OTX 212 - Psychiatric conditions

• Types of neurocognitive disorders

  • Delirium
  • Major Neurocognitive Disorder
  • Mild Neurocognitive Disorder
• Defining features of neurocognitive disorders

  • Cognitive deficit
  • Decline from previous cognitive functioning
• Neurocognitive disorders have subcategories based on underlying etiology
• Cognitive domains


  • Complex attention: sustained-/ divided- /selective attention, processing speed
  • Executive functioning: planning, decision making, inhibition, error correction, problem solving
  • Learning & memory
  • Language: expressive/ receptive
  • Social cognition
  • Perceptual motor: visuospatial/ constructional
  • Mathematical skills/ calculation
• Delirium


  Acute disturbance of brain physiology
• Dementia


  Chronic disturbance of brain anatomy
• Delirium


  • Acute onset (Sudden change)

  Change in attention (easily distractible) & awareness (impaired arousal/ clouded consciousness)

  Accompanied by other cognitive deficits: Disorientation, Memory deficits, Language impairment/incoherent speech, Perceptual disturbances

  Sleep-wake disturbances (day-night reversal)

  Psychomotor changes (hypo - / hyperactive)

  Hypersensitive to light / sounds

  Sleep-rhythm disturbance

  Fluctuation of picture
• DSM-5 criteria for delirium

  • A. Disturbance in attention & awareness

  B. Develop over a short period (hours to days), & fluctuates during the day

  C. Additional disturbance in cognition

  A & C not better explained by another disorder

  Evidence from history, examination or lab findings – direct physiological consequence of another medical condition

  Specify: Substance intoxication / withdrawal, Medication induced, Due to another medical condition / multiple etiologies
• Causes of delirium


  • Drugs (BZ, anti-Ach, antiHT, alcohol intoxication/withdrawal)

  Infections (Any infection in vulnerable, CNS infections)

  Metabolic (hyper-/hypoglycemia, dehydration)

  Trauma (TBI, multiple injuries)

  Oxygen deficit (CVS / respiratory causes)

  Postictal (after seizure)

  Endocrine (Thyroid-, parathyroid- / adrenal dysfunction)

  Nutritional deficiencies (Thiamine, B12, Folic acid)
• Risk factors for delirium

  • Demographics: Older age

  Psychiatric hx: Dementia & depression

  Physical illness: Severity & comorbidity

  Diminished ADL skills / immobility

  Urinary catheters

  Lab results: ↓ albumin, ↓ hematocrit, ↓/↑ glucose

  Sensory impairment (visual & auditory)

  Increased length of hospital stays

  Excess alcohol use

  Polypharmacy
• Management of delirium


  • Medical emergency

  Make an accurate diagnosis

  Get collateral

  Medical, substance history & examination

  Treat the underlying condition

  Stop offending drugs

  Avoid sedation unless absolutely required

  Medication only as a last resort

  Take steps to prevent / manage delirium: Physical support, Maintain nutrition & hydration, Appropriate sensory & social stimulation, Provide clues to environment, Familiar ward & personnel, Reduce noise & soft night-light, Mobilize, Attend to sensory impairments, Prohibit the use of cot sides, Nurse the person low to the floor
• Major Neurocognitive Disorder (Dementia)


  • Gradual onset: Decline in cognition from baseline over months to years

  Some exceptions – stroke / TBI
• Characteristics of Major Neurocognitive Disorder


  • Deterioration in cognition with clear consciousness

  Often mistaken for normal ageing

  Cognitive Sx: forgetful (1st short term), disorientated, aphasia, agnosia, apraxia

  Behavioral & mood Sx: depression, irritability, agitation, wandering, 'sundowning', sleep disturbances, psychosis, personality change (e.g. disinhibition)

  Functional Sx: self-neglect, apraxia, cannot manage finances / make decisions
• DSM-5 criteria for Major Neurocognitive Disorder


  • A. Significant cognitive decline in 1/> domain (complex attention, executive fx, learning, memory, perceptual-motor / social cognition) based on: Concern of individual / informant / clinician, Impairment in cognitive performance on tests / clinical assessment
  • B. Interfere with independence in everyday activities

  Not exclusively during a delirium

  Not better explained by another mental disorder (e.g. depression / schizophrenia)
• Causes of Major Neurocognitive Disorder

  • Degenerative disease of CNS: Alzheimer's, Frontotemporal dementia, Lewy body disease, Huntington's disease, Parkinson's disease, MS

  Systemic disease: Vascular dementia, Thyroid disease, Post-hypoglycemia, Encephalopathy, Hypoxia

  Deficiency States

  Substances, medication & toxins

  Intracranial pathology (TBI/tumors)

  Infectious: Prion disease, HIV, TB, Neurosyphilis

  Other diseases / Multiple etiologies
• Behavioral & psychological symptoms of dementia (BPSD)

  Include agitation, aberrant motor behaviour, anxiety, elation, irritability, depression, apathy, disinhibition, delusions, hallucinations, & sleep or appetite changes
• Management of Major Neurocognitive Disorder

  • Make an etiological diagnosis

  Disease specific management

  Management of behavioral problems

  Prevent of complications

  Support of the family: Social worker, Occupational therapist, Physiotherapist, Lawyer, Nursing personnel

  Non-pharmacological: Cognitive stimulation, Identify behavioral problem & precipitants, Nursing care plan to curb the behavior, Cognitive & behavioral therapy, Interpersonal therapy

  Pharmacological: Acetylcholinesterase inhibitors (ChEI's)

  Familiar personnel, Provide clues to environment, Calm & quiet environment, Avoid physical restraints, Regular physical activity & get patient up, Structured activities & planned pleasurable activities, Social contact – pets, one to one, family, Medical - light therapy, hearing aids, pain management
• Cognitive deficits influence different aspects of daily functioning

  
  

  Hygiene

  Learning

  Leisure activities

  Work

  Communication

  Mobility

  Managing shopping & finances

  Decreased awareness of risks & safety
• Principles of intervention for cognitive impairment

  
  

  Must suit abilities of the person

  Consider motivation, awareness of limitations, personality & environment

  Setting (hospital, home / care-facility)

  Set collaborative goals & intervention priorities
• Modifiable risk factors for dementia

  • Hearing loss

  Hypertension

  Obesity

  Smoking

  Head injury

  Air pollution

  Low educational level in childhood

  Depression (avoid / treat depression)

  Physical inactivity (exercise)

  Social isolation (interact with others – not on Facebook)

  Diabetes (treat & eat healthy)

  Excessive alcohol consumption
• Role of Occupational Therapists for adults with cognitive impairment

  • Facilitate new brain pathways & improve functional skills

  Enabling individuals to participate more fully in self-care, work, leisure & community activities enhance quality of life while reducing the burden on caregivers
• Factors contributing to psychotic disorders

  • Genetic factors

  Biochemical factors (neuropathology, neural circuits, neuroendocrinology)

  Psychosocial factors (stressors, migration, substances)

  Epigenetics (external environment)
• Psychotic disorders tend to be chronic, & affects individual, family, community & economy
• Psychotic disorders are stigmatized/rejected on all levels by family, community, health professionals & colleagues
• Neural pathways affected in psychotic disorders

  • Mesolimbic – positive symptoms

  Mesocortical – negative symptoms

  Tuberoinfibular – hyperprolactaemia

  Nigrostriatal – movement symptoms
• Types of psychotic disorders

  • Schizophrenia

  Schizoaffective Disorder

  Schizophreniform Disorder

  Delusional Disorder

  Brief Psychotic Disorder

  Unspecified

  Psychosis due to Another Medical Condition

  Substance induced Psychotic Disorder
• Schizophrenia spectrum disorders


  • DSM-5 refers to it the schizophrenia spectrum

  Signs & symptoms variable; severe & long lasting

  Onset before 25 years

  Affects persons of all classes; 1% of the population

  Diagnosis leads to poor social care & stigma
• Diagnostic criteria for schizophrenia

  • A. At least 2 ≥ of the following symptoms: Delusions, Hallucinations, Disorganized speech, Grossly disorganized/catatonia behaviour, Negative symptoms

  B. Decrease in functioning; work; interpersonal relations;

  C. Continuous symptoms for at least 6/12

  D. Not meet criteria for SAD or Mood disorder with psychotic features

  E. Not due to a GMC/ physiological effects of Substances

  F. Over & above ASD or Communication disorder of childhood onset
• Positive symptoms of schizophrenia


  • Delusions

  Hallucinations

  Dysfunctional thinking

  Disorganized speech or behaviour

  Catatonia or other movement disorders
• Negative symptoms of schizophrenia

  • "Flat affect," dull or monotonous speech, & lack of facial expression

  Difficulty expressing emotions (alogia)

  Anhedonia

  Lack of motivation (avolition)

  Social withdrawal (asocial)

  Ambivalence
• Cognitive symptoms of schizophrenia


  • Inability to process information & make decisions

  Difficulty focusing or paying attention

  Problems with memory

  Difficulty learning new tasks

  Poor motivation
• Risk factors for suicide & homicide in schizophrenia

  • Long duration of untreated psychosis

  Comorbid major depressive episode with hopelessness; despondency, previous history of suicide

  Comorbid substance uses disorders; personality disorders

  In the 1st 10 years of illness; 1st six months post discharge

  High premorbid functioning: Young high achiever, High expectations of self
• Types of delusions in psychotic disorders

  • Erotomaniac delusion

  Grandiose delusions

  Mixed delusions

  Persecutory delusions

  Somatic delusions

  Bizarre delusions
• Schizophreniform Disorder


  • Same symptoms as schizophrenia

  Lasts more than 1 month, less than 6

  SAD & Bipolar or depressive disorder ruled out

  Not due to substances or GMC

  60-80 % progress to schizophrenia

  Remainder have no recurrent psychotic symptoms
• Schizoaffective Disorder


  • Meets schizophrenia & mood disorder criteria

  Absolute psychotic symptoms for 2/52 without mood symptoms

  Those with mood symptoms do better than those with schizophrenia symptoms

  Increased risk of schizophrenia in relatives
• Delusional Disorder


  • One month history of non-bizarre delusions

  Never met criteria for Schizophrenia

  Functioning not markedly impaired

  Common in advanced ages 40 plus

  Difficult to treat

  Screen for homicide risk
• Brief Psychotic Disorder


  • Retrospective diagnosis

  Lasts more than one day, but less than a month

  Common in personality disorders, people with poor coping skills

  Evidence of a psychosocial stressor (pregnancy can be one)

  There is always a sudden onset

  Symptoms include a labile mood, confusion, screaming/muteness, strange behaviour

  Always exclude GMC or substances

  Hospitalization, pharmacotherapy & individualized psychotherapy
• Unspecified Psychotic Disorder


  • Does not meet any criteria for any psychotic disorder

  Information is lacking or insufficient to make a diagnosis

  Postpartum psychosis common 2-3 weeks after birth, usually within 8 weeks

  Mood symptoms, psychosis & thoughts of harming baby

  Post partum psychosis is a psychiatric emergency
• Psychosis due to Another Medical Condition

  • Also common in medical condition e.g. HIV psychosis; post Epileptic seizures; post head injury; neoplasms, multiple sclerosis, sarcoidosis, Systemic lupus erythematous etc.

  Hospitalization for complete work-up & confirmation of the diagnosis

  Medication used symptomatically
• Substances


  • Hospitalization, pharmacotherapy & individualized psychotherapy
  • Not otherwise specified
  • Due to general medical condition
  • Substance induced psychotic disorder