Psychiatry Flashcards
(128 cards)
1
Q
What blood test results would you expect to see in neuroleptic malignant syndrome?
A
Raised creatine phosphokinase Leukocytosis Raised ALP and lactic acid dehydrogenase Electrolyte abnormality Metabolic acidosis
2
Q
What is neuroleptic malignant syndrome?
A
Adverse reaction to psychotropic meds particularly classical antipsychotics
Tetrad of high grade fever, altered mentation, bradykinesia/rigidity and autonomic instability (tachycardia, labile BP, wide PP) over few days course
3
Q
What is psychopathology?
A
Systematic study of abnormal experience, cognition and behaviour; the study of the products of a disordered mind
4
Q
What are the different domains of psychopathology?
A
Explanatory: psychodynamic, behavioural
Descriptive: observation, phenomenology
5
Q
What different disorders are covered under psychopathology?
A
Disorders of perception Disorders of thoughts and speech Disorders of emotion Disorders of experience of self Disorders of memory Disorders of consciousness Motor disorders Abnormal and psychopathic personalities
6
Q
What is perception?
A
Process of becoming aware of what is presented through the sense organs
7
Q
What categories of disorders of perception are there?
A
Sensory distortions: changes in intensity, quality, spatial form
Sensory deception: illusions, hallucinations
8
Q
What is an illusion?
A
Misperception of a real object/external stimulus
9
Q
What is a hallucination?
A
Perception experienced in the absence of an external stimulus in any modality
10
Q
What are the different types of hallucination?
A
Auditory Visual Tactile Olfactory Gustatory Hypnagogic (when falling asleep) and hypnopompic (when waking)
11
Q
What is a pseudo hallucination?
A
Separate form of perception from a true hallucination
Not concretely real
Experienced in internal subjective space, In the mind’s eye
patient can distinguish them from reality
12
Q
What categories of disorders of thought and speech are there?
A
Stream of thought: tempo - flight of ideas, retardation of thinking, continuity - perseveration, thought blocking
Possession: obsessions, thought alienation
Content: delusions
13
Q
What tempo related disorders of thought and speech are there?
A
Pressure of speech: rapid and frenzied, urgency
Flight of ideas: jumps topic to topic based on discernible associations
Inhibition / retardation of thinking
Circumstantiality: non linear thought pattern, unnecessary details and irrelevant remarks cause delay in getting to the point
14
Q
What continuity related disorders of thought and speech are there?
A
Perseveration: repetition of a word, phrase or gesture despite absence or cessation of stimulus
Thought blocking: stop speaking suddenly, without explanation in middle of sentence
Derailment/Loosening of associations/knight’s move: sequence of unrelated ideas
Tangentiality: speak about topics unrelated to main topic of discussion
Rhyming, clang association: association of words based on sound rather than concept
Neologisms: making up new words
Verbigeration: repetition of words or phrases
15
Q
What are the 5 features of formal thought disorder
A
Derailment- disruption of continuity of speech by insertion of novel and inappropriate material to the chain of thought
Substitution- major thought substituted by subsidiary one
Omission- sudden discontinuation of a chain of thought
Fusion- merging and ‘interweaving’ of separate ideas
Drivelling- muddling of elements within an idea to extent that the meaning is totally obscured to the listener
16
Q
What is an overvalued idea?
A
Acceptable, comprehensible idea pursued by person beyond bounds of reason and causes suffering or disturbed functioning
17
Q
What is an obsession?
A
Recurrent, intrusive, usually unpleasant thoughts that person recognises as their own and tries to resist
18
Q
What is thought alienation?
A
Thought withdrawal, Thought insertion, Thought broadcasting
19
Q
What abnormal possession of thoughts can occur?
A
Overvalued Ideas
Obsessions
Thought alienation: withdrawal, insertion, broadcasting
Delusions of control (passivity)
20
Q
What is passivity?
A
Delusion of control
Feeling that some aspect of themselves is under external control of another
21
Q
What is a delusion?
A
Fixed, false idea
Belief that is firmly held on inadequate grounds, is not affected by rational argument or evidence to the contrary (unshakable),
and is not a conventional belief that the person might be expected to hold given his educational, cultural and religious background
22
Q
What abnormal thought content can occur?
A
Persecutory: think harm is going to occur
Reference: experience coincidence and believing it has strong personal significance
Grandiose: fantastical beliefs of fame, power, wealth
Guilt: believe they have done something sinful or shameful
Hypochondrical: fixed belief of poor state of health despite medical evidence to contrary
Nihilistic: they are dead, do not exist
Religious: preoccupied with religious subjects
Jealous: preoccupied with thought that spouse or partner is being unfaithful without any real proof
Sexual/amorous: believes they are loved by someone they have never met or is inaccessible
Dysmorphophobia: body dysmorphia, obsessive preoccupation that some aspect of appearance is severely flawed
Misidentification: belief that identity of person/object/place has changed
23
Q
What is affect?
A
Objective, synonymous with emotion and also meaning a short-lived feeling state; related to cognitive attitudes and understandings, and to physiological sensations
24
Q
What is mood?
A
Subjective, emotional tone prevailing at any given time -adequate to a surrounding situation and matters discussed; a ‘mood state’ will last over a longer period
25
What is a pathological affect?
Very strong, abrupt affect with a short change of consciousness on its peak
26
What are the 2 pathological poles of mood?
Manic
| Depressive
27
What is a phobia?
Persistent irrational fear and wish to avoid a specific situation, object, activity
28
What disorders of emotion exist?
Pathological affect
Pathological mood
Phobia
29
What are pathological features of mood?
Euphoria: intense excitement and happiness
Mania: excitement, delusion, overactivity
Hypomania: mild form of mania
Depression: depressed mood, loss of interests
Apathy/anhedonia: lack of interest/pleasure
Blunted, flattened affect: reduction in intensity of emotional response
Emotional lability: involuntary crying/laughing
30
What are the characteristics of pathological mood?
Origin – based on pathological grounds
Duration – unusually long-lasting
Intensity – unusually strong, large changes in intensity
31
What is depersonalisation?
Change of self-awareness, person feels unreal, unable to feel emotion
32
What is derealisation?
Environment feels flat, dull unreal, loss of the sense of reality of surroundings, usually involving a visual perceptual distortion; usually associated with a change in mood
33
What is loss of emotional resonance?
Lack of feeling , emotional reactivity
34
What is disturbance of continuity of self?
Not the person they were before the illness
35
What are disturbances of boundaries of self?
Loss of differentiation of one's body and rest of the world e.g. anosognosia
36
What are the different disorders of experience of self?
```
Depersonalisation
Derealisation
Loss of emotional resonance
Disturbance of continuity of self
Disturbances of boundaries of self
```
37
What are the different types of memory?
Sensory stores: retains sensory information for 0.5 sec
Short term memory (working memory): verbal and visual information, retained for 15-20 sec, low capacity
Long term memory: wide capacity and more permanent storage, declarative (explicit) memory – episodic (for events) or semantic (for language and knowledge)
procedural memory – for motor arts
priming – unconscious memory
conditioning – classic or emotional
38
What are disorders of memory?
Amnesia: inability to recall past events
Jamais vu: unfamiliarity in familiar situation
Déja vu: familiarity in unfamiliar situation
Confabulation: production of fabricated, distorted or misinterpreted memories about oneself
Amnesic disorientation
Korsakov’s syndrome: anterograde and retrograde amnesia, confabulation
Pseudologia fantastica: pathological lying
Hypomnesia: abnormally poor memory of the past
Hypermnesia: abnormally strong memory of the past
39
What is consciousness?
Awareness of the self and the environment
40
What is hypnosis?
Artificially incited change of consciousness
41
What is syncope?
Short-term unconsciousness
42
What are the quantitative disorders of consciousness?
Clouding of consciousness: disorientation in time, place, person, disturbances of perception and attention, and amnesia
Drowsiness: further reduction in level of consciousness, with
unconsciousness if unstimulated, but can be stimulated to a wakeful state
Stupor: further loss of responsiveness, can only be aroused by
considerable stimulation. Awareness of environment is maintained in depressive/ catatonic stupor, but not in organic stupor
Coma: profound reduction of conscious level with very little or no
response to stimulation
43
What is delirium?
Confusional state characterized by disorientation, distorted perception, enhanced suggestibility, misinterpretations and mood disorders
44
What are qualitative disorders of consciousness?
Disturbed perception, thinking, affectivity, memory and consequent motor disorders:
Delirium (confusional state)
Obnubilation (twilight state)
45
What is obnubilation?
Twilight state, starts and ends abruptly, amnesia is complete, patient is disordered, his actions are aimless, sometimes aggressive, hard to be understood
46
What are quantitative motor disorders?
Hypoagility
Hyperagility
Agitated behaviour
47
What are qualitative motor disorders?
Mannerisms: unusual habit which can be modified
Stereotypies: repetitive movement
Posturing: odd or inappropriate bodily position
Waxy flexibility: decreased response to stimuli, immobile
Echopraxia: imitation of movements of others
Schizophrenic impulse: failure to resist temptation
Negativism: resists movement and does opposite to what asked
Automatism: sequences of activity which occur without conscious control
Agitation: unpleasant state of extreme arousal
Tics: sudden, rapid, non rhythmic movements
Abulia: lack of will or initiative
Compulsions: repetitive behaviour
48
What is personality?
Complex of persistent mental and physical traits of a person
49
What disturbances of personality can occur?
Transformation of personality
Multiple personality (alteration of personality)
Specific personality disorder: paranoid, schizoid, dissocial, emotionally unstable (borderline type and impulsive type), histrionic (attention seeking), anankastic (obsessive compulsive), anxious (avoidant) and dependent
Deprived personality
50
What are the categories of a mental state examination?
```
Appearance & Behaviour
Speech
Mood
Thoughts
Perception
Cognition
Insight
```
51
What is serious mental illness?
People with psychosis
Schizophrenia
Bi-polar affective disorder
52
What general health problems are people with schizophrenia at higher risk of than the general population?
Mortality rates from respiratory, circulatory, endocrine and digestive disorders 3-4 X higher
Risk of metabolic syndrome for those with schizophrenia is 2–4 times greater than for the general population
Risk of sudden death in schizophrenia increases incrementally with each additional psychotropic medication taken by a patient
2 x death rate from cardiovascular disease
4x death rate from respiratory disease
2 x more likely to have diabetes
People with schizophrenia die 10-25 years earlier than general population
53
What proportion of schizophrenics are smokers as compared with the general population?
61% schizophrenics smoke
| 33% of general population
54
Why do people with mental illness have more physical illness?
Lifestyle: self neglect, smoking, jobs, lack of exercise, poor diet
Poor access to healthcare
Side effects of treatment – mainly Antipsychotics
Suicide contributes to higher mortality rate
55
What patient related factors may contribute to the poor physical health of people with mental illness?
Difficulty comprehending health care advice or carrying out
required changes in lifestyle due to psychiatric symptoms
(cognitive deficits, negative symptoms, poor insight, suspicion)
Adverse consequences related to mental illness (low educational attainment, reduced social networks, lack of employment and family support, poverty, poor housing)
Severity of mental illness (fewer medical visits, with most severely ill patients making the fewest visits)
Less compliant with treatment
Unawareness of physical problems due to cognitive deficits or to a reduced pain sensitivity associated with psychotropic medication
Lack of social skills and difficulties communicating physical needs
Migrant status or cultural and ethnic diversity
56
What clinician related factors may contribute to poor physical health of patients with mental illness?
Tendency to focus on mental rather than physical
Poor communication with patient and/or primary care health
workers
Physical complaints regarded as psychosomatic symptoms
Suboptimal and worse quality of care offered by clinicians to
patients with SMI. Lack of assessment, monitoring and continuity
of care of the physical health status of people with SMI
Erroneous beliefs (SMI patients are not able to adopt healthy
lifestyles, weight gain is mainly adverse effect of medications, lower cardiac risk medications are less effective)
Underfunded teams to handle behavioural and emotional problemsof patients with SMI
57
What service related factors may contribute to poor physical health of patients with mental illness?
Financial barriers, especially in developing countries
High cost of integrated care
Lack of access to health care
Lack of clarity and consensus about who should be responsible for detecting and managing physical problems in patients with SMI
Fragmentation or separation of the medical and mental health systems of care
Under-resourcing of mental health care
58
What modifiable risk factors may contribute to poor physical health of mental illness patients?
```
Overweight / Obesity
Diabetes/ hyper-glycaemia
Dyslipidemia
Exercise
Smoking
Anti Psychotic Drugs
```
59
Give some possible reasons for the high levels of type 2 diabetes in schizophrenic patients
Genetic link between schizophrenia and diabetes
Impact of lifestyle
Medication effect increasing insulin resistance by impacting insulin receptor or post-receptor function
Drug effect on caloric intake or expenditure (obesity, activity)
60
What is metabolic syndrome?
High BP, high blood Sugar , unhealthy Cholesterol level and belly fat
61
Name some typical and atypical antipsychotics
Typical: chlorpromazine and haloperidol
Atypical: quietapine and olanzapine
62
What cardiac side effects can some anti psychotics have?
Prolonged QT interval
63
What physical health checks should be carried out on patients with mental illness?
Weight gain and obesity: Body Mass Index (BMI), Waist Circumference (WC)
Dietary intake
Activity level and exercise
Use of tobacco and alcohol or other substances
Blood pressure
Fasting glucose and lipid levels (esp. TG and HDL-C)
Cardiovascular disease risk and ECG parameters
Prolactin levels (if symptomatic)
Dental check
Liver function tests, blood count, thyroid hormone, electrolytes (periodically, as indicated)
64
What are targets for blood pressure control in patients with mental illness? How is this achieved?
Target BP levels of less than 130/85 mmHg recommended
Lifestyle changes: stopping smoking, reducing salt intake, weight reduction, increased exercise, may be sufficient to reduce mildly elevated BP
Some patients are likely to require pharmacological therapy
65
What blood sugar monitoring should be carried out in patients with mental illness?
Baseline measure of plasma glucose level for all patients pre treatment
Conduct blood glucose measurement in fasting patients. If problematic, conduct a random blood glucose test or haemoglobin A1C test)
Patients with significant risk factors for diabetes should be monitored at baseline, 6 and 12 weeks after starting medication and then approximately every 3-6 months
Patients who are gaining weight (>7%) should be monitored every 4 months
66
What are the monitoring guidelines for cardiovascular disease in patients with mental illness?
Ask patients about heart risks: F/H of early sudden cardiac death (
67
Antipsychotics or antidepressants known for causing QT prolongation should not be prescribed to which patient set?
Patients with known heart disease
Personal history of syncope
Family history of cardiac disease at an early age (
68
What is recommended in patients presenting with Torsade de pointes who are on antipsychotics/antidepressants?
Withdrawal of any offending drugs and correction of electrolyte abnormalities
69
What monitoring for weight gain and obesity should be carried out in patients with mental illness?
Monitor and chart BMI and WC of every SMI patient at every visit, regardless of medication prescribed
Encourage patients to monitor and chart their own weight
BMI and WC assessment is simple, inexpensive and can easily been done with a weighing scale and waist tape measure
70
What healthy eating behaviours should be encouraged in patients with mental illness?
```
Cutting down on fast food
Increase healthy food items (fruits, vegetables, fish)
Decrease processed fat free food
Making healty snack choices
Controlling portion size
Consume 4-6, but small meals
Eating more slowly
Minimising intake of soft drinks with sugar sweetener
Reading food labels
Keeping food diaries/plans/exchange tables
Learning cooking skills
Healthy food shopping
```
71
What physical activity recommendations should be made for patients with mental illness?
Keeping activity diaries, daily activity list
Increasing physical activity such as moderate intensity walking
Reduce sedentary behaviors (TV watching, video/computer games)
Treating/reducing sedation and extrapyrramidal effects of medications
72
What advice on smoking should be given to patients with mental illness?
Treating tobacco dependence is effective in patients with SMI and does not worsen mental state
Advice and encourage SMI patients strongly to stop smoking (cessation associated with approximately a 50% decrease in CHD risk)
Assist patients in developing a quit plan, and arrange follow-up. If necessary and possible, patients should be referred to a smoking cessation service
73
What is the gold standard treatment for patients with mental illness to aid with smoking cessation?
Pharmacotherapy: nicotine replacement therapy,
bupropion or varenicline
Coupled with individual or group psychological support. Care to avoid adverse medication interactions & monitor antipsychotic medication in particular as cigarette consumption reduces
74
What harm reduction can you attempt in a patient with mental illness who does not want to quit smoking?
Awareness raising
Advising on, providing & selling licenced nicotine containing products
Self help materials
Behavioural support, education & training for practitioners
Nicotine is highly addictive but it is primarily the toxins and carcinogens in tobacco smoke that cause death
75
What is the health improvement profile?
Risk assessment tool for physical health
Nurses can be trained to be competent in using HIP in 3 hours
Physical health of all patients can be profiled
A HIP for every patient once a year
Enables nurses to plan care/make appropriate referrals
Guides nurses to evidence based interventions
Bridges communication between primary and secondary care
76
What is the general structure of a psychiatric history?
Personal details: Name, Age, Occupation, Address, pMarital status
Presenting complaint: in patients own words
History of presenting complaint
Past Psychiatric history
Past Medical and Surgical History
Family History: genograms, history of mental illness, suicides, suicide attempts, substance/alcohol abuse, neurological disorders
Personal History: Birth and any complications, Neonatal illnesses, Developmental milestones, Education – schools attended, any learning difficulties, truanting, bullying, other traumas, achievements, interests, exams passed, age at leaving school, physical and sexual abuse, be mindful of patient’s clinical condition and whether or not discussion of such events could be traumatising or intrusive, Occupational history:- details of jobs, duration, reason for leaving, level of satisfaction with employment and ambitions. Assess what impact the illness will have on patient’s job, Psychosexual history: – first experiences, relationships, orientation, marriage history, any children, Present social circumstances: – own or rented
accommodation – financial problems, debts, who patient lives with
Substance and alcohol use history
Forensic History: Previous contact with the police, Get all details including nature of offences, charges, sentencing including fines, custodial sentences, History of violence – against people or property, all details including severity
Premorbid Personality
77
What information about informants and referrals needs to be made with a psychiatric history?
Record place and time patient seen
Voluntary or detained
Source and reason for referral (Self, GP, general hospital, police)
Informants – who the history and other information is taken from
78
What is the general structure of a mental state examination?
```
Appearance and behaviour
Speech
Mood
Thought: Form, Content
Perception
Cognition
Insight
```
79
What features are you looking at in the appearance and behaviour section of a mental state examination?
```
Dress
Self care
Calm/agitated/anxious
Posture
Facial expression
Appropriateness of dress/behaviour
Abnormal movements/gait
Eye contact
Rapport
```
80
What aspects of speech are you looking at in a mental state examination?
```
Spontaneity (poverty of speech)
Reaction time to questions
Rate (slow/fast/pressured?)
Volume
Tone (monotonous or not)
Fluency (dysphasia/dysarthria)
```
81
What aspects of mood are you looking at in a mental state examination?
Subjective vs. objective
Affect vs. mood
Nature of mood: Depressed, Elated, Anxious, Angry, Irritable
Variability of mood: Blunting/flattening, Reactivity, Lability, Incontinence
Incongruity of mood
Depersonalisation
Derealisation
82
What symptoms of mood changes would you look for in a patient with depression?
```
Anhedonia
Low energy
Low confidence
Guilt
Poor concentration
Sleep disturbance
Appetite
Suicide
```
83
What aspects of thought form are you looking at in a mental state examination?
How thoughts are organised and expressed: Amount/volume of thoughts, Connection/flow of thoughts
Objectively = speech
Amount of thought: Pressure of thought, Poverty of thought, Thought blocking
Thought flow: Flight of ideas, Loosening of associations
84
What aspects of thought content are you looking at in a mental state examination?
Delusions: Delusional Mood, Delusional Perception, Delusional Memory
Thought Possession: Insertion, Withdrawal, Broadcast
Delusions of control
Ideas of reference
Overvalued ideas
Obsessive thoughts
85
What is a delusion?
False, unshakeable idea or belief, out of keeping with patient’s educational, cultural and social background. It is held with extraordinary conviction and subjective certainty
86
What types of delusions exist?
Persecutory
Jealousy/infidelity
Grandiose
Nihilism
87
What is obsessional thought?
```
Intrusive thoughts, impulses or images
Persistent and repetitive
Recognised as own thoughts
Recognised as senseless
Patient resists them
```
88
What are compulsive rituals?
```
Repetitive
Seemingly purposeful
Subjective sense of compulsion
Resisted, but this results in anxiety
Often associated with obsessive thoughts
```
89
What aspects of perception are you looking at in a mental state examination?
Hallucination: percept in the absence of a stimulus
Pseudo hallucination: Doesn’t fully have the character of external reality
Illusion: misperception of a stimulus
Voices: Who, when, where? Inside head? Same as me talking to you?Which “person”? Third person ≈ schizophrenia, Second person (commands) – important for risk assessment
90
What are first rank symptoms of schizophrenia?
```
Thought control: Insertion, Withdrawal, Broadcast
Delusional perception
Passivity (delusions of control)
Thoughts spoken aloud
Third person auditory hallucinations
```
91
What aspects of cognition need to be assessed in a mental state examination?
Attention and Concentration: WORLD backwards
Orientation: Time, place and person
Immediate Memory (registration): Repeat 3 objects
Recent memory: Recall 3 objects 5 minutes later, Recent events
Remote memory: Remote personal events
General knowledge: Name Queen, PM, US president– Dates of WW2, Current news events
Executive function
92
What aspects of insight are you looking for in a mental state examination?
```
What is the problem?
Is it an illness?
Is it a mental illness?
Does he/she need treatment and what?
Are they taking prescribed medication?
```
93
What proportion of adults with a mental illness had a prior diagnosis as an adolescent?
Over 80% of people with mental health disorder had a
| prior mental health diagnosis: 74%were present before age 18 and 50% before age 15
94
What is an organic psychiatric disorder?
Demonstrable pathology or aetiology, or which arise directly from a medical disorder
Excludes disorders that develop as a result of a psychological reaction to a condition
95
What are functional psychiatric diseases?
Do not have an identifiable underlying pathological cause and are typically multifactorial: Genetic component, Exposure to certain environmental materials in utero, Changes in brain chemistry
96
What classes of organic psychiatric disorders are there?
Dementia
Other conditions presenting with psychiatric symptoms but having physical cause
Substance misuse disorders
Psychiatric disorders which are considered psychological reactions to
illness (becoming depressed after being told you have cancer) are excluded
97
Give examples of psychiatric syndromes which arise from a physical cause
Organic brain syndromes: Dementia, delirium, amnesic syndrome
Organic delusional: Systemic lupus (psychotic) erythematosus
Organic mood disorders: Multiple sclerosis
Organic anxiety disorders: Thryotoxicosis
Organic personality disorders: Head injury
98
What is sulfasalazine?
DMARD used in treating IBD, RA
99
What is dementia?
Umbrella term to describe change/impairment of cognitive
| functions, resulting from disease of the brain, which is severe enough to affect day to day functioning
100
What are the main causes for dementia?
Alzheimer’s disease
Vascular dementia
Dementia with Lewy bodies
101
What is normal pressure hydrocephalus?
5% of dementia
Commonest potentially reversible type
CSF pressure is often increased
Clinical triad of: confusion, gait apraxia, urinary incontinence
Treatment: ventricular shunting; 50% respond well
102
What is delirium?
Transient, usually reversible, cause of cerebral dysfunction, manifesting clinically with a wide range of neuropsychiatric abnormalities
Also known as acute confusional state or acute brain syndrome
Common on medical and surgical wards, a third of elderly patients in
hospital have an episode of delirium during their admission
103
What are symptoms of delirium?
```
Clouding of consciousness: most important diagnostic sign
Drowsiness
Decreased awareness of surroundings
Disorientation in time and place
Distractibility
Fluctuating course, worse at night
Visual hallucinations
Transient persecutory delusions
Irritability and agitation, or somnolence and decreased activity
Impaired concentration and memory
```
104
What are common causes of delirium?
Prescribed drugs: Tricyclic antidepressants, Benzodiazepines and other sedatives, Digoxin, Diuretics, Lithium, Steroids, Opiates
Alcohol: intoxication, withdrawal and delirium tremens
Medical conditions: Postoperative hypoxia, Febrile illness, Septicaemia, Organ failure (cardiac, renal, hepatic), Hypoglycaemia, Dehydration, Constipation, Burns, Major trauma
Neurological conditions: Epilepsy (postictal), Head injury, Space occupying lesion, Encephalitis
105
What is delirium tremens?
Psychotic condition in withdrawal of alcohol from alcoholics, tremors, hallucinations, anxiety and disorientation
106
What are differences between delirium and dementia?
```
Onset: acute vs insidious
Course: fluctuating vs progressive
Attention: poor vs good
Delusions: common vs not common
Hallucinations: simple/stable vs fleeting
```
107
What are predisposing factors for delirium?
```
Elderly
Male
Pre-existing dementia
Pre-existing frailty or immobility
Previous episode of delirium
Sensory impairment
```
108
What are treatments for delirium?
Environmental components: Quiet surroundings (side room), constant lighting, clock, calendar
Regular routine: Clear simple communications, Limit numbers of staff (e.g. key nurse), Involve family
Medical components: Monitor vital signs, Investigate and treat underlying cause (e.g. antibiotics,oxygen, stop drug), Control agitation or psychotic symptoms with antipsychotics
109
What is the prognosis for delirium?
Prognosis depends on the cause
Within a week the patient is usually better or has died
No good evidence that delirium progresses to dementia
Pre-existing dementia is a risk factor for delirium
Older individuals experiencing delirium are twice as likely to die than those who do not
110
What is Amnesic syndrome?
```
Anterograde and retrograde amnesia
Confabulation
Minimal content in conversation
Lack of insight
Apathy: patients lose interest in things quickly and generally appear
indifferent to change
Time disorientation
Immediate recall intact
```
111
What causes Amnesic syndrome?
Damage to the mammillary bodies, hippocampus or thalamus
Usually alcohol induced thiamine deficiency (Korsakov’s syndrome)
Other causes: herpes simplex encephalitis, severe hypoxia and head injury
Memory deficits are often irreversible
112
What are the most common psychiatric disorders?
Anxiety and depression
113
What psychiatric side effects can phenytoin have?
Ataxia, delirium
114
What psychiatric presentations can occur with temporal lobe epilepsy during a seizure?
```
Impaired consciousness
Hallucinations and other distorted perceptions: olfactory, somatic (especially epigastric)
Sense of déjà vu
Depersonalisation and derealisation
Speech and memory affected
Stereotyped behaviour
```
115
What psychiatric presentations can occur with temporal lobe epilepsy after a seizure?
```
After seizure (Postictal, hours to days): Transient, florid psychosis
Between seizures: Schizophrenia-like psychosis, Depression, Sexual dysfunction and lack of libido
```
116
What is a poor prognostic feature in a head injury?
Anterograde amnesia >24 hours predicts a poor
| long-term outcome, including persistent cognitive deficits
117
What psychiatric symptoms may occur with a head injury?
Personality changes
Mood disorder, anxiety disorders and schizophrenia
Postconcussional syndrome
118
Which patient groups are most likely to be confused?
```
Elderly
Memory problems
Poor hearing or eyesight
People who have had recent surgery
Terminal illness
Brain disorder eg stroke, tumour
```
119
How can we talk to patients with delirium?
Stay calm
Talk to them in short, simple sentences
Check they have understood and repeat things if necessary
Make sure they have their glasses and hearing aid
Reassure them about where they are and how they are doing
Keep history taking short
120
How can we diagnose delirium?
DSM diagnosis of delirium due to a medical condition
Disturbance of consciousness with decreased clarity of awareness and difficulties of attention
Change in cognition: memory deficit and disorientation or presence of perceptual abnormalities. Changes not the result of previous or evolving dementia
Disturbance develops over a short period of time and fluctuates
Evidence that disturbance is the result of a general medical condition
121
What is the confusion assessment method?
Feature 1: Acute Onset and Fluctuating Course: obtained from a family member/nurse
Feature 2: Inattention: difficulty focusing attention, easily distractible, or having difficulty keeping track of what was being said
Feature 3: Disorganized thinking or incoherence
Feature 4: Altered Level of consciousness
The diagnosis of delirium by CAM requires the presence of features 1 and 2 and either 3 or 4
122
What are types of delirium?
Hyperactive delirium: heightened arousal and can be restless, agitated or aggressive
Hypoactive delirium: people who become withdrawn, quiet and sleepy
123
What supportive management of delirium can be provided?
```
Clear communication
Consistency of staff
Family and carer involvement
Prompts to day and time
Familiar environment
Adequate nutrition & fluids
Low stress environment
```
124
What community involvement should there be in the management of a delirious patient?
Admission prevention- CERT (community emergency response team), admission prevention beds
District nurses
Social worker
GP
125
What are risks of medical management of delirium?
Sedation can cause delirium
Increased risk of falls
Increased risk CVA
126
What are risk factors for delirium?
Advanced age
Underlying brain diseases such as dementia, stroke, or Parkinson disease, particularly when there are current problems with memory
Use of multiple medications (particularly psychiatric drugs and sedatives), or multiple medical problems
Sudden withdrawal of a regular medication or cessation of regular alcohol use
Frailty, malnutrition, immobility
Advanced cancer
Undertreated pain
Immobilisation, including physical restraints
Use of bladder catheters
Limb fractures
Interventions, including diagnostic tests
Poor eyesight or hearing
Sleep deprivation
Organ failure, eg, chronic lung disease, heart, kidney, or liver failure
127
What environmental factors are important in preventing delirium?
Provide appropriate lighting and clear signage. A clock and a calendar should also be easily visible to the person at risk
Reorientate the person by explaining where they are, who they are, and what your role is
Introduce cognitively stimulating activities (reminiscence)
Facilitate regular visits from family and friends
128
What sensory input is important in preventing delirium?
Make sure patients have their hearing aids and glasses
