Part of GP Annual Health Check?

Transcription

1 Table A.1 Overview of physical health monitoring in Severe Mental Illness (SMI). isk factor to be monitored at least annually Part of GP Annual Health Check? Needs intervention? History/lifestyle Family history: vascular disease, diabetes, hypertension, hyperlipidaemia Smoker Brief intervention Nicotine eplacement Therapy (NT) efer to Smoking Cessation Clinic Alcohol/drug misuse See Audit Questionnaire, Appendix C Activity level Brief intervention - exercise Diet Dietary advice Measurements/investigations Central obesity (BMI) Initially diet/exercise advice Body Mass Index (BMI) (kg/m 2 ) See NICE CG43 25 overweight 30 obesity Waist circumference Men 94 high; 102 very high Women 80 high; 88 very high Blood Pressure (2 separate measurements, at an interval) 140/90 mmhg Lifestyle advice Discuss antihypertensive with GP See NICE CG127 Blood glucose (mmol/l) Lifestyle advice Fasting 5.5 andom 11.1 HbA1c 6% Discuss oral hypoglycaemics/insulin with GP See NICE CG87 Total cholesterol: HDL ratio Dietary advice High(>10%) according to cardiovascular disease Discuss statin with GP prediction charts (see BNF) NICE CG181 Source: Adapted from Lester UK adaptation Psychiatry: Breaking the ICE Introductions, Common Tasks and Emergencies for Trainees, First Edition. Edited by Sarah Stringer, Juliet Hurn and Anna M Burnside John Wiley & Sons, Ltd. Published 2016 by John Wiley & Sons, Ltd. Companion Website:

2 Table A.2 Delirium investigations. Investigation Essential/ PN Notes/indications Physical observations E H, BP,, temperature, SaO 2 Physical examination E Include: Neurological exam P (exclude constipation) Pressure areas (sores/infection) Evidence of pain Visual acuity Hearing Swallow Missed fractures (e.g. bruising, limited mobility) ECG E Especially: MI, arrhythmia QTc check normal before using antipsychotics, especially if on other QTc-prolonging drugs outine bloods E Minimum: FBC, U&E, LFT, glucose CP Calcium/phosphate Septic screen PN emember that older adults don t always raise inflammatory markers or temperature, so have a low threshold for: Urine dipstick (+MC&S) Blood cultures CX UDS PN All younger patients; older adults if suspect drug misuse CT head PN Urgent if localising neurological signs or anything else indicating cerebral pathology It s otherwise reasonable to leave it until tomorrow. Other bloods PN TFTs Iron studies especially if malnutrition/frail elderly B12, folate especially in drinkers, eating disorders, frail elderly HIV, syphilis remember HIV is increasingly common in older adults ES MI head PN If suspect neuropathology, but CT NAD LP PN If suspect neuropathology/cns infection EEG PN If diagnostic confusion/suspect non-convulsive status

3 Table A.3 First episode psychosis investigations. Investigation Essential/PN Notes/indications Physical observations E H, BP,, temperature, SaO 2 Physical examination E Include: Neurological exam Stigmata of alcohol/drug use Missed concurrent illness ECG E QTc - check normal before using antipsychotics, especially before rapid tranquilisation and always before using haloperidol outine bloods E More important to establish physical health status and any missed needs; occasionally pick up organic cause for psychosis (see Appendix A.2) FBC, U&E, LFT, glucose CP UDS E Carry a kit with you; ED often don t stock them CT head PN Urgent if: Localising neurological signs or anything else indicating cerebral pathology It is not essential to scan everyone with FEP. Threshold for scanning decreases with age, e.g. consider scanning over-40s; definitely scan over-65s with FEP. Check local protocols. May need sedation to allow urgent scan judge carefully, as you still need to assess MSE! Other bloods PN TFTs esults can take time; especially useful if affective component Lipids needed as baseline before starting antipsychotics; may not be practicable acutely, but do as soon as possible HIV almost routine now, depending on risk/sexual history and demographic Syphilis increasingly prevalent Calcium / phosphate (especially if elderly) ANA/Anti-dsDNA consider lupus ES if systemic illness suspected Weight, BMI PN Needed for antipsychotic monitoring do as soon as possible MI head PN May not be practicable acutely, but more sensitive than CT head. Use only when clear suspicion of neuropathology. Lumbar puncture PN If suspicion of neuropathology/cns infection EEG PN If diagnostic confusion/suspect non-convulsive status Pregnancy test PN If possibly pregnant, especially before starting medication Antibody-mediated encephalitis ( autoimmune psychosis ) is increasingly being recognised. Discuss with liaison and neurology if a young person suffers an acute onset of a paranoid psychosis, with any of the following markers: a prodromal physical illness (malaise, headache, fever); spontaneous movement disorder (e.g. catatonia, orofacial dyskinesia); cognitive impairment. Antipsychotics may have little effect, or cause adverse reactions (e.g. collapse) in these patients. Tests would include serum antibodies (NMDA & VGKC), EEG and MI. Treatment may include immunotherapy.

4 Table A.4 Baseline checks before starting psychotropics. Group Antipsychotics Mood stabilisers Antidepressants Test Psychosis patients Clozapine Haloperidol Quetiapine BPAD patients FBC E E E U&E E E Lithium LFT E E E E TFT E PL CK Lipids** Glucose** Troponin BMI BP E Pulse Temperature ECG E E* E Key: E = Essential; = ecommended; * = If clinically indicated/cardiovascular risk factors; ** = Fasting if possible; in elderly patients Sources of information: Maudsley Prescribing Guidelines, British National Formulary, Zaponex Treatment Systems & Lester UK Adaptation 2014 Valproate Carbamazepine Depressed patients SSIs SNIs TCAs Mirtazapine MAOIs Agomelatine

5 Table A.5 Ongoing monitoring - antipsychotics. Test All patients using antipsychotics Clozapine Olanzapine Quetiapine Phenothiazines, e.g. chlorpromazine, trifluoperazine FBC : yearly E: weekly for 18 weeks; then fortnightly until 1y; then monthly U&E : yearly LFT : yearly (not sulpiride/amisulpride) : at 6 weeks, 12 weeks TFT : yearly PL : at 6 months then yearly (not clozapine, olanzapine or aripiprazole) CK E: If suspect NMS (p408) Lipids : at 3 months then yearly : at 6 weeks, then 3-monthly for 1st year G : at 4 6 months, then yearly : at 6 weeks, then 3-monthly for 1st year Troponin : Weekly for 1 month CP : Weekly for 1 month BMI : frequently for 3 months, then yearly BP : frequently in titration (not amisulpride, sulpiride, trifluoperazine, aripiprazole) : at 6 weeks, then 3-monthly for 1st year E: at least daily during titration, then at 6 weeks, 12 weeks, yearly Pulse E: At least daily during titration Temperature E: At least daily during titration ECG : yearly and after dose increases E: If tachycardic EEG : If seizures Drug levels During titration At steady state and yearly If poor response/suspected toxicity/changed smoking status : 3-monthly for 1st year : at 1 month : 3-monthly for 1st year : 3-monthly for 1st year : 3-monthly for 1st year Key: = ecommended; E = Essential eference: Taylor, D., Paton, C. & Kapur, S. (2015) The Maudsley Prescribing Guidelines in Psychiatry (12th edition). Wiley Blackwell.

6 Table A.6 Ongoing monitoring - mood stabilisers. Test All BPAD patients Lithium Valproate Carbamazepine FBC : yearly : 6-monthly : 6-monthly U&E : yearly E: 6-monthly (more if interacting drugs) : 6-monthly LFT : yearly : 6-monthly : 6-monthly Albumin & clotting : if LFTs abnormal TFT : 6-monthly E: 6-monthly PL : if suspect PL Lipids : yearly if >40y G : yearly Calcium : if long-term treatment BMI : yearly 6-monthly : 6-monthly : 6-monthly BP : yearly ECG : if CV risk factors or history : if CV risk factors or history Drug levels E: 5 7 days after each : Check toxicity/ : 2 4 weeks after (trough) dose change until stable levels; then 3-monthly Aim mmol/l adherence/ effect of other drugs on valproate levels Aim >50 mg/l start & any dose changes; then 6-monthly Aim: 7 12 mg/l eference: Taylor, D., Paton, C. & Kapur, S. (2015) The Maudsley Prescribing Guidelines in Psychiatry (12th edition). Wiley Blackwell.

7 Table A.7 apid tranquilisation (T) cautions and contraindications. Condition Potential problem Medication caution Cardiovascular (CV): Sudden CV collapse/death Caution with antipsychotics, Prolonged QTc Cardiac history Metabolic syndrome Significant CV risk factors Hepatic/renal impairment educed rate drug metabolism/excretion especially haloperidol Dose adjustment may be needed, especially if long half-life See BNF espiratory disease espiratory depression/arrest Avoid benzodiazepines Hypotension Worsens hypotension isk of falls Olanzapine can cause vasovagal bradycardia/ syncope. Extra care if using regular medications which lower BP History of: High risk recurrence All antipsychotics NMS Acute dystonia Severe EPSE Avoid FGAs, especially haloperidol eference: Taylor, D., Paton, C. & Kapur, S. (2015) The Maudsley Prescribing Guidelines in Psychiatry (12th edition). Wiley Blackwell.

8 Table A.8 Monitoring after T. Monitoring Concern Action Temperature Pyrexia - NMS? (Ch.67) Stop antipsychotics Benzodiazepine if T needed Urgently check CK and WCC Pulse Arrythmia or bradycardia (<50 bpm) Urgent transfer to ED Do ECG while waiting BP Diastolic <50 mmhg or systolic drop >30 mmhg on standing Lie flat, legs raised Monitor closely ± discuss with medics /SaO 2 espiratory depression < 10 SaO 2 < 90% Manage airway + give O 2 If benzodiazepines involved, give flumazenil: 200 mcg IV over 15 seconds After 60s, if continued respiratory depression 100 mcg over 10 seconds epeat (max 1 mg in 24 h) Continuously monitor until returns to baseline (flumazenil half-life < most benzodiazepines) If not benzodiazepine-induced/ doesn t return to normal with flumazenil Urgent transfer to ED GCS Over-sedation Continuous 1:1 nursing; maintain airway Monitor and SaO 2 Consider dehydration risk General Ongoing agitation Discuss with seniors: benzodiazepine paradoxical agitation or missed organic cause or need for further T? Acute dystonia Procyclidine 5-10 mg IM Akathisia Increases risk of violence/self-harm; consider benzodiazepine Dehydration Offer fluids eference: Taylor, D., Paton, C. & Kapur, S. (2015) The Maudsley Prescribing Guidelines in Psychiatry (12th edition). Wiley Blackwell.