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Imperial. Um and currently try and cross and I'm gonna cover a couple of topics today. There's quite a lot to cover. Um So I'm going to try to give you a good, a good overview, but I'll leave some time if people have questions as we go through conditions and things. Um This essentially is the session plan. So we're gonna start with CAMS, then do a little of old age psychiatry. Um We're gonna look at substance abuse and then the last bit which is psycho sexual kind of um sight conditions will be quite short. Um So starting with CAMS, I think CAMS um is quite an important topic in your five. Um It can come up in your paces. It's quite a good overlap for them to test you in terms of your Pedes knowledge and your psych knowledge. So, in that sense, um I think it's quite important to think about the main difference between adult psychiatry and camps is that you really need to think about um safeguarding in particular, thinking about what other causes as to why patients coming in with anxiety. Is there more going on at home than what meets the eye. Um And also that the emphasis is much more on the psychological conservative and social management as opposed to going in with a pharmacological agent. Um So, we're gonna start with autism spectrum disorders. Um So autism is um a disorder which is characterized by deficits in that in a child, social communication and social interaction. Um Children tend to present around three years of age, that's not to say that they're not autistic before that. It's just that those deficits become really apparent when they start to meet those social milestones. Um Three years, probably around the age as well when a lot of Children start going to nursery and you can really start picking up that they're not engaging with their peers in the same way as you might expect. Um Often when you start taking the history though, you can see that these milestones aren't being met at a much earlier age. So kind of classic history might be a child who doesn't smile quite at the right age. So it takes them a little bit longer, they don't really need eye contact, they have a very narrow repertoire word. So they might just say two or three and not really progress on to full sentences as you would expect. Um The kind of key areas are thinking about kind of restricted behaviors or stereotypical behaviors. So I think the classic examples would be kind of lining up cars or having one specific interest and the interest is very narrow. So rather than saying, oh, I like all football players. The Children were present saying quite fixated on perhaps one specific or one specific team. Um It has about a 1% prevalence within pediatric and adult populations are statistics at the moment, say that it affects males more than females. But there's actually quite a lot of movement within the field to demonstrate that women are probably equally affected. Um they just present differently so we aren't diagnosing them. I think that females tend to have a much later age of diagnosis than males. Um Your risk factors are having an affected siblings or family history being preterm, parental mental health conditions generally raise your risk. But in particular schizophrenia, um if you have a D H D or learning disability of other, other kind of cause um and then chromosomal disorders in particular things like Down Syndrome is associated with autism. Um So thinking about how these Children present. So if you get this as a station in your um paces or if it comes up in a question, the three kind of areas that you really want to exactly explore in your history are impaired social interaction. So parents will say things like my child doesn't really want to play with other Children. They're not interested in play dates. They may have very poor eye contact um and they may have inappropriate behavior so they might not pick up on social cues. So um, parents might say, oh, they were at a party and another child fell over and started crying and the other Children went to comfort her. But they don't, they, my child didn't seem to pick up on that and they just continue doing what they were doing. Um, then the next thing is to detect whether they've got repetitive or restrictive behaviors. So, um, we're talking about, we're talking about rigid routines that when disrupted lead to severe distress, I mean, and tantrums out of proportion for what's going on and beyond the age. So, you know, I think everyone knows about the terrible twos or toddlers and it's quite normal to have some tantrums kind of 2 to 3. Um but they tend not to be provoked by um change out of a rigid routine or things like that. Um, Children with autism can have tantrums all the way through their life. And actually some of the behavioral management is about helping parents to manage that, especially as Children grow and become larger and become there, there can be a risk to parents being injured. They'll have stereotypical movements. Um, they would be really be engaging in play as well. So when you do a play assessment, they won't, they won't come up with imaginary friends, they won't hold conversations and things like that. And then the other third area that you would need to sport, um explore speech and language. So, Eckel areas that's kind of where they're repeating a sound. Um particularly that sounds, sounds, that sounds similar. They have very delayed speech development. Some Children will actually present not being able to speak at all really. Um And they'll have limited facial expressions so they can seem quite removed from everything um in terms of investigation. So um there aren't you do need to consider organic disorders. I think the main thing to think about is just to do a normal developmental examination and physical examination of the child. And think about is there an underlying chromosome abnormality? Is there something genetic that's going on? Um Otherwise it's more about diagnosis. So um we use a couple of screening tools. So childhood autism's rating scale modified checklist and then childhood autism screening tools, the last who are completed by parents. And that can give an indicator as to whether a child is at risk or likely to have autism. The gold standard is an A D R A D O s. These are done within a child development service. So an A D I R is an interview where a psychologist or um a kind of pediatrician will talk to the parents. So it's a parent's history and it will ask really specific questions about the development of the child and how they interact. And then the ADOS is an uh an observation. So it's an observing interview. Um This is often done by um speech and language actually or ot within the development service. And that's with the child. So you've got a component where you talk to the parents, you've got a component where you observe and you interact with the child and that should give you your full picture to diagnose autism um for those who present a lot later. So I think you should, this is usually kind of 2 to 5 years of age may be where I you'd be expecting, expecting these sort of presentations to occur for Children who representing a lot later in life with the kind of speech delay or difficulties um social, with social interaction and things like that. You need to think about organic disorders. So kind of neurological disorders, neurodegenerative disorders need to be thought about before you just go straight into kind of autism um diagnoses. So thinking about management, I've kind of structured it in the same way that I think you'll be expected to structure it within the exam. So you're biopsychosocial model. Um Having said that the the main state of treatment is going to be your psychological intervention. So it's a, it's a family intervention. Um a lot of things in camps involve the family. Um It's quite difficult to um to have meaningful change in a child's behavior if you don't involve the whole family and get them involved. Um So behavior intervention says a whole range of them. Um and really what, which ones you choose depends a little bit on how severely the child is inter affected by their autism. So Children who are able to go into mainstream school, but with kind of specialist um educational assistance helping them with in class will be offered different behavior interventions to those who are able to cope with in a mainstream school. Similarly, depending on the engagement from family. So obviously, you do have autistic Children who end up in care. Um The behavior interventions that you can offer them will differ a little bit. And by their age and the most common one is kind of a applied behavioral analysis. Um And then you can use things called picture exchange communication system. So, rather than Children using words, they'll have a universal set of cards for signs that things like I'd like more food or I need to go to the bathroom and they can use that to communicate instead of talking to people. And that's kind of a gap, a bridge between um Children then developing some speech, um speech skills. Um The other big thing is then speech and language input. Um most, almost all Children will receive this in some form. Um And it's really about building their communication and their ability to engage with the world around them. Now, the pharmacological side is really about those behaviors that are quite problematic or difficult to manage. So, irritability and distress, you can consider antipsychotics in the short term. Um I will caution that in terms of using pharmacological treatments are usually in older Children. So I think if you're getting beyond the age of kind of 10 and Children are really struggling with things that's sort of when you think about adding in a potentially an antipsychotic um S S R I s can be quite useful for obsessional behaviors. Um And then if Children have hyperactivity, then Ritalin, um the only caveat with Ritalin is that it's uh written is actually extremely effective for A D H D within Children. But only about 30% of autistic Children who have symptoms of A D H D or who are hyperactive will respond to Ritalin. There is really no evidence to continue Ritalin if a child doesn't respond to it. So you'll usually trial it for a couple of months and if it has made a big improvement, then you can continue treating them with it. But if not, you, you should really stop. Um And then Buspirone is used in younger Children. Um uh it's, you can use it to be honest, I haven't ever really seen it used just because it can be quite difficult giving medications to younger Children and then monitoring them for side effects. Um The social things that are really important is educational support. So actually every child who has autism needs to have a formal educational assessment. Um and you have to fill in, I think it's an E H C form or, or the school will do that. You won't do that at the doctor, but that's something that will need to happen. Um They can do social skill training session. So that would be with psychologist usually. Um and then thinking more specifically about things that patient might present with that can cause a lot of distress within day to day life. So, um some of them will have very restricted diets because they can't tolerate sound food textures or food, taste or food smells. Um And some of them will have difficulties kind of with clothing textures, things like that. And so occupational therapy and dieticians can be really helpful in Children where that's a big problem. So I've got a short question here. Um I don't mind if you shout out or if you just write in the chat, what you think the answer is, I'll give you a little bit of time to read it. Um And then if you guys just pop an answer into the chat or shout out, then we'll go through the answer shortly. Anyone want to have a go answering the question three, which one, the third one? Active surveillance. So I think thinking through this, I'd probably say actually that four is so at this point, you could refer them to an ASD service um for assessment. Um So if they're under three, they should automatically go to an autism development service for assessment. Once you get over three, that's when you start thinking about whether there's a neurological component to this. Because if they're under three. It suggests that they've never really developed the communication skills that you would expect them to. Meanwhile, if you get to over three, um and it's only when people are coming in at 456, parents might say, oh, they seemed like they were doing fine initially and then they went backwards. It's quite important to go to kind of exclude some other organic neurodegenerative diseases first. So they go to a neurologist. Um So Cam's so an autism, the Autism Services, I think this is something about cyclists learning is knowing a little bit about the pathway. So Cam's is the mental health service and they look after mental health conditions. Autism sits in a slightly gray area where it's slightly considered a developmental condition as opposed to a strictly mental health disorder. So you actually the Autism Spectrum Disorder services runs out of the child development centers as opposed to CAMS. That's not to say that if you refer them to CAMS, cams wouldn't be able to direct them to the right place. But the fastest way would be to go via child development as opposed to CAMS. Um as Children get older because you are at high risk of having concurring mental health problems. Children are often under joint care um with CAMS and autism spectrum Autism Services. Um I would, I think when they're very young, thinking about audiology is reasonable, but I think by time you get to, to that would usually be picked up, um thinking about speech and language so that that would be appropriate if the only thing that the parents were complaining about was a speech and language concern. So saying they're not, they're not really saying much, then I'd say okay. Actually, let's go assess their hearing. Let's do a speech and language evaluation, but they've got behavioral concerns. There's quite a lot in this history that suggests it's an autism diagnosis. Um So four would be the answer here. Um Before we move on to think about mood disorders and counts, were there any other questions related towards them? Um that you wanted to ask. So I'm not gonna go into too much depth. We're gonna talk about depression, anxiety within CAMS. Um The reason I won't go into much depth, so we'll start with depression. Um To be honest, the core symptoms of low mood and depression in Children is very similar to adults. The diagnostic criteria remains the same. Um It's quite uncommon in pre pubertal Children. So in about 1% as Children go through puberty, you get an increase, about 3% are affected with depression and low mood. Um It's a really important diagnosis to make um it can have a big impact on Children in terms of their performance within the within school with an education socially. And um the earlier you diagnose and support Children with this, the the better outcome you have. Um in general, we say that about 10% will recover within three months. Um 50% will still be depressed at a year. Um It's not got the best prognosis though. So about 30% will have a further episode of low mood within five years. And it is quite important actually, especially when you have young Children presenting with very severe episodes of depression. That part of their management is about relapse prevention or about educating them about what they can do if they start to notice the early morning signs um and things that a way to access services, um you work them up very similarly to an adult. So you take a full history and CAMS, the collateral is really important. Um Children don't always have the best insight, especially when they're quite young. Obviously, as you're dealing with teenagers, they can tell you a lot more and they tend to have insight that's closer to that of an adult. But if you've got a prepubertal child coming with low mood, what the parents tell you is really important. Um It's really important to risk, assess them. So um blow mood and anxiety within CAMS can be associated with abuse at home. It can be a sign of bullying at school um and missing a trigger um can mean that treatment is just not as effective. You'd want to examine them and you want to do routine bloods. Now, in adults, I would do bloods for anyone who had low mood um, in Children we tend to reserve, be a little bit more cautious with when we take their blood. Um, it can be a little bit more distressing for them. I wouldn't necessarily rush into doing a set of bloods for them. I think if they were over 12, 13, then it's probably reasonable to do blood with that under that age. Um, I wouldn't really do it unless on examination. I found a reason to do it or in the history there were concerned. So your main things to think about our. So diabetes. So having low mood. So you, that's quite easy. You can do a urine dip test for that to start with. Um, you want to think about hypothyroidism and, and then also think about nutritional deficiency. So that's what kind of the history from mom and dad can be really important, thinking about what their diets like. Um, in terms of management. So in mild, it's similar to adults. You do it as a ladder. Um, and it depends on whether it's mild, moderate or severe. And again, we, we score it very similar to adults. So a mild would be kind of having to court symptoms with an additional, um, your severe would be having all three core symptoms with three or four additional symptoms as well. Um, so if it's mild, you can consider watchful waiting, um, you probably give 2 to 4 weeks if they come back and let's see, see how things have changed. Um The mainstay of treatment will be therapy. Um CBT is first line, particularly adolescents. Um If they're younger, then you might think about family therapy or interpersonal therapy. Um And then medication is reserved ready for those who are very severely depressed. Um And the, the drug of choice is FLUoxetine. FLUoxetine is actually the only antidepressant currently licensed for Cam's um to treat use in adolescents. That's not to say that when you go on your placements or if you've been on your placements, you will see that there are Children on other um antidepressants, they are used off license and quite safely, but it will all be always be under the guidance of a consultant. Um If the exam question comes up, FLUoxetine is the drug of choice. Um So if it's moderate, you add on therapy, if it's severe, then you do pharmacological therapy plus minus um inpatient stays if a child is um severely affected or you consider them to be very high risk. Now, um CAMS, depression and camps can still be managed within primary care. So your your indications for referral to a CAMS clinic is if they've got a high risk family history. So if they've got parental mental health, um particularly if mom, mom or dad have had disorders such as bipolar um or mental health or depression, depressive episodes requiring admission if they have not responded to primary care treatments in 2 to 3 months, if they are a moderate or severe when you score them or if they've had a previous episode of severe depression and then if they've got active plans of suicide or if they've attempted suicide, um or if they have thoughts of self harm or are self harming, then that would be an urgent referral, not just to camps, but you would be considering sending them to um an impatient, you know, which would be a tier four service. Um Thinking about anxiety again, really similar to adults. The big difference with Children is that they often, especially the younger age present with somatic symptoms. So they'll talk about things like, oh, I've got a headache, I feel really nauseous. Um I've got a tummy pain um and it can be really easy to think that that is just, you know, down to something else. But for those who present with it, chronically, you should consider whether they've got anxiety. Um The most common cause in younger Children is school anxiety. And then as they get older and two teenagers, you start two things, see things like generalized anxiety disorders, social anxiety become more prevalent. Um It's managed again very similarly to adults. But um again, we, we reserve treatment with S S R I's for only those who are severe and those who have not responded to CBT um for Children who can engage CBT is your first line um Adjuncts to that would be relaxation techniques. So um you can give them things like muscle relaxation guide. There's some guided videos online and um a lot of camps um have booklets and leaflets about that. Um Sleep hygiene is really important. Um And then just psychoeducation both for the child and the family about what they can do to manage the symptoms. Um So I've got a little question just about cams and mood disorders. Um So again, if you guys, if someone just wants to shout out what they think the right answer is or if you want to put it in remission, we'll go through the answers. Um, and if anyone has any questions about this section, um, then please do just put them in the chat or shut them up. Three. Yeah. So I would agree with that. Um, so I'd say that it's three. Do, do they want to tell me why they picked three? If not, I can just talk you through it because she, she, she's having thoughts of all in her life. Yes. Yeah. So here the, the key thing is, um, suicidal ideation. Um I think it's actually when you go into your exams and particularly paces. Um I think when you do general medical stations, it's really easy to think about kind of just what your definitive treatment is and what you're going to, you know, let's say someone comes in with a heart attack and you think these are the medications I'm going to give them and do this when it comes to psych, um particularly your paces. I think it's, it's really important that when you formulate your management plan, you somehow demonstrate to the examiner that you have assessed that patient's risk and what that risk level means for what you're going to do for them. So even if it's at the end, when you're presenting, saying I'd like to manage this patient with a biopsychosocial model, assessing their risk. I think she's very high risk because she demonstrates suicidal ideation. Therefore, I think she needs urgent assessment by CAMS and consideration for inpatient care. Um You know, depending on how severe, how, how clear her plans are. Um the others don't. So Venn vaccine is not a correct drug to give um an adolescent in this case to would be correct if she didn't have the suicidal ideation. Um And then four and five. So you would never just start pharmacological treatment. You would do um you, you'd always go for therapy over pharmacological first, but I think given that it's quite severe, it would be appropriate to think about pharmacological management for her. Um So we're gonna talk about conduct disorder next. Um So conduct disorder is um falls on a spectrum where the mild end is oppositional defiant disorder. Um This is seen in young Children. So Children under the age of three and we're talking about Children who, who demonstrate hostile defiant behavior, but they're not, they're not necessarily aggressive. So they might, they won't actively kind of harm people. They're not that they don't have any criminal actions of things. And opposition defiant disorder is only present in one environment. So it will be only at home or like within their nursery. Um, and that's the milder side. Some of those Children will grow up and it, that sort of hostility will resolve, some of them will go on and it's sort of thought to be the precursor of conduct disorder, which is what we'll talk about now, which is a disorder of repetitive and persistent, uh, antisocial, aggressive and defiant conduct. Um It needs to be present for over six months and present in more than one environment. Um, and we're talking more than just someone being a little bit rebellious. These are Children who might be really in other Children too, quite a severe degree. They might be aggressive and violent towards their parents. They might be known to the police for things like shoplifting or um damaging other people's property. Um Then the next part of the spectrum is then antisocial personality disorder, which is, um, only really diagnosed once an individual is an adult. Um, we don't diagnose personality disorders in young Children. Um, an antisocial personality disorder has a very high association with kind of criminal offense and um, unemployment and things like that. So if you are able to pick up these Children, um at uh the stage of being conduct disorder, um, and intervene, um, then you can do quite a lot for them. I think antisocial personality disorder is actually quite resistant to treatment. Um, it affects 5 to 7% of Children, not all of them will go on to develop antisocial disorder personality disorder, even without treatment. Um and it is predominantly a male disorder. Risk factors are kind of learning difficulties if they've got a concurrent mental health problem, a family history and critically actually a history of abuse um or having a parent who misuses substances at home. Um So the things that you might get told about. So the symptoms are essentially a child who's easily annoyed their temper that fly, fly off the handle quite quickly. They've got a quick temper arguing a lot. There's a difficulty with hierarchy. They are continuously rebelling against rules. Um Things that you might worry about or behaviors they might demonstrate is persistently fighting or bullying often with a very small triggers and you, you go back and you say, why, why was the fight started over this? This really is not a big thing to be thinking about. Um some of them become sexually aggressive. So actually you might get them, you might get Children who are known because of um kind of sexual assault cases. Um they can be aggressive towards animals. So um kind of thinking about pets at home or animals nearby, causing injury to them. Um And then absconding is another one. So actually running away these Children often have a pattern of just running away from home, running away from school um and truancy as well. So not attending school at all. Um because conduct disorder can only really be diagnosed if you have these behaviors within multiple environments. And it's really important to get the collateral. The reason for that is, let's say a child only does, that only demonstrates these behaviors at home. The thing I would be thinking more about is is this actually a stress or adjustment reaction in a very negative extreme way to something going on at home? So Children who might have an alcoholic parent, they, they're way may of dealing with that might be to be quite aggressive at home. But actually, the schools say they're very good at school, they actually stay late because they're probably avoiding going home. So it's really important to make sure that you get the history from across different environments. Um then thinking about the safeguarding. So potential triggers and then thinking about coexisting conditions. Are there other mental health problems that they might be affected with? Um in terms of the management? Um So again, the the primary thing that you're going to do is psychological intervention. So we talked about different things from 3 to 11 years old, you do parent training courses. So actually in a young child, the emphasis is on helping, helping develop parental skills, of how to discipline a child. And when I say discipline, I don't we're not talking about getting angry. A lot of it is about using positive reinforcement for good behavior rather than negative reinforcement for bad behavior. Um Then from 9 to 14, you can think about child focus programs. The reason why you don't use them before nine is Children often don't have the kind of cognitive ability or the insight to engage with them. Um And then from 11 to 17 use multimodal. So the reason for that is when you get to 11 to 17, the Children are often actually known to the juvenile kind of criminal system, the offenses are probably usually more severe. Um and it requires kind of social worker educational input, probably people from the police helping. So the police often run kind of educational schemes for Children who are involved um in criminal offenses, young age and then as well as your comms team. Um The reason why there's a lot of overlap. So there's a bit of an overlap between parent focused and child focused programs for 9 to 11. Um if a child is nine years old, I think they're still quite young for a child focus program. But a parent focused training program relies on having parents who will engage and unfortunately not all Children have that. So Children in care may not have consistent carers. Um Children have parents who have their own mental health problems or substance misuse, probably aren't going to be parents who are going to be able to execute this parent training program courses very well. So you often might think about delivering child focus programs at an earlier age in these instances. Um then thinking about biological, so risperiDONE can be used for short term treatment and only for severely aggressive behavior. Um I the guidance is usually that you try it for 4 to 6 weeks. If there's no response, you stop it. Um If there is a response, you can use it for a couple of months and it's usually a bridge while you work with them, kind of with the behavioral aspect. Um And then you should treat any concurrent mental health problems. If they've got a D H D, you should start them on written and if they're severely depressed, then you should think about an antidepressant um and so forth. Um The social aspect is really just about this multi agency. And, you know, I think if this comes up in your paces, then it's really about stressing that for these Children having an M D T approach is, is exceptionally important. Um So a quick question just about conduct disorder. Um Again, we'll do similar if you put the questions in. If anyone has any questions that I haven't really addressed um in this bit about conduct disorder, then also put those in the chat. Um and I'll try and answer them. Yeah, exactly. So three would be the option here. And this, this question is touching a little bit on. Um So you, you need to make the diagnosis and then touching on the fact that actually he doesn't have an appropriate carer to attend the parent focused programs. Um So yeah, this would be a child focused. I'm gonna move on to think about old age psychiatry. Were there any questions about what we talked about for Cam's before we move on to this? Okay. Um So I was asked to talk a little bit about geriatric depression as well. Right now, I haven't made a slide on it just cause I think it's essentially the same actually as adult depression. The only caveats and the only things you need to think about is firstly, um the elderly tend to present with more biological symptoms. So, appetite loss, insomnia, things like that than adults than your general younger adults. Um And then the main difference between them and other, you know, you're young and fit healthy, 30 year old who's severely depressed is that um the pharmacological, the antidepressant choice can be a little bit more difficult, partly because they probably have an element of Polar Pharmacy. Um And secondly, they often have more comorbidities. Um Matassa Pine is used more in the elderly than in your general population because it's very helpful for biological symptoms. It's really, it's slightly sedative and it's an appetite um stimulant. So it's really good for those symptoms. Um The other thing is that whenever you're starting an antidepressant in someone who's elderly. You, you tend to start at the lowest dose. There are some antidepressants. You might even start at the half dose of what you'd start with an adult and you will titrate them up more slowly than you would with a, with a, with a young and fit healthy young adult. Um, so I'm going to talk about dementia. Next. Um, dementia is quite a big topic. Um, dementia essentially is, uh, dementia is an umbrella term for a collection of symptoms that is essentially an acquired chronic progressive cognitive impairment, which ultimately leads to impairment. Um your activities of daily living and means that you end up relying on carers or having to be in a home. And there are many, many different subtypes and many different causes of dementia. When you think about dementia, you should think about your primary causes and your secondary causes. So your primary causes of things like Alzheimer's Lewy body dementia, frontotemporal dementia, your secondary causes are vascular um infective. So, tertiary syphilis, um metabolic. So you can have dementia associated with uremia from renal failure or from um very low folate levels. Um you can have um secondly, cause from alcoholism. So you're Vatikay Korsakoff syndrome can give you a dementia. Um it can be related to endocrine disturbances. So, abnormal thyroid function tests. So really, there's, there's there are a lot of conditions that fall under dementia. However, there are things that you can do to manage dementia that are fairly universal and I think I'm going to talk to you a little bit about those things. Working up someone with dementia generally and then the important subtype. So I think the ones that I've listed here are probably the most important ones in terms of the ones that tend to come up in your exam, um, versus some of the other ones that don't, don't come up that much. Um, it's a big problem. Um It's increasing in prevalence. Um You see a, a lot when you start working, it would be a very, very common thing. Um And it really impacts every aspect of the patient's management. So, a patient who has dementia who comes in with a urinary tract infection is automatically more complex in terms of their management than someone who doesn't. So the way they present. So memory impairment, they won't have insight into this. I think a really classic exam question. Um That also came up in our year was um you've got someone who's 60 70 who's come to the GP and they're really worried about their memory and they've got a couple of other symptoms like, but nothing that specific. And one of the one of the questions is, is it, is it Alzheimer's, is it dementia or is it pseudo dementia? Now, in real dementia, patient's will not really recognize how bad the memory problems are even if a patient says to you. Yeah. Actually my memory's not been that great. They'll think it's a mild memory problem and then you talk to their next of kin or their loved one and then their loved one is like, they're really, they're not managing at all. It's really bad. Um, they might have psychiatric disturbance. So we talk about behavioral psychiatric symptoms of dementia. So these are things like when people get really agitated, some of them can have hallucinations, they get very anxious. Um, they might have difficult behavior. So wondering, getting very impulsive. So things like gambling, things like that, um, they have sleep weight reversal, um, and becoming aggressive and then some of them will have speech abnormality. So you might see some dysphasia or some tax errors. Um, and that's a little bit more common in your things like Alzheimer's and things like that. So, thinking about how you're gonna assess someone. Um, so I've kind of, if someone comes to you with a concern of dementia, the first thing you're obviously gonna do to take a very thorough history, you're gonna get a collateral history and you're gonna examine them. Um, you need to think about the secondary causes. So I think there's, there are a lot of secondary causes so you could run blah blood tests for days if you really want to. But the important ones I think are I think are the ones highlighted here. So, b 12 and folate deficiencies using these because, um, in renal failure can cause it. Um, and alcohol history and LFTs. Um I probably do Gamma GT as well then a syphilis and HIV testing and thyroid function testing. Um These are also the blood tests that will be expected to be done before you refer them to memory clinic. Now, memory clinic is a community clinic. Um where the whole point of the existence is to assess people who have sides of a cognitive impairment. They will similarly do a history in a collateral. They won't tend to repeat blood tests if they've been done, but they'll do them if they need to be done. Um They have access to um cranial scanning. So most patients will get a CT head to start with. Um and then depending on what the likely dementia is that they have, they may get further scanning. So um a spect or, or a pet scan can be used for Alzheimer's um but we and simply for frontotemporal dementia. However, an MRI is the imaging of choice for vascular. The reason for that is your pet scans and your spect. They show um brain activity. So you're looking at areas that are deficient or low brain activity, which is what you start to see in those dementias. Meanwhile, in vascular dementia, the MRI, MRI is a very, very sensitive and specific for looking at old infarcts and vascular dementia. You're trying to find those tiny little areas of kind of esque emmick brain or brain damage from small in small insults over time that you wouldn't really see on a CT scan. And then the other thing they'll do is they'll do your cognitive assessments. I think the main want to be aware of is in market test or your MMSC, those are the ones that come up with frequently, but there's a whole battery of them that can be conducted within a memory clinic. Um, so your general principles of management. So there's biological, psychological and social. Um again, psychological and social, I think here are your mainstay um in terms of social. So you really need them to have a physio and ot assessment as their dementia progresses. This is something that will need to be continually reassessed. Um You'll think about home adaptation. So Doucet boxes, so the boxes that have the days of the week carrying I D, especially if they're patient who wonders you'll you might even see some people have their name or phone numbers put into their clothes, um mobility support. So a lot of patients with dementia have mobility problems. So Zimmer frames things like that, then meal supports carers or nursing home placement as needed. Um A big thing to mention is that when you think about looking after a patient that you mentioned, you, you need to give a little bit of thought as well too, who their main carer is and whether there's care of fatigue present, um care of fatigue, care of fatigue can cause a lot of problems both for the care and the patient themselves. And there are things that we can do to minimize that. So there are some day programs. So where a dementia patient goes and they have a day within a kind of old person's home. Unless you provide, that can give some respite or you can think about interim placements, which can also give respite to carers. Um in terms of your psychological therapy, these are a lot about actually just helping manage your distress or agitation about dementia. So, reminiscence therapy. So these are, that's where they use different modalities to help kind of take patient back to kind of familiar comforting safe memories, multisensory therapies again, similarly, just trying to um encourage relaxation and feeling settled our therapies and then cognitive stimulation therapy is memory training. This you can really only do in the early stages of dementia. Um It doesn't really change the prognosis in terms of the progression will still happen, but it can sometimes slow the progression slightly um in terms of your pharmacological. So there's no one drug for all dementias, I'll talk about the specific drugs we use for different type of dimensions as I go through them in a minute. But when we think about if someone is consistently agitated. So if that's um if they struggle with kind of be PSD and their specific thing is agitation, aggression, you can think about a low dose anti psychotic. Um The thing that you might come across most commonly in the hospitals is especially as a junior doctor is nurses calling you because the patient is so agitated that they are trying to leave the ward there causing harm to themselves. The risk of harming others and your standard de escalation techniques haven't worked. Now, um using sedation is not the best option. You should go and assess them yourself and try and get them settled um with kind of verbal de escalation techniques. Um But if not, then um you can give haloperidol is the first line again, check your trust policies, but nice as hell, paradores your first line. Unless they have features of Parkinsonism or if they have a diagnosis of Parkinson's dementia, in which case he's LORazepam. Um So I'm gonna really briefly just talk to you about some of the kind of key things for the dementia that I think come up quite commonly. Um It's by no means an in depth kind of dive into all of them. But I tried to pick out things that I think a high yield or important to pick up with in exams. So Alzheimer's disease, um it's characterized by um cerebral atrophy. Um It's a beta amyloid disorder and they've got intracellular tao aggregation and it's affecting the cholinergic pathways. Um I think those four things are just good to know because I think in your paces, if you get something like that are very common, usually the Viber goes, what are your differentials. What's your management or asking you to elaborate bit more than management? And then they usually say what's the path of physiology of this or, or a little bit about how, what's causing the disorder that you're treating. Um The key features can be remembered by forays. Obviously, they're a lot more features, but it's amnesia, aphasia, agnosia, and apraxia. Um and the way that you treat it pharmacologically is you can either use cholinesterase inhibitors, so Donepezil or reversed igman. Both are very common. You start those in the mild to moderate if they have severe dementia than using uh NMDA antagonist. So mom Antonin is the drug of choice, you wouldn't treat with both at the same time. So if someone had reversed igman and then got a lot worse, you would tend to swap them to moment mean unless there's, unless there's a strong reason. So usually it would be like a consultant, neurologist or a consultant at the memory clinic who might decide to try using both, but those are quite specialist circumstances. Um then think about vascular dementia. So vascular dementia is about thrombo embolic disease. Um And the key feature in your history is that you'll get like a step wise progression. So the next of kin might say, oh, well, dad was, you know, he was doing okay and then he seemed a little bit more forgetful and he seemed to be wandering around and he, he was just like that for about eight months and then it got a little bit worse and he suddenly was behaving really weirdly like he was gambling all the time. He doesn't usually do that and then it got a little bit worse. Um, it's very difficult to have a collection of symptoms. So, unlike Alzheimer's, where you've kind of got the four A's, which are your four key features, vascular dementia will present with whatever area of the brain has been injured. Um And, and so that can make it difficult. So the step wise progression is a really key thing and really important. The other thing in your history is they will be, they will have a lot of risk factors for cardiovascular disease. Were talking about people who have kind of acute limb ischemia, they have heart attacks, they might have had a stroke like a very clear stroke in the past. Um they'll have dyslipidemia type two diabetes, hypertension, things like that. Um There's no, there's no management for the cognitive impairment itself. The pharmacological management for it is about preventing further ischemic damage. So it's your aspirin, it's your secondary prevention aspirin. So 75 mg once a day, um to be honest, it's quite likely that these patients are already on these drugs and in which case, um it's quite difficult about adding more. Um But again, when you manage these, if you had this as a Pacer station that you would need to think about counseling them about um stopping smoking, managing their diet, make sure that their blood pressures are controlled if they need an anti hypertensive, adding that in adding in a statin and so forth. Um Parkinson's dementia is associated with Parkinson's disease. Um It presents as a generalized cognitive impairment, but a large proportion of them will have hallucinations. Um You often get questions in your exams or your paces. And Parkinson's dementia is quite similar to Lewy body dementia. But the differentiation is that Parkinson's dementia it exists if someone has had Parkinson's disease for over a year. So the motor symptoms, the pill rolling tremor, the postural instability, things like that for over a year before they have the cognitive impairment. That is Parkinson's dementia Lewy body dementia is when the cognitive impairment and the motor symptoms start at the same time. Um The way Parkinson's dementia is associated with your dopaminergic neurons. So, having too little dopamine. Um and the way you treat that is we give dopamine. So we give levo dopa every patient will be on it. Um And then you add on either a moderate, I mean um inhibitor or a comped inhibitor depending on what the patient, how the patient's responding. Um You can have them on both. Um the levodopa doses can increase and then you can consider amantadine. Um To be honest, I've actually not really seen patient's on, this is primarily levodopa plus minus an inhibitor that we use. Um The one thing about Parkinson's medication, which I think is good to know for your exams, but also going forward in your future practice. Um, Parkinson medications is what we call time critical. Um, a patient has to have them at the same time, pretty much every single day and it's really important. So, um, if they come into hospital it has to be one of the first things that you prescribed on their drug chart to make sure they get a, um, the withdrawal symptoms can be really severe for them if they've missed it or if that's delayed and it can take days for them to recover back to what they were before. Um And especially in patients who are old frail anyway, and if they come in to hospital, probably unwell in some other way, it can really, really knock them back. Um So think about the other kind of types of dementia. So Lewy body dementia, as I said is when you have um both the cognitive and motor symptoms starting at the same time and it's characterized um in terms of path pathology as Lewy body deposits, um you will have a more um prevailing sense of fluctuating confusion and consciousness. Um and they'll have quite visit hallucination. What I say by fluctuating confusion, consciousnesses, you might, they might have a history of saying, oh, they're actually really good for a couple of hours in the morning. And then it's like a completely different story in the nighttime Meanwhile, with Alzheimer's, you get a little bit of sun downing, but there's never a point where they're really good in the day, they're just a little bit better and then get worse at night. Meanwhile, with Lewy body dementia, especially at the beginning, you can have quite drastic changes in how, how confused a person is um medical treatment. So we actually cholinesterase inhibitors, the river stigma and episil. So you treat it pharmacologically more like an um more like an Alzheimer's dementia. Um frontier temporal dementia is um atrophy for the of the frontal temporal lobes. It's probably one of the most distressing dementia for the family. Um These patient's also unfortunately present a lot younger. Um you tend to see them in their fifties, um forties for fifties and they, you essentially, they turn into a completely different person is what the history ends up being. Um They get personality change, they can become quite aggressive, they can be impulsive, including sexual disinhibition. So you might have um you know, things where people are saying things that are very inappropriate, touching people, things like that. Um They have emotional blunting so they won't respond to cues in the same way they would things that would, you'd expect to make them sad, might not. Um And they will have no insight. So they really won't recognize the risks of their behavior. There's unfortunately no pharmacological treatment for them. It is fundamentally supportive care. Um and it can be very difficult, especially for families where, um, if you think someone in their fifties, they may have Children still at home. And so there's, there's quite a lot about thinking about the environment, especially the ones who present quite young. Um, it's progressive and some, it can be very rapidly progressive on average about eight years from symptom onset till death. Um, and then the last one I'm going to talk about is Huntington's, um, it's an autism bill dominant inheritance and it's because of a trinucleotide repeat. Um, now it's got, um, it's got a very variability in it's, um, penetrance in terms of it's genetic penetrates. What that means is that there's a set number of repeats around 2024 where we'd call that normal between 24 to 40 you at risk and then over 40 is a definitive diagnosis. So from 24 to 40 some people will develop Huntington's and some won't. Um, over 40 everyone will get it. Um, the longer the pie nucleotide repeat sequences, the worse it is. Um, and the trinucleotide repeat sequence tends to get longer with each generation. This means that as you go through the family tree, people will present younger and younger with the symptoms of Huntington's. Um, they, the reason why you have Huntington's is you get abnormal protein formation from the Huntington gene, this deposits within the brain and it's essentially if toxic to the brain and you end up with neuronal death. Um, it causes personality behavior change. And the really classic symptom is that motor courier. Um, I think if you haven't seen it, I would really recommend just kind of, you can find them clips on youtube kind of medical clips of Korea. And it's really good to have an example of what that looks like. Um, the house speech and motor abnormalities and Huntington patient's in particular are quite predisposed to developing epilepsy. So a lot of them, you put on antiepileptics. Again, there's no pharmacological treatment. It is entirely supportive care. Um, the big difference in this with other dimensions is you'd really think about genetic counseling, especially if this was someone who was presenting with it and they didn't know there was no previous, most people will know if there's a family history. But, um, if, if you're the first generation to go over 40 for instance, that it would be you need to talk to the families. Um, so I've got a couple of questions on a question of dementia and things like that. So if I again, just give you a couple of seconds to read through this, um, and then you can just put the answer in the chapter you want, does anyone want to have a go answering this one? Yeah. So it's four. Yeah, exactly. Um, so the reason for that is, um, the diagnosis of Parkinson's disease precedes the cognitive symptoms by over a year. Um, so I'm gonna talk to you a little bit about delirium. Next. Um delirium is uh an acute transient state of confusion where you get impaired consciousness. They're three key features are impaired consciousness and attention, um impaired cognition and a fluctuating course. So they'll have periods where they're better and then periods where they're worse. Um delirium will present in, in two different main forms. So a hyperactive or hyperactive form, it is a really big problem. It affects 20% of our medical impatience. Um And over 70 of the elderly admitted to ICU. Um I'm currently on acute medicine right now and I cannot tell you how many patient's have delirium and it can make their stay very problematic, especially if they're agitated. Um Or if, and it tends to mean they stay longer. Um delirium tends to be triggered by something that doesn't, it's not always the case, but it tends to be um it can be triggered by pretty much anything. The main things to think about is inter current illness, in particular infection. So, if someone suddenly becomes delirious thinking about, do they have a uti do they have anything like that, anyone undergoing a procedure or trauma? So, actually, I've seen 50 year olds who um fit and well come in for a cancer operation. It's a big operation actually, then postoperatively they become delirious and it's just the response to stress essentially um pain. So, one of the big things that we talked about, especially elderly when you start getting confused elderly patient, you should move there, analgesia to being regular rather than just prn a confused patient is not going to ask for pain relief when they have pain. They may not even recognize they have pain, but pain definitely makes the liver and worse thinking about uh drugs, alcohol and then prescribe medication. So asking next of kin, have you have a recent had a medication change? Has there been a dose changes? Anything different? Um And then I think the other two things that are really common and often missed are constipation and urinary retention. So, when you're working up, you're delirious patient, you want to be thinking, when do they last open their bowels? Do they need to pr um and getting a bladder scan and if they have um a lot of volume in their bladder then putting in a catheter. Um So how they present. So, um you can either get, so you get mood changes and they might be um become quite low in mood. Um, they'll have a very changeable. So they get quite disorientated and it will be to the degree where you can go and see someone award around and they can recognize there in a hospital and then you might come back to three hours later because you needed to examine them for something and they will think that they're on an airplane, go somewhere. Um They can have hallucinations. So the most common ones similar to lure, body dementia will be small animals. The other things that they can get is just seeing like shapes. So maybe squiggly lines floating across their vision or they think that things are moving in the distance that's quite classical of delirium as well. Um Sleep disturbance. So, reverse of the sleep wake cycle or sleeping too much or sleeping too little and poor attention. Um You get hyperactive versus hyper hypo active. So, hyperactive is your patient who is wandering around the ward can't sit, doesn't sit, still, doesn't let the kind of put in, they can get quite agitated, they can get a little bit aggressive and you're hyperactive patient's, they're the ones where you often miss the diagnosis, delirium there, your elderly patient who just lies in bed and you go, try to go talk to them and they're really difficult to wake up. They can't really focus on what you're saying. They don't really know where they are and hyperactive comes with quite a risk of things like uh your oral intake. So actually, these patients can come quite dehydrated. If you don't recognize they're not going to be reporting things such as symptoms like symptoms of pain or if they're constipated your new attention. So you need to assess them a little bit more carefully and distances what you're gonna do with them. So you, you see a patient, you think they're delirious, so examine them, get a cluster history. Um I would do a routine set of bloods, antiseptic screen. So um thinking about should they have a chest X ray? Should I do a urine dip? Is there a focus of infection somewhere? Um The two scoring systems that we use to diagnose are the contest and the 4 80 I'll talk you through them in the next one, in the next slide and then um A M T S can still be really good. So if you can't remember how to do the specialist one's doing just doing an A M T s, but the key is doing it at multiple points. So, um, going back and having someone do it again and seeing how it changes through the day, um, you should always review their medications. Is there anything new, is there anything that I can stop? There are some medications that make confusion and delirium worse and then again, yeah, just thinking about any triggers. So the different ways we assess. So the confusion assessment method or the cam method looks at the four key components of delirium and assesses those. It's 10, it's about 10 questions, but it is a little bit, it's a lot more involved than 4 80. the camp test has around a 90% sensitivity. So, so it's very good. It's reasonably quick, but it does, it does rely on a couple of things. So firstly, you need to be able to ask the patient some questions there, your classic questions like where are you can you count backwards from 20. Um you need to like observe the patient for a little bit so their behavior and then the difficult one is getting details from relatives. So there are one or two questions asking about relatives. Um In contrast, the 4 80 was then developed because it can be used in any setting. So in the CAM method, if your patient has hyperactive delirium and can't wake up enough there. So drowsy, they can't wake up to the questions. You can't complete a CAM assessment. Meanwhile, in the 4 80 because you look at um alertness which essentially scores zero if they're normal and nothing if, if you can, if they wake up after sleeping within less than 10 seconds and four is if it's clearly abnormal, if they're really drowsy, you can see that you can assess every single patient using the 4 80. It's very quick. The A M T four is asking for questions that age, date of birth, current place in current year and seeing how many mistakes they make attention is the months backwards. They score zero points if they get more than seven, right? They have score one if they get less than seven, right? Or if they refuse to start and to if they are in testable, um a score of four means they likely have delirium. 123 is likely a cognitive impairment and zero is delorme's unlikely but not excluded. And again, these both of these tests are designed to be done in um like in sequences. So do you do it again and again and monitor, see how they change. So how do we manage delirium? Um So conservative management is reorientation techniques. So putting clocks by their bedside, um you'll notice in hospitals that in wards, we turn on the main lights in the morning and we turn them off at night, that's to help patients' um try and simulate a circadian rhythm or to help patients' know, put the difference between day and night time. Um They might, you can ask family members to bring in things that are familiar to them and have like a calendar on the bedside. Um It'll be things like relaxation involving family and carers, especially if you have a patient going for a procedure or test. It's very common when I have a confused uh the patient that their daughter or their son might escort them to X ray or CT because it's very comforting for them and it helps them feel more orientated to have someone they know they're, you want to avoid them being over or under stimulated that. Now this is very difficult to achieve on a general ward. Um The Jerries Lords tend to have some measures in place to help them do that. So they might have smaller bays, they might try and reduce the amount of noise from the equipment and things like that. Um And then thinking about their nutrition and making sure they've got adequate nutrition. So your medical management is by and large treating the precipitant. So, if they've got a uti I'm going to give them antibiotics. If they're constipated, I'm going to give them laxatives. If they have your only touched, I'll put in a catheter. Um, if they have any electric like abdomens, they'll correct that. And then the other side of medical management is managing distress and agitation. So you should always try conservative methods. So de escalation techniques, verbal de escalation, thinking about ways to make people feel more orientated and comfortable. Um And then you can think about haloperidol. Um So you start the lowest dose and you titrate up. Um You don't really want to use this long term. I'm talking about a week or so and then you would usually stop it. And the idea is that you bridge them while you treat the underlying precipitant. So I hopefully, by the time you get a week down the line that delirium has improved enough that they no longer need the haloperidol. Um if they have Parkinson's, then you use LORazepam. Um And then the only exception to that is if you have delirium secondary to alcohol withdrawal, then you use chlordiazePOXIDE like a weaning dose regime. Um And then your follow up. So it can take weeks to months to recover. So some patient's seem to get better in a week or two. Um Some patient's have ongoing delirium for 34 months down the line. Um But whenever they are as close to their baseline as they get, it's really important to refer them to memory clinic. So, patient's who are, have an episode of delirium mark higher risk of having an underlying cognitive impairment or dementia. Um So we're gonna do another question. Um So I'll give you a little bit of time just to read that and when you're ready, just, uh, let me do, does anyone want to try and get an answer her as to what they think might most likely to diagnosis might be? Yeah. Yeah. So this is a patient who's got hyperactive delirium. Um, they are definitely the ones that tend to get missed. So do try and keep an eye out for them. Um, and they can become quite problematic because, um, they really don't complain of symptoms. So we've had a couple of hyperactive delirious patient's who, um, you think are getting better in the blood tests come back and they're actually really unwell, but they just aren't showing any symptoms with them because they're so drowsy. I'm gonna move on to substance misuse before I do that. Any questions about kind of old age psychiatry or dementia or delay or anything like that. Um, just give you that opportunity now. Okay. Um, so I'm going to talk to you generally about substance misuse and then I will talk to you specifically about alcohol opiates and benzos. Um, obviously, substance misuse stretches far and wide. Um from things like alcohol and nicotine to um your classical so opioids, Benzo's to cannabis and things like that. But I've just tried to focus on the ones that tend to come up the most. So substance misuse, I think some terminology to be aware of. So we talked about intoxication when someone is in the acute phase of being directly under the influence of a substance. Um So that is when you're drunk because you've had alcohol harmful use is where someone is, has features of misusing alcohol. Um So things where, where it's misusing a substance, so where it's starting to have a negative effect on their life, but they don't have signs of dependency yet. So for example, um you could say young professional who binge drinks alcohol every weekend and as a result, he's driven under the influence, he's trespassed or something like that's he's harmfully using alcohol at that point because um he started to display behaviors associated with his use that have a negative physical psychological consequence, um or personal consequence. Now, dependency is strictly when you have um busy or behavioral cognitive symptoms where someone that using that substance is essentially the highest priority thing for that person. So they are dependent on having that. So the key features that um when you take a history, these are the key things you need to be looking at. So if, if I was kind of examining you for an alcohol misuse history. I'd want you to establish tolerance. So, um, how much did you used to drink before you got drunk? How much do you drink now? Compulsion. So that's your cravings when you wake up in the morning. Do you feel like you really need a drink? What's the earliest you have a drink? How do you feel if you don't have a drink? And they'll say I'm really agitated. I can't stop thinking about when I get my next drink, withdrawal. So, withdrawal will depend on the symptoms of withdrawal will depend on every different substance. But generally people get more agitated, more anxious tremors are very common. They'll feel um not very well within themselves and problems controlling use. So today I told myself, I'd only drink one glass of wine, but I drank the whole bottle. That's sort of the example. Um they'll continue to use it. So when you challenge them, let's say someone says, oh, I, you know, I'm starting to worry about my alcohol intake. I've lost my job because of it. And you'll say you might then later in the history say, well, how do you feel about, you know, you know, why, how do you, why do you continue to use it? Because even when you cause your consequences, like losing your job or things, um then Primacy or since that's where it's, it's getting, getting and having and taking the substance becomes the most important part of their day. So people will start to describe things like I walk down. I know at this time, I'm gonna walk to this store and I'm going to buy this and they may almost have a ritual around getting these things, getting the alcohol, getting their substance. And that's the only thing that matters to them in their day and that the most everything drives towards that. So they might say, well, then I, you know, try and get some money from somewhere because I need my next, you know, I need to have money for the next thing. Um So then reinstatement after abstinence is about, you tend to go back. So, um they might have said, oh, I stopped drinking for three days and they go back and they use the same level again. And then narrowing of repertoire means that um you know, if you drank, well, I use alcohol cause any ankle is a good, a good example in terms of um you might go out and you might drink a cocktail. You might the next day you decide to have a wine or you might decide one day to have a shot and you show variants in your use of alcohol. Um Narrowing is when people, when you take a history from an alcoholic, they tend to know they tend to have one or maybe two, they might mix two alcohols at most and they will know exactly what it is that they're, they're drinking and they will just drink that same thing and over and over again, it will always be that that will be there. Drink of choice. Um Then the other thing to think about in substance misuse is thinking about stages of change model. Um I think it gets touched a little bit in your kind of um neuro lectures in earlier years. But it becomes quite important when you're managing substance misuse to identify West. A patient might be. So pre contemplations is they're really not even thinking about change. They may not even think that they have a problem. Um They may be completely unaware of the risks that behavior have. Contemplation is when someone says, is the kind of person who recognizes there's a problem. They might say my drinking is a bit harmful but they don't want to change yet. They might not even be thinking that they're ready for change or anything like that. Preparation is when someone starts to think about changing. So my drink is a bit of a problem. Maybe I should talk to my GP about it. Um That's a preparation stage. Axion is when they actually start to do the things that will stop them drinking. So starting to cut down becoming abstinence, going to self help meetings, maintenance is then that period where they're not drinking and it's called maintenance because a lot of, a lot of effort goes into that stage. Actually, that is probably the hardest stage out of all of them. Um And then six is relapse, six is on there, but it's, it's outside of the circle like when you draw it as a diagram because obviously not everyone relapses, but a lot of people do and a lot of people go through the cycle a couple of times before they are able to achieve abstinence for a long period of time. And then I've just listed some of the common substances that get misused. The two you come across most commonly in hospital is alcohol and nicotine. Um And I probably have a quick look at nicotine um misused and the kind of replacements that uses kind of those differences between the gums and the patches and what you can offer patient's. Uh um So think about alcohol. So we recommend 14 units a week. Um It should be spread over three days. The idea of that is to avoid binge drinking. Um It's a CNS depressants. So it stimulates the gaba receptors, which is why when you um stop drinking, you get over excitability and that's what causes your delirium tremens and your seizures. Um uh effects about 10% lifetime prevalence, males, more than females and risk factors. A family history, trauma or mental health disorders. Those are your key risk factors. Um When you meet someone, the things you'll do is you'll do a cage, cage screening, examination of blood. So the blood you want to do for your um your consequences. So, liver function scam a duty. Um You want to do full blood count for a macrocytic anemia B 12 folate. Um And then depending on them, you would need to ask the history. But if you're misusing one substance, you are at risk of misusing others. So if they are using any IV, any IV drugs, then doing things like a blood borne virus disease is quite important as well. Um The two scores that we use commonly as order and see what these give us an idea of how severe the alcohol dependency or alcohol misuse is. Um see what is what Imperial trust tend to use when we think about how severe um someone's alcohol misuse is and it also helps us stage the severity of withdrawal um that links them to our management. Um So in terms of the long, so you can, the acute management of alcohol withdrawal is um if their severe, you give them a weaning dose of chlordiazePOXIDE and thiamine. Now, if they're severe, you should give it as Pablo necks and then swap them to oral tablets. Um And the reason, the way you assess what severity is use the seawall score. So patient's who are severe will get like 60 mg of chlordiazePOXIDE and wean that down. Meanwhile, the moderate will start at 40 and a mild might start at 20. Um It's really important when you're in hospitals to ask the nursing team to keep score ing them on the seawall score because even though I might say you're severe and I start you at 60 a patient might still have withdrawal symptoms on that. So you always, you always have PRN chlordiazePOXIDE as well. So that if they're still scoring very highly a nurses can give extra and the whole point of that is to prevent seizures. Um Thinking about kind of outside of the acute setting, let's say a patient comes to you and says they want to miss you, they want to come off alcohol. Um You will still do the detoxification. Um You can do that in the community or as an inpatient. So there are community centers that will observe patient's taking their daily chlordiazePOXIDE and support them with that. Um And again, that comes down to a couple of things, um the severity of the alcohol misuse if they have any concurrent mental health disorders, if they have a history of seizures or delirium tremens or if they're like known epileptic, these are kind of the things that would push me towards having someone admitted to come off the alcohol versus a community. Um Now you will get people who are dependent on alcohol who actually don't drink that much. Um And in that case, you may not need to wean them with cord ice park side. Um But that's quite, I mean, that is a minority. Um the other thing to think about then are your psychological, which is CBT is the therapy of choice and then social is primarily yourself health groups and then things like financial support if they're unemployed or reemployment, um, support. Um, the other thing, long time to think about is we can offer some medications. All of these medications are designed to be used in the short term. So six months to a year, um, you can use disulfiram which essentially blocks the metabolism of the alcohol. You get, build up of toxic byproducts and it makes you really nauseous and six. So it makes you, it gives you an ad as adverse reaction. Uh a composer, it is really good for anti cravings. And then Naltrexone doesn't change your cravings, doesn't give you an adverse reaction. But if you drink alcohol on Naltrexone, um you don't get the same kind of buzz, you don't get the same, you don't really feel as good. Um And then your key complications of alcohol misuse are I think we've covered most of these. Um So that's alcohol, think about opioids. Um Opioid misuse is common um is really prevalent within the States. It's, it's relatively common here as well, but I would say obviously, alcohol a lot more than opioid misuse. Um And it's a very similar strategy. So your biological is around um substitution therapy um in an overdose using naloxone and then in your substitute and therapy's you can use um methadone or buprenorphine, there's an induction phase. So what induction means is, it's 2 to 4 weeks where you are increasing the dose of methadone and buprenorphine until you reach the level where they don't get any withdrawal symptoms. So the signs of withdrawal are like a cremation, g eye disturbance. So, nausea and vomiting is really common. They'll have really dilated pupils, they'll feel really agitated. Um They'll usually be quite active, like being quite agitated with the department. They might have myalgias. So they might actually present looking quite sick. Like I've got muscle aches everywhere, they might feel feverish. Um And then, and then actually you, you go and assess them, you might do a urinary drug screen. You might take the history a little bit more realize that it's all part of withdrawal. Um You then once you've reached induction, um you tend to have a period where they're stable on the dose and then you make the decision whether this is someone who will have a weaning regime or a maintenance regime. A weaning regime is used for patient's who are motivated to be abstinent. Um And that's when, then over a course of months because you'll, you'll only reduce the dose every couple of weeks, every 1 to 2 weeks. Over months, you'll take them from whatever the induction dose was down to nothing and they'll be supervised taking the medication each day. There are clinics that run this um, maintenance is used for individuals where they may have failed previously to become abstinence or they may have no interest in, um, stopping their substance misuse. The reason why we advocate for maintenance is that you, it's, it's so much less risky than street use. Um, especially people have been using kind of injecting or anything like that. Um, and buying drugs off the street, you don't really know what's in them. You, you're much more likely to overdose. Um, so maintenance therapy is, um, preferred. So even in patient's where you think they're abusing opioids and they have no motivation to change. It's very worth your while referring them to drugs and alcohol misuse service for consideration of maintenance. Obviously, they still need to engage with the service to a degree. So there are some patient's where it's not suitable for and then you've got a treatment to manage the symptoms of withdrawal. So it's made in your gi so loperamide and metoprolol uh metoclopramide, sorry. Um Your therapies are CBT and then family therapy. Um And then social things are they have Narcotics anonymous, very similar to a a um then harm reduction. So if they are injecting sterile needles, vaccinations doing um blood borne viral screens. Um and it's important to think about safeguarding. So particularly um think about sex work and whether they're being at risk of being exploited in that sense, um That's most about opioids. Um Then thinking about Benzodiazepines, um Benzodiazepines is uh not particularly common drug dependence, but it is one that is actually in most cases iatrogenic. So, um the incidence has gone down now that you have um much clearer guidance on how we prescribe benzos. And previously people would get them for many, many weeks, months and dependence was a real problem. Um um Again, it binds to Gaba receptors. So you get neuro inhibition, which is why when patient's stop suddenly taking benzodiazepine, they are at risk of seizures. Um you can develop dependency very quickly. It only takes 3 to 4 weeks of using it before you to build a tolerance or feel like you have a dependence to it. Um The withdrawal symptoms are very, very similar to alcohol. It really mimics alcohol um in a lot of ways. Um primarily because it acts on the same neuro receptors. So it's your gaba system that has been affected. Um the way that you manage it. So in acute overdoses, we use for Amazon ill. The caveat to that is we only really use Freemason ill if someone is um hemodynamically unstable or has respiratory depression, if someone who's just drowsy, but they are saturating okay and um hemodynamically stable. Um it's safer to actually let the Benz is kind of just wash out of their systems. The risk with Freemason ill is um it can trigger, it can precipitate seizures, um which is obviously not ideal, which then you end up treating by giving them more benders anyway. So you can kind of see how the cycle bit cyclical if the seizure doesn't stop self terminate, um when you want to detox someone. So swap them to something long acting. So your drugs of choice would be diazePAM all chlordiazePOXIDE in that case. And then you would wean them and you wean them over months. It takes many, many months to wean someone off it um alongside this, they should have some therapy. So CBT and then think about and then think about the triggers. So what, why is that they felt like they needed these um a lot of people who end up with Benzo prescriptions are ones who are complaining of anxiety. So it's really important that you address their anxiety when you're managing them. So things would be like starting an SSRI safe to do when you're weaning someone. Um and if they don't have persistent anxiety, but they might have panic attacks, something like that, then just giving them prn propanolol can be really helpful for these patient's and help them um progress through kind of the stages of change. So I got a couple of questions on substance misuse. So the first one is just thinking about um what stage or change on is. So I'll give you guys a couple of seconds and then if you want to put um your answers or what you think the correct answer is in the chat. Uh Yeah, exactly. So um they are in three. So he's starting to think about it and he's starting to think about how he could change. So preparation is exactly the correct answer. Um And then we've got this question now. Um So if you just want to have a go at that, yeah. So it's three again. So here, the, here is a very classic case that you'll see in hospital where someone comes in for another reason, they come acutely and well, and then they develop alcohol, draw on the ward and you may not have picked it up necessarily when you've clocked them in. Um So when you, if you do get reports from nurses saying or someone's shaking or someone's really agitated or whatever, then do you think especially if they're within the 1st 24 hours of the admission? Think about, are they withdrawing from a substance? Um and just try and get a little bit more information from the history or next of kin. Um So in this case, he came in with sepsis essentially. Um So before I move on to the next, but is there anything any questions for substance misuse? Mhm. Um So psycho sexual disorders I think usually doesn't actually get covered. Um I won't go into much depth because I don't, I don't think it's um there, there isn't actually that much evidence for a lot of treatments. Firstly, um and secondly, I think it's this one of the smaller topics that will come up in your exams. Um So we're gonna start by talking about libido disorder. So low libido erectile dysfunction and also hypersexuality. Um And then I'll talk to you a little bit about gender identity, which is probably the slightly bigger component of this um part of psychiatry. Um So libido disorder, so low libido is pretty much as it says. So a loss of sexual desire or sexual drive, um it needs to be ongoing for more than six months and the patient needs to be distressed by it if someone is not interested in um intercourse and they don't mind, it's not a problem to them no matter if other people say that's not normal, whatever, if they're not bothered by it, we don't, it's not really seen as a problem that needs addressing by us. People have very different sex drive's people find that um they have different, you know, expectations of what their sex drive to be. And so when you take these histories, it's really important to explore that. And then the other criteria is that for it to be low libido, it shouldn't be secondary to another condition. So the first thing you essentially a diagnosis of exclusion. So when you investigate them, take a full history, examine them, you should assess for any concurrent mental health disorders. Almost all mental health problems will impact someone's sex drive in some way. For example, depression very commonly results that causes low libido. The other thing then to think about is organic diseases. So, anemia where you get tired, hypothyroidism, where you get tired, renal failure liver failure, uh Any organ failure is gonna probably impact your um libido. Um And then the other thing is hormone profile. So, um especially in young women or young men, you want to think about primary gonadal failure. So, are they going through early menopause? Um Is there another reason do they have a pituitary um panhypopituitarism or something like that? Um So those are the things you need to do and if all of those are normal and everything else was fine, it was causing distress, then you can think about how you manage them. Um First thing is to think about any triggers or any stress. A lot of this has a psychological component. So um thinking about the general well being, so there's a lot of psychoeducation around looking after yourself. So relaxation, thinking about sleep hygiene, addressing any stresses in your life. Um This is where CBT can be a bit use quite useful. So if they have a particular stressor, sometimes if you address that anxiety, then um it can help them. Um in terms of the libido, CBT is also quite useful when there are specific behaviors or patterns of behavior that might prevent them from engaging with their own kind of sexual desires. Um The other thing then especially in patients who are in long term relationships is to emphasize the importance of communication between partners. This can include couples therapy. It is not exclusively mean couples therapy. There's a lot of advice that you can give about having open communication with your partner. Um In some instances, um you can think about things such as um sensate therapy. So this is where um it's not, there's not necessarily therapist there, it's more kind of self help, kind of guided where um you partners should focus on um pleasure and desire without actually having intercourse. Um So thinking about different ways of touch and things like that and that can help build and then for some thinking about in a, in, in some, in some relationships where there's a mismatch and libido is kind of timetable ing sex. Um as part of working on libido and communication can be helpful for them, especially where you have couples where the issues around the frequency of intercourse are causing really significant relationship. Strife. Um and then think about erectile dysfunction. So this is, I mean, it's a male disorder and it's primarily around the inability to have an erection and it's somewhat subjective because it's sufficient satisfactory sexual performance. So again, the key in this is that it needs to bother the patient. Um It's not about you saying this is this is not normal, this isn't. Um And you've got three main main forms, organic psychogenic and mixed. So your organic can be things like vasculogenic, which is the most common. So people who have severe vascular disease often have erectile dysfunction, then neurogenic. So anyone with spinal cord trauma or multiple atrophy or peripheral neurogenic. So, diabetics often have difficulties maintaining erections. And then the other thing is thinking about medications, there are so many medications that affect sexual performance. So, doing a good medications review, I'm not gonna go too much into those because I think that's just treating the organic cause. So we can talk a little bit more about the psychogenic type. Um, so you can have generalized where it affects, um, affects the mail in all situations or you can have situation related where there might be a particular stress and actually they previously not had issues and something's happened in their life and that's, that's caused or contributed or might be partner related or things like that. Um You do need to exclude all the organic causes we talked about. So again, examination, medication, reviewing routine bloods and then your management options. So you can treat any reversible causes. Um And then psychological therapies is really, it's kind of your CBT and then your pharmacological would be your um prostaglandin inhibitors. So, Sildenafil or Viagra is the brand name is uh um your third line are things like vacuum pumps. Um This would be more for patient's where it's not safe to use PD inhibitors. So patient's who might drop their BP, who are hypertensive. Anyway, um you wouldn't really want to give the Viagras. It can cause quite a lot of other problems. Um You can also think about um Intercavernous injections or top of creams. Um, and the vacuum pumps, these tend to be more for the older patient's, um, where they have co morbidities that mean medications are contraindicated. Um, the vacuum pump can be good for fit elderly men in terms of it's an relatively safe procedure and it gives you non invasive than drug management in the future. Um, but these are quite far down the line. Um, by and large, most people it's about optimizing well being psychological therapies. And then thinking about uh prostaglandin inhibitor, um then hypersexuality, this doesn't have much. Um there's not a huge amount of widespread literature on this um or evidence behind treatment, there's no specific nice treatment pathway, but I tried to collect what I could. So um it's where patients have um raised sex drive for over six months, but to an extreme, they'll have recurrent and intense fantasies. It will be intrusive, it will cause them distress. Um They might try to control their desires and it may not, they may, they won't be able to um manage it. So it has a little bit of an obsessional component to it similar to what you see with OCD, but it's around um sex intercourse, sexual behaviors. Um it can, it can result in harmful behavior. So they might put themselves in situations to satisfy these sexual desires that are potentially risky for them or risky for the other individual involved. Um And it needs to cause them some kind of distress the way really that you manage them is self help. So, psychoeducation managing the condition, um the therapy. So CBT um A CT analytical cognitive therapy is actually also quite helpful. It um analytical cognitive therapy looks a little bit more at the thought processes behind um behavior patterns than CBT. CBT has has like more emphasis on the behavior aspect. Um And then you can think about, you can think about medication. So starting with antidepressant SSRI rise um that can help with the compulsion. Although obsession very rarely do what you think about GNRH are antiandrogens. I think you really only use those in the context of someone um being at very high risk to others or themselves because of um the intensity of the um desires. So, thinking about gender identity, um so it refers to um a general state of dissonance between what someone identifies with um identifies their social gender rollers and what their biological sex is at their. So e um someone's board female, but they very much identify and feel they are a man. Um The incidence is the, the epidemiological data is um rapidly changing, primarily because of social education, social awareness and people are starting to come forward um in much higher numbers than they did previously. Um There's still a lot of stigma around the condition. Um And um one of the big risks for these, these individuals is actually the they have very high rates of concurrent mental health problems, um depression and anxiety, low mood, many of them will have a history of self harm and very serious suicide attempts. Um And so it's really important when you care for them that you think about um any underlying mental health problems or anything that might be contributing to that. Now, thinking about how we manage them. Um So the conservative approach firstly is to support them to live in their identified gender, socially. So transitioning in their work environment in their school environment, in their home environment. Um For most, um for most medical or surgical interventions for patient's to be a candidate for them, they need to demonstrate that they have lived in the opposite gender role for over a year. Um A lot of this is around safeguarding, making quite serious changes to an individual's body without them without being sure of the diagnosis. Um There are some differentials that can be difficult to distinguish from gender dysphoria. So um severe body dysmorphia can mimic it. Um psychosis um or individuals with E U P D can also have features that can they might have general issues with an identity crisis. Um That's actually not true gender dysphoria. So you giving them in a year allows you to treat them and also support them and make sure that it's the right decision before you go through with anything medical or surgical. Um all patient should be off with therapy um and then treatment of any concurrent mental health disorders um in terms of the referral process. So in adults, you refer them to a gender, gender identity um service. There are a couple nationally um and they work within mental health units. Um and they will offer therapists who are trade specifically in this um for Children, the referral is slightly different. Um You also refer them to a gender identity service, however, only to exist nationally. So the waiting lists are exceptionally long. Um for everyone, you assess them over a period of months. Now, when their Children involved, you tend to do a individual and group and family assessments. Um And the assessment process is over 3 to 6 months. Um So it's quite an uh an intense process to go through. Um You can then think about the medical treatment. Um So in Children, you can use GNRH analogues to block puberty. This will not give them the secondary sexual characteristics of the opposite gender, this simply blocks puberty. So they will tend to have a prepubertal kind of body shape so that they'll look neither female nor male um as such. Um in order to be a candidate for that, um there, there are quite strict criteria, they need to be within the gender identity service and that gender identity service will then refer them to a specialist endocrine clinic which will deliver the treatment. Um It's only done at the point of puberty. So even if a child was referred to G I S at three, they will not be considered or started on hormonal blockers until they reached the age where they start puberty. So 11, 12, 13, um so those that, that's what you can do for Children in adults, there is no role for these GNRH analogues. Once you have blocked puberty or an adult, if someone has gone through puberty, your options to try and induce secondary sexual characteristics. Um is hormonal treatment. So, for men who want to become women, you start with estrogen. If they don't respond that well to estrogen, um or it's a reduced response, you can add androgen suppression. Um testosterone is very potent and you need very little testosterone to maintain mail, um secondary sexual characteristics. So sometimes you do need to suppress the innate testosterone production to allow the estrogen, the synthetic estrogen, you're giving them to have a full effect for women, it's a lot easier. You tend to just give them androgens and they don't really need to replace it. Um If you think about that, that kind of makes sense in terms of p cost, patient's have some hair suit is um which is because they've got excess androgens and actually need very little before you start having things like facial hair and things like that. Um And then your surgical management is around um giving you further those secondary sexual characteristics, especially adults. If you've gone through puberty, you won't develop breasts. If you've blocked puberty and then you give uh someone estrogen, they will then develop some breast tissue um uh surgical. So we talk about mammoplasty if it's male to female. Um then um uh hysterectomy ureterectomy, um you can have um complete gender reassignment. So where we, you can create a penis from Vodianova diapie is vice versa. Um And then for men who become, who are transitioning to female, you can also think about the thyroid cartilage. So the Adam's Apple shaving that. So it's less obvious. Um It's really critical to emphasize, not all patient's who have gender dysphoria will want all of these, not all of them will want to fully transition through um some of them ops just to have certain components of the treatment. And that's, that's entirely down to their choice in the discussion of therapist. So when you, when you talk about managing these patient's, it's really important to emphasize, especially in this group that is very patient led. Um So I've got a question. Um So if you want to um just have a go and um just pop the uh answer into the chapman, you've got them. Does anyone want to have a good answering that? Yeah, exactly. So four. So um I think this is, this is probably one of the most common scenarios you'll see with concerns about sex drive. Um It's almost always about low sex drive. And actually, when you think about it, you need to think about the precipitating causes. In this case, routine bloods would be appropriate. Um And then thinking about sertraline, um she's got aspects of low mood and referral for CBT. Um So that is the end of the talk. We've gone through everything else. Um Does anyone have any questions or anything? Um Sorry, could you repeat the for gender dysphoria, need for Children? What was the referral pathway? So you send them to a gender, gender identity service. It's a national service at the moment. We only have to um but it's, it's a specific gender identity service. Okay, thank you. I'll just put the feedback link in the chat, everyone. So if you could please fill out that, we'd really appreciate it. And uh thank you very much, you know, for the talk, we really, really appreciate you giving up your time and especially for the Pacers tips as well and the way you structure with the bio cycle social, I think that's gonna be really useful for the students. So thank you very much. Um If anyone has any more questions, if you feel to drop in the chat, I'm going to quickly share my screen as well. So you guys can scan the code if you want to do that. Instead you take a quick scan of that from the feedback. We would appreciate it. Perfect. Well, if there isn't any more questions, thank you very much, Tina and everyone have a lovely evening. I'll stop the recording now. Thank you everyone. Thank you.