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1

what is liaison psychiatry

link between general medicine and psychiatry in hospital setting

2

what is delirium?

an acute confusional state

3

what disturbances are seen in delirium?

1. consciousness and attention
2. perception
3. thinking
4. memory
5. psychomotor behaviour
6. emotion
7. sleep-wake cycle

4

duration of delirium

variable
variable severity

5

onset of delirium

acute, sudden

6

what is the core feature of delirium?

inattention

7

delirium and future cognitive decline?

increases risk

8

how does delirium affect outcomes?

worsens and increases mortality rates

9

RFs for delirium?

1. elderly
2. previous
3. dementia
4. pain
5. constipation
6. infection
7. electrolytes
8. medication
9. sensory impairment

10

causes of delirium?

I WATCH DEATH

Infection
Withdrawal
Acute metabolic syndrome
Trauma
CNS pathology
Hypoxia
Deficiency - thiamine, anoxia
Endocrine - hypo/erthyroid, cushings, addisons
Acute vascular/MI
Toxins/drugs - CO, steroids, opiates, digoxin
Heavy metals - lead, mercury

11

workup for delirium

1. med = psych hx
2. collateral hx
3. MMSE
4. pex
5. ix

12

ix for delirium?

Basically everything
don't forget:

TFTs
B12
folate
VDRL
septic screen
drug screen
EEG
LP

13

assessment scales for delirium?

1. MMSE
2. AMTS
3. AMT-4
4. CAM

attention assessments

14

attention assessments for delirium

MBT - months of the year backwards
days of the week backwards
count from 20 to 1
SAVEAHAART - >2 errors = fail, squeeze hand at A

15

mangt delirium?

tx UC

16

environmental mangt delirium?

1. psychoeducation
2. family involvement
3. reorientate frequently
4. environmental cues - clock/calendar
5. lighting for time of day
6. give glasses, hearing aid
7. mobilise and ADLs
8. 1:1 nursing
9. stop unnecessary meds
10. treat pain, constipation, dehydration etc
11. meds - not 1st line

17

meds in delirium?

antipsychotics may reduce duration
not 1st line

18

indications for meds in delirium?

1. patient distress
2. risk harm to patient/others
3. v disturbed sleep
4. significant behavioural prob

19

what is a conversion disorder?

thoughts or memories that are unacceptable are repressed and converted into physical symptoms

20

what is a dissociative disorder?

condition involving breakdown of memory, awareness, identity or perception - defense mechanism that is pathological and involuntary

21

examples of dissociative disorder?

1. dissociative amnesia
2. dissociative fugue
3. trance and possession disorder
4. dissociative motor disorders - paralysis, aphonia
5. dissociative convulsions
6. dissociative anaesthesia and sensory loss
7. other eg ganser syndrome

22

DSM vs ICD 10 dissociative and conversion

DSM - conversion = motor or sensory deficit, diss = function of consciousess disturbance

ICD10 - use both synonymously, prefer diss.

23

cause of DDs?

1. psychogenic
2. traumatic events

24

what do sufferers hope to gain from DDs?

nothing

25

onset and offset of DDs?

sudden

26

how long do DDs last?

weeks - months max

27

features of dissociative convulsions?

1. non epileptic but commonly in those with epilepsy
2. usually an audience
3. no injury when fall
4. don't bite tongue or incontinent
5. general shaking, not tonic clonic
6. no post ictal confusion or raised prolactin
7. usually a stressor

28

how are DDs diagnosed?

1. clinically inconsistent signs
2. exclude organic dz
3. demonstrate function thought to be absent
4. convincing psych explanation

29

tx DDs?

1. supportive psychotherapy
2. explain initially organic sx but now due to maladaptive response
3. physio
4. tx comorbid psych prob

30

px DDs?

if acute conversion - good esp if obvious cause

poor outcomes in long lasting and established sx