1
Q
What is parasuicide?
A
- An apparent attempt at suicide, commonly called a suicidal gesture, in which the aim is not death
- For example, a sublethal drug overdose or wrist slash.
- Previous parasuicide is a predictor of suicide. * The increased risk of subsequent suicide persists without decline for at least two decades
2
Q
What types of self harm occur more frequently?
A
- The majority of self-poisoning episodes involve prescribed or over-the-counter medication, and a minority involve illicit drugs, other household substances, or plant material
- The majority of self-injury episodes involve cutting
- Less common methods include burning, hanging, stabbing, drowning, swallowing objects, insertion, shooting and jumping from height’s or in front of vehicles
3
Q
What is thought to be the reason for self harm / parasuicide?
A
- Self harm refers to an intentional act of self poisoning or self injury, irrespective of the motivation or apparent purpose of the act, and is an expression of emotional distress
4
Q
How common is self harm?
A
- 1/4 of 16-24 year old women report having self harmed at some point, men 1/10 in the same age range
- Around one in every 20 men and one in every 12 women have attempted suicide at some point with highest rates in women aged 16–24 years and men aged 25–34 years.
5
Q
What is thought to be the reason why although there is overall a higher rate of self harm in women, the rate of suicide in men is higher overall?
A
- In males it is thought to be the choice of more lethal methods (firearms and hanging vs cutting and poisoning)
6
Q
What are the risk factors for self harm?
A
- Age — self-harm rates peak in 16 to 24-year-old women and 25 to 34-year-old men. Suicide rates are highest in both men and women aged 45–49 years.
- Socio-economic disadvantage.
- Social isolation.
- Stressful life events, for example relationship difficulties, previous experience in the armed forces, child maltreatment, or domestic violence.
- Bereavement by suicide.
- Mental health problems, such as depression, psychosis or schizophrenia, bipolar disorder, post-traumatic stress disorder, or a personality disorder.
- Chronic physical health problems.
- Alcohol and/or drug misuse.
- Involvement with the criminal justice system (with people in prison being at particular risk)
7
Q
What are the complications of self harm?
A
- Acute liver failure - paracetamol overdose
- Permanent scarring of skin and damage to tendons and nerves caused by cutting and other injuries
- Repetitive self harm is common - 1/6 self harmers will do it again within 1 year
- Elevated risk of suicide
- Suicide risk in people who self harm is thought to be particularly high in people who are:
- Male
- Repeatedly self harm
- Physical health problems
- Express suicidal intent
8
Q
How should a person be managed following an act of self harm?
A
- Where possible see the person alone to maintain confidentiality (exceptions, lack capacity or significant mental illness)
- Examine physical injuries
- Assess the person’s emotional and mental state and for the presence of features that may increase the person’s risk such as:
- Depression
- Suicidal intent
- Hopelessness
- Associated mental health disorders or misuse of recreational drugs and/or alcohol
- Other risk factors (male, physical health, farmer, unemployment, bereavement, relationship change)
- Assess protective factors
- Coping strategies
- Supportive relationships
- Dependent children
- Religious beliefs
- Assess for safeguarding concerns
- Dependents
- Response to child maltreatment, domestic violence, etc
- Refer to ED if physical injuries or acute mental state are thought to pose a significant risk
- Use TOXBASE where there is uncertainty regarding need for referral
- Refer all children under 16 years who have self harmed to ED with suitable expertise
- Communicate the relevant findings of the psychological risk assessment to the department/personnel involved in the person’s care
9
Q
When should people who have self harmed be followed up?
A
- Within 48 hours
* Ensure the person has had a full assessment of their psychosocial needs and risk
10
Q
In self harm, when is it necessary to assess capacity?
A
- If a person declines or refuses management that is perceived to be in their best interests
- Mental capacity should be assumed in a person aged 16 years or over unless there is evidence to the contrary
11
Q
What are the five key principles of the MCA 2005?
A
- Presumption of capacity - should always be presumed in adults unless the healthcare professional can prove otherwise
- Maximising decision making capacity - support the person to make the decision
- Freedom to make seemingly unwise decisions
- Best interests
- Least restrictive alternative
12
Q
How is capacity assessed?
A
1) Confirm the person has an impairment of the mid or brain which means they are unable to:
* Understand relevant information about the decision to be made
* Retain that information
* Use or weigh that information as part of the decision making process or
* Communicate their decision (by talking, non-verbal communication or any other means).
13
Q
What is the guidance regarding capacity and confidentiality of self harm and health issues with young people aged 16-17 years?
A
- For young people aged 16–17 years who lack capacity, parents can consent on their behalf if the decision to be made is felt to be within parental control. Healthcare professionals are, however, able to give treatment regardless of whether parental consent has been given, as long as the principles of the Mental Capacity Act (2005) are followed, and the decision is judged to be in the young person’s best interests.
- If a young person who self-harms and has capacity refuses to involve their family or carers in their treatment, or refuses consent to disclose issues relating to their safety to family or carers, healthcare professionals must weigh the young person’s right to confidentiality (and risk to the therapeutic relationship if confidentiality is breached) against providing family and carers with sufficient information to protect and care for the young person
14
Q
What is the most common form of dementia?
What is dementia not?
A
- Alzheimer’s disease
* Dementia is never a part of normal ageing
15
Q
How many people in the UK have dementia?
A
- 850,000 people
- 24% of men born in 2015 will develop dementia
- 35% of women will develop dementia
16
Q
How many people under the age of 65 get AZD?
A
- In the UK there are 40,000 people under the age of 65 with AZD - this is called early onset AZD
- Most people who get AZD do so after the age of 65
17
Q
What is the leading risk factor for AZD?
A
- Age (cannot be controlled) over 65 risk doubles every 5 years
18
Q
Who is AZD more common in M/F?
A
- Females - thought to be related to lack of oestrogen after the menopause
19
Q
In people with which condition, the risk of developing AZD is increased?
A
- Down’s syndrome
20
Q
What is the inheritance pattern of AZD?
A
- In families with very clear inheritance it is very rare
- In such groups AZD tends to present before the age of 65
- For someone with a family member over the age of 65 diagnosed with AZD, their risk is increased but it does not mean it is inevitable
- Risk can be reduced by living a healthy lifestyle
21
Q
How can risk factors for AZD be reduced?
A
- Maintaining a healthy lifestyle (especially from mid life onwards)
- Regular exercise
- Maintaining a healthy weight
- Not smoking
- Healthy balanced diet
- Drinking in moderation
- Lifestyle combining physical, social and mental activity will lower risk
22
Q
What are the symptoms of AZD?
A
- Memory loss
- Struggle with language
- Challenges with visuospatial skills
- Poor concentration
- Orientation
23
Q
How could memory loss present in AZD?
A
- Losing items around the house
- Struggling to find the right words in a conversation/forgetting someone’s name
- Forget about recent conversations or events
- Getting lost in a familiar place
- Forgetting appointments or anniversaries
24
Q
How could language problems present in AZD?
A
- Struggling to follow a conversation or repeating themself
25
How could visuospatial problems present in AZD?
* Problems judging distance or seeing objects in three dimensions; navigating stairs or parking the car become more difficult
26
How could concentrating, planning or organising become more difficult with AZD?
* Patients have problems making decisions or carrying out a sequence of tasks
27
How might patients present in the early stages of AZD?
* Become withdrawn, lose interest in activities and hobbies
* Anxious, irritable or depressed
* Changes in mood
28
What happens in the later stages of AZD?
* Problems with memory loss, reasoning, orientation and communication become more severe
* Some may have delusions and/or hallucinations
* Agitation - calling out, repeating the same question, disturbed sleep patterns, reacting aggressively
* Require assistance with eating and walking and become increasingly frail
29
How often does AZD present with other dementia's, what is the most common?
* 10% of patients have more than one type of dementia at the same time (mixed dementia)
* AZD with vascular dementia
30
What is atypical AZD?
* Earliest symptoms are not memory loss
* Underlying accumulation of plaques are present in the brain
* But... the hippocampus is not the first part of the brain to be affected
31
Who is atypical AZD more common in?
* Patients under the age of 65 (compared to those over)
32
What are the atypical forms of AZD?
* Posterior cortical atrophy
* Logopenic aphasia
* Frontal variant Alzheimer's disease
33
What is posterior cortical atrophy?
* Damage to areas at the back and the upper rear of the brain
* Areas that process visual information and deal with spatial awareness
* Early problems are identifying objects, and reading (even if eyes are healthy)
* Patients may struggle to judge distances or seem uncoordinated
34
What is logopenic aphasia?
* Damage to areas on the left side of the brain associated with producing language
* Speech becomes laboured with long pauses
35
What is frontal variant Alzheimer's disease?
* Damage to the lobes at the front of the brain
* Results in problems with planning and decision making
* Behaviour disturbances such as being socially inappropriate or seem not to care about the feelings of others
36
What are the medical treatments for AZD?
* Cholinestrase inhibitors
- Donepezil (Aricept)
- Rivastigmine (Exelon)
- Galantamine (Reminyl)
* Glutamate receptor antagonist
- Memantine
37
What is the mechanism of cholinesterase inhibitors?
* Blocks the normal breakdown of cholinesterase
* Results in more acetylcholine in the synaptic cleft
* Such mechanism has been seen to have a modest effect on cognition
38
What are the side effects of cholinesterase inhibitors?
* Vasodilation
* Constriction of pupils
* Increased sweating, saliva and tears
* Slow heart rate
* Mucus secretion and constriction of the respiratory tract
39
What is the mechanism of memantine?
* Acts on the gluamatergic system by blocking NMDA receptors
* Approved for people with moderate to severe AZD
* Believed to help prevent excess levels of glutamate from damaging the brain
* Glutamate is a substance required for carrying nerve signals
* AZD patients have too much glutamate in their brain - memantine is used to prevent excess glutamate from killing the nerve cells
40
What are the differential diagnoses for people with dementia?
* Drugs, delirium
* Emotions/depression
* Metabolic disorders
* Eye and ear impairment
* Nutritional disorders
* Tumours, toxins, trauma
* Infections
* Alcohol, arteriosclerosis
41
What are the dementia subtypes?
* Alzheimer's disease
* Vascular dementia
* Mixed Vd & Azd
* Lewy body dementia
* Fronto-temporal dementia
* Parkinson's disease dementia
* HIV dementia
* Huntingdon's dementia
42
What is dementia syndrome?
* Progressive neurodegenerative condition
* Disturbance of multiple higher cortical functions - decline in memory and learning new information
* Consciousness is not clouded
* Accompanied by deterioration in judgement, thinking, processing information, emotional control, social behaviour or motivation
43
How is dementia diagnosed?
* Deterioration in both memory and thinking: registration and retrieval of new information
* Reasoning and communication skills affected
* Diagnosis must be an impairment in the person's activities of daily living
* Usually at least 6 months duration
44
What are the 5 pathological findings in Alzheimer's Disease?
* Cerebral atrophy (medial temporal lobe atrophy)
* Senile plaques
* Amyloid deposition
* Neuro-fibrillary tangles
* Acetylcholine - levels reduced
45
Outline 3 biological management options for AZD?
* Treat reversible causes
* Acetylcholinesterase inhibitors - donepezil, rivastigmine, galantamine
* NMDA receptor antagonist - memantine
46
Outline 3 psychological management options for AZD?
* Emotional support
* Cognitive rehabilitation/stimulation/training
* Treatments for comorbid illness (e.g. CBT for anxiety)
47
Outline 3 social management options for AZD?
* Carer support
* Occupational therapy input
* Social care interventions
48
What are the 5 A's of Alzheimer's disease?
* Amnesia - Memory
* Aphasia - Speech
* Agnosia - Recognition
* Apraxia - Doing
* Associated behaviours - Behavioural and psychological symptoms of dementia
49
Why is BPSD important?
Can result in:
* Suffering for the patient
* Suffering for the caregiver
* Excess disability
* Increased hospitalisation
* Premature institutionalisation
* Substantial increase in financial costs
50
What are the antipsychotics used in dementia?
* Haloperidol (1st gen)
* Quetiapine (2nd gen)
* Olanzapine (2nd gen)
* Risperidone (2nd gen)
* Amisulpride (2nd gen)
* Aripiprazole (2nd gen)
51
Which of the antipsychotics is licenced for the treatment of agitation in dementia?
* Risperidone
52
The antipsychotics are often inappropriately given to control BPSD, what is a better alternative to this?
* Patient centred care plans - high quality ward and nursing, access to appropriate activities for dementia patients, collateral history
* Think 'PINCH ME' to identify treatable causes
* Pain
* Infection
* Constipation
* Hydration
* Medication
* Environmental
53
What is the approach to assessing behaviour?
* Antecedents
* Behaviour
* Consequences
54
What is the most common acute confusion disorder in hospitals?
* Delirium
* 20-30% in older medical patients
* 1 in 8 inpatients
* More than 50% occur after admission
55
How common is depression in older people?
* 22% men >65
| * 28% women >65
56
How can depression present in older patients?
* Low mood
* Agitation
* Psychosis
* Suicidal thoughts, ideas or plans
* Suicidal acts
* DD hypoactive delirium
57
What are the factors that increase risk for vascular dementia?
* Stroke
* TIA
* Smoking
* Hypertension
* T2DM
58
What are the biological management options for vascular dementia?
* Treat reversible causes
* Consider anticoagulants
* Consider medications to modify risk factors
59
What are the psychological management options for vascular dementia?
* Emotional support
* Cognitive rehabilitation/stimulation/training
* Treatments for comorbid illness e.g. CBT for anxiety
60
What are the social management options for vascular dementia?
* Carer support
* Occupational therapy input
* Social care interventions
61
What is the second most common cause of dementia in patients under 65 years?
* Fronto-temporal dementia (FTD)
62
What are the three subtypes of FTD?
* Behavioural variant FTD
* Progressive non-fluent aphasia (PNFA)
* Semantic dementia
63
What is behaviour variant FTD?
* Changes in personality, behaviour, interpersonal skills and executive skills e.g. paying bills etc
64
What is progressive non-fluent aphasia?
* Loss of language skills (ability to produce or understand language)
65
What is semantic dementia?
* Loss of semantic memory (long term)
66
What is the stroop test?
* Measure of a person's selective attention capacity
67
What is the investigation of choice in FTD?
* MRI - fronto-temporal atrophy can be seen on scans
68
What is the management of FTD?
* Symptomatic treatment of present symptoms
* SSRI's in some
* Psychosocial interventions are vital to help manage the condition
69
What should not be used to treat FTD?
* AChEI's
70
What are the core features of Lewy body dementia?
* Fluctuating cognition (attention and alertness)
* Spontaneous motor features of Parkinsonism
* ~2/3 visual hallucinations
Additional features:
* Sleep disorder
* Neuroleptic sensitivity
* SPECT/PET changes
* ~2/3 systematised delusions
* 40-50% depressive episode
* Recurrent falls, syncope, LOC
71
What is the SPECT (DaT scan) difference in DLB compared to AD?
* Reduced striatal uptake of ligand for pre-synaptic dopamine transporter site FP-CIT in DLB but not AD
72
What are the management options for DLB?
* Psychiatric symptoms may worsen with L-dopa
* Neurological symptoms may worsen with neuroleptics
* Acetyl cholinesterase inhibitors can help (Rivastigmine)
* Psycholigical interventions are vital in helping manage the condition
73
What is a cognitive assessment to test frontal lobe function?
* Using only 4 lines (straight or curved) create as many different designs as you can in 60 seconds
* Tests design fluency
* Normal adults should score 19+ (15 - low average)
74
What should be remembered when assessing for cognitive impairment?
```
Cognitive impairment is not:
* Confusion
* Dementia
* Delirium
The above are clinical syndromes requiring clinical assessment - they may be fixed or progressive
```
75
How should the results of cognitive assessment be interpreted?
* In context of history (inc. collateral), physical examination, MSE
76
What are the ICD10 features of dementia?
* Syndrome due to disease of the brain usually of chronic or progressive nature
* Disturbance of multiple higher cortical functions including:
- Memory
- Thinking
- Orientation
- Comprehension
- Calculation
- Learning capacity
- Language
- Judgement
- Consciousness is not clouded
* Impairments are commonly accompanied by deterioration in:
- Emotional control
- Social behaviour
- Motivation
* Syndrome is present in Alzheimers disease, cerebrovascular disease and others affecting the brain
77
What is the ICD10 of Alzheimer's disease?
* Primary degenerative cerebral disease of unknown etiology
| * Insidious onset and develops slowly but steadily over a period of several years
78
What is the ICD10 of vascular dementia?
* Result of infarction to the brain due to vascular disease including hypertensive cerebrovascular disease
* Infarcts are usually small but cumulative in their effect
* Onset is usually later in life
79
Which cognitive tests are available for dementia assessment according to NICE?
* 10-point cognitive screen (10-CS)
* 6-point cognitive impairment test (6CIT)
* 6-item screener
* Memory impairment screen (MIS)
* Mini-cog
* Test Your Memory (TYM)
80
Which tool can be used for taking a collateral history from a person with dementia according to NICE?
* Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE)
* Functional Activities Questionnaire (FAQ)
81
When should you refer the patient to a specialist dementia service according to NICE?
* When reversible causes of cognitive decline have been investigated and dementia is still suspected
82
Which clinical tests can be used for AZD dementia if it is unclear if the person has cognitive impairment or if their impairment is caused by dementia or to determine the correct sub type?
Imaging
* AZD - FDG-PET
Or
* perfusion SPECT
CSF Examination
* Total tau and phosphorylated-tau 181 and
* Amyloid beta 1-42 or amyloid beta 1-42 and amyloid beta 1-40
83
Which clinical tests can be used for LBD dementia if it is unclear if the person has cognitive impairment or if their impairment is caused by dementia or to determine the correct sub type?
* I-FP-CIT SPECT
Or if not available consider
* I-MIBG cardiac scintigraphy
84
Which clinical tests can be used for FT dementia if it is unclear if the person has cognitive impairment or if their impairment is caused by dementia or to determine the correct sub type?
* FDG-PET
Or
* Perfusion SPECT
85
Which clinical tests can be used for VD dementia if it is unclear if the person has cognitive impairment or if their impairment is caused by dementia or to determine the correct sub type?
* MRI or CT if contraindicated
86
What is the first line medical management for people with mild to moderate dementia with Lewy bodies?
* Donepezil or Rivastigmine
87
What is normal pressure hydrocephalus?
* A reversible cause of dementia seen in elderly patients
* Thought to be secondary to reduced CSF absorption at the arachnoid villi
* Changes may be secondary to head injury, subarachnoid haemorrhage or meningitis
88
What is the classic triad seen in normal pressure hydrocephalus?
* Urinary incontinence
* Dementia and bradyphrenia
* Gait abnormality (may be similar to Parkinson's disease)
60% of patients will have all 3 features at the time of diagnosis
89
What does imaging show in normal pressure hydrocephalus?
* Hydrocephalus with an enlarged fourth ventricle
| * In addition there is typically an absence of substantial sulcal atrophy
90
What is the management of normal pressure hydrocephalus?
* Ventriculoperitoneal shunting
* Around 10% of patients who have shunts experience complications such as seizures, infection and intracerebral haemorrhages
91
What is Pellagra?
* Caused by nicotinic acid (niacin) deficiency
* Classical features are the 3 D's
- Dermatitis
- Diarrhoea
- Dementia
92
Who is at risk of Pellagra?
* May occur as a consequence of isoniazid therapy (isoniazid inhibits the conversion of tryptophan to niacin)
* More common in alcoholics
93
What are the clinical features of Pellagra?
* Dermatitis (brown scaly rash on sun exposed sites - termed Casal's necklace if around neck)
* Diarrhoea
* Dementia, depression
* Death if not treated
94
What are the 2 types of multiple system atrophy?
1) MSA-P - Predominant Parkinsonian features
| 2) MSA-C - Predominant Cerebellar features
95
Why is Shy-Drager syndrome?
* Type of multiple system atrophy
* Features
- Parkinsonism
- Autonomic disturbance
- Erectile dysfunction - often early feature
- Postural hypotension
- Atonic bladder
- Cerebellar signs
96
What is acute confusional state?
* Delirium or acute organic brain syndrome
| * Affects up to 30% of elderly patients admitted to hospital
97
What are the predisposing factors for developing delirium?
* Age >65 years
* Background of dementia
* Significant injury e.g. hip fracture
* Frailty or multmorbidity
* Polypharmacy
98
What are the precipitating factors for the development of delirium?
* Infection - particularly UTI
* Metabolic - hypercalaemia, hypoglycaemia, hyperglycaemia, dehydration
* Change of environment
* Any significant CV, respiratory, neurological or endocrine condition
* Severe pain
* Alcohol withdrawal
* Constipation
99
What are the presenting features of delirium?
* Memory disturbances (loss of short term > long term)
* May be very agitated or withdrawn
* Disorientation
* Mood change
* Visual hallucination
* Disturbed sleep cycle
* Poor attention
100
What is the management of delirium?
* Treat the underlying cause
* Modification of the environment
* Haloperidol 0.5 mg as first line sedative (or olanzapine)
101
What are the assessment criteria for delirium?
* DSM-IV criteria
| * Short confusional assessment method (short-CAM)
102
What are the CAM criteria for the assessment of delirium?
* Confusion that has developed suddenly and fluctuates, and
* Inattention — ask if the person is easily distracted or has difficulty in focusing attention, and either
* Disorganised thinking — ask if the person's thinking is disorganised, incoherent, illogical, or unpredictable (for example they have an unclear flow of ideas, change subject unpredictably, or have rambling or irrelevant conversation), or
* Altered level of consciousness — ask about changes in level of consciousness from alertness to: lethargy (drowsy, easily aroused); stupor (difficult to arouse); comatose (unable to be aroused); or hypervigilant (hyper-alert)
103
What are the DSM-IV criteria for the assessment of delirium?
* All four features must be present:
- Confusion that has developed over a short period of time and fluctuates and
- Disturbance of consciousness (reduced clarity of awareness of the environment, reduced ability to focus, hold or shift attention) and
- A change in cognition (such as memory deficit, language disturbance or disorientation) or a perceptual disturbance and,
- Evidence from the history, examination, or investigations which is consistent with delirium, cannot be attributed to another diagnosis, and is a direct physiological consequence of a general medical condition
Y5 Psychiatry and Mental Health
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