Geriatrics Flashcards
(155 cards)
1
Q
What is benign paroxysmal positional vertigo?
A
Sudden episodic attacks of vertigo induced by changes in head position
2
Q
Describe the epidemiology of benign paroxysmal positional vertigo
A
Leading cause of vertigo
Increased incidence in the elderly
Increased risk in those with gallstones(calcium deposits)
3
Q
Describe the aetiology of benign paroxysmal positional vertigo
A
Detachment of otoliths from the utricle of the inner ear
Detached particles migrate into semicircular canals where they stimulate hair cells and lead to vertigo symptoms
Acummulation of cholelithiasis in semi circular cells of inner earrr
4
Q
Describe the presentation of patient with benign paroxysmal positional vertigo
A
Vertigo triggered by changes in head position (e.g. rolling in bed, looking up)
Recurrent episodes lasting aroung 30secs-1 minute
May be associated with nausea&vomiting
No auditory symptoms
5
Q
How is benign paroxysmal positional vertigo diagnosed?
A
Positive Dix-Hallpike maneouvre
Lie down with one ear pointed to ground-> check for nystagmus
6
Q
Name some differentials for benign paroxysmal positional vertigo
A
Menieres disease
Vestibular neuritis
Labyrinthitis
7
Q
How is benign paroxysmal positional vertigo managed?
A
Epley maneuver-works in around 80%(aims to detach otoliths out of semicircular canal and back to utricle)
Usually resolves spontaneously after a few weeks/months
Can teach patients at home exercises: ‘vestibular rehab’: e.g Brandt-Daroff exercisesBetahistine not very useful
8
Q
Describe the prognosis for benign paroxysmal positional vertigo
A
1/2 will have recurrence of sx 3-5 years after diagnosis
9
Q
What group of patients are more at risk of developing pressure ulcers?
A
Patients who are unable to move parts of their body due to illness, paralysis or advancing age
10
Q
Where do pressure ulcers typicallly develop?
A
Over bony prminences like the sacrum or heel
11
Q
Name some risk factors for developing pressure ulcers?
A
Malnourishment
Incontinence; urinary and faecal
Lack of mobility
Pain-; leads to decreased mobility
12
Q
What scoring system is used to grade pressure ulcers?
A
Waterlow score
13
Q
How are pressure ulcers manageed?
A
Moist wound environemnt: hydrocolloid dressings and hydrogels(no soap)
Wound swabs not routinely done-> systemic abx use decided on clinical basis(surrounding cellulitis etc)
Consider referral to tissue viability nurses
Surgical debriedement for selected wounds
14
Q
Whata re lower urinary tract sympotms?
A
Group of sx that occur as a result of abnormal storage, voiding or post micturition function of bladder, prostate or urethra
15
Q
Describe the aetiology of LUTS
A
Neurological
Bladder
Prostate
Urethral
Other mass effect
16
Q
How can LUTS be classified?
A
Voiding
Storage
Post-micturition
17
Q
Name somee voiding symptoms LUTS
A
Hesitancy
Straining
Terminal dribbling
Incomplete emptying
Weak/intermittent urinary stream
18
Q
Name some storage sx LUTS
A
Urgency
Frequency
Nocturia
Urinary incontinence
19
Q
Name some post-micturition sx LUTS
A
Post-micturition dribbling
Sensation of incomplete emptying
20
Q
Name some differentials for LUTS
A
Bladder outlet obstruction
Overactive bladder syndrome
Urethral stricture
Prostatitis
Bladder cancer
21
Q
What investigations might be done in a patient presenting with LUTS?
A
Urinalysis: exclude infection and check for haematuria
DRE: size and consistency of prostate
PSA test may be considered
Bladder diary
Urodynamic studies
22
Q
How are LUTS managed?
A
Treat undelrying cause
Depends on type of LUTS
23
Q
How aare voiding LUTS managed?
A
Conservatrive: pelvic floor/bladder trianing
BPH-5-alpha reductase inhibitor-finasteride
Alpha blocker if severe-doxazosin
24
Q
How are voiding and storage LUTS managed?
A
Alpha blocker-doxazosin
Add anticholinergic-oxybutinin
25
How are overactive bladder symptoms managed?
Conservative: fluid management
Antimuscarininc if persistent-oxybutinin, tolteridone
26
How is nocturia managed?
Manage fluid intake at night
Furosemide 40mg in late afternoon
Desmopressin
27
What are the different types of urinary incontinence?
Stress; leaking small amounts when laughing/coughing
Urge/overactive; detrusor overactivity
Mixed: urge/stress
Overflow; bladder outlet obstruction
Functional
28
What causes overflow incontinence
Bladder outlet obstruction(e.g. prostate enlargement)
29
Name some reversible causes of urinary incontinence
DIAPPERS
Delirium
Infection
Atrophic vaginitis/urethritis
Pharmaceutical(medications)
Psychiatric disorders
Endocrine disorders(diabetes)
Restricted mobility
Stool impaction
30
What investigations migh tbe done to look for causes of urinary incontinence?
Physical exam: organ prolapse and ability to contract pelvic floor muscles
Bladder diary: number and types of incontinenceUrinalysis: rule out infection
Cystometry: measures bladder pressure while voiding(not recommended where clear diagnosis)
Cystogram: Contrast in bladder and imaging(fistula)
31
What is stress incontinence?
Leaking of urine when abdominal pressure is high; increases pressure on bladder
32
Name some risk factors for stress incontinence
Childbirth(especially vaginal); injury to pelvic floor muscles and connective tissue
Hysterectomy
33
Name some triggers for stress incontinence
Coughing
Laughing
Sneezing
Exercise
Anything that increases abdominal pressure
34
Describe the management of stress icontinence
Conservative: avoid fizzy, caffeinated drinks, pelvic floor exercises
Medical: Duloxetine
Surgical: GS: mid urethral slings(minimally invasive, done as outpatients)
35
Name some risk factors for urge incontinence
Recurrent UTI
High BMI
Increasing age
Smoking
Caffeine
36
Describe the management of urge incontinence
Conservative: Bladder training, avoid alcoholic/caffeinted/sugary drinks
Medical: anticholinergics: oxybutinin, tolterodine, fesoterodine
Surgical: bladder instillation, sacral neuromodulation
37
Name a side effect of tolterodine
Increased risk of delirium
38
Name the causes of overflow incontinence
Underactivity of detrusor muscle(e.g from nerve damage) or if urinary outlet pressures are too high(constipation, prostatism)
39
What is functional incontinence?
Urge to pass urine but can't access facilities so experience incontinence
40
Name some causes/risk factors for functional incontinence
Sedating meds
Alcohol
Dementias
41
What is quamous cell carcinoma?
Locally invasive malignant tumour of epidermal keratinocytes
With invasion of basement membrane as it is a cancer
42
Name some risk factors for SCC
Excessive exposure to sunlight/UV light
Actinic keratosis and Bowen's disease; predisposing lesions
Genetics: xeroderma pigmentosum Immunosuppresion
Smoking
Old age
Male
43
How might patients with SCC present?
Keratinised, scaly irregular nodules
Might be ulcerating or have everted edgesOften in sun exposed areas
Usually slow growing(months)
Pain, tenderness, bleeding
Complicaotins for local invasion-distant metastases is rare
44
How is SCC diagnosed?
Excision biopsy with 4mm margin
Might require 6mm margin if high risk
45
Name some features of a possible SCC that make it more high risk
>2cm diameter
Located on ear, lip, hands, feet or genitals
Elderly or immunosuppressed
Histology: poor differentiation, blood/nerve involvement, SC tissue invasion
46
How is SCC treated?
Surgical excision
Radiotherapy may be needed
Lifestyle to prevent further lesions; sunscreen
47
What is the prognosis for SCC
5 year survival of 99% if detected early
48
Name some poor prognostic factors for SCC
Poorly differentiated&>;2cm diameter&>4mm deep
Immunosuppression
49
How can constipation be classified?
Primary: no organic cause: dysregulation of function of colon/anorectal muscles
Secondary: diet, medications, metabolic, endocrine, neuro, obstruction
50
What criteria is used for classifying constipation?
Rome 6 criteria
51
Describe the Rome 6 criteria for constipation
<3 bowel movements/week
Hard stool in >25% of movements
Tenesmus in >25% of movements
Increased straining in >25% of movements
Need for manual evacuation
Any or all of them can constitute a diagnosis of constipation
52
Name some risk factors for constipation
Increasing age
Inactivity
Low calorie diet
Low fibre diet
Certain medicationsFemale
53
Name some possible causes of constipation
Inadequate fibre or fluid intake
Behavioural: inactivity of avoidance of defaecation
Electrolyte distrubances like hypercalcemia
Drugs: opiates, CCBs, antipsychotics
Neurological: spinal cord lesions, Parkinson's, diabetic neuropathy
Endocrine-; hypothyroidism
Colon disease :strictures/cancer/obstruction
Anal disease- fissures
54
Name some red flag associated features of constipation
ALARMS
Anaemia
Lost weight
Anorexia
Recent onset
Melaena/bleeding
Swallowing difficulties
55
What investigations might be done in a patient with constipation?
Constipation/diarrhoea+ weight loss+ >60yrs-> 2wwk wait urgent CT/US to rule out pancreatic cancer
Often no need for further ix
PR examStool sample: mcs, ova, cysts, parasites
FIT testing
Faecal calprotectin
Bloods: anaemia, hypercalcaemia, hypothyroidism
Barium enema if suspicion of impaction/rectal mass
Colonoscopy-> lower GI malgnancy
56
Describe the management of constipation
Conservative: dietary imrpovements and increase exercise
Laxatives
57
What are the different types of laxatives
Bulking agents
Stool softeners
Stimulants
Osmotic laxatives
Phosphate enemas
58
Give an example of a bulking agent
Ipsaghula husk
59
How do bulking agents work?
Increase faecal bulk and peristalsis
60
When might bulking agents be contraindicated?
Dysphagia
GI obstruction
Faecal impaction
61
Name a side effect of bulking agents
Cramps
62
Give an example of a stool softener
Docusate
Macrogol
63
How do stool softeners work and when might they be used
Soften bowel movements
Good for fissures
64
When are stool softeners contraindicated?
IBD
Ileus
Risk of inttestinal perforation
65
Name some side effects of stool softeners
Flatulence
Nausea
66
Give an example of a stimulant laxative
Senna
Biisacodyl
67
How do stimulant laxatives work?
Increase intestinal motility
68
When might stimulant laxatives be contraindicated?
Obstruction
Colitis
69
Give a side effect of stimulatn laxatives
Cramps
70
Give an example of on osmotic laxative
Lactulose
Movicol
71
How do osmotic laxatives work?
Retain fluid in the bowel
Decrease NH3
72
Give a side effect of osmotic laxatives
Electrolyte imbalances
Diarrhoea
73
What must be done before a phosphate enema?
DRE first
Will cause rapid bowel evacuation
74
Give some contraindications to a phosphate enema
Renal failure
Heart failure
Electrolyte abnormalities
75
Give some side effects of a phosphate enema
Abdominal cramps
Dehydration
76
Define malnutrition
BMI< 18.5 OR Unintentional weight loss >10% in the last 3-6 mths ORBMI <20 and unintentional weight loss >5% in the last 3-6 mths
77
How is malnutrition diagnosed?
Malnutrition Universal Screen Tool (MUST)
Takes into account BMI, unplanned weight loss score and acute disease effect
Should be done on admission of if there is cause for concern
Categorises patients into low, medium and high risk
78
How is malnutrition managed?
Dietician support if patient is high risk
'Food-first' approach with clear instructions(add full fat cream to potatoes etc)
Oral nutritional supplements between meals
79
What is re-feeding syndrome?
Caused by reintroduction of glucose into the body after a period of malnutrition or fasting
80
Describe the pathophysiology of re-feeding syndrome?
Reintroduction of glucose-> insulin secretion resumes-> shift in electrolytes
81
How might patients with re-feeding syndrome present?
Low phosphate: weakness, resp failure, delirium, seizures
Low magnesium: muscle weakness, arrhythmias, NM excitability
Low potassium: weakness, paralysis, cardiac arrhythmias
High glucose: diabetes sx: increased thirst, urination, fatigue, blurred vision
82
How is re-feeding syndrome managed?
Monitoring and correctin of electrolyte imbalances
Slow reintroduction of food and fluids to avoid sudden shiffts in electrolytes
Thiamine replacement for at risk patients to prevent Wernicke's encephalopathy
83
Name some risk ffactors for non-accidental injury
Caergive substance abuse
Caregiver mental health issues
Socioeconomic disadvantage
84
How might elderly patients with non accidental injury ppresent-history?
Delayed presentation followwing injury
Inconsistencies in caregiver's narratives
Unwitnessed injuries
Evidence of drug/alcohol use
85
How might elderly patients with non accidental injury present-examination?
Injuries of varying ages
Subconjunctival/retinal haemorrhages
Bruises on arms, legs, or face consistent with grippping, burns, scalds
86
Name some differentials for non accidental injury
Accidental injury
Bleeding disorders
Haematological malignancy
87
What investigations might be done if non accidental injury is suspected?
Radiology: comprehensive skeletal survey(rib fractures, skull, finger, clavice etc)
Bloods: organic causes like clotting problems and blood cancers
88
How should non accidentl injury be managed?
Report suspicions to informed senior or safeguarding lead
Measures: admit and ensure safety of anyone else in the home
Treat other injuries
Document everything
Contact social care liaison
89
What is a DoLS?
Procedure used by law when necessary to deprive a patient or resident of their liberty as they lack capacity to consent to treatment/care to keep them safe from harm
90
How must a DoLS be authorised by?
Supervisory authority(e.g. local authority)
91
What conditions must be met to put a DoLS in place?
>18yrs and mental disorder
In hospital or care home
Pt lacks capacity to decide for themselves about the proposed restrictions
Proposed restrictions in person's best interest and would deprive person of their liberty
Not suitable for detention under the MHA
92
What is Power of Attorney
Legal document that nominates another person to make decisions on their behalf related to financial/property or health/welfare
93
What is an advanced decision?
Legally binding document to ensure an individual can refuse a specific treatment(s) they don't want in the future
94
What criteria must be met for an advanced decision to be put into place?
Valid(made when person had capacity)
Applicable(wording specific to medical decision)>18 yrs and fully informed when made
Not made under duress or influence of other people
Written down, signed and witnessed(if it concerns life saving treatment)
95
What does an advanced decision cover?
Refusal of treatments including life sustaining treatments
Can't refuse basic care, food/drink by mouth, measures designed purely for comfort(painkillers) or treatment of a mental health disorder if sectioned under the MHA
Can't demand specific treatment/somethign illegal
96
What is an advanced statement?
Statement of wishes and care preferences
Not legally binding by itself but legally must be taken into account when making a 'best interests' decision
97
What creiteria must be met to make an advanced statement?
Can be made verbally but better written down for documentation
Copies can be given to anyone like GPs, carers, relatives
98
What kind of things might be covered in n advanced statement?
Religious/personal views and how these relate to care
Food preferencesInfo about daily routine
People who you would like to be consulted when best interest decisions are being made on your behalf(not the same as creating a lasting power of attorney)
99
What is osteoporosis?
Systemic skeletal disease characterised by decreased bone mass and altered micro-architecture of bone tissue resultin in increased bone fragility and fracture risk
100
Describe the pathophysiology of osteoporosis
Primary: post menopausal(Type 1) and age related(type 2)-most common
Secondary: hyperthyroidism/hyperparathyroidism/alcohol abuse/immobilisation
Increased bone breakdown by osteoclasts and decreased bone formation by osteoblasts
101
What genes are involved in osteoporosis?
Collagen
1A1Vitamin D receptor
Oestrogen receptor gene
102
How does oestrogen deficiency result in osteoporosis?
Increases number of remodelling units
Premature arrest of osteoblastic synthetic activity and trabeculae perforation
Loss of resistance to fracture
103
How do glucocorticoids cause osteoporosis?
Increase turnover rate initially(increased fracture risk in first 3 months)
Then decreased turnover rate with net loss due to decreased synthesis by osteoblasts
Usually when used minimum 10mg OD for >3 months
104
How does ageing contribute to osteoporosis?
Increased turnover at the bone/vascular interface with cortical bone->weak structure for stresses in long bones/trabeculazation of cortical bone)
105
Name some risk factors for osteoporosis
SHATTERED
Steroid use
Hyperthyroidism/hyperparathyroidism
alcohol and smoking
thin: BMI<22
testosterone deficiency(men with long term androgen deprivation therapy for prostate cancer)
early menopause-renal/liver failure erosive/inflammatory bone disease
diabetes
Also family history
106
How do patients with osteoporosis present?
Pathological or fragility fractures(often from a fall at first
Most commonly vertebral compression fractures of appendicular fractures
107
What are the most common frfactures for patients with osteoporosis?
Vertebral compression fractures
Appendicular fractures(proximal femur/distal radius)
108
How do patients present with a vertebral fracture?
Sudden episode of acute back pain on rest/bending/liftingrestricted spinal felxion and intensified pain with prolonged standing
Dowager's hump: thoracic kyphosis-. anterior thoracic spine
Paravertebral muscle spams and tenderness on deep palpation
109
How do patient with appendicular fractures present?
NOF: hip pain, inability to weight bear, shortened and externally rotated leg
Colles: fall on outstrtched arm: wrist pain and decreased range of motion
110
What is the gold standrad for diagnosing osteoporosis?
DEXA sacn(dual energy x-ray absorptiometry)
Can also use x-rays/MRI for suspected vertebral/other fractures
111
How might you identify secondary causes of osteoporosis?
History and full exam
FBC, U&Es-Creatinine, calcium phosphate TFTsLFTs25OH vit D and 1-25 OH vit
Serum testosterone and prolactin
Lateral radiographs of thoracic and lumbar spine
Protein immunoelectrophoresis and urinary Bence Jones proteins
112
Name some differentials for osteoporosis
Osteomalacia: similar but also generalised bone pain and myopathy
Paget's: bone pain, joint pain, bone deformities, neuro complications
Malignancies: myeloma, lymphoma, metastatic/primary bone disease
Secondary causes: hyper(para)thyroidism, mastocytosis, Cushing's, sickle cell
113
For a patient with osteoporosis, what would their calcium, phosphate, ALP and PTH look like?
All normal
114
For a patient with osteomalacia, what would their calcium, phosphate, ALP and PTH look like?
Low calcium
Low phosphate
High ALP
High pTH
115
For a patient with Paget's, what would their calcium, phosphate, ALP and PTH look like?
Normal calcium
Normal phosphate
High ALP
Normal PTH
116
How should you interpret DEXA scan scoring?
T>;-1: normal
-1>T>;-2.5: osteopenia
T>-2.5: osteoporosis
117
How is osteoporosis diagnosed?
DEXA scan and T score
118
What scoring tool is used to determine the risk of fracture in a patient with osteoporosis?
FRAX score
Estimates 10 year probability of a major osteoporotic fracture
119
What factors are used when calculating FRAX score?
Age: 40-90yrs
Gender
Previous fracture
Parental hip fracture
Smoking
Glucocorticoid use(>3 months at>5mg OD)
Rheumatoid arthritis
Secondary osteoporosis causes
Alcohol consumption
BMD
120
How is FRAX score interpreted?
<10% :normal
10-20%: osteopenia
>20%: osteoporosis
121
How is osteoporosis managed?
Lifestyle: decrease risk factors
Bisphosphonates
Denosumab
122
What lifestyle modifications might be suggested in a patient with osteoporosis?
Decrease risk factors(smoking etc)
Increase calcium and vitamin D intake
Increase weight bearing and muscle strengthening exercises
123
When might bisphosphonates be used as a treatment?
T score<-2.5 OR
-1--> -2.5 with a FRAX >20%
124
How do bisphosphonates work?
Adhere to hydroxyapatite and inhibit oscteoclasts
125
Give some examples of bisphosphonates and how they are used
Oral alendronate and risedronate(1 weekly doses)
Xoledronic acid(once a year infusion)
126
How should bisphosphonates be taken?
On an empty stomach with water and remain upright for at least 30 minutes afterwards
127
Name some side effects of bisphosphonates
Oesophagitis
Dyspepsia
128
What is denosumab and when is it used?
Monoclonal antibody
Used for extensive osteoporosis
129
How is denosumab administered?
SC injection every 6 months
130
How does denosumab work?
Anti-resorptive agent that increases BMD and decreases fracture risk at spine
131
Name some side efffects of denosumab
Limited mobilityIncreased fracture risk
Depression
Pain
Complications of medication
132
What systems are required to function to have a normal gait?
Neurological: basal ganglia and cortical basal ganglia loop
MSK: appropriate tone and strength
Senses: sight, sound and sensation(including fine touch and proprioception)
133
Name some risk factors for falls
biggest: previous falls
lower limb muscle weakness
Vision problems
balance/gait disturbances
polypharmacy
postural hypotension
psychoactive drugs
incontinence
>65 years
fear of falling
depression
cognitive impairment
134
Name some drugs that can cause postural hypootension
Nitrates
Diuretics
Anticholinergics
Antidepressants
Beta blockers
Levodopa
ACE inhibitors
135
Name some drugs that can cause falls through mechanisms other than postural hypotension
benzos
antipsychotics
opiates
anticonvulsants
codeine
digoxin
sedative agents
136
What investigations might be done in patients who have had a fall?
Full hx, risk assessment and examination
Bedside: Obs, BP, glucose, urine dip, ECG
Bloods: FBC, U&Es, LFTs, bone profile
Imaging: x-rays of injured limbs, CT head, cardiac echo
137
Describe the management of patients with falls
'Turn 180 test' or 'Timed get up and go' test
Consider MDT assessment
Treat underlying cause
Manage risk factors
Lifestyle/home changes
138
When should an MDT assessment be considered in patients with falls?
>65 yrs with>;2 falls in the last 12 months
Fall requiring medical treatment
Poor performance or failure to complete above tests
139
What is delirium?
Acute and fluctuating disturbance in attention and cognition, often accompanied by a change in consciousness
140
What are the 3 subtypes of delirium?
Hyperactive: increased psychomotor activity, restlessness, agitation and hallucinations
Hpoactive: lethargy, reduced responsiveness and withdrawal
Mixed: features of both hyper and hypo
141
Descrieb the epidemiology of delirium
Common
Elderly
Incidence increases with age, severity of illness and pre-existing cognitive impairment
142
Describe the aetiology of delirium
DELIRIUMS
Drugs and alcohol
Eyes, ears and emotional disturbances
Low output state(MI, ARDS, PE, CHF, COPD)
Infection
Retention(urine or stool)
Ictal
Under-hydration or under-nutrition
Metabolic(electrolyte imbalances, thyroid disorders, Wernicke's
Subdural haematoma, sleep deprivation
143
Name some drugs that can cause delirium?
Anti-cholinergics
Opiates
Anti-convulsants
Recreational
144
Name some symptoms of delirium
Disorientation
Hallucinations
Inattention
Memory problems
Change in mood or personality
Sundowning-> worse agitation/confusion in late afternoon/evening
Disturbed sleep
Hypoactive can be easily missed
145
Give some differential diagnoses for delirium
Dementia
Psychosis
Depression
Stroke
146
How is delirium diagnosed/assessed?
4AT and CAM: tools
Bedside: bladder scan, review meds, ECG, urine MCS
Bloods: FBC, U&E,LFTs, TFTs, blood cultures
Imaging: CXR, US, neuroimaging if suspected cause
147
Describe the management of delirium
Treat underlying cause
Good lighting, regular sleep-wake cycle, regular orientation and reassurance, glassess and hearing aids if needed
If severely agitated: haloperidol/lorazepam, olanzapine as last resort due to side effects
Don't give haloperidol for Parkionsonism(blocks dopamine receptors)
148
Name some factors favouring delirium over dementia
Acute onset
Impairment of consciousness
Fluctuation of symptoms(worse at night, periods of normality)
Abnormal perception(hallucinations, illusions)
Agitation, fear
Delusions
149
Name some risk factors for delirium
Age>65 yrs
Background of dementia
Significant injury(hip fracture)
Frailty or multimorbidity
Polypharmacy
150
Describe the features of a Grade 1 pressure ulcer
non-blanchable erythema of intact skin. Discolourationof skin, warmth, oedema or hardness used as indicators
151
Describe the features of a Grade 2 pressure ulcer
Partial thickness skin loss involving epidermis/dermis or both.
Ulcer is superficial and present clinically as an abrasion/blister
152
Describe the features of a Grade 3 pressure ulcer
Full thickness skin loss involving damage to or necrosis of SC tissue that may extend down to but not through underlying fascia
153
Describe the features of a Grade 3 pressure ulcer
Extensive destruction, tissue necrosis ordamage to muscle, bone or supporting structures with/wihtout full thickness skin loss
154
Describe the ICD 10 criteria for delirium
ICD-10 criteria for delirium:
1.) Impairment of consciousness and attention
2.) Global disturbance in cognition
3.) Psychomotor disturbance
4.) Disturbance of sleep-wake cycle
5.) Emotional disturbances
155
