Psychiatric Disorders

Front 1

Acute agitation: nonpharm?

Back 1

- safety (pt + others)
- control behaviour
- reassure
- physical restraint if verbal fails

Front 2

What do do for DELIRIUM

Back 2

- remove MEDICAL CAUSE
- HALOPERIDOL (PO/IM/IV) regular not PRN
- 2nd gen (R/O/Q) also used
- BDZ *only* when ETOH withdrawal

Front 3

Why are medium/long-term antipsychotics reserved only when benefits >>> risks in acute agitation?

Back 3

Increased risk of STROKE and DEATH in elderly

Front 4

What to Rx for DEMENTIA? Why? Why not haloperidol?

Back 4

- Atypical antipsychotics
- b/c favourable SFX profile
- Risperidone .5, 1, 2mg QD beneficial in Alz
- Halo only good for AGGRESSION

Front 5

What else has been studied for DEMENTIA-related AGITATION?

Back 5

- trazodone (limited, but good b/c SFX and sedating)
- cholinesterase inhibitors (donepezil + for behav disturbances)
- BDZ + for acute anxiety and agitation

Front 6

Which BDZ to use for acute anxiety/agitation? Why?

Back 6

LORAZEPAM, OXAZEPAM, b/c no active metabolites and metabolism minimally affected by age.

Front 7

What to do for agitation from BRAIN INJURY?

Back 7

- BBlockers (propranolol)
- Antiepileptics (CBZ, VPA)
- !BDZ b/c paradoxical disinhibition

Front 8

Why !-IM olanzapine + BDZ?

Back 8

Cardiac and respiratory complications

Front 9

What serves as an alternative to intramuscular atypical antipsychotics?

Back 9

Rapidly dissolving OLANZAPINE and/or RISPERIDONE (also liq)

Front 10

What to give for substance intoxication vs. withdrawal (ETOH)?

Back 10

Haloperidol + lorazepam vs. diazepam

Front 11

First-gen antipsychotics: DIs?

Back 11

- Antagonisim of dopamine agonists
- Additive CNS depression

Front 12

Atypical antipsychotics: DIs?

Back 12

- Antagonizes dopamine agonists
- CNS depression
- Potentiates antihypertensive drug effects

Front 13

First-gen antipsychotics: SFX?

Back 13

Sedation, parkinsonism, akathisia, acute dystonia, NMS

Front 14

Risperidone: SFX?

Back 14

Akathisia, dizziness, NMS

Front 15

Olanzapine: SFX?

Back 15

Risperidone + anticholinergic

Front 16

Quetiapine: SFX?

Back 16

Sedation, dizziness, NMS

Front 17

NMS: Risk factors?

Back 17

- Up to 1%, within 30 days, younger males, high-potency depots, 10% mortality

Front 18

NMS: S/Sx?

Back 18

>39oC, MM rigidity, delirium, labile BP, tachycard, high CPK, arrhythmia, tremor, sz, coma

Front 19

NMS: Tx?

Back 19

- NonRx: d/c neuroleptic, cooling blanket, hydrate
- Rx: dantrolene, bromocriptine, BDZ

Front 20

TD: Risk factors?

Back 20

Months-years of neuroleptics, elderly

Front 21

TD: S/Sx?

Back 21

Fly catching/protruding tongue, facial tics, chewing, excessive blinking

Front 22

TD: Tx

Back 22

d/c or change or lower dose of neuroleptic, anticholinergic
- Tetrabenazine, donepezil, VitE (400-1600 IU QD)

Front 23

Antipsychotics in pregnancy?

Back 23

- Risk v. benefits
- LOW dose of HIGH potency (eg Haloperidol - cat C)
- d/c b4 delivery if possible
- avoid during 1st trimester if possible

Front 24

BDZ: SFX?

Back 24

Sedation, dizziness, cognitive impairment, respiratory depression (rare)

Front 25

BDZ: DIs?

Back 25

Additive sedation, cardiorespiratory depression.

Front 26

Anxiety: nonpharm

Back 26

!caffeine, !etoh, PRN BDZ !>4 days, > stress, CBT

Front 27

Panic disorder: Tx (with/without agoraphobia)?

Back 27

- SSRIs, venlafaxine (+ BDZ for <=8 weeks to maximize adherence and response)
- Start low to avoid agitation
- Tx months/years

Front 28

Panic disorder: 2nd line?

Back 28

TCA (imip, desip, clomip), mirtazapine, MAOI (phenelzine, tranylcypromine)

Front 29

ACUTE panic disorder tx?

Back 29

Alprazolam 0.25 T-QID, clonazepam 0.25 BID. Also loraz/diaz

Front 30

Role of BDZ?

Back 30

adjunct or failure w/ BDZ, acute

Front 31

Tx for SOCIAL PHOBIA?

Back 31

SSRI/SNRI, or propranolol 10mg 30 min before event

Front 32

Why is dose of MOCLOBEMIDE significant?

Back 32

Loses MAO-A selectivity > 600mg QD thus need to watch consumption of aged cheese, red wine, beer, smoked meat

Front 33

Tx for SPECIFIC PHOBIA

Back 33

No meds. CBT

Front 34

1st- and 2nd-line for OCD? Augment with?

Back 34

1) CBT
2) SSRI (F/X/P/S) @ usual doses. Augment with RISPERIDONE

Front 35

SSRIs used for:

Back 35

PD (FPS), PDA (PS), PTSD (PS), OCD (FXPS), SAD/GAD (PSE)

Front 36

SNRIs used for:

Back 36

GAD/SAD, PD/PDA, ?PTSD, !OCD

Front 37

SSRI SFX?

Back 37

NAUSEA, tremor, anxiety, insomnia, somnolence, sweating, dry mouth, headache, dizz, diarrh, constipation, sexualdysfx

Front 38

SNRI SFX?

Back 38

^BP, agitation, tremor, sweating, nausea, sleep alter, headache, `sexual dysfx than SSRI

Front 39

SSRI: intra-class

Back 39

C, Es - `drug interactions
F - ^anorexia, ^t1/2, ^stimulation
X - ^nausea, ^sedation, ^constipation, ^DIs
P - ^anticholinergic (^weight gain, D/C rxn)
S - ^sexual, ^diarrhea, `DIs, ^for <3 pts

Front 40

PTSD: 1st- and 2nd-line?

Back 40

1) SSRI/SNRI
2) Mirtaz, moclob, phenel, risp, olanz

Front 41

GAD: 1st- and 2nd-line?

Back 41

1) CBT (20 sessions!)
2) SSRI, SNRI
3) Imipramine, bupropion, pregabalin

Front 42

BUSPIRONE: pros and cons?

Back 42

+ | `abuse potential, `sedating than BDZ
- | slow onset of fx; must taper BDZ slowly if switching to busp b/c no cross-tolerance. CAN PRECIPITATE BDZ WITHDRAWAL

Front 43

Anxiety: if one antidepressant fails, what to do?

Back 43

- Confirm dose and time, switch agent (can be same class). If 2nd fails, switch class.

Front 44

BDZ: max length of use for SS/SNRI-related agitation?

Back 44

6-8 weeks

Front 45

BDZ: uses

Back 45

PD, PDA, GAD, SAD

Front 46

BDZ: side effects

Back 46

Drowz,dizz, ^traffic accidents, dependence, `concentration, anterograde amnesia

Front 47

Which BDZ affected by CYP?

Back 47

Alprazolam. Level ^by fluvox, nefaz, GFJ, ketoconazole. Level `by theophylline

Front 48

Which preg cat are most BDZ? Which are X?

Back 48

1) D
2) Temazepam, triazolam, flurazepam

Front 49

Short-acting BDZ? Role?

Back 49

- Alpraz, bromazepam, lorazepam, oxazepam, triazolam
- To sedate, elderly, liver dz

Front 50

Long-acting BDZ? Role?

Back 50

- Diazepam, flurazepam, clonazepam, nitrazepam, chlordiazepoxide
- Tapering off, `rebound

Front 51

BDZ: length of therapy in
1) Anxiety
2) Hypnotic

Back 51

1) Adjunct only - reeval in 4-6wk
2) 4 wk

Front 52

Effects of BDZs in pregnancy?

Back 52

Floppy infant sx, ?teratogen (oral cleft), newborn withdrawal if 3rd trimester

Front 53

BDZs precautioned:

Back 53

Hx of substance abuse, sleep apnea, cog/renal/hepatic dz, elderly, porphyria, CND depression, myasthenia, prego

Front 54

BDZ withdrawal depends on what 4 factors?

Back 54

1) Duration of tx
2) Dose
3) Rate of tapering
4) BDZ t1/2

Front 55

BDZ withdrawal s/sx?

Back 55

Insomnia, NV, twitching, ^anxiety, paresthesia, tinnitus, delirium, sz

Front 56

How to withdraw BDZ?

Back 56

IF > 12 wks, 10-25%/week, esp slow last week. Consider changing to equivalent dose of clonaz/diaz (X/C alprazolam!)

Front 57

Why ~!-BDZ + clozapine?

Back 57

^sedation, salivation, respiratory arrest

Front 58

Which BDZs for ETOH withdrawal?

Back 58

Oxazepam, chlordiazepoxine,

Front 59

Diazepam: why IV q> IM?

Back 59

IM is painful.

Front 60

Which BDZ:
1) severe withdrawal
2) behav disturbs in elderly
3) accumulates

Back 60

1) alprazolam
2) triazolam
3) flurazepam (despite quick onset)

Front 61

ADHD: nonpharm q> or q< than Rx?

Back 61

q< solo. combo better than either alone.

Front 62

ADHD: efficacy of stimulants?

Back 62

70% some benefit. First-line. Switch after 2-3 weeks if none

Front 63

Daily dosing of:
1) Immediate release (Ritalin) vs.
2) Sustained release (Ritalin SR, Dexedrine) vs.
3) Concerta, Biphentin, Adderal XR

Back 63

1) OD-TID
2) BID
3) OD

Front 64

Which formulation first-line? Why?

Back 64

Long-acting. `rebound hyperactivity, adherence, !- @ school, `abuse

Front 65

Stimulants and atomoxetine: what risks highlighted by Health Canada?

Back 65

SCD (if underlying cardiac dz), hallucinations, irritability

Front 66

Modafinil: class? used in ADHD? Other uses?

Back 66

CNS stimulant. Used in narcolepsy. `effective than other agents, !approved. q>placebo.

Front 67

Atomoxetine: class? indicated for? efficacy?

Back 67

NE reuptake inhibitor. !stimulant, !controlled. >= 6yo->adults [esp if comorbid SUBSTANCE ABUSE/DEPRESSION]. >60-70% patients get 20-30% `sx

Front 68

Role of antidepressants in ADHD?

Back 68

1) 2nd/3rd line (!as effective)
2) Comorbid depression, enuresis, anxiety, tics

Front 69

Which antidepressants used, !used in ADHD?

Back 69

Bupropion. TCAs q< stim
!venlafaxine

Front 70

Clonidine: effective/ineffective for?

Back 70

^aggression, impulsivity, overarousal, hyperactivity, `inattention, poor concentration. ADJUNCT with stim

Front 71

Antipsychotics used for?

Back 71

BEHAVIOURAL sx. Low-dose risperidone. !-inattention; `cogfx.

Front 72

What can be sprankled on applesauce?

Back 72

Adderall XR, Dexedrine spansules, biphentin capsules.

Front 73

Drug holidays: Y/N?

Back 73

N in mod-sev who are doing well on stimulant. Use if weight loss >= 10%

Front 74

CIs for ADDERALL

Back 74

Advanced arteriosclerosis, symptomatic CVD,HYPERthy, HTN, glaucoma, agitation, drug abuse hx, MAOI

Front 75

CIs for DEXEDRINE

Back 75

As in ADDERALL + motor tix/Tourettes

Front 76

CIs for METHYLPHENIDATE. Cautions?

Back 76

!- As in ADDERALL + DEXEDRINE +anxiety, pheochromocytoma
~!- SZ/EEG changes: reduces sz thresh; severe depression, normal fatigue, may worsen PSYCHOSIS

Front 77

Methylphenidate SFX? (dex, adderall essentially the same)

Back 77

Insmnia, anorexia, NV, `weight, tic, emotional lability, nasal congestion, headache, RARE-blood dyscrasia, angioedema, sudden death. (Adderall also sexual dysfx)

Front 78

Concerta vs. Biphentin?

Back 78

Concerta 8-12hr, biphentin 10-12hr. Concerta non-deformable shell (in stool!) to `abuse. Biphentin spranklable on foods. NEVER CRUSH EITHER

Front 79

Methylphenidate: DI?

Back 79

Clonidine (ECG/sudden death), linezolid & MAOI (^BP), phenobarbital and phenytoin (^ level), TCAs (^TCA level), warfarin (^INR), CBZ (`MPH level)

Front 80

Stimulants: monitor

Back 80

Sx, academics, behaviour, phys exam, cardiac Hx, ECG, BP/HR @ day 0, 1, 3 mo then q6-12 mo. Peds: weight growth, development

Front 81

Modafanil sfx?

Back 81

Rhinitis, SJS/TEN, anxiety/psych

Front 82

When !-use antipsychotics for DEMENTIA?

Back 82

If hallucinations/delusions are early/presenting signs - may be DLB; ^risk of precipitating antipsychotic sensitivity sx

Front 83

When is a dementia tx considered effective?

Back 83

Provides IMPROVEMENT or N/C in sx

Front 84

DONEPEZIL - dose, when to ^dose?

Back 84

5mg QD, take qAM if sleep disturbances. ^after 28 days to 10mg QD

Front 85

RIVASTIGMINE - dosing? Additional indications?

Back 85

1.5mg BID, after 30 days 3mg BID max 6mg BID. Also DLB and PARKINSON'S DEMENTIA

Front 86

GALANTAMINE - dosisng? Add'l indications?

Back 86

8mg OD, up to 16mg OD after 30D. Max 24mg QD. Vascular dementia

Front 87

Memantine - MOA? Indication?

Back 87

Blocks glutamate-induced neuronal excitotoxicity. Mod-severe AD.

Front 88

Which ONE of the following has proven efficacy and safety benefits for `incidence of dementia?
a) Dyslipidemia tx
b) Estrogen tx
c) Chronic NSAID
d) Hypertension tx

Back 88

d)

Front 89

Why SSRI > TCA for dementia-depression

Back 89

`anticholinergic sfx, `orthostatic HTN (note: elderly need longer trial- 2-3mo)

Front 90

If TCA, which TCA for dementia-depression?

Back 90

Desipramine/nortriptyline

Front 91

For dementia-psychosis, what tx? why? dose?

Back 91

2nd gen. Risperidone `0.25 *1.0 ^2mg QD. Olanzapine `2.5, *5, ^10. Elderly demented brain ^sensitive to antipsychotics!

Front 92

What to give for dementia-psychosis if preexisting mvmt dx or pt develops EPS?

Back 92

QUETIAPINE

Front 93

Trazodone - class/use in dementia?

Back 93

Serotonin agonist. Sundowning (worse behaviour as darkness falls)

Front 94

Buspirone - class/use in dementia?

Back 94

Serotonin agonist; used for anxiety

Front 95

Donepezil & galantamine DIs

Back 95

Metab by CYP 2D6 & 3A4

Front 96

CheIs: onset? when to ^dose?

Back 96

3-6 months, ^qmonth

Front 97

~! for use of CheIs?

Back 97

bradycardia, sick sinus sx, active PUD, asthma/COPD, anethesia, anticholinergic meds, parkinsons (^eps), epilepsy (?`sz thresh), beta-blockers (?^brady)

Front 98

First-line in mild-mod RLS?

Back 98

Levodopa PRN <=400/100

Front 99

First-line in mod-sev RLS?

Back 99

Dopamine agaonists (ropinrole 2mg QD/pramipexole <=0.5mg QD)