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what is the drug treatment for sleep disturbance (insomnia?)
benzodiazepine
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what are the 4 categories of causes for insomnia?
- physiological: need less sleep with age, daytime naps, noise
- pathological: pain, SOB, oesophageal reflux
- pharmacological: caffeine, xanthines, cocaine
- psychiatric: anxiety, depression
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what is the non drug and drug treatment for insomnia?
- 1. address primary cause
- 2. avoid using drugs, especially if the problem is CHRONIC
- 3. sedatives/hypnotics - benzodiazepines
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how do benzodiazepines work?
- activate GABA receptors in brain
- leading to CNS depression
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give 3 examples of BZD sedatives?
- chlordiazepoxide
- diazepam
- temazepam (short half life)
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what are the other uses of BZD?
- pre-op medication: to reduce anxiety and reduce the threshold for anaesthesia
- acutely confused pt
- acute anxiety
- acute epilepsy: status epileptics - injection of diazepam is very good as it has a relatively short half life
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which BZD are good for sleep disturbance and why?
- temazepam
- nitrazepam
- they have short half life so pt is NOT DROWSY the next morning
- less chance of falling over esp. in elderly
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what is chlordiazepoxide specifically used for?
alcohol withdrawal syndrome
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what is the difference between tolerance and dependence of sleeping pills?
- tolerance: happens within a few weeks of using the drugs, the patients are no longer sedated by them
- dependence: without the drugs, pt cant get to sleep
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how are withdrawal reactions from stopping BZD reduced?
reduce the medication in a stepwise manner over a few weeks, don't stop suddenly
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what is the differential diagnosis of a known alcoholic who is acutely confused?
- alcohol/other drug intoxication
- alcohol withdrawal
- acute infection: alcoholics are IMMUNOCOMPROMISED
- hypoglycaemia: alcohol suppresses gluconeogesis in the liver
- head injury/brain haemorrhage
- hepatic encephalopathy
- wernicke's encephalopathy
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what is wenicke's encephalopathy due to? symptoms?
- vitamin B1 deficiency (thiamine)
- leads to C.A.N. (confusion, ataxia, nystagmus)
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if untreated what can wernicke's encephalopathy lead to? and describe this
Korsakoff's psychosis: unable to make NEW MEMORIES
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what 2 diseases can thiamine deficiency cause?
- Wernicke's encephalopathy
- Beriberi disease
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how is Wernicke's encephalopathy prevented?
- initial iv thiamine
- then oral
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what is the treatment of a chronic alcoholic presenting with acute confusion?
- 1. chlordiazepoxide: start with high dose then reduce it
- 2. anti-epileptic if seizures occur
- 3. vitamin B1 (thiamine) to prevent Wernicke's encephalopathy
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what are the common causes of acute confusion in the elderly?
- 1. infection
- 2. heart disease: AMI, acute heart failure
- 3. metabolic disturbances: hypoxia, electrolyte disturbance e.g. low potassium if diuretic use, hypoglycaemia as may be on insulin if DM
- 4. brain disease: stroke, meningitis, epilepsy, encephalitis
- 5. fall
- 6. Drugs: night sedation, alcohol withdrawal, opiates check pinpoint pupils
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what investigations do you need to do in an acute confused person?
ABC EFG
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how are benzodiazepine's reversed?
flumazenil
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what is the treatment for an acutely confused patient?
- 1. treat cause
- 2. nurse in a well lit single room, same staff
- 3. if no primary cause found, give sedation with BZD e.g. lorazepam if danger to herself or others
- 4. or neuroleptic drug: haloperidol (major tranquilliser)
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what is the advantage of haloperidol
no respiratory depression
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what is the advantage of lorazepam?
short half life
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how is status epileptics treated?
- initial benzodiazepine but cannot load with BZD as causes resp depression
- so then change to phenytoin
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what is the main difference between acutely confused patient and dementia?
- acute confused: drowsy
- dementia: chronically confused, but alert
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what are the 4 features of dementia?
- chronically confused
- global brain failure: disorder in mood, thought, memory
- progressive and irreversible
- leads to total dependence on State and carers
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how do you do an AMTS?
first give address to remember at end
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5 questions about person, time place:
- 1. DOB
- 2. Age
- 3. Time to nearest hour
- 4. Year
- 5. name of hospital
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3 Questions about factual knowledge
- 6. present prime minister
- 7. WW2 started
- 8. recognise 2 persons: doctor, nurse...
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2 questions about calculation/memory
- 9. count from 20-1 backwards
- 10. recall of address
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what is the category and example of drug used to treat dementia? and SE?
- cholinesterase inhibitor: donepezil
- NB many don't respond to it and GI disturbances?
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what is memantine?
NMDA antagnoist
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what are the cardinal features of depression?
- low mood
- loss of interest in life
- reduced energy and enjoyment
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what are the 3 main categories of anti-depressants? and what is their MOA? and give an e.g. of each
- SSRI: stop reuptake of 5HT. e.g. fluoxetine/escitalopram
- TCA: block reuptake of NA, 5HT, DA. e.g. amitriptyline/imipramine
- MAO inhibitors: stop the breakdown of monoamine neurotransmitters eg NA, DA, 5HT e.g. hydralazine (MAOi non selective)
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what causes withdrawal of TCA?
anticholinergic SE
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what is the drug treatment of schizophrenia? what is their MOA?
- neuroleptics: chlorpromazine, haloperidol
- interfere with DA transmission
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