Guardianship in Case of MR or Dementia
It is important to determine guardianship status for adult patients with known cognitive impairment, such as those with mental retardation or dementia.
Guardianship in case of MR
- During childhood, the parents are assumed to be the guardian of the patient or a guardian may have been appointed in the event of parental death, child abuse, neglect, or other circumstances.
- At age 18, parents may pursue guardianship in order to continue to make decisions for a child with mental retardation, especially if the adult child has severe impairment or is unable to communicate with others.
Decisions of MR patients
Adult patients with mental retardation are allowed to make health care decisions for themselves, unless guardianship has been established or it is determined that they do not have capacity
Encountaring Substance abuse in a Primary care setting
Taking a thorough history can effectively identify substance abuse in the primary care setting. Once it is identified, the initial approach consists of engaging the patient in a brief counseling session to discuss personal risk and develop collaborative goals and a treatment plan.
Indications for Inpatient hospitalization in Drug Abuse
It is indicated for patients experiencing severe intoxication or physical withdrawal symptoms or those who pose a danger to themselves or others.
Use of Clozapine as Antipsychotic
- FDA requires weekly monitoring of the white blood cell (WBC) count during the first six months of therapy.
- If the WBC count remains normal, the frequency of WBC monitoring can be slowly reduced to bimonthly and then again to monthly.
Acute Stress Disorder
- The DSM-5 criteria specify that symptoms last for at least 3 days and up to 1 month following exposure to the traumatic event.
- Patients typically have some form of intrusive re-experience (distressing memories, nightmares, flashbacks) and are preoccupied with negative thoughts about their role in the traumatic event.
- Symptoms may remit within 1 month or progress to post-traumatic stress disorder (PTSD) after this time.
Depressed patient with Insomnia
- Some patients with major depression do not complain of sadness or depressed mood but rather may present with increased irritability.
- The best treatment option is to target the patient's underlying depressive disorder rather than treat the insomnia symptom in isolation
Obscessive- Compulsive Disorder
- Exposure and response prevention, a form of cognitive behavioral therapy, is considered a first-line nonpharmacologic intervention for obsessive compulsive disorder.
It is a non-serotonergic antidepressant that inhibits the reuptake of norepinephrine and dopamine.
Alcohol Use Screening
- Asking patients how many times in the past year they have had 5 ( 4 for women) or more drinks in a day is an effective screening tool to identify unhealthy alcohol use.
- The Alcohol Use Disorders Identification Test-C is a widely validated instrument that can also be used for assessment.
- It is a psychiatric condition in which the patient feigns an illness to be a patient and to assume a sick role.
- The patient typically does not have an external incentive other than to be a patient, which differentiates this condition from malingering.
- It is usually seen in young women and healthcare professionals.
- It can present in a variety of ways, ranging from a mild exaggeration of symptoms to a much more dramatic form, with patients seeking multiple invasive procedures and operations (Munchausen's syndrome).
- Patients may fake their illnesses by either lying about their history and symptoms, or by creating an illness by the ingestion of drugs or by the injection of exogenous materials such as sputum, urine, feces, or milk.
Acute dystonic reactions
They are common in patients treated with typical antipsychotic medications, and are treated with anticholinergic medications or diphenhydramine.
- It is a slow-release form of haloperidol that is given intramuscularly every two to four weeks. The use of injectable antipsychotics allows for improved therapeutic compliance, and has helped many patients avoid rehospitalization.
- Risperidone and fluphenazine are two other long acting injectable antipsychotics.
Borderline personality disorder (BPD)
- Patients with borderline personality disorder suffer from considerable instability in self-image, mood, impulse control, and relationships.
- Relatively minor events or disagreements are often interpreted as threatening a relationship, causing many borderline patients to respond with dramatic displays of anger or self-harm.
- Marked changes in mood can occur throughout the day.
- When primitive idealization occurs, the patient views another individual as perfect and flawless, and is unable to tolerate any evidence to the contrary
Dialectical behavior therapy
- It is one of the most successful means of treating borderline personality disorder.
- Dialectical behavior therapy focuses on behavior modification and the building of skills.
- Important issues to address during therapy sessions include the establishment of appropriate boundaries, validation of the patient's experience, assumption of responsibility for one's own actions, management of feelings on both sides, promotion of reflecting before acting rather than being impulsive, reduction of tendency to engage in splitting, and the setting of limits on self -destructive behaviors.
Management of Boarderline Personality Disorder
- Dialectical behavior therapy is one of the more successful means of treating borderline personality disorder.
- Tricyclic antidepressants are contraindicated because of the high risk of suicide attempts.
- SSRI can help reduce mood lability and temper outbursts, but are not first-line agents.
- Conditioning is most commonly used in the treatment of phobias.
- Miosis is an indicator of opioid overdose, while mydriasis is an indicator of opioid withdrawal.
- Mydriasis can also be found in cocaine, amphetamines, and tricyclics overdose.
- Lacrimation and yawning are fairly specific for opioid withdrawal.
- Treatment of opioid withdrawal involves the administration of methadone or other opioids (buprenorphine ).
- This syndrome consists of patients reporting a subjective feeling of inner restlessness and the urge to move and/or objective evidence, such as rocking of the body or crossing and uncrossing the legs while sitting.
- Akathisia can occur with use of typical (haloperidol) or atypical antipsychotic medications.
- The treatment of choice for akathisia is addition of a beta-blocker, such as propranolol to the patient's medication regimen.
- It is a reversible, acute confusional state that involves a reduced/fluctuating level of consciousness and attention with difficulties in memory and thought processes.
- It is most common in elderly patients with medical illness and is often associated with anxiety, physical/verbal agitation, delusions, and/or hallucinations.
Treatment of Delirium
- Supportive measures (reassurance, frequent orientation, constant supervision) should be used initially to manage confusion and disorientation.
- However, if the patient demonstrates combative behavior, low-dose antipsychotics with intravenous and intramuscular formulations (haloperidol/risperidone) should be used to control agitation, prevent harm, and allow continuation of safe treatment.
Once the patient is aware of the negative consequences of substance use and contemplates change, the physician should encourage the patient to identify the benefits of change and support initial steps in that direction.
Handling a Psychotic Patient
- Forming a therapeutic alliance with a psychotic patient involves providing a conducive, supportive environment while allowing the patient to maintain a degree of privacy and interpersonal distance.
- Directly confronting irrational beliefs, demonstrating inappropriate friendliness, attempting to gain unwanted disclosure and psychoanalyzing patient thoughts can inhibit the physician-patient relationship.
- It is often used to cope with distressing affective states and is common in adolescents and young adults.
- It is seen in a wide range of disorders, including borderline personality, eating, and dissociative disorders, and in patients with developmental disabilities.
- The most appropriate intervention is to reassure the parents that their daughter is not in danger but needs a thorough psychiatric evaluation to identify any underlying conditions.
Clinical Features of Dementia, Delirium and Depression
- Clinical Features: poor memory, disorientation, paranoid delusions, agitation) that suggest a diagnosis.
- Onset occurs after age 60 and initially affects memory and language predominantly.
- Patients will often attempt to cover these deficits with confabulation or manifest irritability due to frustration with testing.
- Cognitive-enhancing medications can sometimes slow the progression of dementia, but there is no cure.
- If psychotic symptoms lasts more than 2 weeks in the absence of a mood episode, it is schizoaffective disorder.
Criterion A for schizophrenia
2 of the following: delusions, hallucinations, disorganized speech, disorganized or catatonic behavior, negative symptoms
Drug Interaction with Lithium
- Thiazide diuretics increase sodium excretion in the distal tubule, leading to increased renal tubular reabsorption of lithium, potentially resulting in toxic concentrations.
- Angiotensin converting enzyme inhibitors and nonsteroidal anti-inflammatory drugs (NSAIDS) also increase lithium levels.
- Patients co-administered these medications require close lithium level monitoring and lithium dosage reduction if necessary.
Prevention of Serotonin Syndrome
It is recommended that at least 5 weeks should elapse between taking fluoxetine and initiating MAOI treatment.
- It involves symptoms of dry skin, flushing, fever, mydriasis, and altered mental status following exposure to anticholinergic medication.
- Patients may also experience urinary retention, decreased bowel sounds, autonomic instability (tachycardia, hypertension), and tremulousness.
Tetanus usually presents with stiff neck, opisthotonus, risus sardonicus (sardonic smile), a board-like rigid abdomen, and periods of apnea and dysphagia.
Pregnancy and Bipolar Disorder
- The first-generation antipsychotic haloperidol is currently the safest and most effective treatment for pregnant patients with bipolar mania.
- This is due largely to its favorable reproductive safety profile, demonstrated over a long period on the market. Haloperidol has efficacy equal to that of second generation antipsychotics for mood stabilization in bipolar disorder.
- Second-generation antipsychotics (eg, quetiapine, risperidone) can also effectively treat mania. However, due to their shorter time on the market, these agents have not been studied as extensively in pregnancy.
Treating Pregnancy and Bipolar
- Haloperidol is a safe and effective treatment for severe bipolar mania during pregnancy.
- Second-line treatments include lithium, second-generation antipsychotics, and electroconvulsive therapy. Treatment decisions vary from case to case depending on acuity, trimester, and patient preference.
Risk factors associated with the abused and abusers
- Risk factors associated with the abused are female gender, physical and mental impairment from chronic medical conditions, and old age (especially 80 and above).
- Risk factors identified in abusers include young age, relationship with the victim (spouse or children), substance abuse, mental illness, dependence on the victim, and previous history of violence in the abuser.
Encountaring a new onset psychosis in a Patient
- When encountering a patient with new-onset psychosis in the emergency department, the physician must first rule out medical and substance induced causes.
- The most appropriate statement is to acknowledge the seriousness of the patient's psychotic symptoms and the possibility that they are being caused or exacerbated by marijuana use.
Good Prognostic factors in a Psychotic Patient
- 1. Positive psychotic symptoms, such as delusions or hallucinations,
- 2. Acute onset
- 3. Absence of negative symptoms,
- 4. Later age of onset,
- 5. Good premorbid functioning
- 6. Family support
- 7. Affective symptoms,
Risk factors associated with increased falls in elderly
- 1. Use of Benzodiazepine
- 2. Female sex
- 3. Past history of a fall
- 4. Use of psychotropic medications (eg, antipsychotics, antidepressants)
- 5. Cognitive impairment
- 6. Lower-extremity weakness
- 7. Balance problems
- 8. Arthritis.
- 9. Advanced age
- Benzodiazepine withdrawal occurs with abrupt cessation after prolonged use and may occur several days into a hospitalization.
- Clinical Features include restlessness, tremors, and autonomic instability (elevated heart rate, blood pressure, and temperature
- Rapid treatment with a benzodiazepine ( Lorazepam, Diazepam) is needed to manage this potentially life-threatening condition.
- It is a syndrome (not a specific disorder) of marked psychomotor disturbance that occurs in severely ill patients with psychotic disorders, bipolar disorder with psychotic features, major depression with psychotic features, autism spectrum disorder, and medical conditions (infectious, metabolic, neurologic, rheumatologic ).
- Catatonia can range from stupor to marked agitation (catatonic excitement), which contributes to difficulties in recognition.
- Characteristic features include decreased motor activity, lack of responsiveness during interview, or excessive and peculiar motor activity.
- Potential risks include malnutrition, hyperpyrexia, exhaustion, and self-inflicted injury.
Treatment of Catatonia
- The treatment of choice for catatonia is benzodiazepines (especially lorazepam) and/or electroconvulsive therapy (ECT).
- A lorazepam challenge test (IV bolus of lorazepam 1-2 mg) resulting in partial, temporary relief within 5-10 minutes confirms the diagnosis of catatonia.
- However, a negative response does not rule out catatonia, and patients often need repeated doses.
- ECT is recommended in urgent clinical situations or when the patient responds poorly to benzodiazepines.
Urine Drug Screening
- Urine immunoassay drug screen is the preferred initial screening test as it is an inexpensive, on-site, rapid screen that can provide evidence of recent drug use that may influence management.
- The classes of drugs most commonly screened for are opioids, alcohol, cocaine, marijuana, phencyclidine, and amphetamines.
- Positive results reflect drug use over the past 1-3 days, with the exception of marijuana, which can be detected for weeks after heavy use.
- An immunoassay test uses antibodies to detect the presence of drugs.