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
- Making the distinction between psychogenic and neurogenic diseases
can sometimes be difficult. Experience and neurological examinations can
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
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
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)
Attention-seeking and/or fast "anxious" breathing giving partial tetany (see anxiety on
Diazepam IM 10mg x1 and soothing words (not
O2!!! but if necessary can breathe for a minute
into a plastic bag if possible)
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...
- 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")
- Neurological exam is normal. Usually NO psychosomatic symptoms!
- 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