Tuesday 5 November 2013
Alcohol Mnemonics
CAGE
yes to 3/4 indicates dependence
Cut down
Angry
Guilty
Eye opener
Paddington Alcohol Test (PAT)
1. Quite a few people have times when they drink more than usual - what is the most (in total number of units per day) you will drink in any one day?
2. If you drink more than 8 units a day for men or 6 units a day for women is this at least once a week?
If yes, PAT positive –> alcohol advice
If no, question 3
3. Do you feel your current attendance at the emergency department is related to alcohol?
Yes –> PAT positive
No –> interpret carefully
Hazardous drinking: more than twice the recommended daily limit. Advice and information.
Dependent drinking: more than twice recommended daily limit every day, or other signs of dependence. Do not benefit from brief intervention.
Signs of dependence –> compulsion to drink
Signs of tolerance --> repeated failed attempts to stop drinking?
CIWA score - out of 67
Nausea and vomiting
Tactile disturbances
Tremor
Auditory disturbances
Paroxysmal sweats
Visual disturbances
Anxiety
Headache, fullness in head
Agitation
Reduced orientation and clouding of senses Risk assessments
characteristic of the act of self-harm - violence, evidence of planning
characteristic of the person - intention to die, previous self-harm, mental illness or personality disorder, substance misuse.
social circumstances and provoking events
SAD PERSONS
Sex: male 1
Age: 15-24, 45-54, >75 1
Depression/hopelessness 1
Prior history 1
Ethanol 1
Rational thinking loss 1
Support system lack 1
Organised plan 1
No significant other 1
Sickness (cancer, HIV) 1
0-2 Discharge with follow up
3-4 Discharge with close monitoring
5-6 Consider admission
7-10 Definite admission
DSM-IV criteria for major depression
5 or more = major depressive episode
Low mood for most of the day every day
Fatigue
Recurrent suicidal ideation
Lack of concentration
Weight loss >5%
Low self-esteem
Disturbed sleep
Weight loss
Loss of interest
Agitation
(Loss of libido, poor concentration also worth asking about)
All Brides Should Make Tea Cakes in Summer
Appearance
Behaviour - remember to ask about circumstances leading to hospital attendance, if the act had any significance, and if they believed their behaviour is strange or unusual.
Speech - pressure of speech, knight’s move thinking, clang associations, word salad
Mood
Thought - worthlessness, low self-esteem, flight of ideas, delusions of grandeur, delusions
Cognition - orientation, memory, concentration, calculation skills. Spell world backwards.
Insight - are you ill?
Summary - don’t forget focussed medical and psychiatric history.
Sections
Section 2
Compulsory admission for up to 28days
2 practitioners (one approved)
Application made by social worker or nearest relative
Section 4
Emergency section when an urgent admission is required
To be used when the patient poses a significant risk to others or themselves
Can be used when there is not enough time to get a second medical practitioner.
Section 5(2)
Cannot be used in the emergency department.
yes to 3/4 indicates dependence
Cut down
Angry
Guilty
Eye opener
Paddington Alcohol Test (PAT)
1. Quite a few people have times when they drink more than usual - what is the most (in total number of units per day) you will drink in any one day?
2. If you drink more than 8 units a day for men or 6 units a day for women is this at least once a week?
If yes, PAT positive –> alcohol advice
If no, question 3
3. Do you feel your current attendance at the emergency department is related to alcohol?
Yes –> PAT positive
No –> interpret carefully
Hazardous drinking: more than twice the recommended daily limit. Advice and information.
Dependent drinking: more than twice recommended daily limit every day, or other signs of dependence. Do not benefit from brief intervention.
Signs of dependence –> compulsion to drink
Signs of tolerance --> repeated failed attempts to stop drinking?
CIWA score - out of 67
Nausea and vomiting
Tactile disturbances
Tremor
Auditory disturbances
Paroxysmal sweats
Visual disturbances
Anxiety
Headache, fullness in head
Agitation
Reduced orientation and clouding of senses Risk assessments
characteristic of the act of self-harm - violence, evidence of planning
characteristic of the person - intention to die, previous self-harm, mental illness or personality disorder, substance misuse.
social circumstances and provoking events
SAD PERSONS
Sex: male 1
Age: 15-24, 45-54, >75 1
Depression/hopelessness 1
Prior history 1
Ethanol 1
Rational thinking loss 1
Support system lack 1
Organised plan 1
No significant other 1
Sickness (cancer, HIV) 1
0-2 Discharge with follow up
3-4 Discharge with close monitoring
5-6 Consider admission
7-10 Definite admission
DSM-IV criteria for major depression
5 or more = major depressive episode
Low mood for most of the day every day
Fatigue
Recurrent suicidal ideation
Lack of concentration
Weight loss >5%
Low self-esteem
Disturbed sleep
Weight loss
Loss of interest
Agitation
(Loss of libido, poor concentration also worth asking about)
All Brides Should Make Tea Cakes in Summer
Appearance
Behaviour - remember to ask about circumstances leading to hospital attendance, if the act had any significance, and if they believed their behaviour is strange or unusual.
Speech - pressure of speech, knight’s move thinking, clang associations, word salad
Mood
Thought - worthlessness, low self-esteem, flight of ideas, delusions of grandeur, delusions
Cognition - orientation, memory, concentration, calculation skills. Spell world backwards.
Insight - are you ill?
Summary - don’t forget focussed medical and psychiatric history.
Sections
Section 2
Compulsory admission for up to 28days
2 practitioners (one approved)
Application made by social worker or nearest relative
Section 4
Emergency section when an urgent admission is required
To be used when the patient poses a significant risk to others or themselves
Can be used when there is not enough time to get a second medical practitioner.
Section 5(2)
Cannot be used in the emergency department.
Wernickes and Korsakoffs
There is a 70% reduction of thiamine absorption in malnourished patients who are abstaining from drinking alcohol. Absorption is further reduced if these patients continue to drink.
Wernicke's
Only 10% of patients present with the classical triad of Wernicke's:
Ataxia
Ophthalmoplegia - this is usually of the external recti muscles
Confusion or impairment of the short term memory.
Other symptoms include:
Nystagmus
Gaze palsies
Confabulation
Confusion.
It is important to know this because delayed management or incorrect treatment has a mortality rate of 17%. Incorrect treatment includes giving glucose before thiamine. Of the patients that survive, 85% will have permanent brain damage in the form of Korsakoff’s psychosis and 25% will need long term institutionalisation in order to receive full time care
Korsakoff’s syndrome
- Anterograde amnesia
This is an inability to formulate new memories - memories prior to the onset of Korsakoff's syndrome remain intact
- The preservation of immediate memory
- The preservation of implicit memory
The person is able to learn new motor skills or show an improvement in complex tasks, even if they do not remember learning these skills
- Confabulation
Korsakoff’s syndrome is also associated with a loss of spontaneity, drive, and emotional expression. The chronic form of this syndrome is known as Korsakoff's psychosis.
It is possible to improve some aspects of short term memory by:
- Encouraging the patient to stop drinking alcohol
- Improving the patient’s diet
- Advising regular vitamin supplements, including thiamine
- Rehabilitation.
General amnesia is usually irreversible in patients with Korsakoff’s syndrome. Patients can learn to live independently, but most need residential care.
Wernicke's
Only 10% of patients present with the classical triad of Wernicke's:
Ataxia
Ophthalmoplegia - this is usually of the external recti muscles
Confusion or impairment of the short term memory.
Other symptoms include:
Nystagmus
Gaze palsies
Confabulation
Confusion.
It is important to know this because delayed management or incorrect treatment has a mortality rate of 17%. Incorrect treatment includes giving glucose before thiamine. Of the patients that survive, 85% will have permanent brain damage in the form of Korsakoff’s psychosis and 25% will need long term institutionalisation in order to receive full time care
Korsakoff’s syndrome
- Anterograde amnesia
This is an inability to formulate new memories - memories prior to the onset of Korsakoff's syndrome remain intact
- The preservation of immediate memory
- The preservation of implicit memory
The person is able to learn new motor skills or show an improvement in complex tasks, even if they do not remember learning these skills
- Confabulation
Korsakoff’s syndrome is also associated with a loss of spontaneity, drive, and emotional expression. The chronic form of this syndrome is known as Korsakoff's psychosis.
It is possible to improve some aspects of short term memory by:
- Encouraging the patient to stop drinking alcohol
- Improving the patient’s diet
- Advising regular vitamin supplements, including thiamine
- Rehabilitation.
General amnesia is usually irreversible in patients with Korsakoff’s syndrome. Patients can learn to live independently, but most need residential care.
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