By: Edward T. F. Wei PhD
The Although such obstruction most commonly occurs after general treatment of dementia is discussed in Section 5 cholesterol hiv medication order crestor 5mg with mastercard. Finally cholesterol testosterone and estrogen are examples of cheap generic crestor uk, the condithe triad of gait disturbance cholesterol test kit india order crestor master card, dementia foods raise bad cholesterol generic crestor 10mg with amex, and urinary incontion known as normal pressure hydrocephalus is a very tinence or urgency (Adams et al great cholesterol lowering foods cheap 20 mg crestor with amex. Clinical features Differential diagnosis the onset of symptoms is typically gradual and generally the first task in making the differential diagnosis is to disoccurs in late middle age or later. In true hydrocephalus, ventricutypically constitutes the first evidence of this disorder. By contrast, in hydrocephalus ex base, and sometimes there is a degree of shuffling, but the vacuo, ventricular enlargement occurs not because of any distinctive feature is what is often referred to as a ‘magpressure increase but merely secondary to shrinkage of the netic’ gait. Here, patients have difficulty initiating steps, as surrounding brain parenchyma, as may be seen in normal if their feet are held in place on the floor by a large magnet; ageing or in various neurodegenerative conditions such as some may complain that it feels as if their feet are ‘glued to Alzheimer’s disease. First, and most importantly, one should look characterized by forgetfulness, slowness of thought and p19. Rarely the clinical picture that normal pressure hydrocephalus may co-exist with any may be dominated by a personality change (Rice and of these other disorders, thus producing a mixed diagnosGendelman 1973) or depression (Pujol et al. On examination there may be generalized hyperTreatment reflexia and the Babinski sign may be positive bilaterally; snout and grasp reflexes may also be present. Among patients who do respond, the gait disturenlargement of the lateral ventricles out of proportion to bance generally improves first, followed by the dementia any sulcal enlargement that may be present. If lumbar and urinary symptoms; at times the overall response puncture is performed, the opening pressure is typically may be dramatic (Graff-Radford et al. Certainly, in cases in which the classic triad is definitely present and imaging reveals unequivocal hydrocephalus, Course one should strongly consider surgery. However, these features may not all be present and in such cases one may In most cases there is a gradual progression of symptoms consider a number of ancillary tests, including the ‘tap test’, and some patients may eventually develop akinetic mutism prolonged external lumbar drainage, and the ‘infusion’ test and an inability to stand. In both the tap test and external lumbar drainage the patient’s gait is videotaped on at least two occasions and a detailed mental status examination performed. In the tap Etiology test, 30–45 mL of fluid are withdrawn within 2 hours of the test and the patient’s gait re-videotaped along with a repeat Although, as just noted, the opening pressure on lumbar performance of the mental status examination. The mechanism underlying In the infusion test normal saline is infused into the this impaired outflow, however, is not known. The decision as to which of these three ancillary tests to the mechanism whereby symptoms appear probably use is not straightforward and practices differ in this relates to stretching of the long periventricular axonal fibers. The tap test is simplest to perform but may have false negatives; external lumbar drainage and the infusion test are more difficult to perform but are more sensitive. Differential diagnosis Overall, it may be appropriate to do a tap test first and, if this is negative, proceed to either external lumbar drainage From a clinical point of view, consideration must be given or an infusion test. It must be borne in mind, however, that to other disorders such as Alzheimer’s disease and none of these tests is completely accurate in predicting the Binswanger’s disease, and certain parkinsonian disorders response to shunting, and they may yield false negatives in. Consequently, even when these tests are all mal pressure hydrocephalus may only become apparent negative, one may still consider shunting in clinically after neuroimaging. Tumor involving the frontal lobe alone: a symptomatic hydrocephalus with ‘normal’ cerebrospinal fluid pressure. The hypothalamus and central and normal-pressure hydrocephalus: clinical and neurolevels of autonomic function. Central nervous system syndrome of hyperphagia, obesity and disturbances of haemangioblastoma: a clinical and genetic study of 52 cases. Hypothalamic tumor presenting as neurological disease in patients with systemic cancer. Aggressive dementia associated with dementia due to normal-pressure, communicating normal pressure hydrocephalus. Lesions at the diencephalic level shunt surgery in suspected normal pressure hydrocephalus. Neuroblastomas and Stevens–Johnson syndrome in patients receiving cranial gangliocytoma of the central nervous system. Limbic system symptomatology associated consecutive autopsy cases from Switzerland. Acta Neurol ‘asymptomatic’ and ‘compensated’ hydrocephalus benefit from Scand 1993; 87:228–33. Non-tumoral stenosis of the aqueduct in temporal lobe dysfunction: a link to atypical psychosis: a adults. Progressive dementia, without headache or changes in the optic discs, due to tumors of the third ventricle. Acute this illness was first noted by Morel in 1860 (Anonymous onsets occur over weeks or months and may be initially 1954), who referred to it as demence precoce. A full descripmarked by perplexity or depressive symptoms; patients tion of the disease, however, had to await the efforts of Emil may recognize that something is going wrong, and some Kraepelin. Kraepelin, who latinized the name to dementia may make desperate attempts to bring order and structure praecox, was a German psychiatrist of the late nineteenth into a life that is rapidly fragmenting. By contrast, gradual and early twentieth centuries, whose work remains a guidonsets, which may span months or a year or more, may not ing force for modern psychiatry. The current name for the be particularly disturbing to the patient; there may be fleetdisease, schizophrenia, was coined by Eugen Bleuler, a ing, whispering auditory hallucinations, vague intimaSwiss psychiatrist who amplified Kraepelin’s original tions, or strange occurrences. Another guiding light in the elucidation of the Although the symptomatology of schizophrenia may be disease was the German psychiatrist Kurt Schneider, who quite varied, in most cases one sees hallucinations, delusions, isolated certain symptoms, now known as Schneiderian disorganized speech, and catatonic or bizarre behavior. Generally, based on the overall Clinical features constellation of symptoms, one may classify any given case of schizophrenia into one of several subtypes, namely paranoid, the age of onset of schizophrenia, although generally catatonic, disorganized (also known as hebephrenic), or simfalling in the late teens or early twenties, may range from ple schizophrenia; in a large minority, however, there late childhood to the seventh decade (Brodaty et al. A prodrome may or may not be present; in one speaks of ‘undifferentiated’ schizophrenia. Each of these some cases the premorbid personality may have been comsymptoms and subtypes is now considered in some detail. In cases in which the prodrome appears in teenage years or Hallucinations may occur in the auditory, visual, gustalater, well after the patient’s personality has formed, family tory, olfactory, and tactile realms (Mueser et al. An exception to this rule is seen in the phrenia and, as noted by Kraepelin (1919), it is ‘the hearing paranoid subtype of schizophrenia, in which one may find a of voices’ (italics in original) that is by far most ‘peculiarly certain degree of systematization of the patients delusions characteristic’ of schizophrenia. They often speak in short phrases and may at times for example that the police have coordinated their efforts manifest as commands, which patients may or may not be with co-workers or neighbors or that perhaps the mafia is able to resist. Certain auditory hallucinations, included involved or certain underground organizations. Patients among the Schneiderian first rank symptoms although not may believe that they are being followed, that their telespecific for schizophrenia, are highly suggestive: these phone conversations are being listened to, and that their include voices that repeat the patient’s thoughts, voices mail is being cleverly opened. Some patients may endure that comment on what the patient is doing, and voices that these persecutions stoically, whereas others may engage in argue with each other. For most patients the voices sound what to them appears to be a justifiable self-defense and as real as the voice of another person, and they may talk fight back. Some may flee the area, seeking safety in another back to them or argue with them. In some cases, if the delusion of persecution are loud or unpleasant, patients may try and drown them is a bizarre one, the response may be proportionately out by listening to music or watching television. In addibizarre: one patient, believing that ‘rays’ were being sent tion to voices, patients may also hear sounds, such as the through the ceiling to kill him, proceeded to cover the ceilringing of bells, footsteps, or tapping on the walls or ing in aluminum foil in order to protect himself. Delusions of grandeur are also common and may coexVisual hallucinations, although common, play a much ist with delusions of persecution. Patients may believe that less prominent role in the overall symptomatology than they have developed great inventions and that others perauditory hallucinations. Some believe that they have been indistinct and perhaps seen only fleetingly, ‘out of the corner elected by God, that millions of dollars are held privately of the eye’. In some cases, however, they may be detailed, for them, that heads of state secretly await their advice on vivid, and compelling: strange people walk the halls; the foreign affairs. Although some patients may harbour these devil appears in violent red straight ahead; heads may float beliefs quietly, others may feel compelled to make an through the air; and reptilian creatures may crawl the floors. One patient took out a full-page advertiseGustatory and olfactory hallucinations are uncommon ment in the newspaper in which he described his plans for but may at times be quite compelling. Patients may smell ‘world peace’ through alliances with ‘extraterrestrial poison gas and inspect the air ducts to find the source. Tastes, often foul and bitter, may appear on the tongue, Delusions of reference are intimately related to deluand patients may become convinced that their drinks have sions of persecution and to delusions of reference, and been fouled by poisons. Here, patients believe Tactile hallucinations may also occur and may be quite that chance events, rather than being innocuous and varied. Patients may feel electric currents course over their unrelated to them, in fact bear special meaning and bodies; they may complain that fluids are poured on them pertain specifically to them. Newspaper headlines seem to at night or that they are pricked by needles from behind; in be a kind of code, which only the patient can decipher, some cases they may experience movements deep inside, informing him or her that the time is near; street lights such as crampings and twistings. For patients with delusions of reference, although their content is extremely varied, certain themes at times all things seem pregnant with meaning: there stand out, including delusions of persecution, delusions of are no more chance occurrences, no accidents, and no grandeur, delusions of reference, and a number of coincidences. These false beliefs may Schneiderian first rank symptoms may comprise delueither grow slowly in the patient or occur suddenly, as if in an sions, including thought broadcasting, thought withdrawal, enlightenment. Although some patients may entertain some thought insertion, and delusions of influence, control, or lingering doubts as to the veracity of these beliefs, for most passivity. In thought broadcasting, patients believe that they are as self-evidently true as any other belief. Occasionally thoughts can leave the head without being spoken or writpatients may argue with others about these beliefs, and even ten, and that others may ‘pick up’ these thoughts directly; attempt to convince others of their truth, but more often they some patients say that it works ‘like a radio’ and they may do not press their case on the unbeliever. Most patients hold feel no need to speak their thoughts as they assume that multiple delusions; these are often not well elaborated and others, perhaps including the doctors, have already picked are often poorly coordinated with each other, and they may up the ‘broadcast’. In such cases, patients suddenly become may see mere tangentiality or circumstantiality. In tangenbereft of thoughts and are left with blank minds; some may tiality, in response to a question, thoughts proceed off on a elaborate on the experience and speak of electrical or magtangent and patients never get around to giving an answer; netic devices that remove the thoughts. Patients who expein circumstantiality, the responses are circuitous and rience thought withdrawal while speaking may exhibit the patients take a long ‘round about’ path before they finally sign known as ‘thought blocking’. For example, one patient, when asked if he wanted the converse of thought withdrawal, and in this experience anything, replied, ‘Yes, please, some bufkuf. Delusions of influence, control or passivCatatonia may occur in one of two forms, namely stuporous ity are characterized by the belief on the patient’s part that catatonia and excited catatonia. Both forms may be seen in their thoughts, feelings, or actions are somehow directly schizophrenia and, indeed, it is not uncommon to see indiinfluenced or controlled by some outside force or agency, vidual patients with the catatonic subtype of schizophrenia and that they have somehow become like robots or passive exhibit both forms at different times (Morrison 1973). Some again porous catatonia one sees immobility, catalepsy, and mutism, may elaborate on these beliefs and speak of being under the which may be joined by posturing, echolalia or echopraxia, influence of a spell or perhaps of an electrical or magnetic negativism, or automatic obedience, whereas in excited catamachine, or perhaps a distant computer. In a manneristic gesture, the patient may offer a hand to In considering the sign of disorganized speech we are conshake with the fingers splayed out, or the fingers may intercerned not with the content of speech, which may be committently writhe in a peculiar, contorted way. One patient spoke in a ‘sing-song’ ‘loosening of associations’, but may sometimes be termed voice and, in another, random syllables were accented in a ‘derailment’. Overall behavior may undergo manneristic incoherent; thoughts are juxtaposed that have no conceivtransformation; one patient walked in a stiff-legged fashable connection and family members may complain that ion, rigidly swinging only one arm with each step. In some directedness’, and thoughts, lacking such an organizing cases facial expression appears theatrical, wooden, or goal, become disparate and unconnected.
Goal Setting: Patients can prepare a list of goals for the coming month cholesterol levels standard generic crestor 5 mg line, 3 months cholesterol test error cheap crestor 5 mg, 1 year lowering cholesterol triglycerides diet crestor 10 mg on line. As she reflects on the life she imagines cholesterol hdl ratio mercola crestor 5 mg discount, how does she want to cholesterol test for particle size order crestor with paypal be remembered (by the therapist, friends, or family)fi Ask your patient to write about past relapses and to be as detailed as possible about the patterns that were central to relapsing; discuss with her how she can handle things differently this time. Find out how the patient is using these instruments at the end of treatment and discuss how she can maximize their utility for transitioning out of treatment. Role playing: Use this technique to anticipate and work through any anticipated difficult situations. Address low self-esteem Information about the disorder: the cognitive-behavioral theory proposes that binge eating is largely a product of these patients’ distinctive form of dietary restraint (attempts to restrict their eating), which may or may not be accompanied by actual dietary restriction (true undereating in a physiological sense). Additional mechanisms (mood intolerance, clinical perfectionism, core low self-esteem, and major interpersonal difficulties) may also be maintaining the maladaptive behavior. Provide education, and to introduce two important procedures, “weekly weighing” and “regular eating. The overevaluation of shape and weight and its various expressions including body-checking and avoidance b. Clinical perfectionism, core low self-esteem, and major interpersonal difficulties Stage 4: (1) Ensure that the changes made in treatment are maintained over the following months, and (2) Minimize the risk of relapse in the long term. Consolidating gains made during treatment and preparing patients for future work on their own. An assignment of the “sick role” serves several functions, including granting the patient the permission to recover, delineating recovery as a responsibility of the patient, and allowing the patient to be relieved of other responsibilities in order to recover 2. Improvement of insomnia-related daytime impairments such as improvement of energy, attention or memory difficulties, cognitive dysfunction, fatigue, or somatic symptoms. Improvement in sleep related psychological distress Note: Rule out other mental disorders, general medical conditions, and drug abuse. Information about the disorder: Psychological and Behavioral Therapies: Psychological and behavioral interventions are effective and recommended in the treatment of chronic primary and comorbid (secondary) insomnia. Multicomponent therapy (without cognitive therapy) is effective and recommended therapy in the treatment of chronic insomnia. Other common therapies include sleep restriction, paradoxical intention, and biofeedback therapy. Although all patients with chronic insomnia should adhere to rules of good sleep hygiene, there is insufficient evidence to indicate that sleep hygiene alone is effective in the treatment of chronic insomnia. Older approved drugs for insomnia including barbiturates, barbiturate-type drugs and chloral hydrate are not recommended for the treatment of insomnia. The following guidelines apply to prescription of all medications for management of chronic insomnia: • Pharmacological treatment should be accompanied by patient education regarding: (1) treatment goals and expectations; (2) safety concerns; (3) potential side effects and drug interactions; (4) other treatment modalities (cognitive and behavioral treatments); (5) potential for dosage escalation; (6) rebound insomnia. Whenever possible, patients should receive an adequate trial of cognitive behavioral treatment during long-term pharmacotherapy. Long-term prescribing should be accompanied by consistent follow-up, ongoing assessment of effectiveness, monitoring for adverse effects, and evaluation for new onset or exacerbation of existing comorbid disorders Long-term administration may be nightly, intermittent. Stimulus control is designed to extinguish the negative association between the bed and undesirable outcomes such as wakefulness, frustration, and worry. These negative states are frequently conditioned in response to efforts to sleep as a result of prolonged periods of time in bed awake. The objectives of stimulus control therapy are for the patient to form a positive and clear association between the bed and sleep and to establish a stable sleep-wake schedule. Instructions: Go to bed only when sleepy; maintain a regular schedule; avoid naps; use the bed only for sleep; if unable to fall asleep (or back to sleep) within 20 minutes, remove yourself from bed—engage in relaxing activity until drowsy then return to bed—repeat this as necessary. Patients should be advised to leave the bed after they have perceived not to sleep within approximately 20 minutes, rather than actual clock-watching which should be avoided. Relaxation training such as progressive muscle relaxation, guided imagery, or abdominal breathing, is designed to lower somatic and cognitive arousal states which interfere with sleep. Instructions: Progressive muscle relaxation training involves methodical tensing and relaxing different muscle groups throughout the body. Cognitive therapy seeks to change the patient’s overvalued beliefs and unrealistic expectations about sleep. Cognitive therapy uses a psychotherapeutic method to reconstruct cognitive pathways with positive and appropriate concepts about sleep and its effects. Common cognitive distortions that are identified and addressed in the course of treatment include: “I can’t sleep without medication,” “I have a chemical imbalance,” “If I can’t sleep I should stay in bed and rest,” “My life will be ruined if I can’t sleep. Multicomponent therapy [without cognitive therapy] utilizes various combinations of behavioral (stimulus control, relaxation, sleep restriction) therapies, and sleep hygiene education. Many therapists use some form of multimodal approach in treating chronic insomnia. Sleep restriction initially limits the time in bed to the total sleep time, as derived from baseline sleep logs. This approach is intended to improve sleep continuity by using sleep restriction to enhance sleep drive. As sleep drive increases and the window of opportunity for sleep remains restricted with daytime napping prohibited, sleep becomes more consolidated. When sleep continuity substantially improves, time in bed is gradually increased, to provide sufficient sleep time for the patient to feel rested during the day, while preserving the newly acquired sleep consolidation. In addition, the approach is consistent with stimulus control goals in that it minimizes the amount of time spent in bed awake helping to restore the association between bed and sleeping. Instructions (Note, when using sleep restriction, patients should be monitored for and cautioned about possible sleepiness): i. Paradoxical intention is a specific cognitive therapy in which the patient is trained to confront the fear of staying awake and its potential effects. Biofeedback therapy trains the patient to control some physiologic variable through visual or auditory feedback. Sleep hygiene therapy involves teaching patients about healthy lifestyle practices that improve sleep. It should be used in conjunction with stimulus control, relaxation training, sleep restriction or cognitive therapy. Instructions include, but are not limited to, keeping a regular schedule, having a healthy diet and regular daytime exercise, having a quiet sleep environment, and avoiding napping, caffeine, other stimulants, nicotine, alcohol, excessive fluids, or stimulating activities before bedtime. Treatment Plan for Pathological Gambling: the treatment included two components, cognitive therapy and relapse prevention. Understanding the concept of randomness: the therapist explained the concept of chance — that each turn is independent, that no strategies exist to control the outcome, that there is a negative expectation of return, and that it is impossible to predict the outcome of the game. Understanding the erroneous beliefs held by gamblers: this component mainly addressed the difficulty individuals had understanding the principle of independence among random events. The therapist explained how the illusion of control contributes to forming gambling habits and corrected the mistaken beliefs held by the gambler, such as believing that you can use past events to make a better prediction or a sound bet. Awareness of inaccurate perceptions: the participant was informed that incorrect perceptions prevail during gambling. Cognitive corrections of erroneous perceptions: the therapist corrected inadequate verbalizations and faulty beliefs using a recording of the patient’s vocal expressions made during a session of imaginary gambling, such as: “If I lose four times in a row, I’m sure to win next time. The possibility of relapse will be discussed with patient, and they learn to become aware of high-risk situations and thoughts that might lead them to start gambling again. Patients can be asked to describe past relapses and identify high-risk situations and flawed thoughts associated with these situations. The clinician will help patients correct these perceptions to help avoid relapses. Cultivate therapeutic alliance or collaborative relationship with patient to instill trust and enhance outcome of treatment. Refer for or administer a Substance Abuse Screening to accurately identify chemical dependency. Refer patient for medical evaluation to identify physical problems caused by or exacerbated by substance use. Help patient overcome denial by looking at the facts of substance use and the problems they have caused. Teach patient relaxation techniques, hypnosis, or creative visualization to cope with feelings. Investigate ritualistic behaviors related to substance use and teach patient more rational behaviors. Review issues of shame and guilt that may cause or contribute to substance use and dependence. Help patient create support systems and resources in environment to maintain sobriety. Conduct role-playing exercises to help patient deal with persons, places, and things that trigger substance use. Stop or reverse the symptoms of Delirium Additional Information Delirium: Components of delirium management include supportive therapy and pharmacologic management. For the patient suspected of having alcohol toxicity or alcohol withdrawal, therapy should include multivitamins, especially thiamine. Interventions include frequent orientation of patients to time, place and situation; early mobilization; attention to hearing and visual deficits and aids as appropriate; preservation of sleep-wake cycles; and adequate hydration fi Delirium that causes injury to the patient or others should be treated with medications. The condition is a medical emergency associated with increased morbidity and mortality rates. Early diagnosis and resolution of symptoms are correlated with the most favorable outcomes. Medication Summary Delirium that causes injury to the patient or others should be treated with medications. Neuroleptics the medication of choice in the treatment of psychotic symptoms: Older neuroleptics such as haloperidol, a high-potency antipsychotic, are useful but have many adverse neurological effects. Newer neuroleptics such as risperidone, olanzapine, and quetiapine relieve symptoms while minimizing adverse effects. Neuroleptics can be associated with adverse neurological effects such as extrapyramidal symptoms, neuroleptic malignant syndrome, and tardive dyskinesia. Haloperidol (Haldol), Risperidone (Risperdal) Short-acting sedatives Reserved for delirium resulting from seizures or withdrawal from alcohol or sedative hypnotics: Coadministration with neuroleptics is only considered in patients who tolerate lower doses of either medication or have prominent anxiety or agitation. Benzodiazepines are preferred over neuroleptics for treatment of delirium resulting from alcohol or sedative hypnotic withdrawal. Use special precaution when using benzodiazepines because they may cause respiratory 46 depression, especially in patients who are elderly, those with pulmonary problems, or debilitated patients. Lorazepam (Ativan) Vitamins Patients with alcoholism and patients with malnutrition are prone to thiamine and vitamin B-12 deficiency, which can cause delirium. Thiamine (Thiamilate) Cyanocobalamin (Crystamine, Cyomin, Nascobal) Further Inpatient Care: Carefully assess patients to determine their level of care needs. Assessment should include behavior (24 h), daily mental status, potential for injury, and underlying medical and metabolic status. Further Outpatient Care: It is not unusual for patients who are elderly to require 6-8 weeks or longer for full recovery. In particular, elderly patients with postacute care complications are at risk for prolonged and persistent delirium.
In addition cholesterol pills purchase crestor 20mg overnight delivery, relatively high doses and prolonged intake of a barbiturate (such as Seconal) or a benzodiazepine (such as Valium; see Chapter 9) may cause amnestic disorder cholesterol explained cheap crestor master card. Amnestic disorder caused by such substances has a better prognosis than does that caused by alcohol cholesterol test nmr buy generic crestor 20 mg. Once the individual tapers off the use of the drug cholesterol levels webmd order crestor online from canada, the memory problems usually clear up cholesterol test cost in mumbai purchase crestor 10 mg online. The clinician determines whether amnestic disorder due to a medical condition is the most appropriate diagnosis after reviewing the patient’s history— including results of laboratory tests or a physical examination—and determining that the symptoms are not better accounted for by another disorder, such as dissociative disorder or depression. However, depending on the specific brain damage and the areas affected, partial or full memory function can sometimes return over time; when memory returns, it usually does so within a couple of years of the onset of the disorder (Wilson, 2004). In most cases, the goal of treatment is rehabilitation—helping the patient learn to function as well as possible given the symptoms. Currently, there are no medications that improve memory in patients with amnestic disorder, although patients may receive medication for comorbid disorders. Rehabilitation of the patient with amnestic disorder typically targets psychological and social factors: (1) helping the patient to develop strategies to compensate for impaired memory, and (2) changing the physical environment so that the patient does not need to rely as much on memory in order to function. Targeting Psychological Factors: Developing and Implementing New Strategies Rehabilitation teaches patients techniques and strategies to use to compensate for their memory problems (Wilson, 2004), particularly ways of organizing information so that it can later be retrieved from memory more readily. One such strategy is the use of mnemonics, which may help people to remember simple information, such as where the car is parked at the mall. For example, someone whose visual memory is not significantly impaired might imagine the location of the car in the parking lot, which will help him or her retain this information. Another strategy Cognitive Disorders 699 is to write down any information that must be retrieved later, such as by making a Electronic devices can serve as memory aids for note about where in the parking lot the car is parked. They can be programmed so that an alarm goes off at a particular Depending on the patient’s abilities and inclinations, he or she may use a variety time, when the screen displays a message about of memory aids: diaries, notebooks, alarms, calendars, or hand-held electronic persome action the patient should take. If a patient has not previously used such memory aids, however, he or she must be taught how to use them, which can create a paradox: Even after learning how to use a memory aid, the patient must later remember how to use it and then remember to use it in the appropriate situation. Depending on the specific nature of the memory problems, though, many patients can learn new strategies and use them. To ensure that a patient has learned a technique or strategy, the clinician should do the following (Wilson, 2004): Table 15. With Memory Problems • Ask the patient to remember only one piece of information or one procedure at a time. Once she has mastered this step, she can proceed to learn how to add information to the grocery list. Patients are more likely to remember their own actions than the corrections of errors they make. Thus, mental health professionals may use errorless learning techniques to teach patients new information (Kessels & de Haan, 2003): Patients are explicitly guided in learning a new skill rather than being allowed to figure it out through trial and error. If she didn’t know Techniques by which patients are explicitly what to do at a given step, the clinician would show her or provide help ranging from guided in learning a new skill rather than very specific guidance (“Now press the green button”) to hints or prompts (“What do being allowed to figure it out through trial you do first to add an itemfi To facilitate such generalization, the clinician may teach family members or others how to use the strategies and devices and how to help the patient use them in his or her home environment. Targeting Social Factors: Organizing the Environment One way to reduce the cognitive load of someone with amnestic disorder is to enlist others to structure the patient’s environment so that memory is less important. For instance, family members can place labels on the outside of cupboard doors and room doors at home or at a residential facility; each label identifies what is on the other side of the door (for examthis man has significant memory problems. In some rehabilitation centers, the notes on his dresser drawers label the type the doors to bathrooms are painted a distinctive color, and arrows on the walls or of items in each drawer. Such modifications to his environment can reduce the impact of his fioors show the direction to a bathroom, so patients don’t need to rely as much on memory problems, and make his experience memory to get around the facility (Wilson, 2004). Key Concepts and Facts About Amnestic Disorder • Amnestic disorder is characterized by significant deficits solely in • Rehabilitation focuses on helping amnestic patients learn to use memory—other cognitive functions remain relatively intact. A paand they may not be able to report their history accurately during tient’s environment can be structured in order to minimize the a clinical interview. If you would • Amnestic disorder is caused exclusively by two types of neurolike more information to determine her diagnosis, what inforlogical factors: (1) substance use (leading to substance-induced mation—specifically—would you want, and in what ways would persisting amnesia, which most frequently occurs with severe the information infiuence your decisionfi During neuropsychological testing, “the principal areas of difficulty on [certain] tests were in mental control, as evidenced by tangential and repetitive speech; psychomotor slowing [in this case, slow movements based on mental processes, not refiexes]; and reduced fiexibility in thought and action” (LaRue & Watson, p. In this section we focus on dementia: what it is, what neurological factors give rise to it, and what treatments are available for it. A set of cognitive disorders characterized Dementia is the general term for a set of cognitive disorders that is characterized by deficits in learning new information or by deficits in learning new information or recalling information already learned recalling information already learned plus at plus at least one of the following types of impaired cognition (American Psychiatric least one other type of cognitive impairment. In dementia, aphasia often appears as overuse of the words thing and it because of difficulty remembering the correct specific words. Problems with executing motor tasks (even though there isn’t anything wrong with the appropriate muscles, limbs, or nerves) can lead to problems dressing and eating, at which point self-care becomes impossible. People with dementia may not recognize friends, family members, or even the face in the mirror. These problems lead to difficulties in planning, initiating, organizing, abstracting, and sequencing or even in recognizing that one has memory problems. We discussed aphasia, apraxia, and agnosia earlier, in the context of effects of brain damage on cognition. Unlike the effects of a stroke or a head injury, however, dementia is not caused by an isolated incident. Rather, it arises over a period of time, as brain functioning degrades; symptoms of dementia often change over time, typically becoming worse, but sometimes remaining static or even reversing course. To be diagnosed as having dementia, a person must have cognitive deficits severe enough to impair daily functioning, and these deficits must contrast with a prior, more adaptive level of functioning. Mild symptoms of dementia may go unnoticed in people whose cognitive functioning started out at a very high level. Such a patient may detect his or her compromised ability to function, but neuropsychological testing is likely to show that the patient’s abilities are within the normal range for his or her age—and so the early signs of dementia would go undiagnosed (Harvey, 2005a). Early onset, particularly before age 50, is rare and is usually hereditary (Ikeuchi et al. Depending on the specific mental processes that are impaired, a patient with dementia may • behave inappropriately (for instance, tell unsuitable jokes or be overly familiar with strangers); Table 15. The cognitive deficits significantly impair social or occupational functioning and refiect a significant decline from a previous level of higher functioning. The cognitive deficits cannot be better attributed to another Axis I disorder, such as depression [Chapter 6] or schizophrenia [Chapter 12]. Impaired cognitive functioning can lead many patients to feel easily overwhelmed or confused and become agitated. The agitation or confusion may cause a patient to become violent, which can make it difficult or potentially dangerous for the patient to remain living at home with family members—and hence the patients may be moved to a residential care facility. The most common cause of dementia is Alzheimer’s disease (also called “dementia of the Alzheimer’s type,” or simply Alzheimer’s), in which the affiicted individual initially has problems with both memory and executive function (such as difficulty with abstract thinking and impaired judgment). As the disease advances, memory problems worsen, and attention and language problems emerge, and spatial abilities may deteriorate; the patient may even develop psychotic symptoms, such as hallucinations and delusions (particularly delusions of persecution). In the final stage, the patient’s memory loss is complete—he or she doesn’t recognize family members and friends, can’t communicate, and is completely dependent on others for care. Course • People with dementia may be unable to perform complex tasks in new situations but still be able to perform simple ones in familiar surroundings. Cultural Differences • Some cultures and ethnic groups—such as African Americans, Asian Americans, and Hispanic Americans—may be more tolerant of impaired memory and other cognitive dysfunctions that Alzheimer’s disease affect the elderly, in some cases, viewing these changes as a normal part of aging. Family memA medical condition in which the affiicted bers thus may wait longer before seeking medical assistance for an older person with dementia individual initially has problems with both (Cox, 2007). She got lost on the way home because no landmarks looked familiar; she was unable to remember her address or to recognize her cousin. After neuropsychological and neuroimaging tests, she was diagnosed with early-onset Alzheimer’s disease (because the disorder emerged before age 65). In her memoir about the progressive nature of this disease, Living in the Labyrinth (1993), McGowin describes sharing with her neurologist some of the symptoms she was having: I showed him the burns on my wrists and arms sustained because I forgot to protect myself when inserting or removing food from the oven. I told him of becoming lost in the neighborhood grocery store where I had shopped for over twenty years. I showed him my scribbled notes and sketched maps of how to travel to the bank, the post office, the grocery, and work. Memories of childhood and long ago events were quite clear, yet I could not remember if I ate that day. On more than one occasion when my grandchildren were visiting, I forgot they were present and left them to their own devices. Moreover, on occasions when I had picked them up to come play at my house, the small children had to direct me home. Childhood nostalgia is so keen I can actually smell the aroma of the small town library where I spent so many childhood hours. Somewhere there is that ever-present reminder list of what I am supposed to do today. Distinguishing Between Dementia and Other Psychological Disorders the symptoms of dementia—impaired memory and other cognitive dysfunctions— also occur with other disorders and can resemble symptoms of other disorders, which sometimes makes an accurate diagnosis challenging. The following disorders have symptoms that may seem similar to those of dementia: • Mental retardation. However, mental retardation does not primarily involve memory problems; moreover, mental retardation is diagnosed in young people. Such people may technically meet the criteria for dementia in older adulthood (Heaton, Grant, & Matthews, 1991). Although both dementia and schizophrenia often involve hallucinations and delusions, schizophrenia is usually diagnosed earlier in adulthood. Although some people develop schizophrenia later in life (which can make it difficult to distinguish it from dementia by the age of onset), such later-onset schizophrenia often progresses rapidly from the prodromal phase—when symptoms are just beginning to emerge—to a full psychotic episode, whereas psychotic symptoms are likely to emerge more gradually with dementia (Harvey, 2005c). A clinician may find it particularly difficult to distinguish between depression and dementia in elderly patients—both disorders can involve memory problems, poor concentration, and other cognitive dysfunctions. The timing of the onset of symptoms can help distinguish the two disorders: Patients with depression often have relatively normal cognitive functioning before becoming depressed and then rapidly decline. With some patients, the particular symptoms can make it difficult for mental health clinicians to determine whether delirium, dementia, or both are present (see Table 15. Friends or family members may be called on to provide a more accurate history of a patient’s symptoms than the patient can provide. However, a diagnosis of dementia requires that additional cognitive deficits be present. It is normal for adults to experience some decline in cognitive functioning with increasing age; to be considered as dementia, an elderly person’s cognitive problems must be significantly worse than would be normally expected and must be caused by a medical condition or related to substance use. Let’s review the most common types of dementia: dementia of the Alzheimer’s type, vascular dementia, and dementia due to other general medical conditions. Dementia of the Alzheimer’s Type Almost three quarters of dementia cases are caused by Alzheimer’s disease (Plassman et al.
Participation in family and group therapy for an extended period increases likelihood of success as interactional issues cholesterol test drinking coffee before cheap crestor 20 mg on line. Involve family in social support and community activities of their interest and choice cholesterol levels vary day to day 5mg crestor otc. Involvement with others can help family members to definition du cholesterol order crestor 10mg without prescription experience new ways of interacting and gain insight into their behavior cholesterol test kit for sale cheap crestor 20 mg visa, providing opportunity for change cholesterol chart nhs purchase crestor master card. A high level of anxiety and stress interferes with the ability to cope and solve problems effectively. Multidisciplinary specialties may be required to effect positive change and enhance conflict resolution. If substance abuse is a problem, all family members should be encouraged to seek support and assistance in dealing with the situation to promote a healthy outcome. When all members of the family are involved, commitment to goals and continuation of the plan are more likely to be maintained. These agencies may provide both immediate and long-term support to individual members and to the family as a group. Family members verbalize understanding of illness/trauma, treatment regimen, and prognosis. Family members demonstrate ability to express feelings openly and communicate with each other in an appropriate and healthy manner. Long-term Goal Client will work through stages of grief, achieve a healthy acceptance, and express a sense of control over the present situation and future outcome. Help family members to realize that all of the feelings they are having are a normal part of the grieving process. Validate their feelings of anger, loneliness, fear, powerlessness, dysphoria, and distress at separation from their loved one. Individuals need adequate time to accommodate to the loss and all its ramifications. Help the parent to understand that children’s and adolescents’ problematic behaviors are symptoms of grieving and that they should not be deemed unacceptable and result in punishment, but rather be recognized as having their basis in grief. Children and adolescents exhibit grief differently than adults, and they must be allowed to grieve in their own way. Caring support and assistance is required when the behaviors become problematic or maladaptive. Some experts believe children need at least 4 weeks to adjust to a parent’s deployment (Gabany & Shellenbarger, 2010). Refer for professional help if improvement is not observed in a reasonable period of time. Encourage resuming involvement in usual activities, and employ previously used successful coping strategies. Most people have developed effective coping skills that can be useful in the current situation. Journaling can be therapeutic because it helps to get in touch with emotions that are sometimes difficult to express verbally. Writing down thoughts and feelings helps to sort through problems and come to a deeper understanding of oneself or the issues in one’s life. Refer to other resources as needed, such as psychotherapy, family counseling, religious references or pastor, or grief support group. The individual may require ongoing support to work through the feelings of loss associated with long-term separation issues. Family demonstrates ability to adapt to the life change associated with the absence of the service member and to accept assistance and support from others. Long-term Goal Caregiver will demonstrate effective problem-solving skills and develop adaptive coping mechanisms to regain equilibrium. Assess the spouse/caregiver’s ability to anticipate and fulfill the injured service member’s unmet needs. Note caregiver’s physical and emotional health, developmental level and abilities, and additional responsibilities of caregiver. Failure in the caregiver role is likely to occur in a situation in which the caregiver is over-burdened and under-supported. Ensure that the caregiver encourages the injured service member to be as independent as possible. Not only does this relieve the caregiver of some of the responsibilities, it provides the care receiver with increased feelings of capability, personal control, and self-esteem. Encourage the caregiver to express feelings and to participate in a support group. Support group members provide ideas for different ways to manage problems, helping caregivers deal more effectively with the situation. Provide information or demonstrate techniques for dealing with acting out, violent, or disoriented behavior by the injured service member. The presence of cognitive impairment necessitates learning these techniques or skills to enhance safety of the caregiver and receiver. Discuss and demonstrate stress management techniques and importance of self-nurturing. Caregiver is able to solve problems effectively regarding care of their loved one. Caregiver demonstrates adaptive coping strategies for dealing with stress of the caregiver role. The activity may involve the spinal cord, brain stem, cerebellum, limbic system, and cortical areas. Increase dose at intervals of 3 to 4 days in increments of no more than 1 mg/day. May increase the dose at intervals of 3 to 4 days in increments of no more than 1 mg/day until desired effect has been achieved. Some patients may require up to 4 mg/day, in which case the dose may be increased in increments of 0. Clients should be withdrawn gradually from these medications before beginning therapy with buspirone. Adverse Reactions and Side Effects • Drowsiness, dizziness • Excitement, nervousness • Fatigue, headache • Nausea, dry mouth • Incoordination, numbness • Palpitations, tachycardia Interactions • Increased effects of buspirone with cimetidine, erythromycin, itraconazole, nefazodone, ketoconazole, clarithromycin, diltiazem, verapamil, fuvoxamine, and ritonavir. Risk for injury related to seizures, panic anxiety, acute agitation from alcohol withdrawal (indications); abrupt withdrawal from the medication after long-term use; effects of medication intoxication or overdose. Risk for activity intolerance related to medication side effects of sedation, confusion, and lethargy. Disturbed sleep pattern related to situational crises, physical condition, severe level of anxiety. Instruct client not to drive or operate dangerous machinery when taking the medication. Symptoms include depression, insomnia, increased anxiety, abdominal and muscle cramps, tremors, vomiting, sweating, convulsions, and delirium. Have client take frequent sips of water, ice chips, suck on hard candy, or chew sugarless gum to relieve dry mouth. Symptoms of sore throat, fever, malaise, easy bruising, or unusual bleeding should be reported to the physician immediately. Ensure that client taking buspirone understands there is a lag time of 7 to 10 days between onset of therapy and subsiding of anxiety symptoms. Can produce serious withdrawal symptoms, such as depression, insomnia, anxiety, Antianxiety Agents 415 abdominal and muscle cramps, tremors, vomiting, sweating, convulsions, and delirium. Take the medication regularly, as ordered, so that it has suffcient time to take effect. If pregnancy is suspected or planned, the client should notify the physician of the desirability to discontinue the drug. Alternative dosing: May initiate at 50 to 100 mg at bedtime; increase by 25 to 50 mg as necessary, to a total of 150 mg/day. Gradually increase during frst 2 weeks to daily dose of 3 mg/kg or 100 mg, whichever is smaller. Elderly and adolescents: 25 to 100 mg/day in divided doses or as a single daily dose. Should be initiated at the lowest dose and then increased according to tolerability and clinical response. Titrate dosage up to 200 to 300 mg/day, depending on response and adverse effects. May increase after 1 week to 50 mg/night if <12 years of age; up to 75 mg/night if >12 years of age. Elderly and adolescent patients: 30 to 50 mg daily in divided doses or total daily dose may be given once/day. Can occur if taken concurrently with other medications that increase levels of serotonin. Symptoms of serotonin syndrome include diarrhea, cramping, tachycardia, labile blood pressure, diaphoresis, fever, tremor, shivering, restlessness, confusion, disorientation, mania, myoclonus, hyperrefexia, ataxia, seizures, cardiovascular shock, and death. John’s Wort, sumatriptan, trazodone, sympathomimetics, theophylline, procyclidine, propafenone, risperidone, ropivacaine, warfarin, and zolpidem. On the frst day of menses, decrease dose to 20 mg and then to 10 mg on second day of menses. May increase dosage after several weeks if suffcient clinical improvement is not observed. May increase dosage after several weeks if suffcient clinical improvement is not observed. May be increased after 2 weeks to 20 mg/day; additional increases may be made after several more weeks (range 20 to 60 mg/day). Dosage adjustments, if indicated, should be made with the individual components according to effcacy and tolerability (dosage range fuoxetine 20 to 50 mg and oral olanzapine 5 to 20 mg). If no improvement is seen after several weeks, may consider dose increases up to 60 mg/day. May be given continuously throughout the cycle or intermittently (only during the 14 days prior to anticipated onset of menses). May increase dose in 50 mg increments every week until therapeutic beneft is achieved. May increase the dose in 25 mg increments every 4 to 7 days to a maximum dose of 200 mg/day. Some adolescents may require up to a maximum dose of 300 mg/day to achieve a therapeutic beneft. Increase in 50 mg increments every week, as tolerated, until maximum therapeutic benefit is achieved. For clients who fail to respond after several weeks of treatment, further increases up to 300 mg/day may be considered. Increase gradually to target dose of 100 to 250 mg/day in adults, and 100 mg/day in older adults. May increase dose in 10 mg increments at intervals of at least 1 week to a maximum of 50 mg/day. May increase dose in 10 mg/day increments at intervals of at least 1 week to a target dose of 40 mg/day.
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