Mental Health and Overdose

Dr Alice Wood GU medicine

Aims and Objectives

Alcohol misuse/dependency Suicide assessment and management Overdose- paracetamol, salicylate, opiates Dementia Mental Capacity Act

Alcohol Misuse
Recommended weekly limits
21 units for males 14 units for females

In 2011/2012 over 1 million admissions related to alcohol consumption In the UK 7% men and 2% females are thought to be dependent on alcohol

Alcohol Misuse: Aetiology

Genetics Psychological theories Social factors- life events, occupation Comorbidity- depression, anxiety disorders, chronic pain, terminal illness

Alcohol dependence
Compulsion to drink Priority of drinking over other activities Stereotyped pattern of drinking Increased tolerance to alcohol Repeated withdrawal symptoms Relief drinking to avoid withdrawal symptoms Reinstatement after abstinence
At least 3 required occurring at same time in a 12month period

Alcohol Dependence: assessment

History- type, amount, place, time Features of dependence Psychiatric/medical history Drug history Social history CAGE questionnaire

Alcohol dependence: complications

10-72 hours - tachycardia, hypotension, tremor, confusion, nausea. 1-3 days: Delirium Tremens
Clouding of consciousness, disorientation, memory impairment, fear, agitation, vivid hallucinations, insomnia, autonomic disturbances, seizures Wernickes-Korsakovs- confusion, ataxia, ocular palsy only 20% recover. Can be permanent.

Chronic misuse- fatty liver, alcoholic hepatitis, cirrhosis

Alcohol dependence: management

Acute
Chlordiazepoxide reducing dose or depending on symptoms. Eg 10-50mg 6hrly. IV pabrinex (Vitamin B and thiamine)

Chronic
LAU, AA Oral Vitamin B and thiamine Dilsulfiram- unpleasant side effects

Suicide
Act of intentionally killing oneself with the primary aim of dying Parasuicide = acts that looks like suicide but does not result in death. In UK around 5500 recorded suicides per year Completed suicide 3x more common in men

Suicide: Assessment
Ask about history of current episode to determine intent
Precipitant? Planned? Method? Note? Witnesses? Intoxicated? Seek help? Post feelings

Suicide: Assessment
Risk factors Mental state examination Future plans Assess future risk- ?protective factors

Management- discussion with senior +/psychiatry team

Wound management Overdose treatment

Paracetamol Overdose
Most widely used analgesia in UK. Available over the counter and present as numerous preparations Commonest drug overdose Rarely causes death
Approx 130 a year and 15- 20 liver transplants

Paracetamol OD: Assessment

Often self referral- regret or failure Symptoms
<24 hours can be asymptomatic, nausea/vomiting >24 hours RUQ pain +/- signs of acute liver failure eg raised ALT/ALP/PT 3-5 days recovery begins or hepatic failure with coagulopathy, encephalopathy, renal failure, derranged CBGs

Paracetamol: Assessment
ABCDE approach Bloods- FBC, U&Es, LFTs, Coagulation screen, salicylate levels, paracetamol level, CBG Toxbase/poisons service information Hx
When, what, how much, why, any alcohol consumed, initial symptoms Psychiatric hx- prior events, intent, notes/planning, help seeking, stresses PMH- previous attempts, previous psychiatry hx, co-morbidities DH- regular meds, OTC meds, allergies, ETOH intake, recreational drugs SH- relationships, family/friend support, employment.

Paracetamol: Assessment
Paracetamol levels taken 4 hours post OD is possible or ASAP if > 4hours If staggered dose can be more difficult.

Paracetamol: Treatment
N-acetyl cysteine
Replace substrates needed for liver to eliminate toxic metabolites

150mg/kg IV infusion in 200ml 5% glucose over 15 min 50mg/kg IV infusion in 500ml 5% glucose over 4hrs 100mg/kg IV infusion in 1000ml 5% glucose over 16hrs If significant OD and > 4hrs do not wait to treat

Aspirin: Overdose
Effects are dose related Symptoms
Vomiting, increased RR, vertigo, sweating, hyperventilation, tinnitus.

Investigations
ABCDE approach ABG- respiratory alkalosis then metabolic acidosis Bloods + salicylate levels (rpt after 2hrs) Monitor urine output, blood glucose, HCO3

Management
Correct metabolic acidosis with sodium bicarb Urinary alkalinization- 1.5L 1.26% HCO3 with 40mmol KCL IV over 3hours Dialysis may be needed

Opiate: Overdose
Symptoms
Constipation, nausea, vomiting, drowsiness, respiratory depression, hypotension, tachycardia, pinpoint pupils

Investigations
ABCDE Bloods- including paracetamol level

Management
Naloxone 0.4-2mg IV (adult) repeat every 2mins and monitor response

Dementia
Cognition deficits and memory loss. >65% of over 85 yrs olds 25% of all hospital beds Aetiology
Alzheimer's, Vascular, Lewy body, frontal lobe Infections- syphilis, encephalitis, meningitis Metabolic- hypothyroidism, Vit B12 deficiency

Dementia
Diagnosis often made in community after period of observation. CT head useful for formal diagnosis and exclusion. Investigations
AMTS. MMSE Confusion screen: FBC, U&Es, LFTs, CRP, Mg, PO, Ca, TFTs, haematinics, MSU, CXR, CT head

Management
Rule out underlying causes Refer to memory services Donepezil and Memantine

Mental Capacity Act

Framework to protect those who are unable to make their own decisions. Presumption of capacity Right to be supported to make own decisions Retain right to make eccentric/unwise decisions Best interests Least restrictive intervention

Assessing Capacity
Decision specific: 1. Does the patient have an impairment of the mind/brain or a disturbance of mental function? 2. Does the impairment affect their decision making ability? 3. Can they understand relevant information? 4. Retain the information? 5. Use information in process of making decision 6. Communicate their decision

Scenario 1
47 year old male admitted after being found by ambulance staff in the street. On the ward is becoming loud and verbally abusive towards staff and patients
PMH- excess ETOH- numerous previous admissions. HTN Obs- HR 88bpm, BP 135/80. T-36.5. Oxygen- 95% on RA. RR-19 Bloods- WCC- 7.89. Hb- 110 (raised MCV). LFTSALP- 450. ALT- 48. Bilirubin- 25. INR- 1.5

Management
Priority is patient and staff safety Prevent irreversible causes- commence on IV pabrinex Manage symptoms- chlordiazepoxide regimen either reducing regimen or using CIWA Refer to LAU Discharge with oral Thiamine and Vit B

Scenario 2
65yr old female admitted after taking ibuprofen and paracetamol every 3 hours for 3/7 due to dental pain ??? Worried ??? PMH- T2DM, HTN. Laprascopic cholecysectomy. Obs- HR- 98. B/P 140/98. T- 37.3 RR- 21. O2- 98% RA Bloods- Normal. Paracetamol level 22mg/L, Salicylate level <0.

Management
Staggered Overdose- unreliable paracetamol level. Start NAC regardless Monitor bloods as situation could change Remember to take post NAC bloods. Patient still has dental pain what analgesia could we offer instead?

Conclusion
Alcohol abuse and drug overdose are really common Approach in ABCDE manner Start pabrinex for ETOH if in doubt If large paracetamol OD start NAC and wait for 4hrly levels Be aware of other drugs as potential OD and use Toxbase if unsure Know the basics of Mental Capacity Act- make no assumptions.