LESSON FOUR. Treatment of Neurological and Psychological Conditions

Transcription

1 LESSON FOUR Treatment f Neurlgical and Psychlgical Cnditins Intrductin The neurlgical system f the bdy cnsists f cmplex structures that regulate all f ur bdies functins, as well as ur behaviur, frm swinging a baseball bat t crying ver a mvie. When any part f this system is affected by illness r trauma it has a direct effect n many ther aspects f bdily functining, and ur entire lives. The gal f this lessn is t enhance yur knwledge f the pharmaclgical interventins used t treat neurlgical and psychlgical disrders. With this knwledge yu will be prepared t assist clients and their families in the pharmaclgical management f these cnditins. Lessn Outcmes 1. Explain the mechanism f actin, primary actins, and imprtant adverse effects fr: a. Medicatins fr treating epilepsy. b. Medicatins fr treating Parkinsn s Disease. c. Medicatins fr treating mental illness. 2. Describe nursing cncerns regarding the safe administratin f these medicatins. Required Readings See required reading list RN Prfessinal Develpment Centre & Nva Sctia DOH, Halifax, NS 1

2 Pharmaclgical Treatment f Epilepsy Please Read: Lessn Fur: Required Reading 1 What is epilepsy? Epilepsy is a seizure disrder that results frm a brad syndrme f central nervus system dysfunctin and can manifest in a variety f ways. Symptms range frm mild sensry disturbances t severe cnvulsive seizures. Nte that ther cnditins can cause seizures, which is essentially a brief episde f abnrmal electrical brain activity. Clinical manifestatins f a seizure depend n what area f the brain is affected by the abnrmal activity. Epilepsy is a chrnic cnditin in which seizures reccur; the cause f this cnditin is ften unknwn. Knwn causes include develpmental defects, metablic disease, head injury, infectin f brain and spinal crd, brain tumr r sme ther neurlgical disease. MEDICATIONS USED FOR EPILEPSY Belw are suggested medicatins t be used fr a client with acute seizure activity. Fllw hspital guidelines fr dsages and plicies in yur facility. Medicatins used t halt seizures: diazepam (Valium) 2-5 mg IV. lrazepam (Ativan) 4-8 mg IV at 2 mg/minute Nte: With bth f these medicatins, clsely mnitr client s respiratry effrt and pulse ximetry. Medicatins used t prevent recurrence: phenytin (Dilantin) 20 mg/kg IV, n faster than 50 mg/minute phenbarbital (Phenbarbital) 20 mg/kg IV, n faster than 50 mg/minute RN Prfessinal Develpment Centre & Nva Sctia DOH, Halifax, NS 2

3 Activity 1: Review Questins 1. Yu are caring fr a client wh has recently been diagnsed with epilepsy. Fllwing initiatin f carbamazepine (Tegretl) their seizure activity imprves, but nly slightly. The physician feels that the client wuld benefit frm adding an additinal antiepileptic medicatin. What is the therapeutic gal when trying t manage cmplex epilepsy with medicatins? 2. If an antiepileptic drug des nt wrk, hw shuld a secnd medicatin be intrduced? 3. Phenytin is ne example f a medicatin that requires mnitring f therapeutic plasma levels, due t its narrw therapeutic index. (a) What are the tw reasns we try t keep medicatin plasma levels within a therapeutic range? (b) What is mre imprtant, strict adherence t the therapeutic range guidelines r cnsideratin f the clinical symptms and histry f the client? Please discuss belw. a) b) 2012 RN Prfessinal Develpment Centre & Nva Sctia DOH, Halifax, NS 3

4 Pharmaclgical Treatment f Parkinsn s Disease Please Read: Lessn Fur: Required Reading 2 What is Parkinsn s Disease? Parkinsn s disease affects abut 100,000 Canadians and usually strikes after 50 years f age, thus its incidence is n the rise as ur ppulatin ages. Research cntinues int the cause f this degenerative, chrnic disease as well as fr a cure. Management fcuses n maintaining a client s quality f life and preventing assciated cmplicatins. This disease is a prgressive, chrnic disrder caused by the lss f the neurtransmitter dpamine frm the areas f the brain that cntrls mvements. It starts as tremr, slwness f mvement (bradykinesia), stiffness and prblems with gait and balance. The gal f treatment is t maintain independence and quality f life fr as lng as pssible. MEDICATIONS USED FOR PARKINSON S DISEASE The treatment f Parkinsn s disease invlves trying t increase dpamine levels in the brain with the mimicking medicatin levdpa (Sinemet). Levdpa relieves many symptms, such as the slwing f mvements and rigidity. Hwever ver time the effectiveness f Levdpa wanes and side effects develp. One f these side effects is dyskinesia (invluntary mvements). These may prevent the patient frm resting and further impair gait. Sme patients actually prefer this stage because althugh they are jerking invluntarily they are generally able t mve with mre ease. The drug amantadine (Symmetrel) has shwn t be effective in cntrlling dyskinesias. Als switching the client frm sustained-release levdpa t the shrter acting frmula may allw fr better dsage titratin thrughut the day t achieve symptm cntrl withut the adverse effect f dyskinesias. Many patients suffer frm wearing-ff syndrme which ccurs as a dse f medicatin wears ff, causing the client t be immbile. The symptm f immbility may eventually subside nce the next dse takes effect. Slutins t this prblem invlve changing the type r dsage f antiparkinsn s medicatin used. It is als imprtant fr the nurse t cnsider the wearing ff syndrme when planning ut the clients care rutine. Many clients have their wrse perids in the mrning and may require time fr their initial dse f medicatin t take effect befre getting ut f bed. Others have deteriratin at night; this can manifest as truble repsitining, muscular discmfrt, and frequent viding. Adequate rest is crucial fr the client t ptimally participate in exercise regime s ften a sleeping pill r additinal levdpa is required. The client with Parkinsn s may als suffer a Parkinsnian crisis at sme pint in their disease curse. It culd be the result f a sudden withdrawal f antiparkinsn s medicatin r emtinal trauma. The manifestatins include severe Parkinsn s symptms accmpanied by anxiety, sweating, tachycardia, and hyperpnea. Barbiturates (e.g., phenbarbital) cmbined with 2012 RN Prfessinal Develpment Centre & Nva Sctia DOH, Halifax, NS 4

5 Parkinsn s medicatin are used t treat the crisis, but respiratry and cardiac supprt shuld be available. ***************************************** Activity 2: Review Questins 1. Why is the drug levdpa cmbined with ther medicatins such as carbidpa? 2. The drug selegiline (Anipril) is used as an adjunctive medicatin in the management f Parkinsn s Disease. (a) What are the intended utcmes f the medicatin? (b) What effect may happen if the dse given exceeds 10 mg/day? a) b) 2012 RN Prfessinal Develpment Centre & Nva Sctia DOH, Halifax, NS 5

6 3. Describe hw the new medicatin entacapne (Cmtan) wrks, and hw it can help t manage Parkinsn s Disease. 4. Describe hw antichlinergic drugs help t manage the symptms f SLUDGE, and define this acrnym RN Prfessinal Develpment Centre & Nva Sctia DOH, Halifax, NS 6

7 Pharmaclgical Treatment f Mental Illness Please Read: Lessn Fur: Required Reading 3 MEDICATIONS USED FOR MENTAL ILLNESS There are generally five classes f medicatin that are cmmnly administered t individuals wh are diagnsed with psychiatric illnesses, as well as ne class that is frequently used t treat the side-effects f psychiatric medicatins. Each f these will be discussed briefly with additinal infrmatin supplied in the required readings. 1. Antipsychtics The fllwing is brief verview f antipsychtic medicatins. Since the intrductin f chlrprmazine (Thrazine) in 1954 antipsychtic medicatins have been the crnerstne fr treatment f schizphrenia and related psychtic disrders. They have als been applied t the treatment f psychtic symptms in ther disrders such as md disrders, dementia, neurdegenerative disrders and pervasive develpmental disrders. There are tw categries f antipsychtic medicatin available in Canada: Cnventinal/First Generatin (Typical) and Secnd Generatin (Atypical). First generatin antipsychtic medicatins Their primary actin is t blck dpamine D 2 receptrs in the brain. There are a number f dpamine tracts in the brain and unfrtunately the first generatin medicatin are nt selective in which track they blck. If yu knw where the dpamine is blcked, yu will knw what desirable effect and what side effect t expect, fr example: blckade f the Nigrstriatal tract may lead t extrapyramidal symptms (EPS); blckage f the Tuberinfundibular tract may lead t prlactin elevatin; blckade f the Meslimbic tract may lead t a decrease in psitive symptms; and blckade f the Mescrtical tract may lead t a decrease in negative symptms. With these medicatins there is a narrw therapeutic windw between desired effects and undesired side effects and therefre they have high incidents f EPS. The chance f develping Tardive Dyskinesia (TD) with first generatin antipsychtic medicatins increases with the length f time the medicatin is taken. Fr example the chance f develping TD increases by 5% with each year f use and reaches a 60% chance after ten years. The rate is even higher fr lder adults wh take cnventinal antipsychtic 2012 RN Prfessinal Develpment Centre & Nva Sctia DOH, Halifax, NS 7

8 medicatin (i.e., 26% at 1 year; 52% at 2 years; 60% at 3 years). Cnclusin: Older adults are at great risk t develp TD with treatment with first generatin antipsychtics. It is imprtant t nte that if EPS are present yu have passed the therapeutic threshld f D 2 ccupancy and further increase in dse is unlikely t have clinical benefit. These medicatins als prduce a significant increase in the serum prlactin cncentratin; usually 2-3 times greater than nrmal in mst individuals, but cnsiderably greater in sme. This may result in sexual dysfunctin and ther health cmplicatins such as galactrrhea; gynecmastia; amenrrhea; pssible acceleratin f steprsis. Their effectiveness in the treatment f psitive symptms is very similar t that f secnd generatin medicatins but they are less effective in the treatment f negative symptms and cgnitive symptms. The fllwing diagram utlines cmmn side effects seen with the first generatin antipsychtic medicatins. Hierarchy f Side-Effect Distress First Generatin Antipsychtics OTHER - Sedatin - Sexual dysfunctin - Weight gain - Akathisia - Akinesia - Dysphria EPS - Dystnia - Rigidity - Tardive dyskinesia - Tremr Weiden et al J Clinical Psychiatry 1998: 59 suppl RN Prfessinal Develpment Centre & Nva Sctia DOH, Halifax, NS 8

9 Secnd Generatin Antipsychtics Secnd generatin antipsychtic medicatins have als been described as atypical because they d nt have the same extrapyramidal side effects as the typical antipsychtic medicatins. The level f atypicality thugh varies amng the secnd generatin medicatins and is dse dependent. These medicatins wrk by blcking dpamine, sertnin and glutamate receptrs in the brain. This is why they have mre f an effect n negative and cgnitive symptms than the first generatin antipsychtics. Unfrtunately they als blck ther receptrs and results in a variety f side effects: blckage f the Alpha Adrenergic receptrs leads t cardivascular side effects; Muscarinic blckage leads t chlinergic side effects; Histamine blckage leads t weight gain and sedatin. As yu can see frm the diagram belw the side effect prfile is reversed frm that f the cnventinal antipsychtics. Hierarchy f Side-Effect Distress Secnd Generatin Antipsychtics - Amenrrhea - Antichlinergic - Sedatin - Sexual dysfunctin - Weight Gain OTHER EPS Weiden et al J Clinical Psychiatry 1998: 59 suppl RN Prfessinal Develpment Centre & Nva Sctia DOH, Halifax, NS 9

10 Secnd Generatin Adverse Effects 1. Central Nervus System Adverse Effects Headache. Sedatin and fatigue (especially in the first tw weeks). Insmnia, vivid dreams and nightmares. Cnfusin. Dysphria (depressed r restless, unknwn cause). EPS with D2 blckade ver 80%. Lwered seizure threshld with clzapine (Clzaril). Akathisia. Urinary incntinence. Nursing Interventins: Reprt bservatins and cncerns. Headaches, analgesic medicatin. Sedatin, cnsider time f dse. Myclnic jerks r tics may warn f seizures. Insmnia: warm milk, decrease stimulatin. 2. Antichlinergic Adverse Effects Dry Muth. Blurred visin. Cnstipatin. Urinary retentin. Disrientatin, cnfusin, memry lss. Fever. Tachycardia. Nursing Interventins: Sugar free gum, hard candy. Artificial tears. Increase dietary intake f fiber and fluids. Reprt cncerns. Mnitr vital signs. 3. Cardivascular Adverse Effects Hyptensin (N Epinephrine as it further lwers BP). Transient increases in BP. ECG changes, especially QT interval. Cardimypathy, pericarditis, heart failure, MI, mitral valve failure, mycarditis with clzapine (0.16%). Edema. Nursing Interventins: Observe and reprt. Teach persn in care t get up gradually. Mnitr vitals, nte pulse irregularities r changes. Elevate feet RN Prfessinal Develpment Centre & Nva Sctia DOH, Halifax, NS 10

11 4. Gastrintestinal Adverse Effects Weight Gain (many reasns). Nne with ziprasidne (Zeldx). Mderate with quetiapine (Serquel) and risperidne (Resperdal). High with clzapine and lanzapine (Zyprexa). Weight Gain can cause Crnary Artery Disease, Hyperglycemia, Obstructive Sleep Apnea. Anrexia, nausea, dyspepsia (painful digestin) dysphagia (difficulty swallwing), ccasinal diarrhea. Reflux esphagitis (11% with clzapine). Peculiar taste, lss f gag reflex. Sialrrhea (increase in saliva), difficulty swallwing, gagging (80% with clzapine). Severe cnstipatin (can lead t bstructin). Nursing Interventins: Weight Gain. Mnitr weight. Healthy snacks. Fluids, especially water. Exercise. Team apprach. Reflux. Elevate the bed. N spicy fd. N extreme temperatures in fd. N smking. Avid caffeine. Reprt cncerns. Twel n pillw fr drling Mnitr bwel patterns.. Supervisin at meal times (Slw eating; Pleasant, quiet envirnment). 5. Sexual Adverse Effects Decreased libid. Erectile difficulties, imptence. Inhibitin f ejaculatin, abnrmal ejaculatin, retrgrade ejaculatin, anrgasmia. Priapism (prlnged r cnstant penile erectin). Nursing Interventins: Assess. May influence cmpliance. Have cncerns addressed. 6. Endcrine Adverse Effects Prlactin elevatin (lasts fr lnger time with risperidne). Can cause sexual side effects, menstrual disturbances, infertility, and decreased bne density. Increased appetite, weight gain may be due t mre insulin being secreted RN Prfessinal Develpment Centre & Nva Sctia DOH, Halifax, NS 11

12 Hyperglycemia, glycuria, risk fr diabetes. Hyperlipidemia: chlesterl and triglycerides. Higher with clzapine and lanzapine. ziprasidne lwers levels. Nursing Interventins: Observe and reprt. Check n lab values. Discuss cncerns with the team. 7. Ocular Adverse Effects Lens changes with quetiapine, eye exam befre starting and every six mnths. Changes reprted with lanzapine and risperidne. Nursing Interventins: Reprt cncerns. 8. Hypersensitivity Phtsensitivity. Rashes. Chlestatic jaundice. Transient elevatins ALT/SGOT. Pancreatitis. Interstitial nephritis and acute renal failure (clzapine). Agranulcytsis Less than 0.1% within the first 12 weeks f treatment. Occurs in 1-2% n clzapine. Mrtality rate high if drug nt stpped and treatment given. Signs: sre thrat, fever, weakness, muth sres. Neurleptic Malignant Syndrme Ptentially fatal unless recgnized early and medicatin stpped. Supprtive therapy must be started STAT, especially fluid and electrlytes. Mrtality rate 4%; Incidence 1-2% with cnventinal antipsychtics. Related t sympathetic nervus system hyperactivity. Rigidity. High Fever. Respiratry prblems. Tachycardia, hypertensin. Diaphresis, urinary incntinence. Cnfusin, delirium. Nursing Interventins: STAT discntinuatin f medicatin. Supprtive measures in Intensive Care Unit. brmcriptine (Parldel) is given t halt the dpamine blckage. Muscle relaxants are given t relieve the rigidity. Reprt cncerns and bservatins. Recgnize agranulcytsis RN Prfessinal Develpment Centre & Nva Sctia DOH, Halifax, NS 12

13 Recgnize Neurleptic Malignant Syndrme. Mnitr lab reprts. Hld medicatins if yu have cncerns abut the persn in care and cnsult with physician. 9. Temperature Regulatin Adverse Effects Hypthermia. Hyperthermia. Transient elevatins in temperature can ccur with clzapine in first 3 weeks f treatment (lasts fr several days). Nursing Interventins: Cautin persn t keep hydrated when active in ht temperatures and humid cnditins. Encurage apprpriate dress fr cld temperature. Mnitr persn in extreme temperatures. 10. Withdrawal Symptms Symptms are likely t ccur hurs after abrupt discntinuatin r a large decrease in dse, and may last fr 2 weeks. Discntinuatin syndrme: gastritis, nausea, vmiting, dizziness, tremrs, feeling warm r cld, sweating, tachycardia, headache, and insmnia. Rebund neurlgical symptms may ccur: akathisia, dystnia, parkinsnism (in first few days), withdrawal dyskinesia in the first 4 weeks. Acute relapse has been reprted in persns n clzapine. Treatment: restart the medicatin, add Anti-Parkinsn medicatin, and taper slwly. 11. Antichlinergic Crisis Als called antichlinergic delirium. May ccur when persn n regular dse f antichlinergic drug is given anther drug with antichlinergic side effect. It is a life threatening medical emergency. Ht as a hare, blind as a stne, mad as a hatter, dry as a bne (see table belw). Cnfusin Smnlence Fever, increase P Memry lss Parania Increase BP Agitatin Anxiety Urinary retentin Incherence Cma N & V Pressure speech Hallucinatins Seizures Delusins Dilated pupils Swallw Difficult Ataxia Ht & dry skin Dry mucsa Hyperactivity Flushed face Visin Blurred Nursing Interventins: Stp medicatins STAT Reslves in 3 days if treated Treatment is physstigmine (Physstigmine) RN Prfessinal Develpment Centre & Nva Sctia DOH, Halifax, NS 13

14 2. Md stabilizers Lithium (Ap-Lithium) was the first md stabilizing medicatin discvered. Lithium was first discvered in the 1800 s but it wasn t until the late 1940 s that it was recgnized as a treatment fr the symptms f mania. Fr many years it has been the drug f chice fr treating Biplar Disrder. 1. Indicatins: acute mania, biplar disrder, augmentatin f antidepressants in treatment resistant depressin, impulsive and aggressive behavirs and nn-psychiatric disrders (cluster headaches, chemtherapy, antiviral agent). 2. Mde f actin: The exact mechanism is nt knwn. It alters sdium transprt in nerve and muscle cells. Increases sertnergic transmissin, increasing synthesis f nrepinephrine and blcking pstsynaptic dpamine. 3. Adverse Effects and Bld Levels. The therapeutic range f lithium is narrw and peple with levels at the higher end f the range may experience side effects. During the acute phase f mania bld levels f mml/L are maintained. During the maintenance phase the dsage may be decreased t maintain a bld level f mml/l. Mst institutins have a plicy regarding the frequency at which bld levels are mnitred with lithium. Yu shuld be aware f the plicy in yur institutin. Mild side effects <1.5 mml/l. Nausea. Lse stls. Fine hand tremr. Fatigue and muscle weakness. Thirst. Plydipsia. Plyuria. Difficulty cncentrating fuzzy thinking. Weight gain. Edema. Pssible side effects with lng term treatment that need t be mnitred. Kidney damage (mnitr serum creatinine and urea). Hypthyridism (mnitr thyrid-stimulating hrmne (TSH) and bserve fr ther signs such as dry skin, cnstipatin, bradycardia, hair lss, cld intlerance). Hyperparathyridism - increases parathyrid hrmne and calcium levels (mnitr electrlytes). 4. Lithium Txicity. Mderate txicity mml/l. Severe vmiting r diarrhea. Dry muth RN Prfessinal Develpment Centre & Nva Sctia DOH, Halifax, NS 14

15 Increasing hand tremr. Neurlgical signs (sluggishness, drwsiness and cnfusin). Dysarthria (speech difficulty due t impairment f the tngue). Mild t mderate Ataxia. Vertig. Tinnitus (ringing in the ears). Visual disturbance. Seizures. Rigidity. Severe txicity - > 2.5 mml/l. Cardiac arrhythmias. Blackut. Nystagmus. Dysarthria. Curse tremr. Visual r tactile hallucinatins. Oliguria, renal failure. Cnfusin. Seizures. Cma and death. Treatment fr lithium Txicity. Hld lithium. Ntify physician. Bld wrk (serum lithium level and electrlytes). Increase cnsumptin f water and salt. If severe txicity (exceeds 2.5 mml/l transfer t E.R, dialysis). 5. Drug Interactins. Medicatins that decrease lithium levels caffeine, antacids, and smtic diuretics. Medicatins that increase lithium levels Ptassium sparing diuretics, lp diuretics, and NSAIDs. 6. Educatin Pints. Drink 8-12 glasses f water per day. Cautin perating equipment requiring mental alertness. Take tablets/capsules whle. Extra care in ht weather (dehydratin). D nt change salt intake withut cnsulting with prescribing physician RN Prfessinal Develpment Centre & Nva Sctia DOH, Halifax, NS 15

16 3. Anticnvulsants The fllwing five anticnvulsants are cmmnly used t treat Biplar disrder. valpric acid (Divalprex, Ap-Valpric,, Epival, Depakene) 1. Indicatins: Apprved indicatins include: acute mania and epilepsy. Other uses include: prphylaxis f mania/depressin, rapid cycling, mixed states and psychsis mania, adjunct in schizphrenia, chrnic aggressin, impulse disrder, anxiety disrders, brderline persnality disrder, and nn-psychiatric disrders (Jffe & Gardner, 2000). 2. Mde f Actin: An increase in GABA, increase in pstsynaptic respnse t GABA, increase in resting membrane ptential, decreased calcium thrugh calcium channels. 3. Side Effects. Gastrintestinal disturbance, tremr, lethargy, weight gain, hair lss, cnstipatin, urinary retentin and transient elevatin f liver enzymes. valpric acid can be lethal if high dses are ingested. 4. Drug Interactins. Drugs which increase valpric acid levels are: lamtrigine and salicylates. Drugs which may decrease valpric acid levels are: carbamazepine, cimetidine, phenbarbital, primidne (Mysline). carbamazepine (Tegretl) 1. Indicatins: Apprved uses include: acute mania and prphylaxis f mania/depressin, epilepsy, trigeminal neuralgia. Other uses include: anxiety disrders, diatnic disrders in children, sedative/hypntic withdrawal, alchl withdrawal, chrnic aggressin, impulsivity, adjunct t schizphrenia, and nn-psychiatric cnditins (Jffe & Gardner, 2000). 2. Mde f Actin: There is an anti-kindling prperty that decreases the sensitizatin f brain cells making them less easy t stimulate, effects in channels which reduces repetitive firing f actin ptentials in the nerve cells, and effects release and reuptake f nrepinephrine, GABA, dpamine, and glutamate. 3. Side Effects. Very cmmn (ccurs in > 10% f peple): Leukpenia, elevated gamma GT, skin rashes, vertig, smnlence, ataxia, fatigue, nausea and vmiting. Cmmn (ccurs in > 1% t < 10% f peple): Esinphilia, thrmbcytpenia, elevated alkaline phsphatase, seizures, headache, diplpia, blurred visin, dry muth and thrat. Carbamazepine may be lethal if high dses are ingested. Nursing Interventins fr Side Effects: Smnlence/Drwsiness; ges away with time (avid driving r perating machinery). Vertig; get up slwly frm lying psitins, dangle feet. Blurred visin; at beginning f therapy and usually temprary RN Prfessinal Develpment Centre & Nva Sctia DOH, Halifax, NS 16

17 Dry muth and thrat, sugarless candy, gum, drink water. Nausea; take medicatin with fd. If vmiting r diarrhea mre than 24 hurs ntify physician. Bld dyscrasias; assess fr and reprt fever, sre thrat, rash, ulcers in the muth, easy bruising, bleeding, and appearance f spltchy purplish darkening f skin. Rash; assess fr and reprt t physician. 4. Drug Interactins. Cytchrme P450 3A4 (CYP3A4) is the main enzyme fr metablizing carbamazepine therefre CYP3A4 inhibitrs may increase bld levels and CYP3A4 inducers may decrease carbamazepine bld levels (CPS, 2005). Drugs which may increase carbamazepine levels are: cimetidine, clarithrmycin, danazl, diltiazam, erythrmycin, fluxetine, fluvxamine, grapefruit juice, isniazid, lamtrigine, prpxyphene, tricyclic antidepressants, and verapamil (Jffe & Gardner, 2003). Drugs which may decrease carbamazepine levels are: istretinin, phenbarbital, primidne, and phenytin. Carbamazepine decreases the effectiveness f: alprazlam, clnazepam, anticagulants, B-blckers, cyclsprine, etretinate, ral cntraceptives, valprates, and risperidne. Carbamazepine increases the effect f: CNS depressants, clzapine, desmpressin, gabapentin, lithium, and MAOIs. lamtrigine (Lamictal) 1. Indicatins: Apprved indicatins include: epilepsy. Other cnditins include: acute biplar depressin, prphylaxis f biplar disrder, and acute mania. 2. In rare cases prduces a ptentially life threatening rash (highest risk fr children). gabapentin (Neurntin) 1. Indicatins: Apprved indicatins include: epilepsy. Other cnditins include: adjunct in biplar disrder, anxiety disrders, neurpathic pain, and migraine. 2. Relatively few side effects. tpiramate (Tpamax) 1. Indicatins: Apprved indicatins include: epilepsy. Other cnditins include: acute and prphylactic treatment f biplar disrder, and besity. 2. Increases risk f kidney stnes. 3. Decreases digxin levels and may decrease the effectiveness f ral cntraceptives. Nte: Olanzapine has been apprved fr the treatment f biplar disrder and is discussed with the antipsychtic medicatins RN Prfessinal Develpment Centre & Nva Sctia DOH, Halifax, NS 17

18 4. Antidepressants Histry f the medicatins used fr depressin: 1950 s: Tricyclic antidepressants Mnamine Oxidase Inhibitr MAOIs 1990 s: SSRIs, SNRIs and RIMAs Hw they wrk: The principle theries abut antidepressants fcus n the bilgical systems f the brain and their effect n varius neurtransmitters; specifically, nrepinephrine (NE) and sertnin (5HT). Indicatins. Depressin (with r withut psychtic features). Bi-plar Disrder (depressed phase). Md Disrders with a seasnal pattern. Obsessive Cmpulsive Disrder. Panic Disrder. Scial Phbia. Generalized Anxiety Disrder (GAD). Bulimia. Pst Traumatic Stress Disrder (PTSD). Brderline Persnality Disrder. Attentin Deficit Disrders (child and adult). Sleep Disturbance. Pain Management. Premenstrual Syndrme. Smking Cessatin. Fr the withdrawal and treatment f drugs and alchl. Classificatin f antidepressants: Byd (2005) list five classes f antidepressant medicatin while thers list nine brad classes. They are classified based n the neurtransmitters they affect. The varius classes f antidepressants lk at increasing ne r mre f sertnin, nrepinephrine, r dpamine by varius methds. The classes f antidepressants are presented belw. Tricyclic Antidepressants (TCAs) Tricyclics were first marketed in the late 1950 s and were the first line f treatment fr depressin. 2. Mde f Actin: TCAs primarily blck the sertnin and nrepinephrine reuptake transprters. This causes an increase in the level f sertnin and nrepinephrine in the synaptic cleft. Sme TCAs als effect dpamine in the synaptic cleft. Examples: clmipramine (Anafranil); amitriptyline (Elavil); imipramine (Tfranil); dxepin (Sinequan) RN Prfessinal Develpment Centre & Nva Sctia DOH, Halifax, NS 18

19 3. Side Effects. Chlinergic blckade: Cnstipatin. Dry Muth. Urinary retentin. Dry eyes/blurred visin. Antichlinergic delirium. Histaminic blckade: Sedatin. Weight gain. Adrenergic blckade: Orthstatic hyptensin. Reflex tachycardia. Cardivascular: Prlng cnductin time. Avid in peple with a histry f heart blck and recent MI. Sexual Dysfunctin: Males: decreases libid, imptence, ejaculatin difficulties. Females: decreases libid, anrgasmia. CNS. Lwer seizure threshld. Nightmares. Mnamine Oxidase Inhibitrs (MAOIs) Very effective antidepressant. Amng the first antidepressants t be discvered. Rigrus dietary restrictins. N lnger cnsidered 1 st r 2 nd line f treatment. 1. Mde f Actin: Increases the amunt f nrepinephrine, sertnin and dpamine. Examples: phenelzine (Nardil); tranylcyprmine (Parnate) 2. Side Effects. Gastrintestinal: Cnstipatin, anrexia, nausea and vmiting. Cardivascular: Orthstatic hyptensin, decreased heart rate. Hypertensive crisis: Avid fds with tyramine. Avid drugs which ptentiate NE (e.g., Decngestins, OTC cugh preparatins, cdeine, and antihistamines). 3. Dietary Restrictins. Smked and pickled fish, aged cheese, beer, wine, sauerkraut, aged and prcessed meats and sausage, cncentrated yeast extracts, and brad bean pds RN Prfessinal Develpment Centre & Nva Sctia DOH, Halifax, NS 19

20 4. Initial Symptms f Hypertensive Crisis. Palpitatins. Tightness in the chest. Stiff neck. Thrbbing, radiating headache. Diaphresis. Pupillary dilatin. 5. Treatment f Hypertensive Crisis. Discntinue MAOI. Ntify Physician (administer phentlamine[regitine] 5mg IV t decrease B/P) Cling Blanket t manage fever. Prvide supprtive care as indicated. Selective Sertnin Re-uptake Inhibitrs (SSRIs) Came t market in 1980 s. Efficacy is similar t tricyclics and MAOIs. Fewer side effects and are safer in terms f risk related t verdse. 1. Mde f Actin: Acts primarily by blcking the uptake f sertnin thus increasing the amunt f the sertnin activity in the CNS. Examples: fluxetine (Przac), fluvxamine (Luvx), sertraline (Zlft), parxetine (Paxil), citalpram (Celexa). 2. Side Effects. Gastrintestinal: Nausea (mst cmmn side effect). Vmiting, diarrhea, anrexia. Weight gain (parxetine). CNS: Activatin, excitement agitatin (give fluxetine in mrning nly). Extreme agitatin and impulsive acts. Insmnia (fluxetine and sertraline) Sedatin (fluvxamine and parxetine). Headache, dizziness, and anxiety. Sexual Dysfunctin: Males: decreased libid, imptence, ejaculatin difficulties. Females: decreased libid, anrgasmia. Selective Sertnin Nrepinephrine Re-uptake Inhibitrs (SNRIs) 1. Mde f Actin: Increases sertnin and nrepinephrine activity in the CNS. Als increases the amunt f dpamine when used at very high dses. Examples: venlafaxine (Effexr, Effexr XR) 2012 RN Prfessinal Develpment Centre & Nva Sctia DOH, Halifax, NS 20

21 2. Side Effects Gastrintestinal: Nausea, vmiting, and anrexia Cardivascular: Increased diastlic bld pressure (especially with dse greater than 300 mg per day) Reversible Inhibitrs f Mnamine Oxidase (RIMAs) This is a relativity new grup f MAOIs that d nt have the same dietary restrictins as the ld MAOIs. 1. Mde f Actin: They increase the amunt f nrepinephrine, sertnin and dpamine in the synaptic cleft by inhibiting their breakdwn. Examples: mclbemide (Manerix). 2. Side Effects. Gastrintestinal: Dry muth and nausea CNS: Dizziness, headache and sedatin. Sertnin Antagnist Receptr Inhibitrs (SARI) 1. Mde f actin: Increases the amunt f sertnin in the synaptic cleft and affects sertnin binding in the pst synaptic receptrs. Als, mdestly increases nrepinephrine in the synaptic cleft. Examples: trazdne (Desyrel); nefazdne (Serzne), nw ff the market in Canada. 2. Side Effects. trazdne: sedatin, rthstatic hyptensin, and priapism. nefazdne was taken f the market because f liver failure. Nradrenaline Re-uptake Inhibitrs (NARI) Currently nly available in the USA and emergency drug release status in Canada. Examples: rbxetine (Edrnax) RN Prfessinal Develpment Centre & Nva Sctia DOH, Halifax, NS 21

22 Nradrenergic Specific Sertnergic Agents (NaSSA) 1. Mde f actin: Increases the amunt f sertnin and nrepinephrine in the synaptic cleft. Examples: mirtazapine (Remern) 2. Side Effects. CNS: Smnlence 54%. Dizziness 7%. Gastrintestinal Increased appetite 17%. Weight gain 12 %. Nrepinephrine dpamine reuptake inhibitr (NDRI) 1. Mde f actin: Increases the amunt f nrepinephrine (and t a lesser extent dpamine) in the CNS and are als referred t as Nrepinephrine and Dpamine Mdulatrs (NDM). Examples: buprpin (Wellbutrin/Zyban). 2. Side Effects. Gastrintestinal: Nausea and vmiting. CNS: Stimulatin (agitatin, excitement, insmnia, restlessness). Headache and seizures. Antidepressant Dsing and Respnse 1. Start lw and increase gradually every 3-7 days until an ptimal therapeutic dse is achieved. A pr antidepressant respnse may be due t an insufficient trial perid. New research indicates that it may take as lng as 4-6 weeks at an ptimal therapeutic des and in sme cases even lnger. If n imprvement is seen after 4-6 weeks, the antidepressant may be slwly withdrawn and anther antidepressant started (pending washut perid ). Expected Imprvement: During 1 st and 2 nd Week: Sme imprvement in energy, sleep and appetite. Decreased anxiety. Nte: The persn in care is ften unaware f these changes and still may feel terrible with depressed md. During 4 th and 6 th Week: Imprvement in md, memry, and cncentratin. Psychmtr retardatin reslves RN Prfessinal Develpment Centre & Nva Sctia DOH, Halifax, NS 22

23 During 5 th and 6 th Week: Imprvement in depressive thinking. Less hpelessness and helplessness. May still feel blue and sad. Suicidal ideatin begins t subside. 2. Critical Times during Antidepressant Drug Therapy. Careful evaluatin is required thrughut antidepressant drug therapy. Particularly arund week 2-3 when the energy level increases but the md remains lw (high risk fr suicide). 3. Issues Affecting Adherence. Drug interactins. Gastrintestinal (e.g. nausea). Weight gain (parxetine). Sexual side effects. 4. Precautins: all classificatins f Antidepressants. Elderly, debilitated. Pregnancy, lactatin. Pre-existing psychsis r mania. General anesthetic. Urinary retentin. Narrw angle glaucma. Suicidal ideatin. Cardivascular, hyptensin (CVA). Seizure. Thyrid dysfunctin. Severe renal disease. Live dysfunctin. Hazardus task. 5. Cmmn Side Effects fr all Antidepressants. Nausea and vmiting. Agitatin. Headache. Insmnia/sedatin. Dry muth. Fatigue. Weight gain/weight lss. Diarrhea/cnstipatin Sexual Dysfunctin (SSRIs). Asthenia (lss r lack f strength). Dyspepsia. Cnfusin. Amblypia (reductin r dimness f visin). Increase sweating/palpitatins RN Prfessinal Develpment Centre & Nva Sctia DOH, Halifax, NS 23

24 6. Nursing Prcess. Nursing Assessment: Baseline vital signs and weight. Dcument symptms identified by the persn in care and thse bserved by staff (e.g., cncentratin, appearance, thught prcesses, md rating, hpelessness). Emtinal status. Suicidal risk. Pssible Nursing Prblems: Ptential fr vilence and injury. Weight gain r weight lss. Headache. Cnstipatin. Risk f injury related t rthstatic hyptensin r blurred visin. Altered mucus membrane (dry muth). Risk f pisning related t medicatin txicity. Sleep pattern disturbance related t medicatin induced smnlence r insmnia. Urinary retentin. Nursing Interventins: Observe and mnitr the signs f depressin (maintain clse bservatin). Check vital signs (lying, sitting and standing). Observe fr harding r cheeking f medicatins. G.I. symptms; give with fd/milk (except trazdne). Urinary retentin; mnitr in and utput. Blurred visin; educate will dissipate. Cnstipatin; increase fluids, high fiber diet, administer stl sftener. Dry muth; sugarless candies/gum/ice chips. Sexual dysfunctin; reprt t prescribing physician. Mnitr weight; start with baseline. Headache; reprt and administer analgesic. Mnitr sleep patterns; reprt findings t team. Evaluatin: Evaluate the persn s respnse t antidepressant medicatin. Evaluate the persn s weight management regime. Evaluate side effects. 7. Antidepressants and Manic Reactins. There is a risk that antidepressant therapy may elevate md such that it precipitates a manic episde. This is particularly true fr peple with biplar disrder. A first episde f mania may be triggered by antidepressant therapy (Frtinash, 2000). 8. Cnsideratins when Discntinuing Antidepressants. Taper all SSRIs; fluxetine is an exceptin due t lng half life. Avid drug hlidays. Avid abrupt discntinuatin. Re-initiate the riginal agent and slw the tapering rate if symptms are intlerable. Cautin is advised when antidepressants are discntinued abruptly r reduced significantly. General guideline: discntinue slw ver 1-2 weeks t avid withdraw symptms RN Prfessinal Develpment Centre & Nva Sctia DOH, Halifax, NS 24

25 During discntinuatin the persn may experience: Flu like symptms: fever, sweating, nausea, vmiting, malaise, headache, dizziness, muscle pain, cld like symptms. Sleep disturbance and vivid dreams. Electric shck-like feelings. Withdrawal tardive dyskinesia. 9. Augmentatin Agents Antidepressants alne may nt be sufficient t manage treatment resistant depressin. Adding anther psychtrpic agent may serve t synergistically increase the activity f the antidepressant. Main augmentatin agents include: Thyrid agents. Lithium. L-Tryptphan. Dextramphetamine. Cmbinatin f antidepressants. Cmbinatin f antidepressant and antipsychtic. 10. Switching Antidepressants In mst cases, switching frm ne SSRI t anther requires a 2 week taper perid (with the exceptin f fluxetine, which may be discntinued withut tapering due t its lng half-life). MAOIs require at least 14 days between discntinuatin and initiatin f anther antidepressant (with the exceptin f fluxetine). 11. Sertnin Syndrme. Sertnin Syndrme is a ptentially fatal reactin that results frm the cmbinatin f sertnergic agents. When given at the same time r withut a sufficient time t wash ut frm the system, may result in serius reactin (e.g., SSRI with TCA r SRI, MAOIs). Onset f Sertnin Syndrme is rapid within a few hurs r days fllwing an increase in dse f a sertnergic drug r fllwing the additin f a sertnergic drug. Signs and Symptms f Sertnin Syndrme: Diarrhea. Shivering fever. Incntinence. Diaphresis. Uncrdinated. In sme cases it may resemble Neurleptic Malignant Syndrme. Treatment f Sertnin Syndrme Medical emergency Immediate discntinuatin f medicatin Cling blanket Antihypertensive Anticnvulsant Antipsychtic Artificial ventilatin as required 2012 RN Prfessinal Develpment Centre & Nva Sctia DOH, Halifax, NS 25

26 5. Antianxiety and Sedative Hypntics There are tw classes f antianxiety and sedative hypntic medicatins: benzdiazepines and nnbenzdiazepine medicatins. Benzdiazepine Anxilytics and Sedative-Hypntics 1. Indicatins: Anxiety, acute insmnia, alchl withdrawal, depressin with cmrbid anxiety, panic disrder, seizures, neurleptic-induced akathesia, behaviral prblems in peple with mania r psychsis and catatnia. 2. Mde f actin: These drugs act n the limbic system and the reticular activating system. They prduce a calming effect by ptentiating the effects f GABA, ne f the inhibitry neurtransmitters. The CNS depressin frm benzdiazepines can range frm mild sedatin t cma. Other physilgical effects are muscle relaxatin and anticnvulsant prperties. Individual benzdiazepines differ in their ptency, speed in crssing the bld-brain barrier and their degree f receptr binding. These factrs must be cnsider when chsing which benzdiazepine t use and hw ften the drug in given. Examples f Anxilytics Benzdiazepine: alprazlam (Xanax), lrazepam (Ativan), xazepam (Serax), clrazepate (Tranxene), diazepam (Valium) chlrdiazepxide (Librium), clnazepam (Rivtril). Examples f Sedative Hypntic Benzdiazepines: fluazepam (Dalmane), temazepam (Restril), triazlam (Halcin). 3. Side Effects are primarily related t the general sedative effect and include drwsiness, dizziness and psychmtr impairment. Benzdiazepines ptentiate the effects f alchl n the CNS and can lead t severe CNS depressin. There is a ptential fr addictin and abuse. Benzdiazepines shuld nt be discntinued abruptly because f the risk f severe withdrawal symptms, which include seizures, abdminal and ther muscle cramps, vmiting and insmnia. Benzdiazepine sedative-hypntics decrease REM sleep s are nt gd fr prlnged use. These drugs shuld nly be used fr shrt term treatment f sleep prblems (2-4 weeks) because they can cause rebund insmnia. 4. Drug Interactins: alprazlam and triazlam cncentratins are increased several times when cmbined with drugs that inhibit P450 3A3/4 enzymes including nefazdne, fluxetine, fluvxamine, ketcnazle, itracnazle, erythrmycin, and clarithrmycin RN Prfessinal Develpment Centre & Nva Sctia DOH, Halifax, NS 26

27 Nnbenzdiazepine Anxilytics and Sedative-Hypntics Nnbenzdiazepine anxilytics are frm the azaspirne class f drugs and the beta-adrenergic blckers. 1. Azaspirne antianxiety medicatin des nt bind t GABA receptrs but rather balances 5- HT activity by stimulating the 5-HT receptrs. They d nt tranquilize and sedate and may have a mild antidepressant effect. Usually it takes ne t tw weeks fr the level f anxiety t decrease. Buspirne falls in this class f medicatin. It has n ptential fr dependence and des nt ptentiate the effects f alchl. It is the drug f chice fr individuals wh are prne t substance abuse r fr thse requiring lng-term antianxiety medicatin. Side effects: drwsiness, dizziness, headache and nervusness. Drug interactins: Increases bld pressure with nn-selective MAOIs. Increases halperidl cncentratin, increases digxin effects. Buspirne cncentratin is increased with erythrmycin, clarithrmycin, ketcnazle, itracnazle, and nefazdne. 2. The beta-adrenergic blcker prpranll is used in the treatment f perfrmance anxiety. Examples f Nnbenzdiazepine anxilytics: buspirne (Buspar); prpranll (Inderal). The fllwing three medicatins are nnbenzdiazepine sedative-hypntics. chlral hydrate (Chlral Hydrate) 1. Side effects: gastrintestinal irritatin leading t nausea, vmiting, stmach pain, flatulence and diarrhea, unpleasant taste, unsteadiness, daytime drwsiness, and cnfusin. 2. Chlral hydrate will add t the CNS depressant effect f alchl, narctics, barbiturates, sedating antihistamines, sedating antipsychtics and antidepressants, and ther sedative hypntics. 3. Rapid lss f effect is seen with regular use f ver ne week therefre use shuld be limited t brief intermittent management f insmnia. zpiclne (Imvane) 1. Side effects: bitter taste, dry muth, daytime sedatin, weakness, cnfusin and memry impairment. 2. zpiclne will add t the CNS depressant effect f alchl, narctics, barbiturates, sedating antihistamines, sedating antipsychtics and antidepressants, and ther sedative hypntics. 3. Rebund insmnia is cmmn with abrupt discntinuatin after prlnged use. Other withdrawal symptms similar t the benzdiazepines may als be seen RN Prfessinal Develpment Centre & Nva Sctia DOH, Halifax, NS 27

28 zalepln (Starnc) 1. zalepln is a shrt-acting hypntic agent f the pyrazlpyrimidine class. While zalepln has a chemical structure unrelated t benzdiazepines, barbiturates, r ther drugs with knwn hypntic prperties, it interacts with the GABA A -receptr cmplex. 2. Side effects: headache, dizziness and drwsiness. Examples f Nnbenzdiazepine sedative-hypntics: chlral hydrate, zpiclne (Imvane), zalepln (Starnc). ********************************************************* Activity 1: Case Study Ms. Kathy Wright is a 38 year ld wman wh has recently been diagnsed with depressin. She is divrced and lives alne with her tw children, ages 7 and 9. Ms. Wright began experiencing symptms f depressin 4 mnths ag, but nly recently did her illness becme severe enugh t affect her ability t d her jb and care fr her children. Her parents brught her t the hspital when they became extremely cncerned abut her well-being, and that f her children. Ms. Wright has n histry f any ther medical cnditin, exercises regularly and eats a balanced diet. She has n family histry f mental illness. Ms. Wright wrks as an investment banker in a very stressful jb. She has made an appintment t see yu, the family practice nurse, as she has sme questins abut her medicatin. 1. Ms. Wright has been taking sertraline fr the past 2 weeks, and she cmplains t yu that she really desn t feel like her md is much better. Hw d yu respnd t her cmment? 2012 RN Prfessinal Develpment Centre & Nva Sctia DOH, Halifax, NS 28

29 2. She asks why she wasn t started n a different medicatin. What benefits des a newergeneratin antidepressant such as sertraline have ver lder classes f antidepressants, such as TCAs and MAOIs? 3. What ptential adverse effects shuld yu ensure that Ms. Wright is aware f? 4. The newer generatin antidepressants (NGA) are highly prtein bund. Describe what may happen if a NGA is given with anther medicatin that is highly prtein bund, such as warfarin RN Prfessinal Develpment Centre & Nva Sctia DOH, Halifax, NS 29

30 Cnclusin This review f cmmn neurlgical and psychlgical pharmaceuticals will help yu t prvide cmpetent, hlistic care t clients wh suffer frm cnditins that affect their nervus system and mental state. As ur ppulatin ages, and the prevalence f certain cnditins increases such medicatins will be seen mre and mre in varius areas f nursing practice. It is imprtant t mnitr fr adverse effects, signs f txicity and cllabrate with ther members f the health care team t ensure that the pharmaclgical treatments being used have mre psitive utcmes then negative effects RN Prfessinal Develpment Centre & Nva Sctia DOH, Halifax, NS 30