Workbook

Week 4

78
 Week 4: Curriculum Topics

22. Psychiatry of the Elderly

23. Neuropsychiatry

24. Alcohol and Substance Misuse

25. Acute behavioural disturbance

79
 Overview of curriculum topics for week 4
STEPWISE
deterioration in: Dementia
(RCSI Psychiatry Course Book Chapter 22)

Irreversible causes of dementia Potentially treatable

ascular dementia causes of dementia

• Head injury.
Alzheimer’s disease Vascular dementia Dementia in Lewy body dementia Other causes of
• Chronic
• #1 cause of dementia. • 2nd most Pick’s disease • Dementia. dementia
alcohol use.
• INSIDIOUS onset with common form of (frontotemporal • Features of • Dementia in
• Infections
SLOW deterioration. dementia. dementia) Parkinson’s disease, CJD.
(e.g.
• No neurological signs • ABRUPT onset • Progressive (e.g. tremor, rigidity, • Dementia in meningitis,
Note: the early in the illness. with STEPWISE dementia. bradykinesia, Huntington’s encephalitis).
boundary Risk factors deterioration. • Occurs at an postural change, disease.
• Normal
between • ↑ age. • History of earlier age to gait disturbance). • Dementia in pressure
Alzheimer’s transient Alzheimer’s • Fluctuation in Parkinson’s
• ↑ maternal age at birth. hydrocephalus
disease and ischemic disease. cognitive function disease.
• ♀ > ♂. • Brain tumours.
vascular attacks (or • Frontal & with varying levels of • Dementia in
dementia • Down’s syndrome. • Heavy metal
major stroke). parietal lobes alertness & HIV.
can be • < 8 years of education. exposure (e.g.
• Mild cognitive • Associated with mostly affected. attention. lead, arsenic).
blurred. In hypertension & • Frontal features • Visual hallucinations
such impairment. • Hypoxia.
carotid bruit. (e.g. euphoria, • ↑ sensitivity to
instances, • Systemic vascular • Endocrine
disease. • Presence of emotional antipsychotic
the term disorders.
focal blunting, medication (↑ risk of
MIXED • Small head size. • Metabolic
neurological coarsening of EPSEs).
DEMENTIA • History of head trauma. disorders.
signs & social
can be • Family history of symptoms. • Nutritional
behaviour, Management
used. A lot Alzheimer’s disease. Risk factors deficiencies.
disinhibition, & • Acetylcholinesterase
of people • Molecular genetics • ↑ age (usually apathy or • Drug reactions
inhibitors have been
with o Presenilin2 (PS2) occurs at a restlessness). or misuse.
used.
Alzheimer’s on chromosome 1. younger age • Behavioural • Memantine (if AChE
disease o Presenilin1 (PS1) than changes often inhibitors are not
have neuro- on chromosome14. Alzheimer’s precede frank tolerated or are
vascular o ApoE4 on disease). memory contradicted).
disease. chromosome 19
• ♂ > ♀. impairment. • Antipsychotics: use Dementia
o Amyloid precursor
• Genetics: with care due to ↑ • Dementia is a syndrome due to
protein (APP) on
ApoE4 gene MMSE & MoCA sensitivity. If needed disease of the brain, usually of
chromosome 21.
(also a risk • MMSE & MoCA= use a low dose chronic or progressive nature
Note: PS1, PS2 & APP →
factor for routine cognitive atypical (e.g. in which there is a disturbance
early onset Alzheimer’s
Alzheimer’s screening tests quetiapine). of higher cortical functions,
disease. ApoE2 → late onset
disease). rated on a 30 point • Levodopa/ including memory, thinking,
Alzheimer’s disease.
Mutations in scale. carbidopa: may orientation, comprehension,
Neuropathology
Notch 3 gene • MMSE = widely improve motor calculation, learning capacity,
• Brain atrophy, on chromosome used screening function. language & judgement.
neurofibrillary tangles,
19 is a risk tool for dementia; • Psychological & • Consciousness is NOT
amyloid plaques.
factor for a form ≥ 27 points = social: same as for clouded (versus delirium).
• ↑ lateral ventricles. of vascular normal, 21-26 = Alzheimer’s disease. • Sundowning = confusion &
• ↓ neurons. dementia mild, 11-20 = wandering which are worse at
Neurochemistry known as moderate, ≤ 10 = night.
• ↓ acetylcholine, CADASIL. severe cognitive • “4 As” of dementia:
norepinephrine, • Vascular risk impairment. o Amnesia: loss of
epinephrine, serotonin, factors. • MoCA = more RECENT rather than
somatostatin, GABA, Management sensitive at remote memory.
creatine kinase. • ↓ vascular risk detecting mild o Agnosia: inability to
• ↑ glutamate in factors. cognitive recognise objects, a
extrasynaptic space → • Acetylcholines- impairment & mild family member or one’s
NMDA receptor terase inhibitors Alzheimer’s own mirror reflection.
overstimulation → have been used disease. o Apraxia: inability to carry
synaptic loss/cell death. (unlicensed). out simple tasks (e.g.
• MoCA = more
Management
• Psychological & emphasis on tasks dressing, eating).
• Acetylcholinesterase social – same of frontal executive o Aphasia: inability to
inhibitors (e.g. as for functioning & speak.
donepezil, rivastigmine, Alzheimer’s attention which • Prevalence: 5% of people > 65
galantamine). disease. may make it more years, 20% > 80 years.
• Memantine. sensitive in
• Depression detecting non-
(mild/moderate): Alzheimer’s
consider psychological dementia.
treatment. If pre-
existing severe mental
• Psychological management of Alzheimer’s disease: art therapy, music therapy, behavioural therapy, reality orientation
health problem consider
(reminding the person about themselves & their environment, e.g. signposts/notices for fridge etc.), validation therapy
antidepressant.
(emphasise with their feelings & meanings hidden behind their confused speech & behaviour), reminiscence therapy (helping
• Psychosis: low dose people with dementia to relive past experiences, e.g. showing photos of family holidays & weddings).
atypical antipsychotic.
• Social management of Alzheimer’s disease: meals on wheels, home help, activity therapy (e.g. dance, sport, drama),
• Psychological & social complementary therapy (e.g. massage, aromatherapy), animal assisted therapy (pet therapy), social work, occupational
management: see box therapy (to improve skills), carer support, support groups (e.g. Alzheimer’s Society of Ireland).
opposite.
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 Alzheimer’s disease Vascular dementia
Ranking • Most common form of dementia. • Second most common form of dementia.
Gender • Females > males. • Males > females.
Age • Later age of onset. • Earlier age of onset.
Onset • Insidious (gradual). • Abrupt.
Progression • Slow and steady. • Stepwise.
Vascular risk factors • Less common. • More common.
Focal neurological signs and symptoms • Less common. • More common.
Risk of co-existent depression, persecutory delusions, • Less common. • More common.
anxiety and emotional disturbance
Personality changes • More common. • Less common.
Deterioration in insight and judgement • More common. • Less common.
Acetylcholinesterase inhibitors and memantine • Licensed for use. • Not licensed for use.
CT scan • Mainly temporal lobe atrophy. • Infarcts. White matter change.
EEG • Usually abnormal even early in the • EEG is of limited help, although it is possible
disease. It shows a slowing of alpha that there may be focal activities at the site of
waves initially, later increased delta a thrombosis.
and theta waves.

Dementia Pseudodementia
Features • Disturbance of higher • Depression in the elderly that may Delirium
cortical functions, resemble dementia. • Impairment of consciousness &
including memory, • Typical symptoms of depression attention.
thinking, orientation, are present. • Global disturbance of cognition
comprehension, • Patients may complain of memory (perceptual distortions, illusions &
calculation, learning impairment and other cognitive hallucinations - most often visual,
capacity, language and problems. However, upon careful impairment of abstract thinking &
judgement. testing, memory and language comprehension with or without
functioning are intact. The history transient delusions but typically with
of cognitive problems is usually some degree of incoherence,
short, with depressive symptoms impairment of immediate recall & of
appearing before cognitive recent memory with relatively intact
symptoms. remote memory, disorientation for time
Onset • Slow. • Acute. & in the more severe cases, for place &
Focus of patients • Patient focuses on past • Patient focuses on failures. person).
success. • Psychomotor disturbances (hypo, or
Confusion at night • Present. • Absent. hyperactivity).
Answers • Guesses at answers • Often avoids answering questions • Disturbance of the sleep-wake cycle.
(confabulation). and makes little effort to find the • Emotional disturbances
correct answer (“don’t know”
answers). Epidemiology: can occur at any age but
Past history of • Less likely. • More likely. most common in the elderly.
depression
Awareness of • Less likely. • More likely - the person is more Main causes: infections (e.g. UTI),
difficulties likely to complain of memory electrolyte disturbances, dehydration,
problems. medications, organ failure, post-surgery &
Neurological signs • More likely. • Less likely. among nursing home residents & ICU
patients.

Feature Delirium Dementia Management

Onset • Acute (abrupt) • Insidious (gradual) • Avoid aggravating factors (e.g. certain
Course • Fluctuating • Progressive medications).
Duration • Days to weeks • Months to years • Identify & treat the underlying illness.
• Provide supportive & restorative care.
Consciousness • Altered • Clear
• Control disturbed behaviour (i.e. see
Cognitive testing • Rapid fluctuations • Slow decline
“acute behavioural disturbance”).
Visual hallucinations • Common • Uncommon • Fluid & nutrition.
Inattention • Significant • Mild • Environmental modifications -
Disorganised thinking • Common • Unusual unless severe o Consider one to one nursing.
Psychomotor changes • Increased or • Often normal o Re-orientation techniques/memory
decreased cues such as a calendar, clock &
Sleep wake cycle • Disrupted • Preserved family photos.
Reversibility • More common • Less common o Stable, quite & well lit
environment with support from a
familiar nurse & family.
o Family members & staff should
explain to the patient what is
Elder abuse
happening to them. They should
• Abuse of older people is often ignored by society, also reassure the patient.
• This abuse is often hidden & may not be obvious, even to the victim. o Physical restraints should be
• Elder abuse is likely to be underreported. AVOIDED.
• Types of elder abuse: physical, emotional, sexual, discriminatory (e.g. racist, sexist or based on • Biological: antipsychotics (e.g.
the person’s disability), neglect, financial exploitation. haloperidol or olanzapine). Consider
• Carer risk factors for elder abuse: depression, alcohol & substance misuse, lack of support benzodiazepine if severe agitation (e.g.
from someone else/other people, thinking that care giving is a burden. lorazepam).
• Elder risk factors for elder abuse: severe illness or dementia, behavioural disturbance, previous
role as an abusive parent/spouse, history of domestic violence, social isolation.
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 Psychiatric consequences of
Wilson’s disease stroke
• Autosomal recessive • Cognitive disorders
disorder of copper o Vascular dementia. Psychiatric consequences of temporal lobe epilepsy
metabolism. o Subcortical dementia. • Most commonly: depression, anxiety & psychosis.
o Amnestic disorder. • Psychiatric syndromes associated with epilepsy can be
• Genetic defect is on
chromosome 13 → affects • Personality changes divided as follows -
the copper-transporting o Difficulty adjusting to 1. Preictal = the stage before the seizure (symptoms ↑
ATPase in the liver → ↑ anything different. as seizure nears while the seizure itself relives these
copper in liver (initially) then o Irritability. symptoms)
in other organs (e.g. brain, o ↑ previous personality o Derealization & depersonalization.
kidney & cornea). features. o Cognitive symptoms (déjà vu, jamis vu, fugue,
o In severe cases, with twilight states).
• ↑ serum/urine copper.
significant frontal lobe o Affective symptoms (irritability, lability, anxiety,
• ↓ serum caeruloplasmin
damage → euphoria).
(copper binding protein).
disinhibition. o Perceptual experiences (auditory, visual &
• Psychiatric symptoms:
• Pathological emotionalism. olfactory hallucinations or illusions).
cognitive impairment,
• Post-stroke depression (#1 2. Ictal = the phase during the seizure
depression, personality
psychiatric consequence of o Anxiety.
change, psychosis.
stroke). o Depression.
• Treatment: penicillamine
• Post-stroke anxiety o Psychosis.
binds to accumulated
copper & eliminates copper • Psychosis o Aggression (very rare).
through the urine. o Automatisms (e.g. lip smacking).
3. Post-ictal = the phase after the seizure
Multiple sclerosis o Confusion.
• Mostly a white matter o Mood disturbance (depression, anxiety or
disease. mania).
o Psychosis.
• Psychiatric
4. Inter-ictal = the phase between seizures
symptoms: cognitive
o Depression.
deterioration, lability
o Bipolar disorder.
of mood, depression
o Anxiety.
(#1), mania, anxiety,
o Psychosis.
psychosis,
5. Other psychiatric presentations
involuntary emotional
o Cognitive deterioration (common in chronic
expression disorder
epilepsy).
(episodes of
o Epileptic personality change.
Parkinson’s disease laughing/crying
o Violence (controversial issue)
• Caused by progressive unrelated to
deterioration of neurons in the mood/event).
substantia nigra → ↓ dopamine
→ abnormal nerve functioning
→ loss of ability to control body
movements.
• Psychiatric symptoms
o Depression (#1).
o Anxiety. Psychiatric consequences of head injury
o Psychosis. Neuropsychiatry • Cognitive impairment - includes
o Dementia. (RCSI Psychiatry Course problems with:
o Dopamine dysregulation Book Chapter 23) o Memory & thinking.
syndrome (impulse control o Executive function
disorders, e.g. compulsive o Language (e.g. dysphasia, word-
gambling/shopping/eating, finding difficulties, impaired
hypersexuality). reading & writing skills).
o Judgement & safety awareness.
• Personality & behavioural changes.
• Mood disorders (particularly
Huntington’s disease Psychogenic non- depression. The risk of suicide is ↑ in
• Autosomal dominant. epileptic seizures people with traumatic brain injury).
• 100% penetrance. • Episodes that • Anxiety.
• Caused by the expansion of > 35 resemble & are often • Psychosis.
repeats of CAG. misdiagnosed as • Substance misuse (alcohol & illicit
• The longer the CAG repeats, the epileptic seizures. substances).
earlier the onset & eventual severity • Psychological origin • Impulse control disorder (failure to
of illness. (i.e. emotional, resist an impulsive act or behaviour
• Psychiatric symptoms stress-related). that may be harmful to oneself or
o Depression (#1). • Involuntary. others. The person has little or no
o Other symptoms: hypomania, • Classified in ICD-10 control over the impulsive behaviour
bipolar affective disorder, under dissociative or act).
obsessive compulsive disorder (conversion)
& psychosis). disorders.

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 Alcohol & Substance Misuse (RCSI Psychiatry Course Book Chapter 24)
Dependence on alcohol/illicit substance
• Strong DESIRE or sense of COMPULSION to take the substance.
• Difficulties in CONTROLLING substance-taking behaviour in terms of its onset, termination or levels of use.
• Physiological WITHDRAWAL.
• TOLERANCE (i.e. ↑ amount of alcohol/illicit substance is needed to achieve original effects).
• Progressive NEGLECT of alternative pleasures/interests because of alcohol/substance use, ↑ time needed to obtain/take
alcohol/substance or to recover from its effects.
• Persisting with alcohol/substance use despite clear evidence of HARMFUL consequences (e.g. liver damage).
• NARROWING of the personal repertoire of patterns of alcohol/substance use (e.g. tendency to drink alcohol in the same way on
weekdays & weekends, regardless of social constraints).

Guidelines for safe alcohol use: No “safe” amount of alcohol. Recommended low-risk limits for alcohol consumption: ♂ = 17 units per
week, ♀ = 11 units per week.

1 unit of alcohol = ½ pint beer = single measure of spirit = small glass of wine.

Genetics: ↑ risk of alcohol dependency for the child of a parent who is alcohol dependent. The risk is strongest for the SON of an
alcohol dependent FATHER.

Ethnic differences: many Asians demonstrate acute toxic effects (e.g. intoxication, flushing, dizziness, headache) after small amounts
of alcohol. The genetic pathology is a single base pair change in exon 12 of aldehyde dehydrogenase 2.

CAGE Questionnaire (C-A-G-E): SCREENING TEST for alcohol dependency. NOT diagnostic.

Indirect alcohol biomarkers which suggest heavy alcohol use: AST, ALT, GGT, CDT, MCV.
Direct alcohol biomarkers: blood alcohol content, ethyl glucuronide (EtG), acetaldehyde fatty acid ethyl esters (FAEE), ethyl sulphate
(EtS), phosphatidylethanol (PEth).

Complications of alcohol dependency: see RCSI Psychiatry Course Book Chapter 24.

Delirium tremens
• Acute confusional state secondary to alcohol withdrawal. Symptoms peak 48-72 hours after the last drink (but can occur up to 7-
10 days after the last drink). Mortality is 5-10%.
• Mental state changes: agitation, amnesia for recent events, delirium, delusions, disorientation, irritability & mood fluctuations,
hallucinations (visual, olfactory, tactile). Lilliputian hallucinations = visual hallucinations if of little people/animals.
• Seizures: usually generalised tonic clonic.
• Autonomic over-activity: hypertension, hyperthermia, palpitations, sweating, tachycardia, tachypnoea.

Wernicke Korsakoff’s syndrome

• Heavy, long-term alcohol use → thiamine (vitamin B1) deficiency which can result in Wernicke’s syndrome which is an acute
phase of clouded consciousness with nystagmus, ophthalmoplegia, ataxia & peripheral neuropathy.
• Thiamine is crucial to prevent the progression to Korsakoff’s syndrome (+ electrolyte supplementation, especially Mg & K).
• Korsakoff’s syndrome is a state of clear consciousness with confabulation, disorientation, amnesia (retrograde & anterograde),
apathy or repetitive behaviour, no insight into memory loss peripheral neuropathy. Treatment = thiamine + electrolyte
supplementation (especially Mg & K).

Management of alcohol withdrawal

• Biological: chlordiazepoxide + thiamine, rehydration, consider an anticonvulsant (e.g. carbamazepine) if previous history of
withdrawal seizures. Haloperidol can ↓ agitation.
• Psychological: determine the person’s readiness for change (5 stages of change = pre-contemplation, contemplation,
determination/preparation, action, maintenance & relapse management), brief advice to ↓ drinking can be helpful,
psychoeducation (about addiction & medical complications), CBT, family therapy.
• Social: Alcohol Anonymous (AA) 12-step programme, Al-Alon for families/friends of people who are alcohol dependent, Al-Teen
for young people affected by a problem drinker. Also consider intervention by social work & occupational therapy.

Achieving abstinence from alcohol: disulfiram (people taking disulfiram have a very unpleasant reaction when they take even small
amounts of alcohol, e.g. flushing, headache, nausea, vomiting, sweating), naltrexone (↓ alcohol craving), acamprosate (for people
who have already achieved abstinence to remain abstinent), nalmefene (↓ alcohol consumption in people with alcohol dependence).

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 Substance Misuse (RCSI Psychiatry Course Book Chapter 24)
Categories of drugs of abuse
• Depressants (e.g. benzodiazepines, barbiturates, gamma hydroxybutyrate [GHB], flunitrazepam [Rohypnol®]).
• Opioids (e.g. naturally occurring opioids [opium, codeine, morphine], semi-synthetic opioids [heroin], synthetic opioids
[methadone, pethidine]).
• Depressant & stimulant (e.g. nicotine).
• Stimulants (e.g. amphetamines, caffeine, cocaine, khat, MDMA [ecstasy]).
• Hallucinogens (e.g. LSD, psilocybin [magic mushrooms], mescaline, PCP).
• Other agents (e.g. anabolic steroids, cannabis, volatile substances).

Intoxication & withdrawal of various substances: see table in Chapter 24 of RCSI Psychiatry Course Book.

For how long can drugs be detected in the urine? Most street drugs remain in the urine for 2-3 days. It usually takes a few hours
after drug use for detection in urine. Cannabis can be detected in urine for ~ 30 days in chronic users.

Benzodiazepine detoxification: gradually ↓ the dose of the benzodiazepine. If the above fails, switch to a LONGER acting
benzodiazepine (e.g. diazepam or clonazepam).

Smoking cessation treatments: brief clinical advice to stop smoking, behavioural counselling, nicotine replacement therapy (e.g.
patches, chewing gum, nicotine inhalators, tablets/lozenges, nasal spray), bupropion (which can also be used as an antidepressant),
varenicline.

Management of stimulant misuse

• Biological
o Detoxification.
o Treatment of withdrawal: biological treatment is mainly symptomatic. Psychological treatment is the main treatment.
o Substitution prescribing (e.g. oral cocaine instead of IV cocaine, dexamphetamine or methylphenidate).
o Dopamine agonists may ↓ craving (e.g. amantadine, atomoxetine, bromocriptine or modafinil).
o Dopamine antagonists (e.g. antipsychotics) may be useful in people with a dual diagnosis.
o Disulfiram ↓ cocaine clearance without toxicity and works well with co-morbid alcohol dependence.
• Psychological: CBT.

Management of opiate misuse

• Biological (withdrawal symptoms appear 6-24 hours after the last dose in an opiate dependent person, typically lasting 5-7
hours, peaking on the second or third day).
o Substitution prescribing
✓ Methadone (taken once daily): most commonly used agent to treat opiate withdrawal & dependence. NOT an effective
treatment for drugs of abuse other than opioids. ALSO used in the management of chronic pain. Methadone has a
high dependency potential.
✓ Buprenorphine: less commonly used than methadone. ALSO used in managing chronic pain. BETTER safety profile
than methadone which may cause fatal respiratory depression in overdose.
✓ Dihydrocodeine: short acting agent with a shorter half-life than methadone. Needs to be taken up to four times daily.
o Symptomatic medication
➢ Clonidine: ↓ the sympathetic nervous system response to opiate withdrawal (e.g. tachycardia & hypertension) in
the initial days of withdrawal. Hypotension can be a side effect.
➢ Lofexidine: ↓ blood pressure is less marked than that produced by clonidine.
➢ Loperamide: treatment of diarrhoea.
➢ Metoclopramide: treatment of nausea & vomiting.
➢ Ibuprofen: treatment of headaches & muscle pains.
o Maintenance of abstinence after detoxification: naltrexone (↓ opioid craving).
o Management of opioid overdose: naloxone.
• Psychological: determine the person’s readiness for change (as with management of alcohol misuse), psychoeducation
(regarding addiction, medical complications), supportive counselling, CBT, family therapy.
• Social: Narcotics Anonymous (NA), social work & occupational therapy input (if needed).

84
 Substances which produce BOTH physical AND psychological dependence

“Great Vacation in an Orlando CABANA”

Great → G → Ghb

Vacation → V → Volatile substances

Orlando → O → Opioids

CABANA → C
→ A
→ B
→ A
→ N
→ A
→ Caffeine
→ Amphetamines
→ Benzodiazepines
→ Anabolic steroids
→ Nicotine
→ Alcohol

Substances which JUST produce psychological dependence (i.e. NO physical dependence)

“a Man was taking Pure Cannabis and Cocaine under a PaLM tree”

Man → M → Mdma (ecstasy)

Pure → P → Pcp

Cannabis → C → Cannabis

Cocaine → C → Cocaine

PaLM → P → Psilocybin (magic mushrooms)

→ L → Lsd
→ M → Mescaline

85
 Acute behavioural disturbance (RCSI Psychiatry Course Book Chapter 25)
• Disturbed or violent behaviour by an individual in an adult inpatient unit, general hospital ward or emergency department
poses a significant risk to that person, other patients & staff.
• Look for warning signs that a person may be escalating towards physically violent behaviour (e.g. tense & angry facial
expressions, ↑ or prolonged restlessness), over-arousal of body systems (↑ breathing, ↑ heart rate, muscle twitching &
dilated pupils) verbal threats or gestures, person reporting angry or violent thoughts.
• Main goal in the management of patients with acute behavioural disturbance is ensuring SAFETY for the patient, staff &
other individuals.
• Rapid tranquillisation: giving carefully monitored amounts of medication over brief intervals of time to control, agitated,
threatening & potentially destructive behaviour in patients.
• Rapid tranquillisation is ONLY used when de-escalation & time out approaches have failed to control acutely disturbed
behaviour. It is therefore a treatment of last resort.

Management steps
1. REVIEW case notes & the medication kardex. Get a COLLATERAL HISTORY (A, B, C approach = Antecedence [what
happened leading up to the acute behavioural disturbance?], current Behaviour [get an account from staff & compare with
the known behaviour at baseline], Consequences [what happened as a result of the behaviour, e.g. any injuries to the
patient, to any staff member, or to anyone else?]).
2. Try to establish the CAUSE of the acute behavioural disturbance (e.g. delirium, psychiatric cause such as acute psychosis,
agitated depression, mania, borderline/antisocial personality disorder, or other cause such as intoxication with or withdrawal
from alcohol/illicit substance, antisocial behaviour, pain).
3. Get EXPERT ADVICE from a senior colleague.
4. De-escalation & time out.
5. ONLY when de-escalation has failed to reduce the disturbed behaviour, should medication be considered = rapid
tranquillisation (see table in RCSI Psychiatry Course Book Chapter 25).
6. MONITOR blood pressure, pulse, temperature, respiratory rate regularly after rapid tranquillisation.
7. RECORD the rapid tranquillisation in the patient’s chart.
8. POST-INCIDENT REVIEW as soon as possible after the incident (within 72 hours) to support staff & patients, and to
encourage the therapeutic relationship between patients, their carers & staff.
9. DEBRIEFING: both before & after the rapid tranquillisation the patient should have the reasons for this treatment explained
to them.

Medications used for rapid tranquillisation: haloperidol 5-10mg + lorazepam 1-2mg.

Alternatives to haloperidol for rapid tranquillisation: olanzapine 10mg or risperidone 2mg. However, do NOT give
benzodiazepines within 60 minutes of IM olanzapine due to the risk of somnolence & hypotension.

86
 Case-based learning for week 4

Vignette G

Mark is a 68 year old man who presents to the psychiatry outpatient clinic with his daughter Betty who is concerned that her father
“has not been himself” over the last number of weeks. She says she has experienced difficulty on a number of occasions in
communicating with her father. During such instances Betty says her father appears confused and is unable to remember what they
said or what happened, a few minutes previous. For example, if they are looking at television together, during the ads, he is sometimes
unable to remember the programme they are watching. Mark’s confusion is worse at night. He has some more lucid intervals during
the day.

Question 1g: What is your preferred diagnosis?

Question 2g: What are the clinical characteristics for the preferred diagnosis you mentioned in question 1g above?

Question 3g: Name four examples of possible causes which might lead to the diagnosis you mentioned in question 1g above.

Question 4g: Describe how you would manage the diagnosis you mentioned in question 1g above.

Question 5g: Imagine that Mark has been admitted to a medical ward of a hospital with sepsis. You are a psychiatry registrar who
receives a telephone call from the medical registrar, to inform you that Mark is not sleeping at night. Mark is described as being
confused and agitated; he wanders in and out of the ward bedrooms during the night, and is threatening and hostile towards the staff
working in the medical ward. The medical registrar requests that Mark is transferred to the psychiatry inpatient unit because according
to him, they are unable to manage Mark in the medical ward. How would you respond?

Question 6g: Which psychiatric conditions would be important to differentiate from the diagnosis you made in question 1g above?

Question 7g: How would you differentiate between the psychiatric conditions you mentioned in question 6g and the diagnosis you
made in question 1g above?

Question 8g: What collateral information would you ask Betty about her father?

87
Vignette G answers

Answer 1g: What is your preferred diagnosis?

• Delirium.

Answer 2g: What are the clinical characteristics for the preferred diagnosis you mentioned in question 1g above?
• Impairment of consciousness and attention.
• Global disturbance of cognition (perceptual distortions, illusions and hallucinations - most often visual, impairment of abstract
thinking and comprehension with or without transient delusions but typically with some degree of incoherence, impairment of
immediate recall and of recent memory but with relatively intact remote memory, disorientation for time as well as in the more
severe cases, for place and person).
• Psychomotor disturbances (hypo- or hyperactivity and unpredictable shifts from one to the other, increased reaction time,
increased or decreased flow of speech, enhanced startle reaction).
• Disturbances of the sleep-wake cycle (insomnia, or in severe cases, total sleep loss or reversal of the sleep-wake cycle, daytime
drowsiness, nocturnal worsening of symptoms, disturbing dreams or nightmares, which may continue as hallucinations after
wakening).
• Emotional disturbances (depression, anxiety or fear, irritability, euphoria, apathy, or worsening perplexity).

Answer 3g: Name four examples of possible causes which might lead to the diagnosis you mentioned in question 1g above.
• Infections (e.g. UTI).
• Electrolyte disturbances.
• Dehydration.
• Medications.
• Organ failure (e.g. severe lung or liver disease).
• Post-surgery.
• Among nursing home residents and IUC patients.

Answer 4g: Describe how you would manage the diagnosis you mentioned in question 1g above.
• Avoid factors known to cause of aggravate delirium (e.g. certain medications).
• Identify and treat the underlying illness.
• Provide supportive and restorative care.
• Control dangerous and disruptive behaviours to avoid harm to the patient or others.
• Fluid and nutrition
o These should be carefully given because the patient may be unwilling or physically unable to maintain a balanced intake.
o For the patient suspected of having alcohol toxicity or alcohol withdrawal, therapy should include multivitamins, especially
thiamine.
• Environmental modifications
o Consider one to one nursing.
o Re-orientation techniques or memory cues such as a calendar, clock and family photos may be helpful.
o The environment should be stable, quiet and well-lit.
o Support from a familiar nurse and family should be encouraged.
o Family members and staff should explain proceedings at every opportunity reinforce orientation and reassure the patient.
o Physical restraints should be avoided.
• Biological management
o Antipsychotics (e.g. haloperidol, olanzapine).
o Consider benzodiazepine if severe agitation (e.g. lorazepam).
o Rapid tranquilisation may be required. See the flow diagram in the RCSI Psychiatry Course Book Chapter 25.

Answer 5g: Imagine that Mark was admitted to a medical ward of a hospital with sepsis. You are a psychiatry registrar who receives
a telephone call from the medical registrar, to inform you that Mark is not sleeping at night. Mark is described as being confused and
agitated; he wanders in and out of the ward bedrooms during the night, and is threatening and hostile towards the staff working in the
medical ward. The medical registrar requests that Mark is transferred to the psychiatry inpatient unit because according to him, they
are unable to manage Mark in the medical ward. How would you respond?
• Inform the medical registrar that you will assess Mark on the medical ward.
• If following your assessment you make the diagnosis as in question 1g above, inform the medical registrar that you are happy to
remain linked in with Mark and continue to review him on a regular basis on the medical ward.
• You can say that Mark’s current presentation (delirium) is a medical problem. It would therefore be inappropriate to transfer
Mark to the psychiatry inpatient unit.

Answer 6g: Which psychiatric conditions would be important to differentiate from the diagnosis you made in question 1g above?
• Dementia.
• Pseudodementia.
• Alcohol/substance misuse.

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Answer 7g: How would you differentiate between the psychiatric conditions you mentioned in question 6g and the diagnosis you
made in question 1g above?
Feature Delirium Dementia
Onset • Acute (abrupt). • Insidious (gradual).
Course • Fluctuating. • Progressive.
Duration • Days to weeks. • Months to years.
Consciousness • Altered. • Clear.
Cognitive testing • Rapid fluctuations. • Slow decline.
Visual hallucinations • Common. • Uncommon.
Inattention • Significant. • Mild.
Disorganised thinking • Common. • Unusual unless severe.
Psychomotor changes • Increased or decreased. • Often normal.
Sleep wake cycle • Disrupted. • Preserved.
Reversibility • More common. • Less common.

Dementia Pseudodementia
Features • Disturbance of higher cortical • Depression in the elderly that may resemble dementia.
functions, including memory, • Typical symptoms of depression are present.
thinking, orientation, comprehension, • Patients may complain of memory impairment and other
calculation, learning capacity, cognitive problems. However, upon careful testing, memory and
language and judgement. language functioning are intact. The history of cognitive
problems is usually short, with depressive symptoms appearing
before cognitive symptoms.
Onset • Slow. • Acute.
Focus of • Patient focuses on past success. • Patient focuses on failures.
patients
Confusion at • Present. • Absent.
night
Answers • Guesses at answers (confabulation). • Often avoids answering questions and makes little effort to find
the correct answer (“don’t know” answers).

Past history • Less likely. • More likely.

of depression
Awareness of • Less likely. • More likely - the person is more likely to complain of memory
difficulties problems.
Neurological • More likely. • Less likely.
signs

Answer 8g: What collateral information would you ask Betty about her father?
• When did the symptoms begin? For how long have the symptoms been present?
• Did the symptoms appear abruptly or did they appear gradually over time?
• Has she noticed any disturbance of consciousness?
• Has her father mentioned anything about seeing objects or people which might not actually be there?
• Has she noticed any changes in her father’s flow of speech (e.g. increased or decreased flow of speech)?
• Is her father more ‘jumpy’ than usual? Has she noticed that her father becomes startled more easily than usual?
• Does she know how her father is sleeping? Is he sleeping during the day or at night? Does he have difficulty getting off to sleep?
Broken sleep? Early morning wakening? Is he tired during the day? Has he mentioned any disturbing dreams or nightmares?
• Has she noticed any emotional changes in her father (e.g. depression, anxiety or fear, irritability, euphoria).
• Has she noticed a deterioration in her father’s memory? Has this memory deterioration been a slow deterioration? A stepwise
deterioration? Rapid fluctuations in memory?
• Does her father have any underlying medical conditions? History of head injury?
• Has she noticed any physical changes in her father recently (e.g. signs of weakness/paralysis of part of his body, sensory loss)?
• Does anyone in the family have a history of dementia?
• Does he smoke? How much alcohol does he drink? How often does he drink?
• Is he currently taking any medication? Is he compliant with his prescribed medication?
• Is there a possibility he might have taken any drugs recently?

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Vignette H

Margaret is a 46 year old lady who was referred to the psychiatry new patient clinic. During your assessment, Margaret informs you
that over the past year on a daily basis she has been consuming one bottle of wine, two pints of beer and two glasses of spirits.

Question 1h: How many units of alcohol does Margaret consume per week?

Question 2h: What is your evaluation of the Margaret’s weekly alcohol consumption?

Question 3h: What questions would you ask Margaret in relation to her current use of alcohol?

Question 4h: Name four laboratory alcohol biomarkers.

Question 5h: What are the possible complications of long-standing heavy alcohol consumption?

Question 6h: What risks might be associated with this case?

Question 7h: How would you manage the risks that you mentioned in question 6h above?

Question 8h: What diagnosis would you consider if Margaret presented with irritability, agitation, palpitations, and hypertension, and
if she described “little people” hiding under a chair in the corner of the interview room?

Question 9h: How would you manage the condition you named in question 8h above?

Question 10h: What diagnosis would you consider if Margaret presented with staggering gait, loss of sensation in her lower legs and
clouded consciousness?

Question 11h: How would you manage the condition you named in question 10h above?

Question 12h: What are the outcomes of the condition you named in question 10h above?

Question 13h: What diagnosis would you consider if Margaret presented with a tremor, tachycardia, sweating and anxiety?

Question 14h: How would you manage the condition you named in question 13h above?

Question 15h: If Margaret presented two weeks later with insomnia, diarrhoea, dilated pupils, increased heart rate, sweating,
agitation, and muscle pain, what diagnosis would you consider?

Question 16h: How would you manage the condition you named in question 15h above?

Question 17h: For how long can drugs be detected in urine?

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Vignette H answers

Answer 1h: How many units of alcohol does Margaret consume per week?
• “Margaret informs you that over the past year on a daily basis she has been consuming one bottle of wine, two pints of beer and
two glasses of spirits”.
o One bottle of wine = 7 units of alcohol.
o One pints of beer = 2 units of alcohol (two pints of beer = 4 units).
o One measure of spirits = 1 unit of alcohol (two measures of sprits = 2 units).
o Each day Margaret therefore consumes 7 units + 4 units + 2 units = 13 units.
o Each week Margaret consumes 13 units x 7 days = 91 units of alcohol.

Answer 2h: What is your evaluation of the Margaret’s weekly alcohol consumption?
• The guideline for low-risk limits for alcohol consumption in a female is 11 units per week. Margaret’s alcohol consumption is
therefore significantly greater than that.

Answer 3h: What questions would you ask Margaret in relation to her current use of alcohol?
• History of presenting difficulty
o Type of alcohol consumed
✓ What type of alcohol do you drink?
✓ Has the type of alcohol you drink changed over time?
o Frequency of alcohol use
✓ How often do you drink alcohol?
✓ During a typical week, on how many days would you drink alcohol? What days do you drink alcohol?
o Level of alcohol consumption (change over time?)
✓ How much alcohol do you drink during a typical week?
✓ How much alcohol do you consume on average on any one occasion that you drink?
✓ Has the amount that you drink changed over time? Can you tell me more about that?
o Duration of current level of use
✓ For how long have you been drinking your current amount of alcohol?
o Pattern of drinking
✓ Approximately at what time of the day would you have your first drink?
✓ Has your pattern of drinking changed over time?
o Drinking alone vs with others
✓ Where do you tend to drink alcohol?
✓ Do you drink alcohol at home, in pubs, in clubs or elsewhere?
✓ Do you tend to drink alone or with other people? With whom do you tend to drink?
o Reason for alcohol consumption
✓ Why do you drink alcohol?
✓ People drink alcohol for different reasons. What is your reason (or what are your reasons)?
✓ Did you have your first drink with your own free will or was there peer pressure to drink?
o Trigger/stressor associated with onset or increased consumption
✓ Where there any particular difficulties or stressors in your life around the time you first consumed alcohol? Can you tell
me more about that?”
✓ Where there any particular difficulties or stressors in your life around the time you increased your level of alcohol
consumption? Can you tell me more about that?
o C-A-G-E
✓ Have you ever thought that you should cut down on your drinking?
✓ Have people annoyed you by criticising your drinking?
✓ Have you ever felt bad or guilty about your drinking?
✓ Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover?
o Periods of abstinence
✓ What is the longest time that you have been abstinent from alcohol? When was that? What helped you to achieve
abstinence? Why did you start drinking again?
o Insight
✓ Do you think that you have a problem with alcohol?
✓ If I told you that you have an alcohol problem what would you think about that?
✓ Do you think that some of the difficulties in your life might be related to your alcohol use? Can you tell me more about
this?
✓ Do you think that you need any help regarding your alcohol use? What help do you think you need?
• Dependence criteria
o Strong desire or sense of compulsion to drink
✓ Do you sometimes crave alcohol?
✓ Do you have a compulsive urge to drink?

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 o Difficulty in controlling substance-taking behaviour
✓ Do you find it difficult to stop drinking once you start?
o Withdrawal state
✓ What happens if you do not drink?
✓ What happens if you go without a drink for a day or two?
✓ If you do not drink for a day or two do you experience any withdrawal symptoms such as sweating, shaking, feeling sick,
headaches or pounding in your heart?
o Tolerance
✓ How much can you drink without feeling drunk?
✓ Do you need to drink more alcohol to get drunk than you did previously?
✓ Does alcohol have less of an effect on you now than it did previously?
o Neglect of alternate pleasures or interests
✓ How important is alcohol to you compared with other activities in your life?
✓ How often do you miss family and social commitments because of drinking?
✓ Have you been putting greater importance on alcohol and neglecting other pleasures or interests in your life?
o Persisting with use despite harmful consequences
✓ Have you experienced any harmful consequences of drinking such as memory blackouts or falling while under the
influence of alcohol? Can you tell me more about the blackouts? How often has that happened to you? Can you tell me
more about the falls? How many times have you fallen under the influence of alcohol? What injuries have you sustained?
Have you hit your head? Were you unconscious? For how long were you unconscious?
✓ Have you had blood tests that looked at your liver functioning? Were these results normal?
✓ What do you think about having memory blackouts/falls under the influence of alcohol? Does it concern you?
✓ Have you continued to drink alcohol despite experiencing these harmful consequences? Why are you continuing to drink?

Answer 4h: Name four laboratory alcohol biomarkers.

• Alcohol biomarkers
o Indirect alcohol biomarkers suggest heavy alcohol use by detecting the toxic effects that alcohol may have had on organ
systems or body chemistry, e.g.
✓ Aspartate aminotransferase (AST), alanine aminotransferase (ALT), gamma glutamyltransferase (GGT), carbohydrate-
deficient transferrin (CDT) and mean corpuscular volume (MCV).
 Long-term heavy alcohol consumption results in increased AST, ALT and CDT and macrocytosis (enlarged MCV).
o Direct alcohol biomarkers are analytes of alcohol metabolism, e.g.
✓ Blood alcohol content (BAC), ethyl glucuronide (EtG), acetaldehyde, fatty acid ethyl esters (FAEE), ethyl sulphate (EtS)
and phosphatidylethanol (PEth).

Answer 5h: What are the possible complications of long-standing heavy alcohol consumption?
Biological • Eyes (e.g. optic atrophy).
(physical) • Cardiovascular (e.g. hypertension, cardiomyopathy).
complications • Gastrointestinal (e.g. oesophagitis, oesophageal varices, oesophageal carcinoma, gastritis, peptic ulcer, liver
fatty degeneration, cirrhosis, pancreatitis).
• Haematological (e.g. anaemia, B12 & folate deficiency).
• Endocrine (e.g. reduced sperm production & ejaculatory volume of sperm, decreased sperm count & ultimately
infertility).
• Neurological (e.g. head injury, peripheral neuropathy, seizures).
• Muscular (e.g. myopathy).
• Foetal alcohol syndrome.
Psychological • Psychiatric (e.g. alcohol-induced mood & psychotic disorders, self-harm, suicide).
complications • Memory blackouts.
• Alcohol dementia.
• Delirium tremens.
• Wernicke’s encephalopathy.
• Korsakoff’s psychosis.
Social • Occupational (e.g. absenteeism, poor punctuality & productivity, accidents, fights with colleagues, loss of job).
complications • Financial (e.g. adverse impact on the financial status of the family, borrowing money, theft and/or selling
household items to buy alcohol).
• Accidents.
• Family & relationship difficulties.
• Forensic (e.g. physical/sexual assault, drink driving, homicide).
• Homelessness.

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Answer 6h: What risks might be associated with this case?
• Risk to self
o Self-harm or suicide.
o Medical complications resulting from the heavy alcohol use (e.g. cirrhosis, pancreatitis, oesophageal varices, peptic
ulceration, peripheral neuropathy, dementia).
o Psychiatric complications (e.g. alcohol mood disorder, alcohol induced psychotic disorder).
o Work absenteeism may result in job loss and unemployment.
o Non-collection of any payments due to the person (e.g. social welfare).
o Driving while under the influence of alcohol could put the person themselves at risk of injury or death.
o Falling under the influence of alcohol could result in bruising, fractures, head injury, paralysis or even death.
• Risk to others
o Not adequately caring for any vulnerable individuals and/or any pets in the household.
o Verbal and/or physical aggression (varying from mild irritability to actual bodily harm/death).
o If pregnancy were to occur there would be a risk of foetal alcohol syndrome.
o Driving while under the influence of alcohol could put other road users at risk of injury or death (e.g. pedestrians, cyclists and
other drivers). Furthermore, any other passenger in the car of the person who is driving under the influence of intoxication is
put at risk of injury or death.
o Borrowing money to buy alcohol or getting fired from work secondary to alcohol could result in a difficult financial situation
not only for the person themselves but also for their family.
• Risk from others
o Getting fired from work due to poor work productivity or absenteeism.
o A vulnerable individual and/or pet might be removed from the household by the appropriate authorities if they are deemed to
be neglected/abused/not adequately cared for.
o Break-up of an existing relationship with a partner.
o Loss of friends (and potential psychosocial isolation).
• Risk of self-neglect
o Reduction in the intake of food and/or fluids could result in medical difficulties (or in an extreme case, death).
o Not washing one’s self and/or changing their clothes and/or not brushing their hair.
• Risk of further deterioration without adequate treatment
• Risk of alcohol/substance misuse
• Risk of absconsion from hospital
o If the patient left hospital in their nightclothes they could be vulnerable to the effects of the cold which might be fatal.
o If the patient walked out (or ran out) onto the road they could get knocked down by a car/other vehicle which might result in
physical injury or even death.
o Potentially no access to food/fluid and/or prescribed medication which could result in physical ill-health and a further
deterioration in mental state.
• Risk of non-compliance with proposed management plan
o This could lead to worsening of the patient’s mental state.

Answer 7h: How would you manage the risks that you mentioned in question 6h above?
• Risk to self
o Psychiatric history, mental state examination, investigations (e.g. blood tests - FBC, RFT, LFT, TFT, fasting glucose; random
supervised urinary drug screen, CT/MRI brain scan; chest x-ray, EEG).
o Risk assessment (e.g. using a rating scale such as S-RAMM).
o Rating scale to assess for a co-morbid mood disorder (e.g. Beck Depression Scale or Hamilton Rating Scale for Depression)
and psychosis (e.g. 4-Item Positive Symptom Rating Scale and Brief Negative Symptom Assessment).
o Rating scale to assess alcohol impact on memory (e.g. Mini Mental State Examination [MMSE], Montreal Cognitive
Assessment [MoCA] and Clock Drawing Test).
o Rating scale to assess alcohol withdrawal (e.g. Clinical Institute Withdrawal Assessment for Alcohol [CIWA]).
o If the person is found to have a mental health problem, they could be admitted to inpatient psychiatric unit if needed (on a
voluntary basis or under the Mental Health Act 2001), following the management of any primary organic condition.
o Decide on the appropriate level of patient observation if the person is admitted to a psychiatric ward (e.g. 1:1 special nurse, 15
minute observations, general observations), if the person can wear their day clothes (or if they should remain in night clothes),
and if the person can have leave from the ward (supervised or unsupervised?)
o Remove potential ligatures from the person (e.g. laptop cable, mobile phone charger, dressing gown belt).
o No unsupervised access to a razor.
o If the person is found to have a mental health problem, they could be followed up in the psychiatry day hospital or psychiatry
outpatient department following their discharge from hospital.
o If the person is found to have a mental health problem, a community mental health nurse (CPN) could link in with them
following their discharge from hospital.
o Management: appropriate biological, psychological and social management. Treat any existing or co-morbid medical
conditions.
o Good communication between the patient, treating doctors, and other staff members.
o Involvement of the spouse/partner or family member in the management plan (if appropriate).

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 o Psychoeducation of the patient and their family regarding the symptoms and signs to look out for which may point to a
recurrence of the condition. Instruct the person that they must not drive while under the influence of alcohol.
• Risk to others
o Same as is mentioned for “risk to self”, apart from the use of the HCR-20 risk assessment.
• Risk from others
o Same as is mentioned for “risk to self”.
o Social work assistance with the protection of the person’s finances and other assets from exploitation by unscrupulous
individuals.
o Close monitoring of the individual concerned by means of one to one nursing if they are an inpatient in a psychiatric unit and
regular monitoring of their mental state and response to medication.
• Risk of self-neglect
o Monitoring of food and fluid intake (input-output chart).
o Measure the weight of the person weekly and record in their chart.
o Assistance with maintaining adequate hygiene (e.g. encourage the person to shower and wash their hair, as well as to put on
clean clothes).
o Involvement of the spouse/partner or family member in the management plan (if appropriate).
o Community psychiatric nurse could do regular (weekly if needed) home visits to check that the person has adequate food and
to monitor their mental state and general well-being.
• Risk of further deterioration without adequate treatment
o If the person is found to have a mental health problem, they could be admitted to inpatient psychiatric unit if needed (on a
voluntary basis or under the Mental Health Act 2001), following the management of any primary organic condition.
o Management: appropriate biological, psychological and social management. Treat any existing or co-morbid medical
conditions.
o Involvement of the multidisciplinary team in the management plan.
o Preparation of a care plan for the patient.
• Risk of alcohol/illicit substance misuse
o Alcohol
✓ Biological
 Management of alcohol withdrawal if present (e.g. with chlordiazepoxide and thiamine).
 Achieving abstinence from alcohol (e.g. with disulfiram which helps to maintain abstinence from alcohol by
irreversible inhibition of acetaldehyde dehydrogenase, resulting in an unpleasant reaction if alcohol is ingested, such as
flushing, headache, nausea, vomiting, tachycardia, hyperventilation, hypoventilation, sweating, anxiety and confusion,
naltrexone which decreases craving for alcohol thereby aiding to achieve abstinence, acamprosate which is used in
people who have already achieved abstinence to remain abstinent, and nalmefene which is an option for reducing
alcohol consumption for people with alcohol dependence).
✓ Psychological: determine the person’s readiness for change (at which of the five stages is person currently? i.e. pre-
contemplation, contemplation, determination [preparation], action, maintenance and relapse prevention). Simply asking
about alcohol consumption can act as an intervention and reduce levels of alcohol consumption, brief physician advice
about alcohol consumption, psychoeducation regarding addiction and medical complications, supportive counselling,
CBT, and family/couples therapy.
✓ Social: a goal orientated treatment plan (total abstinence from alcohol or controlled drinking), Alcohol Anonymous (AA)
12 step programme for anyone with a desire to tackle their own drinking problem, Al-Alon to help families and friends
who are dependent on alcohol recover from the effects of living with the problem drinking of a relative or friend in an
anonymous environment, Al-Teen which is for young people affected by a problem drinker, social work input to assist
with employment opportunities and supported accommodation if needed, and occupational therapy input to improve skills
if needed.
o Opiate misuse
✓ Biological (withdrawal symptoms appear 6-24 hours after the last dose in an opiate dependent person, typically lasting 5-7
hours, peaking on the second or third day).
 Substitution prescribing
 Methadone (taken once daily): most commonly used agent to treat opiate withdrawal & dependence. NOT an
effective treatment for drugs of abuse other than opioids. ALSO used in the management of chronic pain. Methadone
has a high dependency potential.
 Buprenorphine: less commonly used than methadone. ALSO used in managing chronic pain. Better safety profile
than methadone which may cause fatal respiratory depression in overdose.
 Dihydrocodeine: short acting agent with a shorter half-life than methadone. Needs to be taken up to four times daily.
 Symptomatic medication
- Clonidine: ↓ the sympathetic nervous system response to opiate withdrawal (e.g. tachycardia & hypertension) in the
initial days of withdrawal. Hypotension can be a side effect.
- Lofexidine: ↓ blood pressure is less marked than that produced by clonidine.
- Loperamide: treatment of diarrhoea
- Metoclopramide: treatment of nausea & vomiting.
- Ibuprofen: treatment of headaches & muscle pains.
- Maintenance of abstinence after detoxification: naltrexone (↓ opioid craving).

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 - Management of opioid overdose: naloxone.
✓ Psychological: determine the person’s readiness for change (as with management of alcohol misuse), psychoeducation
(regarding addiction, medical complications), supportive counselling, CBT, family therapy.
✓ Social: Narcotics Anonymous (NA), social work & occupational therapy input.
• Risk of absconsion from hospital
o Close observation of the patient on the ward.
o Consider one to one special nursing.
o Consider keeping the patient in their night clothes (i.e. not allowing them to have their day clothes).
o A photograph of each patient on the ward could be taken on admission and kept in their chart. This photo could be given to
the hospital security and/or the police if the person managed to leave hospital without permission.
o Patients on the ward could be asked to wear a hospital wrist band, indicating their name, date of birth, ward name and treating
consultant.
o Swipe card access to the ward.
• Risk of non-compliance with proposed treatment plan
o If the person is an inpatient in a psychiatric unit, their medication compliance could be monitored by means of a member of
the nursing staff observing the individual taking their prescribed medication.
o Regular assessment of the person by a psychiatrist and a community psychiatric nurse when they are not in hospital.
o Involvement of the person’s spouse/partner or family member by perhaps suggesting that someone takes charge of the
patient’s medication, thereby giving the patient the required medication at the necessary time and observing the person taking
their medication.
o Good communication between the patient and the psychiatrist (and with the MDT in general).

Answer 8h: What diagnosis would you consider if Margaret presented with irritability, agitation, palpitations, and hypertension, and
if she described “little people” hiding under a chair in the corner of the interview room?
• Delirium tremens.

Answer 9h: How would you manage the condition you named in question 8h above?
• See the flow diagram in RCSI Psychiatry Course Book Chapter 24.

Answer 10h: What diagnosis would you consider if Margaret presented with staggering gait, loss of sensation in her lower legs and
clouded consciousness?
• Wernicke’s encephalopathy.

Answer 11h: How would you manage the condition you named in question 10h above?
• Thiamine (crucial to prevent progression to Korsakoff’s syndrome): initially IV, then continued as IV, IM or PO depending on
the patient status.
• Supplementation of electrolytes, particularly magnesium and potassium (often low in people with alcohol dependency), may be
required in addition to thiamine. Magnesium acts as a cofactor for many enzymes (e.g. transketolase for the conversion of
thiamine to thiamine pyrophosphate) and therefore, its deficiency may lead to refractory response to thiamine supplementation.
• Administration of IV glucose to patients who are very malnourished can exhaust their supply of thiamine and precipitate
Wernicke-Korsakoff’s syndrome.

Answer 12h: What are the outcomes of the condition you named in question 10h above?
• If treated in time, most symptoms could be reduced.
• If untreated, or not treated in time, it may progress to Korsakoff’s psychosis or may be fatal.

Answer 13h: What diagnosis would you consider if Margaret presented with a tremor, tachycardia, sweating and anxiety?
• Alcohol withdrawal.

Answer 14h: How would you manage the condition you named in question 13h above?
• See flow diagram in RCSI Psychiatry Course Book Chapter 24 for the biological management.
• Psychological & social management are described on the page after that flow diagram.

Answer 15h: If Margaret presented two weeks later with insomnia, diarrhoea, dilated pupils, increased heart rate, sweating,
agitation, and muscle pain, what diagnosis would you consider?
• Opioid withdrawal.

Answer 16h: How would you manage the condition you named in question 15h above?
• Biological (withdrawal symptoms appear 6-24 hours after the last dose in an opiate dependent person, typically lasting 5-7 hours,
peaking on the second or third day).
o Substitution prescribing
✓ Methadone (taken once daily): most commonly used agent to treat opiate withdrawal & dependence. NOT an effective
treatment for drugs of abuse other than opioids. ALSO used in the management of chronic pain. Methadone has a high
dependency potential.
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 ✓ Buprenorphine: less commonly used than methadone. ALSO used in managing chronic pain. Better safety profile than
methadone which may cause fatal respiratory depression in overdose.
✓ Dihydrocodeine: short acting agent with a shorter half-life than methadone. Needs to be taken up to four times daily.
o Symptomatic medication
✓ Clonidine: ↓ the sympathetic nervous system response to opiate withdrawal (e.g. tachycardia & hypertension) in the
initial days of withdrawal. Hypotension can be a side effect.
✓ Lofexidine: ↓ blood pressure is less marked than that produced by clonidine.
✓ Loperamide: treatment of diarrhoea.
✓ Metoclopramide: treatment of nausea & vomiting.
✓ Ibuprofen: treatment of headaches & muscle pains.
o Maintenance of abstinence after detoxification: naltrexone (↓ opioid craving).
o Management of opioid overdose: naloxone.
• Psychological: determine the person’s readiness for change (as with management of alcohol misuse), psychoeducation (regarding
addiction, medical complications), supportive counselling, CBT, family therapy.
• Social: Narcotics Anonymous (NA), social work & occupational therapy input.

Answer 17h: For how long can drugs be detected in urine?

• Simple rule of thumb for most ‘street drugs’ is that they remain in the urine for about 2-3 days. It usually takes a few hours after
drug use for detection in the urine.
• Cannabis can however be detected in the urine for approximately 30 days in chronic users.

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Week 4 - notes

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