Insomnia organic causes
Restless Legs Syndrome. Restless legs syndrome is characterized by
unpleasant sensations in the legs or feet that are temporarily relieved by moving the limbs. Symptoms increase in the evening, especially when a person is lying down and remaining still. The dysesthesias cause
difficulty falling asleep and are often accompanied by periodic limb
movements.
* Periodic Limb Movement Disorder. Periodic limb movement disorder
is characterized by bilateral repeated, rhythmic, small-amplitude jerking
or twitching movements in the lower extremities and, less frequently, in
the arms. These movements occur every 20 to 90 seconds and can lead
to arousals, which are usually not perceived by the patient. Rather, the
patient reports that sleep is not refreshing. Characteristically, the bed
partner is more likely to report the movement problem. This condition
and restless legs syndrome are more common in older patients.
* Obstructive Sleep Apnea. Obstructive sleep apnea is most commonly
associated with snoring, daytime sleepiness and obesity but occasionally presents with insomnia.
* Circadian Rhythm Sleep Disorders. Circadian rhythm sleep disorders
are characterized by an inability to sleep because of a mismatch
between the circadian sleep rhythm and the desired or required sleep
schedule.
Sleep Hygiene
Wake up at the same time each day.
* Discontinue caffeine intake four to six hours before bedtime and minimize total daily use. Caffeine is a stimulant and may disrupt sleep.
* Avoid nicotine, especially near bedtime and on night awakenings. It is also a stimulant.
* Avoid the use of alcohol in the late evening to facilitate sleep onset. Alcohol can cause awakening later in the night.
* Avoid heavy meals too close to bedtime, since this may interfere with
sleep. A light snack may be sleep inducing.
* Regular exercise in the late afternoon may deepen sleep. Vigorous exercise within three to four hours of bedtime may interfere with sleep.
* Minimize noise, light and excessive temperatures during the sleep period.
* Move the alarm clock away from the bed if it is a source of distraction.
* Avoid using I-pad, I-phone or other mobile devices as reading tools.
Communication skills of ID
- Pre-symbolic (severe ID have this only) - Rely on people to anticipate their needs and interpret their vocalisations, facial expressions and body language
- Symbolic - about 60% can use such as pictures, symbols, signs or speech
- Verbal - closed questions (yes/no) -difficult as not understood question and merely went on tone of voice and facial expression
open question also difficult
How to communicate with ID
- Break down info into small chunks - check understanding before moving on
- Giving qs in an either/or format (but check not repeating final option)
- Check understanding of the words that the pt uses
- Everyday words, no jargon
- Use pictures and photos as well as facial expression, affect and tone of voice
- Give time to formulate a response
- Rephrase the q
Ax of ECT causing memory loss
Temporality – ECT and memory complaints, memory complaints before or after ECT started, before or after depression/mood symptoms
Type of ECT – unilateral, bilateral, right, any complications
Psychiatric history – previous memory complaints, relation to mood episodes, previous ECT
D+A and medication history – any withdrawal, benzodiazepines, alcohol use
Cognitive exam – memory loss with ECT associated with retrograde and anterograde amnesia, autobiographical memory loss and loss of cognitive functions such as learning and attention. If disoriented to time and place then perhaps organic cause. Frontal lobe exam – Luria 3 step test, FAB, NUCOG.
o Neuropsychiatry Unit Cognitive Assessment Tool (NUCOG)
Medical history – thyroid disease, vitamin deficiencies, iron deficiency anaemia, high blood pressure (vascular changes), family history of medical illness
Physical exam – neurological examination, cogwheel or lead pipe rigidity, Romberg’s sign (helping to determine if ataxia is sensory or motor; if sensory then the test is positive due to disturbed proprioception), weakness or evidence of stroke/TIA
Family member requesting to speak to you, patient gives consent but the family member hasn’t been involved for some time in patient’s life
- Approach
o Address confidentiality limits
o Introduce yourself
o Clarify your level of contact with patient
o Clarify the role of the team, who you are what you’re doing for him (expectations) - Clarify
o Clarify the family members agenda
o Clarify their understanding - Information
o If have consent can update family member on current diagnoses and treatment, and current supports/services - Collateral
o Use opportunity to obtain collateral regarding family understanding, past treatment, etc. reasons for family estrangement - Legal aspects
o MGA, competency, capacity, family meeting and consultation - Family and supports
o Social worker aspects, NGO’s, local cultural teams etc.
During the meeting the family member states medication is cruel and inhumane and produces article (antipsychiatry sentiment)
- Approach – as above, manage counter transference
- Discuss – explore her understanding of patient illness – medication in the past
- Psychoeducation – about illness and medications, safety, side-effects
- Risks – explain risks of treatment versus non-treatment
- Negotiate and advocate – aim for a shared treatment goals, include the whanau/family as possible – emphasise patients role in his treatment and his decisions
- Support and collaboration – offer f/u, and further input
Upset carer/parent/complaint management
o Approach
Calm, friendly, listening, reflective
o Setting
Offer to meet with person in comfortable environment
Meet the person with case manager or more senior medical staff
o Clarify
Clarify patient current state prior to the meeting
Clarify what the person making the complaint has been told
o Escalate
Inform and discuss with clinical director for advice and guidance before the meeting
o Legal
Obtain advice from medical indemnity insurance
o Peers
Discuss in peer support group, confidential support
Self-care, manage anxiety and guilt
o Follow-up
Offer to see again
