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MRCPsych Part B - Al-Rashid Hospital > Emergency Psychiatry > Flashcards

Emergency Psychiatry Flashcards

1
Q

Goals of Emergency Psychiatry

A 
Triage
Assessment
Diagnosis
Short term management
Discharge planning
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2
Q

Describe triage

A

Collection first line information
Prioritise as per need
Communicate/escalate appropriately to arrange further care

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3
Q

Describe assessment

A

Appropriate assessment to seek further diagnostic information pertinent to manage presenting problem.
Rapid understanding of aetiology is a key skill required.

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4
Q

Describe short term management

A

Options such as medications, hospitalisation, seclusion/restraint and crisis social interventions and psychoeducation.

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5
Q

Describe discharge planning

A

Longer term interventions should be planned including preventative strategies aimed at averting crises and rational follow-up strategies.

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6
Q

What sx would make one suspect of withdrawal or intoxication of substances?

A 
Disorientation
Impaired consciousness
Ataxia
Autonomic dysfunction
Hallucinations
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7
Q

What sx would make one suspect agitated depression?

A

Subdued mood
Anxiety
Catastrophic/guilt delusions

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8
Q

What would make one suspect of organic cause of catatonia?

A

No psychiatric hx

Worsens with benzos

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9
Q

What makes one suspect depressive stupor?

A

Low mood
Hx of depression
Hopelessness

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10
Q

What makes one suspect psychotropic induced catatonia such as NMS?

A

Rapid onset
Marked rigidity
Autonomic instability without posturing

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11
Q

Causes of catatonia

A 
Organic
Depressive stupor
Schizophrenia
Manic excitement
Psychotropic induced - NMS
Autism/neurodevelopmental disorders
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12
Q

What can cause starvation in the psychiatric patient?

A 
ED
Psychotic depression
Schizophrenia
Manic neglect
Psychotropic induced - NMS
OCD - food obsessions
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13
Q

How can schizophrenia lead to starvation?

A

Suspicions around poisoning, disorganised behaviour

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14
Q

How can OCD lead to starvation?

A

Recurrent irrational worries about safety, ritualistic behaviour

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15
Q

Total global mortality from suicide

A

1-2%

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16
Q

How high does suicide rank in developed countries?

A

Fifth most common cause

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17
Q

How many deaths in England and Wales are from suicide?

A

1%

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18
Q

Rate of suicide in England and Wales

A

8 per 100,000 per year

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19
Q

In which group are suicide rates increasing?

A

Young men

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20
Q

Most common suicide method in men

A

Hanging

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21
Q

How many deaths by men are from hanging?

A

40%

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22
Q

Second most common cause of death by men

A

OD

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23
Q

How many deaths from OD are caused by men?

A

20%

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24
Q

Third most common cause of death by men

A

Poisoning by car exhaust fumes

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25
Q

How many men die by poisoning from car exhaust fumes?

A

10%

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26
Q

Most common method of suicide by women

A

OD

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27
Q

Second most common method of suicide by women

A

Hanging

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28
Q

Third most common method of suicide by women

A

Drowning

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29
Q

How many women die by OD

A

46%

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30
Q

How many women die by hanging?

A

27%

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31
Q

How many women die by drowning?

A

7%

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32
Q

In most countries which age group has the highest rate of suicide?

A

> 75

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33
Q

Predictors of suicide in the elderly

A

Depression
Social isolation
Impaired physical health
Personality traits - anxious, obsessive

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34
Q

Where is there an increase in suicide rates in kids?

A

Males aged 15-19

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35
Q

Principal methods of suicide in young males

A

Hanging

Poisoning with car exhaust fumes

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36
Q

Traits amongst children who die by suicide

A

Antisocial behaviour
Suicide behaviour
Depressive disorders amongst parents and siblings

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37
Q

In which ethnic group is there a higher rate of suicide?

A

Asian women

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38
Q

Which occupational groups are at high risk of suicide?

A

Doctors - especially female
Anaesthetists, GPs and Psychiatrists
Farmers

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39
Q

Suicide due to depression

A

36-90%

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40
Q

Suicide due to alcohol abuse

A

43-54%

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41
Q

Suicide due to drug abuse

A

4-45%

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42
Q

Suicide due to schizophrenia

A

3-10%

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43
Q

Suicide due to organic mental disorder

A

2-7%

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44
Q

Suicide due to PD

A

5-44$

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45
Q

How many patients with a mood disorder will die by suicide?

A

6-10%

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46
Q

Which patients with depression are at highest risk?

A

Inpatients
Hx of impulsive and aggressive behaviour
Alcohol and drug misuse
Cluster B PD

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47
Q

How much does the risk of suicide increase if there is a history of a suicide attempt?

A

40x increase

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48
Q

Lifetime risk of suicide in alcohol dependence

A

7%

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49
Q

Suicide rate in heavy drinks

A

3.5x higher than general population

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50
Q

Suicide rate in alcohol use disorders

A

15x higher than general population

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51
Q

Suicide rate in drug dependence

A

15x higher than general population

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52
Q

Suicide rate in Anorexia

A

20-fold higher than general population

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53
Q

Lifetime suicide risk in schizophrenia

A

6%

10x higher than genera population

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54
Q

When do majority of schizophrenia patients commit suicide?

A

Active phase of disorder after suffering depressive sx

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55
Q

Characteristic traits of patients with PD who commit suicide

A

Comorbid depression or substance misuse
Impulsive and aggressive behaviour
Younger

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56
Q

Global annual suicide rate

A

1 in 6000/year

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57
Q

Male:female ratio of suicide

A

2-4:1

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58
Q

Most common age of suicide

A

15-24 females

25-34 males

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59
Q

In which age group is suicide rate decreasing?

A

> 65

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60
Q

Most common psychiatric diagnosis in suicide

A

Depression 30-31%

Alcohol dependence 17-24%

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61
Q

Mental disorders without much increase in suicide rate

A

Mental retardation
Dementia
OCD - if no depression

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62
Q

Suicides that have at least one recorded DSH attempt

A

40-60%

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63
Q

Number of people that will repeat DSH in one year

A

30%

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64
Q

Patients who were in contact with MH services at time of suicide

A

25%

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65
Q

Patients on psychiatry OP registers at time of suicide

A

25%

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66
Q

Patients who attempt suicide under alcohol influence

A

25%

50% of those who had alcohol within 6 hours

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67
Q

Patients who committed suicide who had seen a psychiatrist in the previous week

A

12.5%

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68
Q

Patients who commit suicide who had seen a health worker in last 3 weeks

A

33%

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69
Q

Patients who commit suicide who had seen their GP in last four weeks

A

66%

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70
Q

Patients who commit suicide who had seen their GP in the last week

A

40%

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71
Q

Most common method of IP suicide

A

Hanging - belt, curtain rail

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72
Q

How many IP suicides occur during first week of admission

A

25%

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73
Q

How many IP suicides occur when under routine (not constant or intermittent observations)

A

80%

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74
Q

How many patients who commit suicide were not compliant with meds?

A

20%

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75
Q

How many patients committed suicide within 3 months of d/c

A

25%

40% before first follow-up

76
Q

How many patients committed suicide within 28 days of d/c

A

1 in 500-1000 patients

77
Q

How many suicides were preventable according to MH teams in England?

A

22%

78
Q

Strongest RF for suicide

A

DSH history

79
Q

Risk of suicide within one year of DSH

A

0.7%
Males: 1.1%
Females: 0.5%
66x more than general population

80
Q

How many patients who committed suicide were on the enhanced CPA

A

50%

81
Q

How many elderly patients who committed suicide visited their GP

A

20% on same day
40% within 1 week
70% within one month

82
Q

How many suicides do MH teams in England regard as identifiable factors which could have reduced risk?

A

67%

83
Q

How many IP suicides occurred while on leave?

A

33%

84
Q

How many patients who committed suicide missed a recent appointment in the community?

A

30%

85
Q

How many Black Carribean patients in England and Wales who commit suicide have a diagnosis of Schizophrenia?

A

75%

86
Q

What are suicides in ethnic minorities associated with?

A

Higher rates of recent onset treatment non-compliance

87
Q

How many suicides in England are in the homeless community?

A

3%

88
Q

Cross-national lifetime prevalence of suicidal ideation, plan and attempts?

A
  1. 2%
  2. 1%
  3. 7%
89
Q

How many transitions from suicidal ideation to plan to attempt occur within first year of onset?

A

60%

90
Q

How many suicide attempts are recorded for every suicide?

A

25

91
Q

How many suicide attempts are due to OD?

A

90%

92
Q

Most common drug overdoses

A

Paracetamol

Aspirin

93
Q

Which antidepressants are commonly overdosed on?

A

TCAs
SSRI
(25%)

94
Q

Age of those who complete suicide

A

Late middle age

95
Q

Age of those who attempt suicide

A

Late teens/early 20s

96
Q

Marital status of those who complete suicide

A

Widowed>Divorced>Single>Married

97
Q

Marital status of those who attempt suicide

A

No pattern

98
Q

Social class of those who complete suicide

A

Higher among unemployed and retired

99
Q

Social class of those who attempt suicide

A

Lower and unemployed

100
Q

Early childhood of those who complete suicide

A

Death of parent

101
Q

Early childhood of those who attempt suicide

A

Broken home

102
Q

Family history of those who complete suicide

A

Depression
Suicide
Alcoholism

103
Q

FHx of those who attempt suicide

A

Similar episodes

104
Q

Physical health of those who complete suicide

A

Handicapped

Terminal illness

105
Q

Personality traits of those who attempt suicide

A

Cluster B traits

106
Q

Diagnosis of those who complete suicide

A

Major psychiatric disorders

Substance use

107
Q

Diagnosis of those who attempt suicide

A

Mental distress

Reactive depression

108
Q

Cognitive precipitants of those who complete suicide

A

Guilt

Hopelessness

109
Q

Cognitive precipitants of those who attempt suicide

A

Identity difficulties

Emotional distress

110
Q

Rate of DSH in UK

A

3 per 1000 per year

111
Q

How many people who DSH will repeat the act in the next year

A

20%

112
Q

How many people who DSH will die within the next year

A

1%

113
Q

How many people who DSH will eventually complete suicide?

A

10%

114
Q

How may people consume alcohol 6 hours before committing suicide?

A

33% males

25% females

115
Q

Most common method of DSH

A

Laceration

116
Q

How many people of DSH patients in hospital have a likely psych disorder?

A

90%

117
Q

Most frequency diagnoses of those who DSH

A

Depression
Alcohol misuse and drugs (men) and anxiety (women)
PD

118
Q

Factors associated with risk of repeating DSH

A 
Age 25-54
Alcohol/substance use
PD
Hx of violence
Lower social class
Previous psychiatric treatment
Previous self harm
Single, divorced or separated
Unemployed
119
Q

Clinical indicators of high suicidal intent

A

Act carried out in isolation and timed so intervention unlikely
Precautions taken to avoid discovery
Precaution made in anticipation of death (will, note)
Premeditated actions leading to final act (saving up tablets)
Communicating intent beforehand
Not altering potential helps after act
Admission of intent
Ongoing plans to repeat act
Continued access to means to reattempt
Diagnosable MI or PD
Physical illness - esp chronic conditions or those with pain/functional impairment
Recent contact with psych services
Recent d/c from psych IP

120
Q

Demographic indicators of high suicidal intent

A

Male
Low socio-economic status
Unmarried, separated, widowed
Unemployed and living alone

121
Q

Background history suggestive of high suicidal intent

A 
DSH (with high suicidal intent)
Childhood adversity
FHx of suicide
FHx of MI
Clinical Hx
122
Q

Psychosocial factors suggestive of high suicidal intent

A 
Hopelessness
Impulsiveness
Low self-esteem
Recent stressful life event
Relationship instability
Lack of social support
123
Q

Current content indicators of high suicidal intent

A

Suicidal ideation
Suicidal plans
Availability of means

124
Q

Risk factors for completing suicide

A 
Past DSH
Older age
Male
Social isolation
Psychiatric hx
Unemployment
Poor physical health
Access to means
125
Q

What scales can be used to assess suicide risk?

A

SAD PERSONS
Beck Hopelessness
Beck Scale for Suicidal Ideation

126
Q

What is the SAD PERSONS score?

A

10 major demographic risk factors used to assess immediate suicide risk in general hospital setting.

127
Q

Outline the SAD PERSONS score

A

Sex - 1 if male, 0 if female
Age - 1 if <20 or >44
Depression - 1 if depression present
Previous attempt - 1
Ethanol abuse - 1
Rational thinking loss - 1
Social support lacking - 1
Organized plan - 1 if plan is made and lethal
No spouse - 1 if divorced, widowed, separated of single
Sickness - 1 if chronic, debilitating and severe

128
Q

What is Beck Hopelessness Scale?

A

20 T/F statements focused on pessimism about the future.

129
Q

Scores of Beck Hopelessness Scale

A

0-3 - minimal risk
4-8 - mild risk
9-14 - moderate risk
15-20 - severe risk

130
Q

What is Beck Scale for Suicidal Ideation?

A

Self-reported 24-item scale (5 screening items) that assess patients thoughts, plans and intent to commit suicide.

131
Q

Scoring of Beck Scale for Suicidal Ideation?

A

Scores range form 0-48.
Each item scored 0-2.
Higher score = greater suicide risk. No cut-offs.

132
Q

What questions need to be asked when making a decision of someone who is at risk of suicide?

A

Is there evidence of MI?
Is there on-going suicidal intent?
Are there non-MH issues that can be addressed?
What is the level of social support?

133
Q

Care of the potentially suicidal patient in the community

A

Full MH and social context assessment
Considering place of safety
Regular review of suicide risk and arrangements
Safe treatment using adequate dosage of less toxic drugs
Restricting prescriptions and other means of access
Involving relatives for safe keeping of tablest
Arrangement for crisis or urgent access for patient and cares

134
Q

How many adolscents in the UK report suicidal ideation?

A

15%
Females: 22%
Males: 8.5%

135
Q

Most common method of suicide in adolescence

A

Paracetamol OD

Cutting

136
Q

One year prevalence of self-harm amongst 5-10 year olds w/o MH issues

A

0.8%

137
Q

One year prevalence of SH in 5-10 y/o with anxiety

A

6.2%

138
Q

One year prevalence of SH among 5-10 year olds in children with conduct, hyperkinetic or less common MI

A

7.5%

139
Q

One year prevalence of SH in 11-15 year olds without MI problems

A

1.2%

140
Q

One year prevalence of SH among 11-15 year olds with anxiety

A

9.4%

141
Q

One year prevalence of SH among 11-15 year olds with conduct, hyperkinetic or less common MI

A

8-13%

142
Q

One year prevalence of SH among 11-15 year olds with depression

A

18.8%

143
Q

Proportion of DSH in children that receives hospital attention

A

<13%

144
Q

One year prevalence of SH in 15-16 year olds

A

6.9%

145
Q

Proportion of under 16s who attend ED with self harm

A

5%

146
Q

Proportion of adolescents that self harm at least once a week

A

41%

147
Q

Factors associated with dangerousness

A 
Younger age
Males
Past hx of criminality and violence
Childhood physical or sexual abuse
Childhood conduct disturbances
Psychiatric diagnosis
Conducive environment
Specific sx
Unemployment
148
Q

Which specific sx are linked to dangerousness?

A

Command hallucinations
Agitation
Hostile suspiciousness

149
Q

Initial steps to manage an agitated patient

A

Securing safety of patient and others
Verbal de-escalation
Defusing

150
Q

Second line treatment of agitation

A

Lorazepam 1-2mg IM/PO
Haloperidol 5mg PO/IM
Olanzapine 5-10mg IM
Promethazine 25-50mg PO, repeated after 1-2 hours, max 100mg

151
Q

Side effects of rapid tranq

A

Bradycardia or irregular pulse
Acute dystonia
Reduced breathing (<10) or falling sats
Drop in BP (orthostatic drop, <50 diastolic)

152
Q

What to do if acute dystonia secondary to rapid tranq?

A

Procyclidine 5-10mg IM

Benztropine 1-2mg

153
Q

What to do if reduced RR/low sats secondary to rapid tranq?

A

Flumazenil if previous use of benzos

Arrange ITU transfer for mechanical ventilation

154
Q

What to do if drop in BP secondary to rapid tranq?

A

Lie flat
Raise legs
If no response, refer to physicians

155
Q

What types of catatonia are there?

A

Withdrawn

Agitated/excited

156
Q

Risks in withdrawn catatonia?

A

Self-neglect leading to dehydration and starvation

157
Q

Risks of untreated catatonia?

A

Physical complications - electrolyte complications, renal damage

158
Q

Psychiatric associations with catatonia

A

Depression
NMS
Mania
Schizophrenia

159
Q

Neurological associations with Catatonia

A 
Postencephalitic states
Parkinsonism
Seizures
Basal Ganglia damage
Stroke
Tumours
160
Q

Treatment of caatonia

A

Lorazepam 1-2mg IM/IV and treatment of underlying disorder

161
Q

Treatment of NMS

A 
Stop offending neuroleptic
Rehydration
Antipyretic
Dantrolene 2-3mg/kg or
Bromocriptine 2.5-10mg TDS
162
Q

Most important intervention for the confused/delirious patient

A

Optimising patients environment by promoting presence of familiar people in vicinity
Well-lit nursing bay
Frequent reorientation to place and purpose
1:1 nursing
Encouraging fluid and food intake
Avoiding polypharmacy including routine sedatives and anticholinergics

163
Q

Medication options for confused/delirious patients in distress who are elderly

A

Haloperidol 0.5mg, repeat after 2 hours.

164
Q

Medication options for adults who are confused/delirious

A

Haloperidol PO 2mg

165
Q

Factors associated with self neglect in the elderly

A

Advanced age
Lack of social contacts
Presence of medical morbidity
Diagnosis of dementia, depression or alcoholism
Poverty and illiteracy
Suspicious, mistrustful, avoidant or paranoid personality
Loss of a caregiver
Bereavement or other loss events
Decreased vision/hearing or other physical impairments

166
Q

What must risk assessment of the elderly include?

A 
ADLs
Environmental assessment
Cognitive assessment
Physical assessment
Capacity
167
Q

Who can make an application for detention under s2?

A

Nearest Relative

AMPH

168
Q

Medical recommendation requirement for s2?

A

Two medical recommendations, one of which must be by an approved doctor

169
Q

Duration of detention under s3

A

6 months
May be renewed for a further 6 months
Then can be renewed for 12 months

170
Q

Who can be detained under s4?

A

Not yet admitted to hospital, including ED, OP and day hospitals

171
Q

Who can use S5(2)?

A

Registered medical practitioner in charge of treatment

172
Q

Where can S5(2) not be used?

A

ED/OP

173
Q

What transfers cannot occur while a patient is under 5(2)?

A

Cannot be transferred to another ward as they are technically in a ‘place of safety’ unless the patients life is at risk and irreversible harm would be done.

174
Q

How long does 5(4) last?

A

6 hours

175
Q

Can treatment be given under 5(2)?

A

No

176
Q

How were patients who lacked capacity treated prior to the MCA?

A

Under common law ‘duty of care’ (doctrine of necessity)

177
Q

What are the five principles of the MCA?

A

Any person is assumed to have capacity unless it is established otherwise
An individual should not be regarded as unable to make a decision unless all practical steps to help him do so have been undertaken without success
An individual is not to be treated as unable to make a decision merely because he makes an unwise decision
Any action made under the Act or on behalf of someone who lacks capacity must be done in his best interests
Regard must be taken before an act is done as to whether there is a less restrictive option

178
Q

What are the two stages of the assessment of capacity?

A

Is there impairment or disturbance in the functioning of the patients mind or brain?
If there is, does this make the person unable to make a particular decision?
Decision based on balance of probabilities

179
Q

What is considered central to the assessment of capacity?

A

Understand info relevant to decision
Retain that info
Use or weigh up that info as prt of process of making the decision
Communicate decision

180
Q

What is the person assessing capacity required to do?

A

Only has to have reasonable belief about what is in persons best interests

181
Q

Focus of CRHTT

A

Reduce need for acute psychiatric hospital admission and occupancy of beds

182
Q

Main reasons for focus on home treatment in CRHTTs

A

INterpersonal problems are major causes of psychiatric crises and best treated in settings where they arise. Coping skills are most effectively applied in context in which they are learned.
Patients prefer treatment at home than in hospital. Reduction in inequality of power at home.
Home treatment costs less
Hospital admission has harmful effects

183
Q

What can CRHTTs do?

A

Avoid admission

Facilitate early d/c with intensive home treatment and support

184
Q

Key characteristics of a CRHTT

A

Multidisciplinary
Community based
Rapidly responsive (same day)
Partnership-working with other MH teams to ensure continuity of care
Focused on emergency situations where admission would otherwise be indicated
Maintain contact and facilitate early d/c when a patient is admitted
R/v patients daily (at least)

185
Q

Responsivity of CRHTTs

A

Lower patient to staff ratio with capacity to visit a patient several times a day, 24 hour availability, response within 1 hour if needed.
May direct administration of medication up to QDS if needed.

186
Q

Gate-keeping role of CRHTT?

A

No individuals are admitted to an acute psychiatric IP unit w/o CRHTT first assessing the patient and considering whether intensive home support and treatment would avoid admission

MRCPsych Part B - Al-Rashid Hospital (64 decks)

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