Care of the Patient with Mental Health Presentation in the Waiting Room

N Role for Mental Health (MH) esentationse Primary Role for the CIN is to monitor the person’s mental state ilst they are in the ED waiting area.

s can be achieved by:

aintaining discrete observations of the person

•Watch what they are doing & record/report significant changes

rectly asking the person how they are coping

•Ask ‘How are you?’

viting communication from those accompanying the person

•Reassure carers that they can ask you questions during their stay

D Physical Examination for MH esentationse main aim of an ED physical exam is to reasonably exclude organic ease:

– As a cause for the presentation, or

– As a clinical issue that requires acute management

organic cause for the presentation is more likely with:

– New presentations

– The elderly

– Abnormal vital signs

– Atypical symptoms (e.g. visual hallucinations)

hysical Examination

sical exam must be guided by the history & presenting mptomsa minimum, an exam will include:

Vital signs

Cardiovascular system

Respiratory system

Gastrointestinal system

Neurological system

orroborative History

s essential to confirm the history obtained during the sessment with other sources such as:

– Medical file

– Family & carers

– GP

– Case Manager

– Police/Ambulance

– Support services, etc.

tial Investigations

outine investigations for a person provisionally diagnosed with a ental illness include:– Full blood count

– Urea & electrolytes

– Blood glucose

– Liver function test

– Thyroid function test

– Others as clinically indicated

proaching Patients & Carersintain a calm controlled manner/voice.

People who are fearful can be reassured by a calm presenceroduce yourself and explain the assessment process.

en when acutely psychotic a person can usually communicate and eract rationally.

Do not assume a person who expresses bizarre ideas is less intelligent

k directly to the person and not behind their back.

People with mental health issues can easily misinterpret what is said

nvironmental Influenceseople with anxiety/trauma history may become very withdrawn in busy environment

– Often people who are frightened respond by becoming very quiet to make themselves less of an obvious target

eople with psychosis are less able to filter out sensory formation

– They are very sensitive to their environment & can be quickly overwhelmed in noisy, busy areas

Conversely, they may respond by escalating their behaviour

uicide & Self-Harmeople who have been identified as being at risk of suicide must ver be left alone

– If the risk is low, they may be left briefly in the care of someone such as a responsible family member

hey are not able to be found their absence must be reported mediately and appropriate action taken

– This may require contacting the policeefer to the Guidelines in ‘Framework for Suicide Risk sessment & Management for NSW Health Staff’

– http://www.health.nsw.gov.au/pubs/2005/pdf/suicide_risk.pdf

cal Referral Pathways for MH esentationseferral pathways for person’s presenting to ED’s for Mental Health rvices are highly variable.

s essential the CIN is familiar with local practices and mmunicates these to patients and carers

•Many ED’s do not have immediate access to specialist Mental Health clinicians

•MH clinicians often attend from other units, community mental health teams etc

This can be very confusing to patients as well as Health Staff

entifying Risk of Violenceall people with mental health issues are violent

owever, due care must be taken with people who have:

– Overtly aggressive/threatening behaviour

– Recent history of aggression/using weapons

– History of impulsive behaviour

– Expressing delusions/hallucinations with a violent content

– Drug/alcohol intoxication

ecognising Agitation/ Risk of olencearly signs that the person is escalating include:– Pacing,

– Gesturing,

– Increased voice volume,

– Restlessness,

– Irritability

ow your local Safety Procedures!

esponding to Increasing Agitation/ sk of Violenceall for help early– Never confront a violent person on your own

o not put yourself in danger– When in danger, your priority is YOUR safety

– Retreat to a safe location and continue to call for help

pproach in a calm, confident mannervoid sudden or violent gesturesocus the discussion on the ‘here and now’– Do not delve into long-term grievances or issues

upport Persons

onsider the effect of the support person.– The support person’s presence may be positive or negative

– Consider their needs also as they may be exhausted by the patient, especially if the person has been unwell for some time

– Carers can often be quite anxious that the patient’s concerns will not be taken seriously

– Carers should be given an opportunity to discuss their concerns away from the patient

– Never leave an unaccompanied adolescent with a mental health presentation alone in the waiting room

ental Health Literacy

– The Mental State Examination (MSE) is the tool that is used to assess and describe a persons mental state

– The use of this terminology can greatly assist communication between clinicians

– The use of these concepts can significantly enhance clinician’s ability to recognise important changes in a persons mental state

SE- Appearanceosture – slumped, tense, bizarre

rooming – dishevelled, inappropriate, hygiene

othing – bizarre, inappropriate to climate, dirty

utritional status – thin, obese, significantly altered

tigmata of drug or alcohol use – flushed, dilated/pinpoint pupils, track marks

SE- Mannerthe person easily engaged?they:

– Cooperative, pleasant, make good eye contact

– Uncooperative, belligerent, evasive

SE- Behaviourw is the patient behaving?• Motor activity

» immobile, pacing, restless, hyperventilating

• Abnormal movements

» tremor, dyskinetic movement, abnormal gait, ataxic, tics

• Bizarre, odd or unpredictable actions

SE- Speech

ow is the patient talking?• Rate

» rapid, uninterruptible, slow, mute

• Tone

» loud, angry, quiet, whispering

• Quality

» clear, slurred

• Quantity

» plentiful, reduced, monosyllabic

SE- Affect (their display of their emotional state)

What do you observe about the patient’s emotional state?• Depressed

» Crying, frowning, restricted, tearful

• Anxious » agitated, distressed, fearful

• Labile » changing rapidly

• Inappropriate/Incongruent » inconsistent with situation

• High » Smiling, elevated, excessively animated, cheerful

SE- Mood (their perception of their emotional state)

ow does the patient describe their emotional state?– Down, depressed, flat– Angry, irritable, irrational– Anxious, fearful– High, happy, elevated

Use / document the patient’s own words.

SE- ThoughtORM -How does the patient express him/herself?

– Illogical, incoherent, disjointed, nonsensical– Rapid thoughts or few thoughts

ONTENT-What is the patient thinking about?– Bizarre, – Delusional, – Paranoid, – Depressive, – Anxious, – Suicidal, – Homicidal

SE- Perceptionny unusual sensory phenomena such as:• Illusions

» Misinterpreting sensory stimuli

• Hallucinations» Spontaneously generated sensory stimuli, e.g. ‘voices’

• Derealisation, depersonalisation.

hat can you observe and what does the patient report?

ognition

vel of consciousness

–Alert, fluctuating, hypervigilant, stuporous

ientation to time, place and person

tention

ecent and remote memory

e they able to make reasonable judgements about their current uation?

edicationsedications commonly used in the treatment of mental ness include:• Antipsychotics

» e.g. haloperidol, chlorpromazine, olanzapine, risperidone

• Anxiolytics» Benzodiazepines. e.g. diazepam, midazolam, lorazepam

• Antidepressants» e.g. SSRI’s (fluoxetine, citalopram), tricyclics (dothiepin,

prothiaden), SNRI’s (venlafaxine), MAOI’s (moclobemide)

• Mood Stabilisers» e.g. lithium carbonate, sodium valproate

ntipsychotics (AP’s)- Adverse Effects

ntipsychotics are broadly divided into two categories:

–Typicals (generally older medications such as haloperidol & chlorpromazine)

–Atypicals (generally newer medications such as risperidone, zyprexa, quetiapine)

–NB- the distinction is arbitrary and no clearly defined criteria has been established between them

enerally adverse effects are less severe and less common with ypicals.

eight Gain

sociated with all antipsychotic drugs but pecially with clozapine, olanzapine, and etiapine.

etabolic Effects

pecially associated with olanzapine and clozapine

fects include:• Abnormal glucose tolerance

• Increased serum lipids

ese effects increase the risk of diabetes and heart disease, pecially if other risk factors such as obesity are present

yperprolactinemia

aised prolactin can lead to:

• Gynecomastia

• Galactorrhea

• Amenorrhoea

• Impaired spermatogenesis

• Decreased libido

• Impotence

• Anorgasmia

ese effects have been associated with all AP’s but especially e typicals

dationssociated with all ntipsychotics, especially hen first started or with creased dosage

ay be a desirable effect hen agitation is extreme

ostural Hypotension

sociated with many antipsychotics

pically more pronounced in elderly or frail persons

nticholinergic Effects

ssociated with almost all antipsychotic drugs.fects include:• Dry mouth

• Blurred vision

• Increased intraocular pressure

• Constipation

• Urinary hesitancy

• Delirium (particularly in elderly persons)

Tc Interval Prolongation

Some Antipsychotics (especially thioridazine) can increase the QTc interval quite dangerously.Great caution should be used when using AP’s in people with a history of cardiac disease

granulocytosis

granulocytosis is a condition in which there is an sufficient number of neutrophils/White Cells (WC’s)an occur (rarely) with most AP’sost likely with Clozapine (1%) thus it requires strict onitoring of WC’s

trapyramidal side-effects (EPSE’s)

ssociated with all AP’s except clozapine & quetiapine.fects Include:• Acute dystonia

• Akathisia

• Parkinsonism

• Tardive dyskinesia

PSE’s- Acute dystoniaystonia is an involuntary, sustained contraction of muscles

Often associated with ‘high potency’ medications such as haloperidol

They are very frightening for patients/carers and quite painful

Generally effect the trunk, neck and face

culogyric crisis (the ‘look ups’)- dramatic spasm of the eye uscles forcing them to rotate upryngeal spasm can be fatal

ponds very quickly to anticholinergic medication such as benztropine

PSE’s- Parkinsonism

enerally seen in the early weeks of treatment.oduces general poverty of movement & rigidity.

ater tremor, hypersalivation, & drooling are seen.he bradykinesia is sometimes confused with depression or egative symptoms.

PSE’s- Akathisia (aka ‘restless legs’)severe sense of agitation or inner stlessness which tends to be experienced in e limbs, particularly the legs, or as a mental rturbation.

an sometimes be mistaken for increased mptomatologyenerally occurs within a few weeks of arting medication.ere is no direct antidote • Dose reduction is usually required.

• Benzodiazepines may help in the short term!

PSE’s- Tardive Dyskinesia (TD)

p to 30% of people on typical AP’s will develop TD after 10 ars.e it is established there is no treatment!

s a complex syndrome of involuntary hyperkinetic ovements.frequently effects the mouth, lips, tongue, & jaws.ozapine has not been associated with TD.has yet to be confirmed as being associated with atypicals

uroleptic Malignant Syndrome (NMS)

ssociated with all AP’ss a rare (<0.02%) but potentially fatal syndrome (approx 10% tality rate)ymptoms include:• High fever• Muscle rigidity• Altered consciousness• Autonomic instability• Raised creatinine kinase

closely resembles malignant hyperthermiacan present at any time for people taking AP’s, even if they ave been maintained on the same medication for many years

enzodiazepinesteract significantly with alcohol• Can cause respiratory depression

an rarely cause paradoxical excitation• Check patient history

eople taking benzodiazepines for long periods will develop lerance• Dosage ranges among individuals can vary enormously

ntidepressants

icyclic antidepressants are extremely dangerous in verdose• Death can result from cardiac arrythmial antidepressants can trigger mania in vulnerable people• Patients must be screened for history of

mania/bipolar disorder prior to prescriptionay cause serotonin syndrome

rotonin Syndrome/Toxicity

aused by excessive stimulation of the serotonergic systeman be caused by medications & recreational drugs cluding:• Antidepressants, amphetamines, St John’s Wort

ymptoms include:• Restlessness, agitation, abdominal cramps, diarrhoea,

confusion, myoclonus, diaphoresis, & hyperreflexia• Can progress to hyperthermia, renal failure, coma &

death

thium Toxicity

thium has a very narrow therapeutic window• NB: Some people may develop toxicity even when their serum level

is ‘therapeutic’ (i.e. between 0.4- 1.0mmol/L)

ymptoms include:• Diarrhoea, vomiting, tremor, dysarthria, ataxia, twitching, seizures,

hypotension, confusion, arrhythmia

an be caused by dehydration, major dietary changes, or terractions with other drugs such as NSAIDS & diuretics

x for Side Effects

mazenil (Anexate) is a benzodiazepine antagonist

it should only be used if respiratory depression is severe and not responding to basic airway support.

nztropine (Cogentin) 2mg IMI should be used if the patient eriences a dystonic reaction

Prophylactic benztropine should not be used routinely

Refer to local hospital guidelines for further information

her Medications

is important that patients are asked about ALL eatments they are currently taking

ccasionally people take:• Prescription medicines that have not been prescribed for them

• ‘Herbal’ or ‘Natural’ substances that they may not regard as medicine. Some of these are quite powerful, especially if used with prescription drugs– E.g. St John’s Wort is a herb that acts on the same

neurotransmitter as SSRI’s. If used in combination it can cause serotonergic syndrome

uides

More information is available in:

‘Mental Health for Emergency Departments- A Reference Guide,

NSW Health 2009’

Accessible from:

//internal.health.nsw.gov.au/pubs/2009/pdf/mh_emergency.pdf

cknowledgement

eferences– Mental Health for Emergency

Departments- A Reference Guide, NSW Health 2009’

– Proctor, NG (2007) Mental Health Emergencies cited in Curtis K, Ramsden C, and Friendship J. Emergency & Trauma Nursing. Elsevier Australia: China.

– Images downloaded and used courtesy of Google Images

• Developed with thanks• Andrew Burke: Mental Health ED

Liaison CNC, Southern LHN

• Leanne Horvath: ED CNC South Eastern Sydney LHN