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what is the drug treatment for sleep disturbance (insomnia?)
what are the 4 categories of causes for insomnia?
- physiological: need less sleep with age, daytime naps, noise
- pathological: pain, SOB, oesophageal reflux
- pharmacological: caffeine, xanthines, cocaine
- psychiatric: anxiety, depression
what is the non drug and drug treatment for insomnia?
- 1. address primary cause
- 2. avoid using drugs, especially if the problem is CHRONIC
- 3. sedatives/hypnotics - benzodiazepines
how do benzodiazepines work?
- activate GABA receptors in brain
- leading to CNS depression
give 3 examples of BZD sedatives?
- temazepam (short half life)
what are the other uses of BZD?
- pre-op medication: to reduce anxiety and reduce the threshold for anaesthesia
- acutely confused pt
- acute anxiety
- acute epilepsy: status epileptics - injection of diazepam is very good as it has a relatively short half life
which BZD are good for sleep disturbance and why?
- they have short half life so pt is NOT DROWSY the next morning
- less chance of falling over esp. in elderly
what is chlordiazepoxide specifically used for?
alcohol withdrawal syndrome
what is the difference between tolerance and dependence of sleeping pills?
- tolerance: happens within a few weeks of using the drugs, the patients are no longer sedated by them
- dependence: without the drugs, pt cant get to sleep
how are withdrawal reactions from stopping BZD reduced?
reduce the medication in a stepwise manner over a few weeks, don't stop suddenly
what is the differential diagnosis of a known alcoholic who is acutely confused?
- alcohol/other drug intoxication
- alcohol withdrawal
- acute infection: alcoholics are IMMUNOCOMPROMISED
- hypoglycaemia: alcohol suppresses gluconeogesis in the liver
- head injury/brain haemorrhage
- hepatic encephalopathy
- wernicke's encephalopathy
what is wenicke's encephalopathy due to? symptoms?
- vitamin B1 deficiency (thiamine)
- leads to C.A.N. (confusion, ataxia, nystagmus)
if untreated what can wernicke's encephalopathy lead to? and describe this
Korsakoff's psychosis: unable to make NEW MEMORIES
what 2 diseases can thiamine deficiency cause?
- Wernicke's encephalopathy
- Beriberi disease
how is Wernicke's encephalopathy prevented?
- initial iv thiamine
- then oral
what is the treatment of a chronic alcoholic presenting with acute confusion?
- 1. chlordiazepoxide: start with high dose then reduce it
- 2. anti-epileptic if seizures occur
- 3. vitamin B1 (thiamine) to prevent Wernicke's encephalopathy
what are the common causes of acute confusion in the elderly?
- 1. infection
- 2. heart disease: AMI, acute heart failure
- 3. metabolic disturbances: hypoxia, electrolyte disturbance e.g. low potassium if diuretic use, hypoglycaemia as may be on insulin if DM
- 4. brain disease: stroke, meningitis, epilepsy, encephalitis
- 5. fall
- 6. Drugs: night sedation, alcohol withdrawal, opiates check pinpoint pupils
what investigations do you need to do in an acute confused person?
how are benzodiazepine's reversed?
what is the treatment for an acutely confused patient?
- 1. treat cause
- 2. nurse in a well lit single room, same staff
- 3. if no primary cause found, give sedation with BZD e.g. lorazepam if danger to herself or others
- 4. or neuroleptic drug: haloperidol (major tranquilliser)
what is the advantage of haloperidol
no respiratory depression
what is the advantage of lorazepam?
short half life
how is status epileptics treated?
- initial benzodiazepine but cannot load with BZD as causes resp depression
- so then change to phenytoin
what is the main difference between acutely confused patient and dementia?
- acute confused: drowsy
- dementia: chronically confused, but alert
what are the 4 features of dementia?
- chronically confused
- global brain failure: disorder in mood, thought, memory
- progressive and irreversible
- leads to total dependence on State and carers
how do you do an AMTS?
first give address to remember at end
5 questions about person, time place:
- 1. DOB
- 2. Age
- 3. Time to nearest hour
- 4. Year
- 5. name of hospital
3 Questions about factual knowledge
- 6. present prime minister
- 7. WW2 started
- 8. recognise 2 persons: doctor, nurse...
2 questions about calculation/memory
- 9. count from 20-1 backwards
- 10. recall of address
what is the category and example of drug used to treat dementia? and SE?
- cholinesterase inhibitor: donepezil
- NB many don't respond to it and GI disturbances?
what is memantine?
what are the cardinal features of depression?
- low mood
- loss of interest in life
- reduced energy and enjoyment
what are the 3 main categories of anti-depressants? and what is their MOA? and give an e.g. of each
- SSRI: stop reuptake of 5HT. e.g. fluoxetine/escitalopram
- TCA: block reuptake of NA, 5HT, DA. e.g. amitriptyline/imipramine
- MAO inhibitors: stop the breakdown of monoamine neurotransmitters eg NA, DA, 5HT e.g. hydralazine (MAOi non selective)
what causes withdrawal of TCA?
what is the drug treatment of schizophrenia? what is their MOA?
- neuroleptics: chlorpromazine, haloperidol
- interfere with DA transmission