Mental Health Session 12: PTSD and Neurocognitive disorders In the Elderly

Session 12: PTSD, and Neurocognitive disorders

 

  • Having a traumatic event of any kind can lead to PTSD symptoms
  • Almost 1 out of 10 people one month after 9/11 had symptoms of PTSD
  • In PTSD there are recurring symptoms of the stressor that has occurred.
    • The stress needs to be processed or else it will run on a continuous loop that will not allow the person to be free from the stressor.
    • Ted talk about PTSD
  • Thalamus, amygdala and hippocampus – emotional response to the experience
    • Overactive amygdala can cause increased sympathetic response and PTSD symptoms.
  • Cortisol – the stress hormone, longer exposure times allow the stress to have a higher reaction in this patient ie. a kindling effect the more stress there is.
  • Norepinephrine – high levels in PTSD
  • Coping skills are aimed at bringing them back to baseline levels of functioning
  • Exposure therapy is allowing the person to deal with the trauma in a safe more manageable place.
  • EMDR – is therapy using patterned eye movement thought to mimic REM sleep eye movement and this helps some people separate the trauma from the physical response that is elicited from the trauma memory.
  • Medications –
    • SSRI – fluoxetine, Paroxetine, Sertraline
    • Alpha agonist – Prazosin, Clonidine
  • Compassion fatigue – decrease ion compassion over time due to repeated secondary trauma
    • Common in healthcare workers
  • Adjustment disorder – precipitated by a traumatic or stressful event. Less intense than PTSD
  • Acute stress disorder – PTSD symptoms that last for one month only
  • Dissociative disorders – commonly occur with a history of trauma. Unconscious defence mechanisms, where the patient dissociates with consciousness. (out of body experience)   
    • Fugue state – amnestic state of personality
  • Dissociative Identity Disorder – presence of more than one personality state. Each personality perceives, relates and thinks in a specific unique way.

 

Neurocognitive disorders In the Elderly

  • Common Mental disorders in the elderly
    • Dementia
    • Delirium
    • Depression
    • Confusion – from withdrawal, illness, dementia, delirium
  • s/s to be aware of:
    • Short attention, irritable

 

  • Benzodiazepines are not recommended to patients with any confusion s/s because it may exacerbate them.
  • In anxiety disorders sleep initiation is an issue, with depression it is sleep fragmentation.
  • Confabulation – filling in details of a story that are not true to connect to a scenario that they do not remember.
    • Creating stories relating to factual events
  • 15% of the elderly commit suicide
  • Dementia – impairment of intellectual functioning affecting memory and cognition
    • Primary caused by alzheimer’s Disease.

 

  • Anticholinergics have a high chance of a person experiencing dementia
    • Can also be very flushed, and have poor secretions.

 

  • Alzheimer’s disease – 4th leading cause of death
    • Progressive decrease in cognitive functioning
    • Risk Increases with age, head trauma, and lower education level
    • Confabulation
    • Medications –
      • Namenda (Memantine – blocks excess glutamate
      • Exelon (rivastigmine – Cholinesterase inhibitor
      • Aricept (donepezil) – Cholinesterase inhibitor, stops breakdown of Acetylcholine. Fewer side effects then exelon.

Mental Health Session 11: Personality Disorders

Session: 11 Personality Disorders

 

Pervasive behavior

 

Cluster A: Odd or eccentric – Paranoid, Schizoid, Schizotypal

  • Paranoid – distrusting to the people around them
  • Schizoid – detachment from relationships
  • Schizotypal – Deficits in social and personal skills as well cognitive distortions and eccentricities.  

Cluster B: Dramatic or erratic – Antisocial, borderline, Histrionic,

  • Borderline personality disorder – can have self injurious behaviors, lack of sense of self, emotionally unstable.
  • Narcissistic personality disorder: (Bernie Madoff) wants to be seen as a hero for people.
  • Histrionic personality disorder: needs to be in the center of attention, (housewives series on bravo)
  • Antisocial – Ted Bundy, criminal lack of remorse or regard, and can be charming.

Cluster C: Anxious or fearful – Avoidant, Dependent, Obsessive compulsive

  • Avoidant personality disorder
  • Dependent personality disorder
  • Obsessive-compulsive personality disorder – different than OCD, rigidity to routine to the extreme.

 

Somatic and fictitious symptom disorder

 

Disorders with a base in anxiety that present as real disease processes.

 

Illness anxiety disorder – always think there is some thing else. Have a lot of tests do to rule out causes but they always think there is something else

 

Conversion disorder – neurological disorders that results in a deficit of motor or sensory function.

  • pseudo seizures , paralysis, blindness, paresthesias, loss of sensation.

 

Factitious Disorders (formerly munchausen’s disorder)

  • Faking symptoms or inflict injury to self for secondary gain.
  • They want to be in the role of a sick person
  • About 1% of the population
  • This disorder “imposed on another” – giving their child a disease to have the child in the role of the sick person.
  • Malingering – is to fake an illness for a gain of some sort, personal or otherwise 

 

Mental Health Session 10: Eating Disorders

Session: 10 Eating disorders

 

Hypothalamus signals hunger and satiation

  • Regulation of the person’s appetite

 

Anorexia nervosa – usually in females ages in 12-30 y.o. And the prevalence is about 1%

  • Restrict eating
  • Medical complications
    • Cardiac arrhythmias, seizures, poor enamel, amenorrhea, constipation,

Bulimia nervosa – more chronic than anorexia. Prevalence ½% in males and three times that in females.

  • Cannot control eating or how much you eat.
  • Purging, laxatives, enemas, or diuretics
  • Purging weekly for at least three months
  • Generally normal weight to slightly over weight
  • Medical complications: bradycardia, electrolyte imbalances, russell’s sign which is calloused knuckles on the hands, stomach pain, dehydration, and poor dentition.

 

Binge eating disorder – similar to bulimia but do not purge

  • Extreme overeating from feelings of worthless self.

 

Biological influences

  • Genetic component is not proven but is hypothesised
  • Serotonin release occurs with eating almost any food. People with anorexia will feel anxious instead when feeling full.

 

Psychological influences

  • May start development at a very early age and delay the development of the ego.
  • Cognitive-behavioral theory – learned behaviour based on the positive reinforcement for loss of weight.

 

Family influence

 

Obesity – over 30 BMI

  • Increases mortality
  • Overweight americans are about 65% of the population
  • Not classified as an eating disorder

 

Psychopharmacology

  • Contraindicated meds
    • Bupropion (wellbutrin) – lowers seizure threshold which increases risk when the patient is already at a high risk.
    • Caution psychostimulants
  • Meds to use: there are no medications specific for an eating disorder
    • Use medications that target anxiety and depression ie. SSRI’s,

  • Medication for people with binge eating disorder: reduction of appetite
    • Topiramate (topamax)
    • Fluoxetine (Prozac)
    • Phentermine or topiramate (Osymia) – may have paresthesias, tingling in the periphery.

Mental health session 9: Schizophrenia

Session 9: Schizophrenia

 

About one percent of the population suffers from this disease

Strong genetic link

More common in men

  • s/s positive: delusions, hallucinations, disorganized, speech
  • s/s negative: not connecting socially, decreased expression

 

Schizophreniform disorder

  • Less intense than schizophrenia
  • 2 or more s/s for more than a month
  • This is the diagnosis before full blown schizophrenia

Schizophrenia

  • 2 or more s/s for more than 6 months
  • Phases
    • Premorbid phase
      • Shy, withdrawn, a- or anti social behaviour
      • Prodromal phase
    • Acute phase
      • Decline in functioning
      • Increase in thoughts and behaviour that are overwhelming
    • Stabilization phase
      • Decrease in symptoms
      • Increase socialization
      • Needs medication
    • Maintenance phase
      • Try to get back to previous level of functioning
      • Medications may decrease in this phase
      • Family support and community is crucial

 

Hallucinations

  • Auditory is most common,
  • Visual, tactile, olfactory, gustatory (taste)

 

Positive hallucination are added effects, and negative hallucinations are things that they stop doing like social activities and coping mechanisms

 

Neurocognitive impairment

  • Reduction of normal cognitive level
  • Memory attention, and thinking,
  • This could be independent of other cognitive functions.

 

Alterations in behaviour and catalonia

  • Negativism – the person does not react to stimulus even when painful
  • Immobile
  • Mutisim
  • excessive motor activity without purpose

 

Risk factors of schizophrenia

  • Stresses in prenatal period – lack of food to starvation, influenza and other infections
  • Strong genetic connection

 

Risk factors for suicide

  • Male, not adherent to medications, impulsive, psychosis, and multiple hospitalizations

 

Pharmacology

  • First gen: (mostly treats positive s/s)  Haloperidol, Chlorpromazine, THiothixene, fluphenazine
  • EPS that are severe – dystonia, akathisia
    • This can lead to parkinson’s like permanent movements

 

  • Second gen: treat the negative s/s as well.
    • Clozapine – great drug, but at risk for agranulocytosis
    • Ziprasidone -done – take with meal to increase absorption.

 

Nicotine – interacts with CYP450 enzyme so that the medication may be need to be reduced if the person smokes les cigarettes per day. clozapine and zyprexa

Mental Health Session 8: Mania

Session 8: Mania

 

  • Mania – poor sleep, poor impulse control, hyperverbal, sexually impulsive, extreme increased self esteem, and may include symptoms of psychosis.

 

  • Bipolar 1 – needs a manic episode for one week straight with at least 3 mania s/s
    • Mostly mania
    • About 4.5% of the population
    • More common in women

 

  • Bipolar 2 – meets criteria for major depressive episode, with hypomania s/s for 3 – 4 days
    • Some maina with a major depressive episode
    • Less than 1% of the population
    • More common in women
  • Major depressive episode 5 symptoms for 2 weeks
    • Low energy, sad, hopeless, decreased activity ect.
  • Cyclothymic – alternating hypomania and a mild to moderate depressive episode. This lasts for 2 years in adults and 1 year in
    • Moderate swings in mood, never get to manic or major depressive episode

  • Bipolar disorder is linked to genetic factors, and risk of getting the disease increases with the closer the family member is to you.
    • Up to 60% of the population with this disorder will attempt suicide.
  • Duty to warn

 

  • Pharmacology
    • Stimulants and antidepressants can make bipolar worse, and will make the manic episode much more prominent.
    • Norepinephrine, dopamine, Serotonin
    • Lithium – for mania with suicidal thoughts
      • Dosed 2-3 times a day
      • 1200mg average total daily dose
      • Mood stabilization, and desired med for manic state. (can also use benzodiazepines to calm a person down)
      • Toxicity s/s – slurred speech, tremors, EKG changes, severe dysrhythmias, coma, death, headache, nausea, vomiting, diarrhea.
      • Is a salt, they will get polydipsia
      • Lab values .8-1.2mEq/L drawn 12 post dose
      • Cipriani (2013) meta analysis  lithium is the only med to decrease suicidal ideation

 

  • Depakote
    • Seizure medication
    • Sedation, weight gain, teratogenic
  • Lamotrigine (lamictal)
    • Steven johnson’s rash!
    • Excreted renally
  • Tegretol, carbamazepine
    • Makes birth control pill decrease efficacy
  • Risperdal Consta
    • Long acting injectable
    • Bipolar
    • Increases adherence

 

  • ECT
    • Electroconvulsive therapy
    • Temporary memory loss
    • Headache
    • Only used if pharmacologic interventions fail.