A 35-year-old woman with a history of alcohol abuse and depression presents in an obtunded state after an overdose of alcohol, benzodiazepines and a MAOI.
Which of the following represents the most serious threat under these circumstances?
Correct Answer B:
Alcohol overdose may cause slurred speech, confusion and aggression and puts the patient at risk of aspiration of vomit. Wernicke’s encephalopathy requires immediate referral for urgent thiamine infusion.
Benzodiazepine overdose leads to drowsiness, ataxia and nystagmus to hypotension, respiratory depression and coma.
Monoamine oxidase inhibitors (MAOIs) overdose symptoms include: tremor, sweating, agitation, tachycardia and hyperthermia. Hyper or hypotension may occur and in severe cases the patient may have seizures, respiratory depression and/or cardiac arrest.
Which one of the following would justify a patient's being declared incompetent with respect to self care?
Correct Answer D:
Incompetence is determined by establishing the inability to understand the risks, benefits, and alternatives of particular activities.
The diagnosis of mental illness lies in the hands of medical and psychiatric personnel. On the other hand, the determination of mental incompetence lies with a court of law.
A homeless 30-year-old man dressed in tattered clothes is brought into the Emergency Room by police after he was found haranguing passersby.
Which one of the following is most suggestive of psychosis?
Correct Answer C:
Psychosis is a loss of contact with reality. Some people with psychosis have false beliefs that can best be described as fearfulness and suspiciousness (paranoia). They may have vague fears or complaints about others controlling their lives (choice C), but many describe consistent suspicions of very specific, elaborate, and persistent plots against them. Very often, these beliefs are directed at family members or friends. For example, people with psychosis may believe that their spouse or children have deserted them or that their family or friends are scheming to obtain control of their finances or property.
Hallucinations, seeing or hearing things that no one else sees or hears, are sometimes experienced by people with psychosis. These hallucinations may seem dangerous and threatening to the person, although in some cases they are taken in stride.
People with psychosis may lose the ability to take care of their personal hygiene. They may seem withdrawn and without any emotions. However, when a psychotic disorder, such as paraphrenia, develops during old age, it is common for a person to communicate and function quite well despite delusions or hallucinations.
→ Hyper-religiosity and ascetic living habits (choice A) is more suggestive of schizoid personality disorder.
→ Rumination about the meaninglessness of material things (choice B) and loss of interests in activities one used to enjoy are characteristic of depression.
→ Disorientation to time and place (choice D) can be noted in dementia or amnesia.
→ Grandiose ideas that he would become the world's president (choice E) would be suggestive of bipolar disorder.
A 38-year-old man is taking medications for psychosis. You would like to change his treatment from his current antipsychotic agent to risperidone.
What is the best way to do it?
When treating patients with psychosis, you must often consider changing their treatment from one antipsychotic agent to another. A principal problem in changing antipsychotic agents is the potential for withdrawal symptoms resulting from discontinuation of the existing therapy. These syndromes can manifest as reemergence or worsening of psychosis, rebound or unmasked dyskinesia, and cholinergic-rebound symptoms. Withdrawal signs and symptoms may include insomnia, nausea, vomiting, anxiety, and agitation.
When switching a patient to the new antipsychotic agent risperidone, you can keep withdrawal symptoms to a minimum. Usually, the dose of the previous medication must be gradually reduced before risperidone is initiated. However, in many cases, the transition is best made by overlapping the existing therapy and risperidone.
A 76-year-old male has psychosis secondary to dementia associated with Parkinson’s disease. After exhausting all other options you decide to prescribe an antipsychotic agent.
Which one of the following would be the best choice in this situation?
Antipsychotics are indicated when other efforts to treat psychosis or agitation have failed or if antiparkinsonian medications cannot be reduced without sacrificing motor function. Importantly, they enable increases in antiparkinsonian medications. Since “typical” antipsychotics block dopamine D2 receptors and lead to increased parkinsonism, only “atypical” antipsychotics with a low potential for inducing parkinsonism (rigidity, bradykinesia, and tremor) are used. Among those currently available (clozapine, risperidone, olanzapine, quetiapine, ziprasidone, and aripiprazole), only quetiapine and clozapine are consistently recommended.
Clozapine is currently the gold standard of antipsychotic agents in PD given its demonstrated safety and efficacy in controlled trials without worsening parkinsonian symptoms. Sedation or confusion can occur at low doses in this fragile population and most patients respond to <50 mg/day, though some require higher doses or an additional low dose in the mornings. The most common side effects are sedation, orthostasis, confusion, and drooling. Weekly phlebotomy is required to monitor for potential agranulocytosis. Any inconvenience of this is offset by therapeutic benefits.
Quetiapine is a common first choice because it can be used without the risk of agranulocytosis and weekly blood monitoring. However, quetiapine has not been subject to controlled trials. Its safety and efficacy profile in open-label studies is favorable, but inadequate symptom control or increased parkinsonism or motor fluctuations can occur. Lower doses are used initially because patients with hypotension or orthostasis may not tolerate higher doses. Sedation and confusion are common side effects, but a recent open-label study showed improved cognitive functioning on quetiapine.
→ Typical antipsychotics, namely haloperidol (choice A), which is used to treat agitation or delirium in non-PD patients, are not recommended as they induce severe parkinsonism.
→ Initial open-label studies of olanzapine (choice B) were favorable in terms of effectiveness and safety, but this was not shown in controlled trials. It may also be associated with worsening of parkinsonian symptoms.
→ Risperidone (choice C) is an effective antipsychotic, but is poorly tolerated in PD, even at doses < 1 mg/day.
→ Effects of aripiprazole (choice E) on psychosis in PD are varied, and some patients have worse motor function.
Click to expand