Psychiatric S/S

PSYCHIATRY

*** DELIRIUM: S/S: Mental status fluctuation, poor attention, hypervigilence, agitation, rage, visual / auditory hallucination, confusion, delusions, paranoia, disorganized thinking, disoriented to time/place/person, worse with darkness, marked startle response, apathy, depression, fear, tremors, anxiety # CAUSES: advanced disease & old age are high risk factors, CNS Metastases, metabolic, vital organ failure, Heart / Hepatic failure, electrolyte abnormalities, hypocalcemia, nutritional, infection, sepsis, drugs, fecal impaction, Opiates, steroids toxicity, sedatives / alcohol withdrawal, anti-nauseant, anticholinergics *Rx: *stop responsible meds ** adjust narcotics ** fluid & electrolyte balance** Quiet, well lit surroundings ** frequent reassurance/reorientation ** treat the cause ** Haldol 1-2 mg PO TID, for severe 1-2 mg IM q ½ to 1 hr X4 max 20 mg/d + Benadryl or Cogentin po or I/m to prevent extra pyramidal S/S ** Benzodiazepine may worsen the condition, use only for sedation, Valium suppository or Versed SQ ; *Ativan 0.5 -1 mg po q 1-4 hrs prn can be given alternating with Haldol ** Mellaril ** Thorazine ** Magnesium ** Clonidine-PO/Patch ** Neurontin ** Change narcotic agent

*** ANXIETY (generalized): # S/S: unable to relax, persistent motor hyperactivity, irritable, shaky, autonomic hyperactivity (sweating, epigastric discomfort, palpitations, shortness of breath); Numbness, Apprehension, Worry, Vigilance, Trouble Concentrating, Hyper-attentiveness, Insomnia, Distractibility # Causes: Unrealistic goals, fear, Impending death, Electrolyte imbalance, medical (hyperthyroidism, sympathomimetics, weight loss meds, decongestants, caffeine), withdrawal of sedatives, Medications, Fear *Rx: ** Treat the cause ** counselling ** use ancillary hospice services: social, chaplainry ** Buspar ** Benzodiazepines: Ativan, Valium ** Beta blockers: Inderol, Tenormin ** Phenobarbital, Nembutal, ** Mellaril

*** PHOBIA: Social phobias (social functions), simple phobia (claustrophobia), agoraphobia (public places) Ú *Rx: ** Imipramine ** SSR1s (Paxil, Zoloft, Prozac), ** Xanax

*** PANIC ATTACK: 1-2%, F>M, afraid to go out because of the fear of attacks, sudden paroxysmal terror, somatisation (chest pain, dyspnea), *Rx *TCA *SSRI’s (Paxil, Zoloft, Celexa, Prozac) *Benzodiazepine: Valium, Xanax (Xanax or Klonopin can be given SL) ** Haldol

*** OCD: Obsessive compulsive disorder: ** SSRIs: Paxil, Zoloft ** Anafranil (clomipramine)

*** Depression: 20% • High suicide rate # Persistent sadness; worthlessness; guilty; excessive self blame; loss of pleasure in any activity whatsoever; lack of energy; sleep disturbances; weight & appetite changes; crying; suicidal thoughts; # multiple risk factors, pancreatic ca, steroids, beta-blocker, Tagamet, pain, disability, fear, frustrations, personal or social problems *Rx: *use support system *active listening ** relaxation ** chaplain services ** guided imagery ** TCA antidepressants: Elavil (sedative); Pamelor (if no sleep disturbance) ** SSRI: Prozac; Paxil; Zoloft; Celexa ** Remeron: weight gain & sleep with smaller doses 15 mg 1/2 tab in evening £ to 45 mg/d; Adjust the dose • other antidepressants: ** Trazodone (desyrel) sedative ** to ¤ drowsiness & £ alertness, ¤ apathy: Ritalin; Dexedrine

*** Suicide: • Assess all depressed patients for risk • Discussion of thoughts of suicide may reduce the risk • Suicidal thoughts are a sign of depression • High risk if recurrent thoughts / plans • utilize all members of the team psychologist/psychiatric consultation • listen & encourage patient to talk about his worries & treat appropriately • *Rx depression, pain & other s/s aggressively • advise caretakers to take weapons out of the house • Psychiatric consultation • Social worker • Psychologist • chaplain

*** Stress of dying: # Death, interpersonal conflicts, guilt, unfinished work, religion, leaving survivors: spouse / children / friends ** utilize the team members ** occasionally use anxiolitics, antidepressants

*** GRIEF: Normal emotional reaction to loss

*** BEREAVEMENT: Reaction to loss of a love one

*** MOURNING: The social expression of grief

*** INSOMNIA: Up to 50% in advanced ca # CAUSES: crisis, fear, pain, dyspnea, phobias, anxiety, depression, nausea, dyspepsia, restless leg syndrome, cramps, urinary frequency, steroids, diuretics, stimulants, coffee, heavy smoking, Prozac, Wellbutrin, pruritis, check meds • *RX: ** Rx the cause ** restore sleep cycle ** Analgesic for pain: ** Antihistamine: Benadryl ** Antidepressants(if depressed): Doxepin, amitryptiline or Trazodone are the most sedating agents ** Chloral Hydrate ** Mellaril ** Thorazine ** Valium (very long acting) ** Nembutal suppository/PO/IV/IM ** Phenobarbital po hs ** Restoril (8-25 hrs half life) ** Dalmane, rapid absorption, sleep, but long acting ** Ambien ** Sonata ** with anxiety: Ativan, Klonopin A with pruritis: Hydroxyzine (Vistaril), local applications, soothing skin prep ** Combination of different classes (Benzo + Anxiolytic + Opiods + adjuvant analgesics) in adequate doses should help anybody sleep

*** TERMINAL RESTLESSNESS: #causes: Terminal event, Pain, fecal impaction, Urinary retention, Anxiety, severe Dyspnea, steroids, itching, uncomfortable position # S/S: respiratory difficulties (dyspnea, death rattle, Ÿ secretions); CNS (restless & agitation 40%, Ü level of consciousness, myoclonus); pain: bladder distention n *Rx: • prepare the family, make patient comfortable, do not prolong nor hasten the process ** stop all meds except one for pain, vomiting, seizures, agitation, anticholinergics ** keep the patient dry ** stop IV, tube feeding n ** morphine: don’t stop, increase or Decrease the dose depending on discomfort, change oral to Buccal or suppository or SQ ** use 50% of previous 24 hrs dose of morphine ** to avoid morphine withdraws use 10-25% of the usual dose ** if not on Morphine: Start 10mg SQ / buccal / PR and titrate up fast ** If already on morphine £ the dose by 25-50% ** Valium per rectum ** Lorazepam SL / IM / PO ** Scopolamine patch ** Atropine SC / IM / SL If restlessness persists use: ** Thorazine PR/IM ** Haldol buccal / IM ** Versed (midazolam) SQ/IM Phenorbital or Nembutal IM / PR ** Catheterize for retention ** Inapsine (for nausea) Death rattles: A raise HOB 30 degrees A reassure family that patient not aware A to dry secretions use Atropine SL/IM or Scopolamine SL/ up to 3 patches at one given time A Lasix