg: wishes, feelings, values, beliefs - Not legally binding, but should be used in ‘best interest’ decisions

Answer 132

1) HEALTH + welfare 2) property + FINANCES one individual can be both - or each position can be shared pt asigns before they lose capacity - "who would you want to make decisions for you once you've lost the capacity to make them for yourselves?" - can do on gov.uk website - encourage pts with early dementia to do As a physician, can apply for the courts to displace these powers if you disagree with decisions nb Must EXPLICITLY state that you give them the right to refuse life-sustaining treatment

Answer 133

Best interests are PERSONAL - so need to gather as much info as possible to make a best guess as to what that person would have wanted before they lacked capacity Can talk to: - Patient (even if they lack capacity) - Relatives and carers - what would they have accepted/refused - Medical knowledge - to know what options are available - find least restrictive option - Can appoint an IMCA to find out this info and act as an advocate for the pt

Answer 134

independent mental capacity advocate people who lack capacity and do not have family or friends to consult consult if: A) decision involves 'serious medical treatment' B) decision involves a hospital stay of >28 days or care home stay of >8 weeks

Answer 135

ACID TEST 1) Are they under continuous supervision and control? (continuous doesn’t need to mean 24/7) 2) Are they not free to leave? if answer yes to both: then you are depriving the pt of their liberty and should have a DOLS in place restriction is in best interest and MHA wouldn't be more appropriate (eg LD or short term delirium) pt LACKS CAPACITY is in a hospital OR care home (only valid in one location) DoLS give NO RIGHT to treatment. - If treatment’s required then we must assess capacity and if they lack capacity provide treatment in their best interests Soon to be replaced by Liberty Protection Safeguards (LPS) two types 1) emergency DOLS - 7 days - just a form 2) standard DOLS - up to a year - needs a DOLS assessment DOLS assessment - best interest assessor AND mental health assessor Challenging a DOLS - request a review - appeal to the court of protection nb 18 years or over

Answer 136

TO SELF - self-neglect (incl wandering) - physical health (incl not taking meds) - self-harm / suicide - financial risk (if manic/psychotic) - sexual risk TO OTHERS - physical harm to others - reckless driving - neglecting children or dependent adults - financial exploitation - arson (esp w LD) FROM OTHERS - financial exploitation - violence from others - domestic violence - expolitation (esp LD + elderly) nb any self-harm in older people is taken a lot more seriously (as more likely to be attempted suicide and not just 'cry for help')

Answer 137

TO SELF - any thoughts of harming self? - if you did get these thoughts, what would you do? - able to look after yourself? - any financial worries? TO OTHERS - anyone out to get you? what would you do if you faced that person in the street? - any thoughts of protecting yourself or harming others? - any dependents? children? FROM OTHERS - do you feel safe at home? - who has control of your finances?

Answer 138

LIKELIHOOD - plans? - means? (eg access to gun) IMMEDIACY - planned a date? as soon as they leave? IMPACT - something potentially lethal? or superficial arm cutting?

Answer 139

FIXED - hx of self-harm / suicide attempts? - hx of substance misuse - past trauma - Fhx of suicide - age (<20 or >45) - gender (male) DYNAMIC - bereavement - relationship breakdown - loss of job - current financial stress - current substance misuse - current mental health deterioration

Answer 140

``` S = Sex (male) A = Age (<20 or >45) D = Depression ``` ``` P = Previous suicide attempts E = Excessive drug use / Ethanol R = Rational thinking loss (eg psychosis) S = Seperated (or no Spouse) O = Organised plan N = No social support / isolated S = Sickness (chronic illness) ```

Answer 141

- PSYCHOTIC phenomena - HOPELESSNESS for future - sense of ENTRAPMENT - well-formed PLANS - PAIN or chronic medical illness - lack of SOCIAL support (or perception of) for child/adolescent: PARENTAL psychotic OR suicidal behaviour

Answer 142

BEFORE - PLANNED or impulsive? (planned worse) - how did you get the MEANS? (just in house or stockpilling?) - leave a NOTE? DURING - WHERE? (private place worse) - make steps to AVOID BEING FOUND (locking door, forest, not texting people) - under influence of ALCOHOL? - METHOD? (violent bad, also high no pills) AFTER - did you SEEK HELP? (bad if did) - do you REGRET it now?

Answer 143

1) verbal de-escalation 2) medication - lorazepam (1-2mg PO/IV/IM) - Antipsychotic IM norm use lorazepam (esp if think under infuence of drugs, if known psychotic disorder then use A/Ps) be careful w lorazepam if high on opioids or alcohol or if risk of resp depression (eg COPD) Procyclidine for EPSEs!

Answer 144

An abnormal, extreme and persistent variation from the normal (statistical) range of one or more personality attributes (traits), causing the individual and/or family and/or society to suffer can only be diagnosed aged after 18 years - childhood trauma - violence - attachment issues - ADHD - behavioural issues aetiology: Interaction between genetic predisposition and invalidating environment Ie bad early experience

Answer 145

CLUSTER A: ODD / ECCENTRIC - paranoid - schizoid - schizotypical (ideas of reference) CLUSTER B: DRAMATIC / IMPULSIVE - antisocial (dissocial) - emotionally unstable (borderline) - histrionic - narcissistic CLUSTER C: ANXIOUS / FEARFUL - anxious (avoidant) - dependent - anankastic (obsessive-compulsive)

Answer 146

- Help individual find lifestyle that suits them, minimising negative effects - Consistency of care - Education of insight – to prevent shifting of blame over other - Psychological treatment – DBT for cluster B (?and others) nb also Medication for comorbid conditions - SSRIs - Anti-psychotics.

Answer 147

1) IQ under 70 2) loss adaptive social functioning 3) onset before age of 18 mild, moderate, severe + profound (based on level of IQ, don't learn the cut offs) ---> Does NOT include impairment developed >18 years, people with ABI after 18, people with complex medical conditions affecting intellectual abilities that develop >18 year e.g. Huntington’s, Alzheimer’s. nb Many people with learning disabilities prefer the term ‘learning difficulty’. - However, in UK education services, ‘learning difficulty’ also includes people who have ‘specific learning difficulties’ (e.g., dyslexia), but who do not have a significant impairment in intelligence. - intellectual disability (USA) = learning disability (UK) About 2% of population have at least a mild learning disability

Answer 148

most common cause = unknown - down's syndrome - Fragile X (X-linked inheritance, excess CCG repeats) - prader-willi - tuberous sclerosis - di-george (associated w psychosis) - maternal drug or alcohol use (foetal alcohol syndrome / spectrum disorder) PERINATAL - oxygen deprivation during birth - injury secondary to birth complications (eg bleed) - difficulties resulting from premature birth AFTER BIRTH - illnesses (eg meningitis) - head injuries - environmental conditions also a lot of people have multiple causes of the above

Answer 149

- cerebral palsy (more likely to have a learning disability) - autism - epilepsy (30% of people w epilepsy have an LD) - mental health condition (25-40% people with LD will have MH problems) nb also dementia more common - esp alzheimers in down's

Answer 150

BIO - Medical management as appropriate - but lower doses and be aware of comorbidities (Response to medication may take longer or there may be increased sensitivity to side-effects) - ALWAYS check thyroid in downs PSYCHO - may not be able to engage with psychological therapies - Standard assessment tools for dementia in the general population may not be appropriate. (Be aware of changes in behaviour as an early indicator of dementia) SOCIAL - really important - MDT approach - Support with complex social functions – finances, parents, carers - Education support in mainstream schools - Sheltered accommodation/ residential care don't worry tooo much about remembering this stuff off by heart

Answer 151

challenging behaviour = Any kind of behaviour which causes a problem to the patient or any other people around them behaviour is influenced by: BIO - Mental Illness. Epilepsy. Pain. Hunger. - Lesch Nhyan Syndrome (self injury). - Prader Willi (overeating) PSYCHO - Fear. Learned responses. Belief. SOCIAL - Limited space. Noise. - Others demands.Boredom MANAGEMENT: - use ABC charts to work out what causing behaviour - avoid triggers - use positive reinforcement