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Pyschiatry Flashcards

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1
Q

What are the 7 stages of addiction?

A

1) craving
2) dependance
3) withdrawal
4) salience
5) narrowing of repitoire
6) loss of control
7) relapse

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2
Q

Regarding the 7 stages of addiction, how many do you need to have at one time in a 12 month period to be classified as addicted?

A

3 stages

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3
Q

What are the the different parts of the mental state exam?

A

Appearance and behaviour
Speech (look for formal thought disorder)
Mood (3 core, 4 biological, psychological and risk)
Thought (obsessive or delusional thoughts)
Perception (illusion or hallucinations)
Cognition - are they orientated in time, person and place
Insight and capacity

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4
Q

What are the 3 core elements of mood?

A

Energy
Enjoyment
Mood scale (1-10)
- objective and subjective

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5
Q

What are the 4 biological elements of mood?

A

Sleep
Appetite
Concentration
Libido

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6
Q

What are the 5 stepwise questions to ask regarding risk assessment in a psychiatric history?

A

1) Thoughts of life not worth living
2) thoughts of self harm
3) thoughts of killing
4) plans to kill
5) Protective factors

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7
Q

Apart from risk of self harm what else do you need to assess in a psychiatric risk assessment?

A

Risk to self - neglect, vulnerability

Risk to others

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8
Q

What is the difference between thought form and thought content?

A

Thought form - the form of the speech (this is abnormal in formal thought disorders)
Thought content - what they are speaking about

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9
Q

What are the 4 types of formal thought disorder?

A

Poverty - depression
Pressure - manic phase of bipolar
Loss of association - schizophrenia
Circumstantiality - dementia

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10
Q

What are the hallmarks of an obsessive thought?

A

Recurrent
Intrusive
Unpleasant

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11
Q

What is the definition of a delusional thought?

A

Fixed, false and out of keeping

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12
Q

What are the different types of delusional thoughts?

A 
Persecutory (most common and non-specific)
Mood congerent (nilhilistic or grandiose)
Schizophrenic delusions
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13
Q

What are the different types of delusional thoughts which are specific to schizophrenia?

A

Thought insertion
Thought extraction
Control - like someone is moving arms and legs like puppet
Reference - like the TV is talking to you

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14
Q

What is the difference between an illusion and a hallucination?

A

Illusion - incorrect image in the presence of a stimulus

Hallucination - no stimulus present, but all the qualities of a true perception

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15
Q

What are the different types of hallucinations?

Which is most common?

A 
Based on senses:
Auditory (most common)
Visual 
Touch 
Smell 
Taste
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16
Q

What is a pseudohallucination?

A

Eg, hearing a voice in your head

Doesn’t have all the qualities of a true perception

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17
Q

What is formulation in psychiatry?

What are the components?

A

Formulations are used to communicate a hypothesis from the history and provide a framework for treatment approach

3 P’s (predisposing, precipitating, perpetuating)
3 components (biological, psychological and social)
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18
Q

What does the accrynom SADMOPP stand for regarding differentials in psychiatry?

A 
Substance abuse
Anxiety 
Developmental disorder
Mood disorder (unipolar or bipolar)
Organic (ALWAYS CONSIDER UNTIL RULED OUT)
Psychosis 
Personality Disorder
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19
Q

What is the ICD-10 Diagnosis Criteria for Depression?

A

Symptoms need to be present for a minimum of 2 weeks
Must contain at least 2 of the core symptoms
Must contain at least 2 of the other symptoms

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20
Q

What are the 3 core symptoms for depression?

A

Depressed mood - that doesn’t improve to positive events
Anhedonia (loss of pleasure and enjoyment)
Anergia (loss of energy, fatigue)

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21
Q

What are the other non core depressive symptoms?

A

Impaired concentration
Reduced self a stem
Sleep disturbance
Loss of appetite
Psychomotor changes - retardation and agitation
Psychotic symptoms - delusions and auditory hallucinations

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22
Q

What are the classic sleep disturbances seen in a patient with depression?

A

Early morning awakening - 2 hours before usual time
Middle insomnia - waking up during the night and having difficulty falling asleep again
Initial insomnia - problems falling asleep initially

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23
Q

If you suspected someone had depression, how could you confirm this?

A

Using a PHQ-9 Questionnaire

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24
Q

What are the important differentials when thinking about depression?

A

Bipolar - ask about manic phases
Bereavement - ask about recent family death
Chronic medical conditions - increase risk
Medications - some increase risk

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25
Which medications increase the risk of depression?
``` Corticosteroids Beta blockers Stains Oral contraception Isotretinoin Topiromate ```
26
What initial investigations should you do when investigating depression?
BP, pulse, BMI - good baseline for medications FBC, U&Es, LFTs, TFTs HbA1C - look for underlying chronic conditions ECG - useful for some antidepressant meds can increase QT interval
27
What are the different grading of depression?
Mild, moderate, severe Graded on severity of symptoms and functional impairment
28
How is depression managed?
Mild - watchful waiting and supportive consultation, review in 2 weeks Moderate/severe - trial antidepressant
29
What lifestyle management is important in depression?
Time off work - especially if stress is impacting mood Stop drinking/smoking Exercise - 30 mins 3x a week Encourage social support
30
What guidance should you give to someone before starting an antidepressant medication?
Can take 3-6 weeks before they start to work Tend to feel worse initially - because side effects kick in before therapeutic effect of drug Need to trial antidepressant for at least 2 months before switching Must continue on drug even once they feel better to decrease risk of relapse Little benefit switching between classes - unless for side effect reasons
31
What are the different classes of antidepressants?
TCAs (tricyclic antidepressants) SSRIs (selective serotonin reuptake inhibitors) SNRIs (serotonin and noradrenaline reuptake inhibitors) MOIs (Monoamine oxidase inhibitors) 5HT2A Antagonists
32
How do tricyclic antidepressants work?
Block reuptake of noradrenaline, serotonin and dopamine
33
Give examples of TCAs
Disipramine Amitriptyline Clomipramine
34
What are the main side effects of TCAs?
Lower seizure threshold Cardiotoxic - can prolong QT interval Lethal in overdose Anticholinergic effects - dry mouth, blurred vision, constipation, urinary retention, confusion Antiadrenergic effects - postural hypotension, sexual dysfunction Antihistamine effects - sedation, weight gain
35
How to SSRIs work?
Block serotonin reuptake by SERT (Serotonin transporter) This prolongs the actions of released serotonin However this takes weeks to come into affect as initially the 5HT neurons decrease the firing in response to increased serotonin and autoreceptors on the neurons. Over time these autoreceptors desensitise
36
Give examples of the common SSRIs used?
Sertraline Citalopram Paroxetine Fluoxetine
37
What are the common SSRI side effects?
``` GI disturbance - nausea and diarrhoea Sexual dysfunction Restlessness, nervousness, agitation, sweating (note that these initial symptoms can make the patient feel worse) Dry mouth Loss of appetite Insomnia ```
38
How do SNRIs work?
Inhibit the reuptake of serotonin and noradrenaline Act like TCAs but without the anticholingergic, antiadrenergic and antihistamic side effects - this is because they don’t inhibit dopamine reuptake
39
Give examples of the commonly used SNRIs
Venlafaxine | Duloxetine
40
How do MOIs (Monoamine oxidase inhibitors)
Monoamine oxidase is an enzyme that breaks down serotonin, noradrenaline and dopamine MOIs bind to monoamine oxidase and prevent its action
41
What is the main side effect of MOIs? Why are they not used anymore in treating depression?
Hypertensive crisis This is because monoamine oxidase is also needed to metabolise other monoamines - such as dietary tyramine (which is found in red wine, cheese) If you block activity then this will lead to a build up of these foods which will cause a hypertensive crisis
42
Give an example of a MAOIs Why is this famous?
Iproniazid First antidepressant ever licensed, originally a TB drug
43
What s serotonin syndrome?
Major side effect of antidepressant Caused by excessive serotonin Presents with extreme sympathetic nervous system response (hyperthermia, hypertension, hyperreflexia, tachycardia, tremor, agitation, irritability, sweating, diarrhoea, dilated pupils)
44
Many patients with depression relapse after their first episode. How is the risk of relapse determined?
Low risk of relapse - in first episode patients with no risk factors Moderate risk of relapse - any risk factors present e.g, (residual symptoms, previous depressive episodes, severe depression) High risk of relapse - patients with >5 lifetime episodes or 2 episodes in the last year
45
How long should patients stay on antidepressants for?
This depends on their risk of relapse: - Low risk of relapse - 6-9 months - moderate risk of relapse - at least 1 year - high risk of relapse - at least 2 years
46
What is the process for coming off antidepressant medication
Need to consider withdrawal symptoms and reccurance of symptoms Come off slowly over a course of 4 weeks - several months depending on dose and severity of depression Only come off medication at an appropriate time - not during a time of stress e.g, moving house, new job, wedding, exam
47
What options are there for treatment resistant depression?
Lithium | ECT
48
When would you refer a patient with depression to psychiatric services?
If the patient doesn’t respond to multiple treatments If there is significant risk of suicide, self harm, self neglect or harm to others If there are any psychotic symptoms present If you suspect bipolar disorder If the patient is a child/adolescent with severe major depression
49
What are the important questions to ask someone after a suicide attempt?
``` What precipitated the event Was it planned or impulse Did they plan to kill themselves or was it a cry for help Did they leave a note Were they intoxicated Previous attempts Current risk assessment ```
50
Which pathway in the brain is associated with excessive dopamine in schizophrenia?
Associative striatum of the nigrostriatal pathway
51
What is psychosis?
A mental disorder in which thoughts and emotions are impaired so the person loses contact with reality Note that psychosis is not a diagnosis - but recognising it is the first step towards making a diagnosis
52
How does psychosis commonly present?
Delusions and/or hallucinations - these often drive a disturbance of behaviour Paranoid thinking
53
What are the causes of psychosis?
``` Organic cause - important to rule out Schizophrenia Drug induced psychosis Bipolar - manic phase Severe depression Dementia ```
54
What other features may be present if psychosis is caused by an underlying physical disease?
Disorientation Memory problems Neurological features
55
What initial investigations would be done for a patient presenting with psychosis?
Need to investigate to rule out organic cause: Bloods - FBC, LFTs, TFTs, bone profile, U&Es ECG - as some antipsychotics prolong QT interval MRI scan - rule out organic cause (done if there are other neurological findings)
56
In a patient presenting with a 1st episode psychosis, what is the management?
Referral to the EIS (Early intervention service) mental health team Trial of oral antipsychotic Physiological interventions e.g, CBT
57
What is the EIS (Early intervention service)?
Mental health team which help people aged 14-35 with early psychosis Help to reduce the duration of untreated psychosis (DUP) to help improve outcomes Help improve access to effective treatment particularly in the ‘critical period’ (3-5 years following onset)
58
Who can initiate antipsychotic treatment?
Only a qualified psychiatrist GP can not initiate but can continue treatment in community with consent from psychiatry team
59
What are the 4 main dopamine pathways in the brain?
Nigrostriatal - involved in motor control, and emotion Mesolimbic - involved in feelings of reward/pleasure Mesocortical - inovled in cognition and memory Tuberoinfundibular - involved in inhibiting prolactin production
60
What is the main mechanism of antipsychotics?
Act on the 4 main dopamine pathways in the brain | Majority act on D2 receptors (inhibitory receptors)
61
What are the main side effects of antipsychotics?
``` Metabolic side effects (weight gain, diabetes, metabolic syndrome, Hyperlipidemia) Sedation Extrapyramidal (movement disorders) Cardiovascular (prolong QT interval) Hormonal (increase prolactin) ```
62
What monitoring would you do before starting a patient on an antipsychotic?
Need to check baseline due to side effect profile Weight Pulse, BP, ECG Bloods - glucose, HbA1c, lipid profile, prolactin Assess for movement disorders Assess nutritional status, diet and exercise level
63
What is the difference between typical and atypical antipsychotics?
Typical - act to reduce dopamine by acting as D2 receptor antagonists (because of this they have a high EPS side effect profile) Atypical - have lower D2 receptor affinity and higher serotonin 5-HT2A receptor affinity (serotonin-dopamine 2 antagonists). They affect dopamine and serotonin neurotransmission in the 4 main dopamine pathways
64
Give examples of typical antipsychotics used?
Haloperidol Sulpiride Fluphenazine Amisulpiride
65
How is amisulpiride different to the other typical antipsychotics used?
Highly selective for D2 and D3 Limbic subtypes Reduces EPS side effects e.g, parkinsonism Has favourable outcomes for weight gain Side effect - may cause hyperprolactinaemia
66
Give some examples of atypical antipsychotics used?
``` Risperidone Olanzapine Quetiapine Aripiprazole Clozapine ```
67
Which of the atypical antipsychotics is most likely to cause extrapyramidal side effects?
Risperidone
68
Which of the atypical antipsychotics is most associated with weight gain?
Olanzapine
69
Which atypical antipsychotic can also be used as an antidepressant at lower doses?
Quetiapine
70
Which atypical antipsychotic is most likely to prolong the QT interval?
Quetiapine
71
Which atypical antipsychotic has a unique mechanism in that is acts as a D2 agonist?
Aripiprazole
72
Which atypical antipsychotic is reserved for treatment resistant psychosis? (Must have tried 2 previous antipsychotics, one being atypical)
Clozapine
73
What is the major side effect of clozapine to be aware of? How is this monitored for?
Agranulocytosis (0.5-2% risk) Requires weekly blood monitoring for first 6 months Requires 2 weekly blood monitoring for next 6 months
74
Apart from agranulocytosis, what are the other main side effects of clozapine?
Increased risk of seizures - especially if taken with lithium Sedation Weight gain Deranged LFTs
75
What is neuroleptic malignant syndrome?
Major side effect of antipsychotics Results in autonomic dysfunction - like serotonin syndrome Can have severe muscle breakdown and increased CK which can cause rhabdomyolysis
76
How does neuroleptic malignant syndrome present?
``` Hyperthermia Hypertension Hyperreflexia Tachycardia Tremor, agitation, sweating Dilated pupils ```
77
How is neuroleptic malignant syndrome managed?
``` Discontinue antipsychotic medication Transfer to ICU Benzodiazepines for agitation May need active cooling Aggressive IV hydration ```
78
What are the 3 symptom categories in schizophrenia?
``` Positive symptoms (delusions, hallucination) Negative symptoms (blunted emotions, anhedonia, lack of motivation) Cognitive impairments (memory problems) ```
79
What type of hallucinations are commonly seen in schizophrenia?
Auditory hallucinations
80
What does catatonic behaviour mean?
Marked psychomotor movements - generally movements are rigid - can present as bizzare and inappropriate movements - wavy flexibility (the limbs remain in the position they are placed)
81
What are the risk factors for developing schizophrenia?
Genetic link? Prenatal exposure to infections Heavy canabis use - particularly if used before the age of 16 Obstetric complications
82
How does schizophrenia commonly present? (3 phases)
Prodromal phase - patient becomes withdrawn Active phase - positive symptoms occur e.g, delusions, hallucinations, catatonic behaviour Residual - patients show cognitive symptoms
83
Hyperprolactinaemia is a major side effect of antipsychotic medication. What can it lead to?
``` Sexual dysfunction Reproductive dysfunction Breast pathology - e.g, enlargement Hypogondism - decreased BMD (leading to hip fractures) Acne and hirsutism ```
84
What is section 2 of the mental health act?
Detained in hospital for assessment of mental health and to get any treatment needed Requires 2 doctors + approved mental health worker Length is up to 28 days
85
What is section 3 of the mental health act?
detained in hospital for treatment Either follows from section 2 OR if patient is known mental illness Length is up to 6 months Requires 2 doctors + mental health worker
86
What is section 4 of the mental health act?
Used in emergency situations Detained in hospital for assessment Lasts up to 72 hours Requires one doctor + one mental health worker Should move to section 2 as soon as possible
87
What is section 5 of the mental health act?
``` Detained by doctor or nurse holding power Section 5(2) - doctor holding power up to 72 hours Section 5(4) - nurse holding power up to 6 hours ```
88
What is section 136 of the mental health act?
Detained under police officer for up to 72 hours
89
How is schizophrenia managed?
Antipsychotic use CBT if this helps Assigned care coordinator (key worker) in the community to follow up patient
90
How many patients with schizophrenia will have a repeated episode in the 5 years following their first episode?
80%
91
What is the care programme approach (CPA)?
Package of care for patients with mental health problems (severe mental disorder, risk of subsided, recently sectioned) Patients will get a written care plan and support Provides help in emergencies Provides a CPA care coordinator to manage care plan and review yearly
92
How does delirium tremens present?
Alcohol withdrawal Altered consciousness Fluctuating motor cavities Autonomic hyperactivity - raised temp, raised BP, tachycardia Hallucinations - auditory, visual, tactile
93
How is delirium tremens managed?
Benzodiazepines - usually chlordiazepoxide Pabrinex (thiamine) - to prevent wenicke’s encephalopathy IV fluids - for dehydration
94
How is alcohol withdrawal managed long term?
Vitamin B and thiamine | Psychosocial support
95
What is the difference between Wernicke’s encephalopathy and Korsakoff’s syndrome?
Wernicke’s - neurological deficit relating to thiamine deficiency Korsacoffs - brain damage when Wernicke’s is not treated, results in irreversible damage to thalamus and hypothalamus and neuronal loss. Short term memory is diminished (presents with cognitive impairment and significant deficit in anterograde and retrograde memory)
96
What is the typical triad of Wernicke’s encephalopathy?
Ophthalmoplegia (eye movements disorders e.g, nystagmus) Ataxia Confusion
97
How is Wernicke’s managed?
Thiamine replacement - this is the only way to stop the damage Cardiovascular stabilisation Long term support for alcohol cessation
98
What medications can be given to recovering alcoholics to help reduce cravings?
Acamprosate | Naltrexone
99
What is disulfiram and how does it work?
Used in alcohol recovery Produces acute sensitivity to drinking alcohol Inhibits the enzyme acetaldehyde dehydrogenase So it makes the effects of a hangover to be felt immediately following alcohol consumption - feeling sick
100
What are the difference types of bipolar disorder?
Type 1 - cycles of mania episodes and depressive episodes Type 2 - cycles of severe depression with hypomania Cyclothymia - hypomania an depressive mood states cycles. Symptoms less severe than type 1 and 2
101
What are the symptoms of mania? | DIG FAST acronym
``` Distractability Impulsivity - e.g, spending lots of money Grandiosity Flight of ideas Activity increase Sleep deficit Talkative - pressured speech ```
102
What is the difference between mania and hypomania?
Hypomania is shorter lived and is not accompanied by psychotic symptoms. Hypomania episodes are less severe and don’t cause marked impairment in social or occupational functioning Manic episodes must last for a minimum of a week Hypomania episodes should last for at least 4 days
103
How are acute episodes of mania in bipolar disorder managed?
With antipsychotics E.g olanzapine, risperidone
104
What blood monitoring needs to be done with patients on lithium?
U&Es | Lithium is excreted by the kidneys so can effect renal function
105
What are the the contraindications for taking lithium?
Renal failure patients Cardiovascular insufficiency patients Addison’s disease Untreated hypothyroidism
106
Which medications should not be used alongside lithium?
Any medications which can reduce renal function: - NSAIDs - ACEi - Certain antibiotics
107
What is the risk of taking lithium in pregnancy
Risk of congenital heart defects
108
What is the risk of sodium valproate (depakote) in pregnancy?
Risk of neural tube defects
109
How many hours after abrupt cessation of alcohol consumption do delirium tremens usually occur?
Can occurs within 72 hours of cessation
110
Which medications are used as maintenance treatment in bipolar disorder?
Lithium - mood stabiliser Sodium valproate (depokate) - epilepsy treatment used in bipolar
111
What are the 3 key features of dementia?
Decline in memory Decline in cognitive domains (planning, organising, thinking, recognition) Functional impairment
112
How many months do symptoms of dementia need to be present for a diagnosis to be suspected?
6 months | With NO clouding of consciousness
113
What are the 4 primary degenerative causes of dementia?
Alzheimer’s Vascular dementia Lewy body dementia Fronto-temporal dementia
114
What is the most common primary degenerative cause of dementia?
Alzheimer’s disease
115
What is the difference between early and late onset Alzheimer’s disease?
Early onset <65 years | Late onset >65 years
116
What is the usual presentation of Alzheimer’s disease?
Slow and gradual memory loss Signs usually noticed by carers/family rather than patient Normally attributed initially as normal ageing Disease usually well established by the time of presentation to health service
117
What are the signs of Alzheimer’s disease?
``` Determination in self care Repetitive phone calls Episodes of wandering Missed appointments Dangerous lapses of memory ```
118
What are the 5 A’s of Alzheimer’s?
Amnesia - slow but progressive Agnostic - inability to recognise objects and people Apraxia - decreased motor coordination Aphasia - difficulty speaking (this is a late symptom) Associated behaviour - personality change, psychotic symptoms, challenging behaviour
119
What are the risk factors for Alzheimer’s disease?
``` Increasing age Family history - 1st degree relative increases risk by 3-4x CVD history Parkinson’s disease Down’s syndrome Hypothyroidism Significant head injury ```
120
What genes have been linked to Alzheimer’s?
APOE (E4 allele of apolipoprotein E gene) - around 40-80% of AD patients have at least one of these alleles Amyloid precursor protein (APP) - present in Down’s syndrome
121
What is the pathophysiology of Alzheimer’s?
Accumulation of beta amyloid plaques - these interfere with neuronal function Neurofibrillary tangles - due to abnormal tau protein which tangles. Tau is responsible for internal cell transport. Without this neurons die
122
What are the risk factors for vascular dementia?
Ischaemic disease - HTN, heart disease, vascular disease AF Diabetes FH of stroke or vascular disease Ethnicity - Indian, Bangladesh, Pakistani, Sri Lanka Male sex
123
What are the different causes of vascular dementia?
Stroke - results in single onset Multi infarct dementia - multiple mini strokes causing sudden decline in function every time Subcoritcal vascular dementia - damage to smaller blood vessels in the brain results in gradual decline in function
124
What is Lewy body dementia?
Less common type of dementia - related to Parkinson’s disease Results from clumps of Lewy body proteins accumulating inside nerve cells and causing them to die
125
How does Lewy body dementia differ in its presentation to other types of dementia?
Onset slightly earlier (50’s-60’s) Features of Parkinsonism- bradykinesia, difficulty moving, falls Fluctuation in symptoms - symptoms vary day to day. Variation in orientation and alter Tess Visual Hallucinations may be present Sleep disturbances - patients can have vivid dreams 40-50% of patients can have depressive episodes
126
How is Lewy body dementia diagnosed?
Using a DaTSCAN - dopamine imaging | Will show specific cell death related to Lewy body dementia
127
How does the presentation of fronto-temporal dementia differ to other types of dementia?
``` Often younger onset (50-60) Predominance of frontal lobe involvement: - emotional blunting - coarsening of social behaviour - disinhibition - apathy or restlessness ```
128
What are pick bodies? How does this relate to fronto-temporal dementia?
Pick bodies are composed of tau fibrils - usually accumulate in the frontal and temporal lobes of the brain A build up of these can cause picks disease Fronto-temporal dementia used to be known as picks disease - however now known only 20-30% of patients have pick bodies present
129
Apart from the 4 primary progressive causes of dementia, what are the other organic causes?
Brain tumours Normal pressure hydrocephalus Subdural haemotoma Alcohol dementia
130
What diseases are linked to causing dementia?
``` Creutzfeldt Jakob disease Huntington’s disease Parkinson’s disease HIV Down’s syndrome ```
131
What is the difference between delirium and dementia?
Delirium is an acute cause of cognitive impairment Duration of delirium will be hours-weeks long Patients will have clouding of consciousness - reduced clarity of the environment Patients can be agitated and psychotic Delirium is usually reversible
132
How is delirium managed?
Identity the underlying cause - usually infection | Treat cause - this should treat delirium state
133
What are the differentials for dementia?
Delirium Pseudo-dementia Mild cognitive impairment
134
How does pseudo dementia present?
Depression related cognitive impairment Patients will not feel fine and will be distressed by their cognitive impairment (compared to dementia where they will be unaware or unconcerned by impairment)
135
What investigations should you do in a patient presenting with suspected dementia?
Need to rule out any underlying cause for symptoms and any treatable causes of dementia: Urinalysis - UTI can cause confusion Bloods - FBC, U&E, HbA1c, B12, folate, TFTs, CRP, syphillis serology (if suspected) CT/MRI scan - look for SOL, or areas of atrophy
136
What screening tools are used to help aid dementia diagnosis?
ACE III (Addenbrokes cognitive examination) MOCA (Montreal cognitive assessment) MMSE (mini mental state exam)
137
What ACE III score is highly suggestive of possible dementia?
ACE III <82
138
How would you assess a patients functional impairment in a patient presenting with dementia symptoms?
Activities of daily living questionnaire
139
What are the two types of medications used to help manage cognitive symptoms in dementia?
``` Acetylcholinesterase inhibitors (AChE inhibitors) Glutamate receptor antagonist ```
140
Name the common AChE inhibitors used in Alzheimer’s disease?
Donepezil Galantamine Rivastigmine
141
Which AChE inhibitor is also licences for use in Lewy body dementia and Parkinson’s disease?
Rivastigmine
142
Name the common Glutamate receptor antagonist use in moderate/severe dementia?
Memantine
143
What investigation must you do before starting a patient on an acetylcholinesterase inhibitor and why?
ECG | AChE inhibitors are contraindicated for patients with bradykinesia, LBBB and prolonged QT interval
144
In which patients should memantine be avoided? Which blood test is done before use?
Patients with renal failure Important to check renal function before starting
145
Which Alzheimer’s medications is the safest choice in patients with cardiovascular disease?
Rivastigmine
146
Which antipsychotic medication can be used to help patients with Alzheimer’s who experience symptoms of agitation or hallucinations? Why should antipsychotics be used with caution in dementia?
Quetiapine Antipsychotics are associated with increased mortality in dementia
147
What other teams are involved in the care for dementia patients?
Physiotherapy - assess fall risk Occupational therapist - assess home risks e.g, fires, self neglect, wandering Care coordinator - dementia patients may have a CPA involved in care
148
What are the two different types of lasting power of attorney?
LPA for health and welfare | LPA for property and affairs
149
What is a lasting power of attorney (LPA)
Where you nominate someone to make decisions on your behalf when you lose the capacity to do so
150
What is DoLs?
Deprivation of liberty safeguarding Where you restrict someone’s free will and independence in their best interest E.g, keeping them in a hospital or care home for their wellbeing
151
What is the duration of restriction of a DoLs
12 months | Must be reviewed after this to be extended
152
What is triad of symptoms for normal pressure hydrocephalus?
Memory problems Ataxia Urinary incontinence
153
What is REM sleep behaviour disorder and how is it managed?
Where people act out their dreams Patients are not confused when they wake up Can co exist with narcolepsy leading to day time sleepiness Seen in patients suffering from neurological disorders Managed with Clonazepem
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What is the criteria for diagnosing a personality disorder?
Deeply ingrained maladaptive patterns of behaviour Patterns must arise in childhood and continue into adulthood Patterns must cause stress to themselves and to people around them
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What are the 3 clusters of personality disorder?
A - odd/eccentric cluster B - dramatic/emotional/erratic cluster C - anxious/fearful
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What are the different types of personality disorder in cluster A?
Paranoid Schizoid Schizotypal
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What type of personality does someone with a schizoid personality disorder have?
Detached emotionally | Finds it difficult to form close relationships
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What type of personality does a person with a schizotypical personality disorder have?
Disorientated thoughts or perceptions e.g, think they are able to read minds May express themselves in an odd way
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What are the different personality disorders in cluster B?
Antisocial Borderline (emotionally unstable) Histrionic Narcissistic
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What kind of personality does someone with an antisocial personality disorder have?
Act impulsively Has little regard for others Lacks empathy
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What kind of personality does someone with emotionally unstable personality disorder have?
Has unstable relationships Has unstable emotions - switches from happy to sad Problems with self image May have suicidal or self harm thoughts
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What kind of personality does someone with a histrionic personality disorder have?
Enjoys being the centre of attention | May flirt or act provocatively to ensure this
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What kind of personality does someone with a narcissistic personality disorder have?
Someone who thinks highly of themselves (big ego) | Puts their own needs before others
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What are the different personality disorders in cluster C?
Avoidant Dependant Obsessive compulsive
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How are personality disorders managed?
Biological - treat any anxiety/depression/psychosis with meds Psychosocial - dialectic behavioural therapy Social - support, crisis management
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What is DBT (dialectic behavioural therapy)?
Treatment specifically for personality disorders such as EUPD (emotionally unstable personality disorder) Works in a similar way to CBT Incorporates mindfulness Helps with coping mechanisms
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What are the different Extrapyamidal side effects (EPSEs) that can be seen on typical antipsychotics?
Parkinsonism Acute dystonia: sustained muscle contraction (oculogyric crisis) Akathisia (severe restlessness) Tardive dyskinesia (abnormal involuntary movements, most common is chewing and pouting of the jaw)
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What medication can be used to treat drug induced extra pyramidal side effects? What is its MOA?
Procyclidine Anticholinergic drug
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Which antidepressant is most commonly used in bipolar disorder?
Fluoxetine
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Which chronic health conditions does bipolar disorder increase your risk of?
Diabetes Cardiovascular disease COPD
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What is a oculogyric crisis?
Dystocia reaction to certain drugs (usually typical antipsychotics) Cause prolonged involuntary upward deviation of the eyes
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What class of drugs does mirtazapine belong to? What is the MOA?
``` It is its own class of antidepressant Noradrenergic and specific serotonergic antidepressant ``` Works by blocking alpha2 adrenoreceptors to increase the release of neurotransmitters
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What are the side effects of mirtazapine? What can this be good for?
Sedation and weight gain Good for patients with depression who have trouble with sleep and poor appetite
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What are the indications for ECT (electroconvulsive therapy)
Treatment resistant severe depression Manic episodes Moderate depression known to respond to ECT in the past Life threatening Catatonia
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What are the short term side effects of ECT?
``` Headache Nausea Short term memory impairment Memory loss of events prior to ECT Cardiac arrhythmia ```
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What is the only absolute contraindication to ECT?
Raised intracranial pressure
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What are the most common causes for acute delirium in the elderly?
``` Pain Infection Constipation Urinary retention Metabolic - hyperglycaemia, hypoglycaemia, dehydration Medications - e.g, opoids Hypoxia ```
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Which medications should be avoided in patients with Lewy body dementia and why?
Typical antipsychotics e.g risperidone and haloperidol | D2 antagonists can lead to irreversible parkinsonism
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How is REM sleep behaviour disturbances managed?
Clonazepam Given at a low dose 30 mins before bedtime

Year 4 (16 decks)

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