27- Psychological-Cognition Disturbance

·         Basic examination should include neuro exam: brachial deep tendon reflex + patellar reflex + stiff neck + eye mobility + anisocoria + Babinski + paresis/paralysis + consciousness + confusion -- all to deduce symmetrical or asymmetrical neurology and mental status...  In an HIV hospice, brain damage is the main cause of psycho troubles.  (See "Neuro Protocol")

·         Making the distinction between psychogenic and neurogenic diseases can sometimes be difficult.  Experience and neurological examinations can help.

Anxiety Patient thinks” too much", worries obsessively.  Hysteria is also a kind of anxiety (intentional? strategy to get attention...).  Phobia is another...  Psychosomatic signs are possible (pain, tetany, tremors, sweating, palpitations...), which makes diagnosis difficult.

We have to admit also that it is quite normal to be anxious when you enter a hospice for dying destitutes!

Diazepam 2mg 1tab 3x/day or other benzodiazepines active against anxiety

Depression -See nxx004- Patient looks very very tired, and is suffering mentally...  He does not speak, does not relate to others, and does not like to eat...  Nearly all patients have a short episode of depression when admitted into the hospice...

For all patients on admission, we give prednisolone 1tab each morning for 4 days to make them feel stronger.

Fluoxetine20 (or cheaper "fluoxine-like" drugs) 1-3tabs each morning for at least 30 days (first signs of effect take 15 days or more)- Add prednisolone 1tab each morning for the first few days.

Only prednisolone or dexamethasone can really help in short term.  (See "Dexamethasone")  Sometimes nothing really helps and depression progresses to catalepsy ("suffering statue," often in foetal position… which leaves us helpless)

Agitation-aggression

Haloperidol 5mg 1tab 1-6x/day and/or diazepam IM 10mg 1-2x/day

(Consider also the possibility of drug addiction and withdrawal syndrome: for them you may have to increase the quantity of diazepam)

Hysteria and/or hypocapnia: Attention-seeking and/or fast "anxious" breathing giving partial tetany (see anxiety on same page!)

Diazepam IM 10mg x1 and soothing words (not O2!!! but if necessary can breathe for a minute into a plastic bag if possible)

Weak and/or no appetite

Prednisolone 1tab each morning for 4 days and dexamethasone 1cc IM each morning can be a gift sometimes if not contra-indicated.  (See "Dexamethasone")

Delirium-confusion (disconnected from reality)

• DEHYDRATION: Common!!!
• Dehydration only can give confusion!!!  See "Dehydration"
• CEREBRAL TB Common!!!
• Diagnosis: "Chronic", many of the "normal" TB signs: irregular low fever, loss of weight, skin color...  Sometimes confusion, +/- convulsion, stiff neck is common...  See "Tuberculosis"
• HIV DEMENTIA?  Common!!!
• No fever.  Can be the first manifestation of HIV!  Often begins as Alzheimer's or chronic depression (memory loss, loss of concentration...) Confusion/delirium, behavioral problems, aphasia, lack of motor coordination, trembling, etc. and sometimes paraplegia!  No curative treatment is available (but often a TOXO treatment test is indicated before making this diagnosis!)  Symptomatic therapy as for psychological diseases: haloperidol, diazepam…  Death will come in weeks or months...
• See also "Symmetrical Neuro Protocol")
• TOXO?  Common!!!  See also "Asymmetrical Neuro Protocol")
• Diagnosis: Basically, toxo is like one or several tumors in the brain: the symptoms depend on position of the tumors.  Alertness can be reduced ("slow brain"), the pronunciation of words can be strange, aphasia can be the only sign, or confusion, or headache... +/-convulsion, +/-fever...
• "Toxo test" is the first thing to do (for a minimum of 5 days!!!): Pyrimethamine 25mg 1tab 2x/day (first day 1tab 4x/day) + sulfadiazine 500mg 2-3tabs 4x/day.  If patient is allergic to sulfa give pyrimethamine 25mg 1tab 2x/day + one of the following drugs: clindamycin150mg 3-4tabs 4x/day or doxycycline 100mg 1tab 2x/day or dapsone 100mg 1tab daily.
• If neuro signs improves (stop all pain killers on fifth day and observe how level of pain is compared with pre-treatment) you should continue the treatment for at least 6 weeks (or forever if possible)
• See also "Asymmetrical Neuro Protocol")
• PSYCHOSIS?

o        Neurological exam is normal.  Usually NO psychosomatic symptoms!

o        Haloperidol 5mg 1-4tabs 1-2x/day for a few days and then stop.  Often the symptoms do not return because the patient becomes less afraid of the new environment

• Can also be stroke, lymphoma, syphilis, hepatic failure, etc. (as for HIV negative patients)
• See "Protocol”,” Asymmetrical", "Symmetrical Neuro Protocol"...

 

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