Transcript Physical health in Psychiatry

Physical health in Psychiatry
Dr Thushara Stanly
ST4 ,Adult Psychiatry
Why we need to consider physical
health?
• Mortality rate in patients with mental health
problems is twice than the general population
• The excess mortality is related to natural
causes than substance misuse and side effects
to medications
Aim
• Improve awareness and knowledge among the
staff
• Focussed approach
-what is your role?
-can you make a change ?
Why is it difficult?
• Lack of engagement/compliance
• Lack of training
Morbidity/mortality rate in psychiatry
patients
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-Genetics
-Medication
-Poor diet
-Lack of exercise
-Smoking
-Substance misuse
• May be -poverty/unemployment /poor
housing
• They are less likely to report their physical
problems due to
-Cognitive impairment
-Social isolation
-Paranoia
How we can manage the situation
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Understanding the presentations of illnesses
Improve assessment skills
Improve monitoring
Health education and promotion
TRAINING NEEDS
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CPR –basic techniques
Anaphylaxis
First aid
Wound care and pressure care
Infection control
Neurological observations
MEWS scores
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Venepuncture
Cardiovascular effects of medications
Assessing BMI
Diabetes diagnosis
Abnormal lipid profile
Medical emergencies
Organic causes for psychosis
• Epilepsy/headinjury/tumours/dementia/
stroke/encephalitis
• Thyroid /parathyroid /Addisons/Cushings
• Electrolyte imbalance
• Steroids/Ldopa/antihypertensives/
anticonvulsants/Ritalin/anticholinergics
• Illicit drugscannabis/cocaine/Opiods/LSD/amphetamine
Organic causes of depression
• Elipelepsy/stroke/tumours/dementia/head
injury/MS/Parkinson
• SLE/rhuematoidarthritis
• HIV/infectious mononucleosis
• Thyroid/parathyroid/cushings/addisons/b12
/folate deficiency
• Cardiac disease-MI/CCF
• Alcohol/benozodiazepines/cannabis/cocaine/
opiods
Examination /Investigations
• BP/pulse/weight
• Physical exam-rule out physical causes
• Bloods –depending on physical condition and
medications
routine –fbc/uec/lft/thyroid/calcium
• ECG
Antidepressants•
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Tricylics –ECG/weight gain
Mirtazapine-Weight gain
Venlafaxine high doses –BP
Serotonin syndrome
Mood stabilisers
• Valproate-FBC/LFT
• Lamotrigine-FBC/LFT
• Lithium-FBC
Lithium levels/UEC -3 monthly
Thyroid -6 monthly
ECG –yearly
Lithium and side effects
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Polyuria and polydypsia
Weight gain
Oedema
Vomiting/diarrhoea
Confusion/tiredness/impaired co-ordination
Hairloss/acne
Antipsychotics
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Yearly- FBC/LFT/Lipids/glucose/ECG
Neuroleptic malignant syndrome
Diabetes /hyperlipidaemia
QTc prolongation
> 470 in men
> 500 in women
Clozapine and side effects
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Sedation
Hyper salivation/nausea/constipation
Nocturnal enuresis
Hyper/hypotension
Cardiomyopathy/arrythmias/myocarditis
Pulmonary embolism
Agranulocytosis
Metabolic syndrome
Metabolic syndrome
• Obesity-abdominal circumference /BMI
• High blood pressure>140/90
• Glucose -microalbuminuria
• BMI- BMI Categories:
Underweight = <18.5
Normal weight = 18.5–24.9
Overweight = 25–29.9
Obesity = BMI of 30 or greater
• Waist Circumference
This risk goes up with a waist size that is
greater than 35 inches for women or
greater than 40 inches for men
diagnosiS- diabetes mellitus
Diabetes symptoms (ie polyuria, polydipsia and
unexplained weight loss) plus
 a random venous plasma glucose concentration > 11.1
mmol/l
or
-a fasting plasma glucose concentration > 7.0
mmol/l (whole blood > 6.1mmol/l)
or
-two hour plasma glucose concentration > 11.1
mmol/l two hours after 75g anhydrous glucose in an
oral glucose tolerance test (OGTT).
• With no symptoms diagnosis should not be
based on a single glucose determination
• Impaired Glucose Tolerance (IGT)* is a
stage of impaired glucose regulation
(Fasting plasma glucose < 7.0 mmol/ and
OGTT two hour value > 7.8mmol/l but <
11.1 mmol/l).
Lipids
• Cholesterol levels >6.5 mmol/L.
• It is characterised by increased levels of LDLcholesterol (> 4.0 mmol/L). Triglyceride levels
are < 2.3 mmol/L.
• In familial hypercholesterolaemia
characteristically total cholesterol is >
7.5mmol/L, LDL-cholesterol is > 5.0 mmol/L
and triglyceride is < 2.3 mmol/L
• Non-drug treatment:
– Diet: low fat, avoid alcohol
– Other measures: avoid smoking and increase exercise
• Drug treatment
– Statin therapy for the primary prevention of CVD for
adults with 10-year risk of developing CVD
Delirium tremens
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Acute confusional state
Occurs in 5% of episodes of withdrawal
Peak incidence -48 hrs
Fluctuating consciousness /clouding of
consciousness
Disorientation
Amnesia
Agiatation
Hallucination
• Raised temp/pulse
• Mortality -5-10%
Serotonin syndrome
• Confusion/coma
• GI symptoms-Nausea/ Diarhoea
• Rigidity/tremor/myoclonus/increased
reflexes/ataxia/seizures
• Temp and pulse increased/low or raised BP/
Dilated pupils
Neuro-leptic malignant syndrome
• Confusion/altered sensorium/rigidity
• Temp and pulse increased/low or raised BP
• Sweating/tremor/retention or incontinence of
urine
Difference between NMS and Serotoin
syndrome
• NMS
Antipsychotics
onset slow
progression slow
led pipe rigidity
Bradykinesia
SS
Serotonergic agents
Rapid
Rapid
less severe
Hyperkinesia
Management
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Bring down temp
Hydrate
Withhold or reduce the medication
If severe, transfer to emergency treatment
Medical treatment available
Health education
• Avoid smoking /alcohol
• Exercises and activities
• Engaging in monitoring-BP/pulse/bloods/ECG
/physical examination
• Getting help in emergencies
This is to certify that:
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Has reviewed/completed
Physical Health in
Psychiatry
Date
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