Exam Slam #2

What do the different phases of AUD look like?

Phase 1: Pre-alcoholic- drinking to relieve everyday stressors, tolerance starts to build

Phase 2: Early alcoholic- ETOH consumption is required to get through the day, may feel guilty and hide/lie about their drinking

Phase 3: Crucial phase- Loss of control, dependence is evident. Drinking interferes with daily life/responsibilities. Experiences symptoms of withdrawal when not drinking

Phase 4: Chronic phase- emotional and physical disintegration, intoxicated more often than sober, drinking is necessary to function

CAGE screening

have you ever felt the need to Cut down on your drinking?

have people Annoyed you by criticizing your drinking?

have you ever felt Guilty about your drinking?

have you ever had a drink first thing in the morning? (Eye opener)

A score of 2 or more is clinically significant

Potential complications of chronic alcohol use

• Wernicke-Korsakoff syndrome→ from vitamin B1 (thiamine) deficiency

• Megaloblastic anemia→ from vitamin B9 (folate) and B12 deficiency

• Peripheral neuropathy

• Alcoholic myopathy- muscle weakness and wasting

• Pancreatitis

• Cirrhosis

• Hepatitis

• Alcohol-related dementia

• hepatic encephalopathy

• esophageal varices—if ruptured, is a medical emergency (hemorrhage)

Early vs Late signs of alcohol withdrawal s/s

Early- anxiety, tremors, irritability, sweating, n/v, tachycardia, insomnia

Late- delirium, tremors, diaphoresis, severe agitation, visual hallucinations, maybe delirium tremens

Medication management of alcohol withdrawal

1. Benzodiazepines (diazepam, lorazepam, chlordiazepoxide)

2. B vitamin therapy (thiamine, folate, B12)

3. Antipsychotics for severe agitation or hallucinations

4. Disulfiram- deters dinking by causing nasty effects if ETOH is consumed or applied on the skin. Requires patient motivation and compliance

5. Naltrexone- reduces the rewarding effects of alcohol and opioids

6. Acamprosate- maintains abstinence by reducing cravings and withdrawal symptoms

CIWA-Ar assessment

Assessment to manage alcohol withdrawal in hospitalized patients, done every 1-8 hours.

• Score of 8-10: minimal-mild overdose

• Score of 8-15: moderate withdrawal

• Score of 15+: severe withdrawal

Stimulant intoxication, overdose, and withdrawal s/s

Intoxication: everything is up, mydriasis, n/v, diarrhea, palpitations, tremor, diaphoresis

Overdose: acute delirium and toxic psychosis, stroke, hyperthermia, seizures and muscle rigidity, rhabdomyolysis

Withdrawal: everything is down, cravings

Cocaine overdose s/s

Severe anxiety, panic, agitation; hallucinations and paranoid delusions, seizures, delirium, MI or arrythmias, hyperthermia, rhabdomyolysis, respiratory failure

Heroin and opiates intoxication, overdose s/s

Intoxication: euphoria, drowsiness and sedation, miosis, slowed breathing and HR, dry mouth, n/v, itching and flushing of the skin, impaired cognitive function

Overdose: extremely slow/shallow breathing or may completely stop, severely decreased LOC or coma, miosis, cyanosis, cold clammy skin, weak pulse and hypotension, inability to wake the person (even with painful stimuli), gurgling/choking sounds

Heroin and opiates early and late withdrawal s/s

Early: intense drug cravings, anxiety and irritability, yawning, rhinorrhea and watery eyes, sweating

Late: muscle and bone pain, n/v/diarrhea, insomnia, cold flashes and piloerection, restlessness and agitation

Buprenorphine

By itself: produces some opioid effects but has a “ceiling effect”, lowers the risk of respiratory depression compared to full agonists

Buprenorphine-naloxone: maintenance treatment of opioid use disorder

Hallucinogenic intoxication, overdose, and withdrawal s/s

Intoxication: altered sensations and perceptions, distorted time/reality, depersonalization, mydriasis, tachycardia and HTN, sweating,

Overdose: dangerously high temp/HR, depersonalization, extreme anxiety and panic, psychosis or severe paranoia, seizures, respiratory distress, CV complications, dangerous behavior

Withdrawal: anxiety, depression, flashbacks, depersonalization, may include fatigue, sweating, tremors, mood swings, sleep disturbances

Behaviors of ODD, signs and symptoms, goals?

Behavior:

s/s:

goals:

Behaviors of ADHD, signs and symptoms, goals?

Behavior: inattention, hyperactivity, impulsivity, emotional dysregulation, disorganization

s/s:

goals:

Behaviors of CD, signs and symptoms, goals?

Behavior: aggression towards people and animals, destruction of property, deceitfulness, serious violations of rules, lack of empathy or remorse

s/s:

goals:

Behaviors of ASD, signs and symptoms, goals?

Behavior: social communication challenges, repetitive behaviors, sensory processing difficulties, emotional regulation challenges, difficulty with changes in routine

s/s:

goals:

Paranoid personality disorder behaviors:

Distrust and suspiciousness, tendency to interpret other people’s motives as malevolent; hypervigilant, constantly tests loyalty of others, blames shortcomings onto others

Schizoid personality disorder behaviors:

Detachment from social relationships, restricted range of emotional expression, perceived as cold, chooses solitary activities, lack of spontaneity

Schizotypal personality disorder behaviors:

Ideas of reference, magical thinking, paranoia, inappropriate/constricted affect, odd, eccentric, or peculiar behavior

Antisocial personality disorder behaviors:

Disregard and violates the right of others, appears very charming but doesn’t talk much about themselves, lack of remorse, irritability and aggressiveness

Borderline personality disorder behaviors:

Unstable relationships, frantic efforts to avoid abandonment (cutting themself but doesn’t want to die, for attention), impulsive, suicidal behavior, inappropriate anger, depression is very common

• Set BOUNDARIES

Histrionic personality disorder behaviors:

Attention-seeking as a form of impulsivity, shallow, seductive/provocative behaviors, suggestible, difficulty maintaining long-lasting relationships

Narcissistic personality disorder behaviors:

Grandiose self-importance, fragile self-esteem, sense of entitlement, requires excessive admiration, lacks empathy, interpersonally exploitative

Avoidant personality disorder behaviors:

views self as inferior, internally preoccupied with criticism/rejection, hypersensitivity to negative evaluation,

Dependent personality disorder behaviors:

difficulty making decisions, uncomfortable when alone, needs other to assume responsibility, excessive reassurance, clingy

Obsessive-compulsive personality disorder behaviors:

preoccupation with details/rules, perfectionist, inflexibility, excessive devotion to work, stubbornness, interpersonal control, traits do not cause distress to individual (not OCD)

Fluoxetine (Prozac) class, indication and side effects

SSRI: depression treatment, Bulimia nervosa

• n/d, insomnia, headache, dry mouth, sexual dysfunction

Sertraline (Zoloft) class, indication and side effects

SSRI: depression

• n/d, insomnia, sexual dysfunction, fatigue, dizziness

Venlafaxine (Effexor) class, indication, and side effects

SNRI: depression

• nausea, headache, dry mouth, sweating, dizziness, insomnia

Escitalopram class, indication, and side effects

SSRI: depression

• nausea, insomnia, sexual dysfunction, fatigue, drowsiness, dry mouth

Duloxetine

SNRI: depression

• n/c, dry mouth, fatigue, decreased appetite, increased sweating

What does discontinuation syndrome look like?

Flu-like symptoms

• may occur when suddenly stopping antidepressants or switching medication

• most effective treatment is restarting medication

What does a manic episode of bipolar disorder look like?

elevated mood, reckless, increased sexual drive, grandiose thinking, DO NOT SLEEP, racing thoughts, impulsive (may be risky) behavior, over focus on own goals, increased energy

Lithium indication, toxicity and what to do about it, patient ed

DOC for bipolar disorder; drug levels are 0.6-1.2

Toxicity: flu-like symptoms PLUS blurred vision, vomiting/diarrhea, tremors, sedation, confusion, delirium, seizures, ataxia

Drink 2L/day for hydration and renal protection, adequate sodium, know signs of toxicity, carry medical bracelet and note taking lithium, do not drive until you know how it affects you

Anticonvulsants

2nd choice drug if lithium is not viable/tolerable

Carbamazepine, Depakote, Gabapentin, lamotrigine

Valproic acid/Depakote monitoring and education

monitor LFTs, educate about potential teratogenicity and potential skin reactions, monitor drug levels and weight gain

Carbamazepine monitoring and education

Monitor CBC and LFTs, numerous drug interactions, potential skin reactions, monitor drug levels

Lamotrigine monitoring and education

monitor for skin rashes and SJS, educate about titration to reduce skin rashes, interaction with oral contraception

Atypical antipsychotics (2nd gen)

Aripiprazole (Abilify), Olanzapine (Zyprexa), Quetiapine (Seroquel), and Risperidone (Risperdal)

• monitor for EPS, metabolic changes, akathisia, sedation, orthostatic hypotension, prolactin levels, glucose levels

Medication for BED (binge eating disorder)

Lisdexamfetamine

• treat moderate-severe BED in adults

• CNS stimulant that controls impulsive behavior that can lead to bingeing, enhances impulse control and brain processing, improves mood

• side effects: dry mouth, decreased appetite, insomnia, tachycardia

Topiramate (Topamax)

• significantly reduce binge eating frequency, binge days per week, and body weight

Medication for Bulimia Nervosa

Fluoxetine (Prozac) SSRI

• only FDA med approved for Bulimia

• shown to significantly reduce binge eating and vomiting episodes

Delirium (what is it, what causes it, treatment)

Alteration in awareness, overstimulated, disorganized thinking, impaired reasoning, disorientation, memory impairment, possible psychosis, nutritional deficiency

• can develop FAST

Can result from systemic infections like UTIs, medication-induced, stress or social isolation, febrile illness, metabolic disorders, poly-pharmacy (side effects)

Treatment: treat underlying cause, reorientation/reassurance, psychotic and benzo is possible

Risk factors for delirium

• older age

• young children

• poor cognitive status

• depression, pain, sleep disturbances

• drug interactions or side effects (anticholinergics, sedatives, opioids)

Early-mid stage symptoms of dementia

• impairments in judgement, impulse control

• physical appearance and hygiene are neglected

• personality change, confabulation (filling in the gaps of what they forget by lying)

• agnosia, aphasia, misplacing objects, forgetting key details of their life

Late symptoms of dementia

• inability to care for personal needs (incontinence)

• irritability and moodiness

• profound memory deficit

• minimal verbal communication

• repeating phrases/behaviors

Dementia interventions

• non-pharmacological treatment is first

• medications for specific symptoms

• orient patient, patience with them, acknowledge their emotions

Stages of dementia and s/s

Stage 1: no overt symptoms

Stage 2: forgetfulness noticed by patient

Stage 3: mild cognitive cognitive decline, changes noticed by others, interferes with work performance, gets lost

Stage 4: mild-moderate cognitive decline, forgets major events like birthdays, confabulation, needs some assistance

Stage 5: moderate cognitive decline, decreased ADL ability, loses independence, more disoriented to place/time, requires some assistance

Stage 6: moderate-severe cognitive decline, needs assistance with ADLs, sundowning, incontinence

Stage 7: severe/hospice- aphasic, bedridden, imminent death