mental health Flashcards
(46 cards)
1
Q
define generalised anxiety disorder
A
worry that is:
- disproportionate
- pervasive
- uncontrollable
- widespread
range of somatic, cognitive, and behavioural symptoms
2
Q
aetiology of GAD
A
multifactorial
environmental
genetic
chronic illness
substance abuse
3
Q
management of GAD step 1
A
assess severity using GAD-7 questionnaire
ask about comorbidities and environmental stressors
written material about GAD and treatment options
active monitoring of symptoms, functioning, and response to treatment
4
Q
managemet of GAD step 2
A
if no improvement following step 1 management
low intensity psychological interventions
psychoeducational groups
self-help, non-facilitated and guided
5
Q
when to escalate management of GAD to step 3
A
if marked functional impairment or no improvement following step 2 interventions
6
Q
management of GAD step 3
A
individual high-intensity psychological intervention, eg. CBT
drug treatment: SSRI, SNRI, pregabalin if SSRI/SNRI contraindicated
- review effectiveness every 2-4 weeks in first 3 months, then every 3 months
7
Q
do not offer what medications for GAD
A
benzodiazepines (antipsychotic) in primary care except as short term measure during crises
antipsychotics in primary care
8
Q
cautions for SSRI/SNRIs
A
<30yrs: increased risk of suicidal thinking and self-harm
monitor weekly for first month
9
Q
when to escalate management of GAD to step 4 (referral for specialist treatment)
A
severe anxiety
marked functional impairment
no improvement following step 3
self harm
self neglect
signifcant comorbidity
suicide
10
Q
define dementia
A
chronic and progressive deterioration in coginitive ability due to organic brain disease
- irreversible
- no impaired consciousness
- all types present with progressive memory loss + impaired cognition
11
Q
Types of dementia
A
- Alzheimers (70%)
- Vascular (25%)
- Lewy body
- Frontotemporal dementia- affects frontal/temporal brain lobes
12
Q
pathophysiology of Alzheimer’s
A
- degeneration of neurons in cerebral cortex
- beta amyloid plaques deposit outsde neurons and tau tangles develop in neurons
- causes brain atrophy (narrow gyri, wide sulchi, larger ventricles)
- affects ACh neurons => reduced ACh release
13
Q
risk factors for Alzheimer’s
A
- increasing age
- genetic susceptibility
14
Q
risk factors for dementia
A
- older age
- learning disability
- genetics
- CVD
- Cerebrovascular
- Parkinson’s
Modifiable
- higher levels of education
- hearing impairment (less cognitive stimulation)
- obesity
- hypertension
- depression
15
Q
pathophysiology of vascular dementia
A
brain damage due to repeated attacks of cerebrovascular disease (strokes/TIAs)
16
Q
pathophysiology of lewy body dementia
A
- deposition of lewy bodies (abnormal proteins) in brainstem
- has parkinsonian symptoms
17
Q
general presenting symptoms of dementia
A
Cognitive impairment
- memory loss (can’t learn new info, forget recent events)
- can’t make decisions
- poor communication
- poor coordination (can’t dress themselves)
- disorientation
- poor planning/judgement
Behavioural
- psychosis (hallucinations/ delusions)
- depression/anxiety
- withdrawal
- agitation/ mood swings
- motor disturbance - wandering, pacing, restlessness, repetitive activity
- affects activities of daily living
18
Q
presenting symptoms of Alzheimer’s
A
- Insidious onset (episodic memory loss- repeated questionning, forgets recent events, can’t learn new info)
- short term memory loss
- motor skills affected- apraxia (can’t do familiar movements)
- language affected- aphasia (can’t communicate)
- long term memory affected
- disorientated
19
Q
presenting symptoms of Vascular dementia
A
- step-wise deterioration
- gait problems
- attention problems
- personality change
- focal neurological problems (visual field defects)
20
Q
presenting symptoms of Lewy body dementia
A
- visual hallucinations
- fluctuating cognition
- Parkinsonian features- bradykinesia, rest tremor, or rigidity
- memory loss usually later
21
Q
presenting symptoms of Frontotemporal dementia
A
- personality/behaviour change
- poor hygiene
- aphasia
- memory usually preserved
22
Q
History taking for dementia
A
- onset (acute => infection/delerium, chronic => dementia)
- ask about recent head traum
- PMHx - parkinson’s, stroke, depression, epilepsy
- DHx- anticholinergics, benzodiazepine, opioids (cause confusion)
- FHx- dementia
- Safety - Activities of daily living, support at home, drive
- SHx - smoking, alcohol
- Collaborative history
23
Q
Examinations for dementia
A
Neuro exam
- gait
- sensory- neuropathy
- motor- tremor, rigidity, bradykinesia (parkinsonian features)
- visual
24
Q
Investigations for dementia
A
Bloods: (exclude other causes)
- FBC (WCC-infection)
- ESR/CRP
- TFTs (hypothyroidism)
- serum B12/folate
- Calcium (hypercalcemia-pschycic groans)
- HbA1c (hypoglycaemia)
- LFTs
Assess cognition
25
How to assess congition in dementia
10- cognition score
* 3 temporal orientation questions (year, month, date)
* 3-word recall
* 4 point scaled animal naming task
\*score = 8 is normal (\<8= probably cognitive impairment)
26
Management of dementia
* acetylecholinesterase inhibitors (donepezil)
27
differentials for dementia (memory loss/confusion)
* delerium
* hypothyroidism- TFTs
* infection
* low B12/folate
* hydrocephaleus
* expanding brain lesion (tumours)- CT scan
* medication (anticholinergics, benzodiazepine)
28
define delirium
reversible acute confusional state usually in susceptible individuals (elderly/multiple comorbidities) caused by a precipitating factor
29
predisposing factors for delirium
* older age
* multiple comorbidities/ frail
* immobility
* XS alcohol consumption
* dementia
* sensory impairment - visual/hearing
30
precipitating factors that trigger delirium
* infection- UTI, pneumonia
* CO-MORBIDITIES: CVD/MI, stroke, thyroid dysfunction, COPD, Cushing's, hypo/perglycaemia
* alcohol withdrawal
* medication- benzodiazepine, opioids, CCBs
* depression
* change in environment
* poor sleep
* PAIN
* malnutrition
* Constipation
31
History taking for delirium (confusion/behaviour change)
* onset of symptoms (acute
* PMHx- cormorbidities (dementia), recent hospital admission, falls
* DHx- medicine compliance
* SHx- alcohol intake, food/fluid intake, PAIN, recent changes in environment
* safety - care packages, who's at home- support
* GP cognition assessement score
32
presenting symptoms of delirium
acute behavious change (hours-days)
* impaired cognition (memory loss/ confusion/ disorientation)
* disorganised thoughts (rambling speech)
* inattention
* hallucinations/delusions
* impaired consciousness
33
types of delirium behaviour
* hyperactive- agitated, restlessness, wandering, sleep disturbance
* hypoactive (most common) - withdrawn, **_reduced appetite,_** lethargic, reduced movement, anhedonia
* mixed
34
investigations for delirium
Identify cause:
Bedside:
* urinalysis- UTI
* sputum culture- chest infection
* ECG- arrythmias
Bloods:
* FBC- WCC (infection), anaemia
* ESR/CRP (infection/inflammation)
* TFTs - hypothyroidism
* Calcium (hypercalcemia)
* U&Es- AKI, dehydration
* B12/folate
* drug toxicity
* HbA1c- hypoglycaemia
Imaging
* CXR- chest infection
35
What criteria are used to diagnose delirium?
* short-CAM/confusion assessment method - confusion, inattention, disorganised thinking, altered consciousness
* DSM-5 -
* 4 A's- ACUTE, alertness, attention, cognition (memory loss/confusion)
36
management for delerium
treat cause
* antibiotics for infection
* analgesia for PAIN
* fluids for dehydration
* correct electrolyte imbalances
* reduce/replace dosage of drugs (avoid WITHDRAWAL)
* treat constipation (laxatives)
* treat sensory impairments (remove wax, glasses)
1. reorientate patient (date, clocks, calendars)
2. advise carers to support (reorientate, maintain mobility -avoid restraints), place in low stimulation environment
3. avoid giving anti-psychotics
37
define depression
persisitent low mood/ loss of interest in activities (anhedonia) for \>2 weeks which affects functioning
* diagnosed with DSM-5 criteria (5/9)
38
risk factors for depression (in the history)
* FEMALE
* older age
PMHx:
* Hx of depression
* chronic comorbidites (PAIN/ disability/ CVD/ diabetes)
* other mental health problems (dementia)
FHx of depression
DHx: corticosteroids
SHx:
* Adverse childhood experiences (poor parent-chid relationship, abuse)
* Recent psychosocial trauma - divorce, unemployment, poverty, homeless
* recent childbirth (port-partum depression)
39
DSM-5 criteria for diagnosis of depression
\>1 CORE + 5/9 needed
* **CORE** (2): low mood, anhedonia
* PHYSICAL: low appetite, anergia (low energy/ fatigue/lethargy), distubed sleep, slowed movements
* PSYCHOLOGICAL: suicidal thoughts, guilt/feelings of worthlessness, poor concentration
40
How to classify depression
* **subthreshold depression**- \<5 symptoms
* **mild**- \>5 symptoms + minor functional impairment
* **moderate**- \>5 symptoms + some impaired function
* **severe**- most symptoms + severe impaired function +/- psychotic symptoms
* **seasonal affective disorder** - symptoms occur around same time of the year
41
How to assess for depression?
* patient health questionnaire/PHQ-9 (GP)
* Hospital anxiety and depression scale (HAD)
42
Investigations for depression
Not routinly done for depression but can exclude other causes/ differentials
Bloods:
* FBC- infection (high WCC)
* TFTs - hypothyroidism (low T4/TSH)
* Calcium - hypercalcemia
* U&Es, creatinine
* ESR-inflammation
* low glucose - hypoglycaemia
Imaging:
* CT/MRI - head injury (hypopituitarism)
43
differentials for depression
* Grief reaction (loss)
* anxiety disorders
* bipolar disorder
* neurological conditions (Parkinson's)
* Obstructive sleep apnoea
* Hypothyroidism
* Substance misuse / CO poisoning
44
Management of depression
1. manage suicide risk
2. safeguarding for children
3. advise patient about medication side effects/withdrawal, hive leaflets for self-help and numbers to contact
4. routine follow-up/ monitoring
mild/moderate
* low intensity psychosocial intervention (guided self-help)
* CBT
moderate/severe
* anti-depressants (SSRIs- **sertraline**, citalopram, fluoxetine)
* high intensity pschycologial intervention (individual CBT)
\*Mirtazapine (SNRI)- depression/anxiety + sleep problems
45
What antidepressants should be given for people taking
1. NSAIDs
2. anticoagulants (Warfarin/ heparin)
3. antiplatelet (aspirin)
4. anti-epileptics
5. had a previous overdose
1. **_Mirtazapine_** (avoid SSRIs)
2. Mirtazapine (avoid TCAs, SSRIs, SNRIs)
3. Mirtazapine (avoid SSRIs, SNRIs)
4. SSRIs
5. avoid TCAs
46
complications of depression
* SUICIDE
* increased risk of substance use
* pain exacerbation
* increased morbidity/mortality in comorbid conditions
* lower quality of life
* medication side effects: SSRIs=\>suicide risk, hyponatremia, agitation, weight gain
* medication withdrawal effects: mania
