ppt chapter 17

Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Chapter 17

Drugs Treating Psychotic Disorders and Dementia

Chapter 17

Drugs Treating Psychotic Disorders and Dementia


Physiology Physiology • The cerebrum, the highest functional area of the brain, is

concerned with activities such as creative thought, judgment, memory, and reason, and it is divided into two hemispheres.

• The primary neurotransmitter related to thought processing is believed to be dopamine.

• Dopamine is secreted by neurons originating in the midbrain that function in coordination, emotion, and voluntary decision making.

• Many areas of the brain secrete ACh; reductions in the amount of this neurotransmitter cause cognitive changes.

• ACh has a number of functions, including arousal, coordination of movement, memory acquisition, and memory retention.


Schizophrenia Schizophrenia

• Schizophrenia is a particular kind of psychosis that is characterized mainly by a clear sensorium but a marked disturbance in thinking.

• It is a complex illness with uncertain etiology.

• Schizophrenia interferes with a person’s ability to think clearly, manage emotions, make decisions, and relate to others.

• Schizophrenia is considered to have multiple causes.


Dementia Dementia

• Dementia is a clinical syndrome of progressive, degenerative loss of memory and of one or more of these abilities:

– Language skills

– Higher level skills, such as judgment, comprehension, and problem solving

– Ability to recognize or identify objects despite intact sensory function

– Ability to perform motor skills (American Psychiatric Association, 2000)

• Mood and behavior may also be affected in dementia.

• Agitation or withdrawal, hallucinations, delusions, insomnia, emotional apathy, and loss of inhibitions are also common.


Alzheimer Disease Alzheimer Disease • Alzheimer disease is one form of progressive dementia.

• Alzheimer disease is the most common cause of dementia among people 65 years of age and older.

• At this time, there is no cure or way to prevent Alzheimer disease.

• Alzheimer disease causes a gross, diffuse atrophy of the cerebral cortex.

• It is associated with extracellular plaques with beta-amyloid protein deposits and neurofibrillary tangles in the cortical neurons.

• Typically, Alzheimer disease begins insidiously with short-term memory loss.


Vascular Dementia Vascular Dementia

• Vascular dementia results from damage to brain tissue, caused by cerebrovascular events, such as transient ischemic attacks.

• The areas that experience infarcts are associated with specific neurologic functions.

• Although vascular dementia and Alzheimer dementia differ in cause, many of the symptoms are similar.


Other Dementia Other Dementia

• Dementia can also be caused by a variety of medical conditions.

• The primary mechanism of this diagnosis is the presence of or a noted history of other diseases, such as AIDS, Parkinson disease, Huntington chorea, and others.

• The symptoms caused by these conditions are also similar to those for Alzheimer disease.


Causes of DementiaCauses of Dementia


Delirium Delirium

• Delirium is a sudden disruption in cognitive functioning, most often caused by a physical change in the body.

• This physical change prevents the brain from receiving some critical element that it needs to function effectively.

• There is a disturbance in the level of consciousness that comes and goes throughout the day or days when delirium is present.

• To treat delirium effectively, the underlying cause must first be identified.


Typical Antipsychotics Typical Antipsychotics

• The typical antipsychotics were the first antipsychotic drugs created.

• They are sometimes referred to as the conventional antipsychotics.

• Prototype drug: haloperidol (Haldol)


Haloperidol: Core Drug Knowledge Haloperidol: Core Drug Knowledge

• Pharmacotherapeutics

– Used to treat psychotic disorders

• Pharmacokinetics

– Protein bound, delayed onset of action

• Pharmacodynamics

– Blocks the dopamine (specifically D2), alpha, and serotonin receptors

– Effective: decrease in movement disorders, relief of hallucinations, delusions, and psychosis


Haloperidol: Core Drug Knowledge (cont.)Haloperidol: Core Drug Knowledge (cont.)

• Contraindications and precautions

– Hypersensitivity and Parkinson disease

• Adverse effects

– Extrapyramidal symptoms (EPS), drowsiness, sedation, somnolence, lethargy, and dysphoria

• Drug interactions

– Few drug interactions, smoking decreases serum levels


Haloperidol: Core Patient Variables Haloperidol: Core Patient Variables • Health status

– Assess past medical: any contraindications to the drug

• Life span and gender

– Pregnancy Category C drug, safety not assessed in children

• Lifestyle, diet, and habits

– Document occupation and daily activities.

• Environment

– Assess environment where the drug will be given.

• Culture and inherited traits

– Asians have a 50% higher serum level than whites.


Haloperidol: Nursing Diagnoses and Outcomes Haloperidol: Nursing Diagnoses and Outcomes

• Risk for Injury related to EPS from haloperidol

– Desired outcome: The patient will remain injury-free from haloperidol as EPS are prevented or minimized.

• Altered Thought Processes related to hallucinations and delusion

– Desired outcome: The patient’s hallucinations and delusions will be controlled by haloperidol therapy.

• Risk for Ineffective Management of Therapeutic Regimen, Individual, related to adverse effects of drug therapy or poor understanding of the need for drug therapy

– Desired outcome: The patient will take haloperidol therapy as directed.


Haloperidol: Planning and InterventionsHaloperidol: Planning and Interventions

• Maximizing therapeutic effects

– Encourage to take the drug routinely.

• Minimizing adverse effects

– The goal of therapy is to find a dose that effectively controls the psychotic symptoms but produces minimal adverse effects.

– EPS are more likely to occur if the patient repeatedly stops and restarts therapy.


Haloperidol: Teaching, Assessment, and EvaluationsHaloperidol: Teaching, Assessment, and Evaluations

• Patient and family education

– Provide realistic expectations of antipsychotic therapy.

– Discuss adverse effects of therapy.

– Advise the patient to avoid alcohol while on drug.

• Ongoing assessment and evaluation

– Treatment is considered effective if the psychotic symptoms are controlled and the patient does not develop serious adverse effects.


QuestionQuestion

• One of the side effects of haloperidol is extrapyramidal symptoms.

– A. True

– B. False


AnswerAnswer

• A. True

• Rationale: Haloperidol causes extrapyramidal symptoms (EPS). The cause of these symptoms is the relative lack of dopamine stimulation and the relative excess of cholinergic stimulation.


Atypical Antipsychotics Atypical Antipsychotics

• Atypical antipsychotics differ from the typical antipsychotics in that they target only specific dopamine receptors.

• This specificity creates a much lower adverse effect profile.

• Another major advantage of the atypical antipsychotics is that they treat both the negative and the positive symptoms of schizophrenia.

• Prototype drug: olanzapine (Zyprexa)


Olanzapine: Core Drug Knowledge Olanzapine: Core Drug Knowledge


– Used to treat psychotic symptoms in schizophrenia and for short-term treatment of acute bipolar disorder.


– Highly protein bound, T½: 21 to 54 hours


– Olanzapine works by blocking several neuroreceptor sites, including serotonin, dopamine, muscarinic, histamine-1 (H1), and alpha-1.


Olanzapine: Core Drug Knowledge (cont.)Olanzapine: Core Drug Knowledge (cont.)


– Hypersensitivity

• Adverse effects

– Drowsiness, insomnia, agitation, nervousness, hostility, tardive dyskinesia, and neuroleptic malignant syndrome


– Centrally acting drugs, alcohol, omeprazole, rifampin, and carbamazepine


Olanzapine: Core Patient Variables Olanzapine: Core Patient Variables

• Health status

– Baseline assessment including laboratory studies


– Pregnancy Category C drug


– Evaluate caffeine intake and diet.

• Environment

– Assess climate where the drug is given.


Olanzapine: Nursing Diagnoses and Outcomes Olanzapine: Nursing Diagnoses and Outcomes

• Imbalanced nutrition: More than Body Requirements related to increased appetite and secondary to olanzapine use

– Desired outcome: The patient will state that there is a risk for weight gain and will identify the effects of a low-fat diet and exercise on weight control.

• Risk for Injury related to drug-induced dizziness, blurred vision, and orthostatic hypotension

– Desired outcome: The patient will identify factors that increase the risk for injury and will relate intent to use safety measures and practices to prevent injury.


Olanzapine: Nursing Diagnoses and Outcomes (cont.)Olanzapine: Nursing Diagnoses and Outcomes (cont.)

• Risk for Fluid and Electrolyte Imbalance and Hyperglycemia related to adverse effects of medication

– Desired outcome: The patient will maintain appropriate fluid and electrolyte balance while receiving medication.

• Risk for Sedation related to adverse effects of the medication

– Desired outcome: The patient will maintain appropriate level of wakefulness while receiving medication.


Olanzapine: Planning and InterventionsOlanzapine: Planning and Interventions


– Maintain adherence to any medication regimen once a patient experiences relief of symptoms.


– Assess fasting blood sugar before drug therapy is initiated and during therapy.

– To minimize daytime drowsiness, you can give the entire daily dose at night.


Olanzapine: Teaching, Assessment, and EvaluationsOlanzapine: Teaching, Assessment, and Evaluations


– Teach signs of hyperglycemia.

– Therapeutic response will not be immediate.

– Stress the importance of continuing drug therapy.


– Ongoing assessment and evaluation.

– Monitor for adverse response and effectiveness of therapy.


QuestionQuestion

• What is the advantage of olanzapine over other atypical antipsychotic drugs?

– A. No risk of dependency

– B. No adverse side effects

– C. Increased effectiveness

– D. No risk for agranulocytosis


AnswerAnswer

• D. No risk for agranulocytosis

• Rationale: Olanzapine does not cause agranulocytosis, which is a common side effect with other atypical antipsychotic drugs.


Acetylcholinesterase Enzyme Inhibitors Acetylcholinesterase Enzyme Inhibitors

• Acetylcholine is a neurotransmitter for several CNS circuits in the brain.

• By inhibiting the action of AChE, acetylcholinesterase inhibitors (AChEIs) prolong the activity of acetylcholine on cortical cholinergic receptors and in the synapse.

• These agents increase concentrations of the memory-regulating and cognition-regulating neurotransmitter acetylcholine by reversibly inhibiting the enzyme cholinesterase.

• Prototype drug: rivastigmine (Exelon)


Rivastigmine: Core Drug Knowledge Rivastigmine: Core Drug Knowledge


– Treating mild-to-moderate dementia


– Administered: oral. Distribution: throughout the body. Metabolism: liver. Excreted: urine. Peak: 1 hour.


– Carbamate derivative that enhances cholinergic function.


Rivastigmine: Core Drug Knowledge (cont.)Rivastigmine: Core Drug Knowledge (cont.)


– Hypersensitivity

• Adverse effects

– GI effects, dizziness, headache, chest pain, peripheral edema, vertigo, joint pain, agitation, and coughing


– Succinylcholine, similar neuromuscular blocking agents, or cholinergic agonists


Rivastigmine: Core Patient Variables Rivastigmine: Core Patient Variables • Health status

– Assess body systems; assess for cardiac dysfunction.


– Assess age of the patient.


– Assess for tobacco use.

• Environment

– Assess environment where the drug will be given.


Rivastigmine: Nursing Diagnoses and Outcomes Rivastigmine: Nursing Diagnoses and Outcomes

• Imbalanced nutrition: Less than Body Requirements related to decreased desire to eat secondary to nausea and vomiting from drug therapy

– Desired outcome: The patient will ingest daily nutritional requirements in relation to activity level and metabolic needs.

• Risk for Injury related to adverse effect of sedation

– Desired outcome: The patient will establish appropriate sleep and rest patterns, participate in activities, and establish priorities for daily and weekly activities.


Rivastigmine: Planning and InterventionsRivastigmine: Planning and Interventions


– Detect and correct any treatable factors that can cause or contribute to cognitive impairment.


– Offer small, frequent meals or give the drug with food to offset GI effects.

– Monitor weight throughout therapy.


Rivastigmine: Teaching, Assessment, and EvaluationsRivastigmine: Teaching, Assessment, and Evaluations


– Discuss disease process and its progressive nature as well as the burdens facing the caregiver.

– Discuss side effects of medication.


– Continually assess cognitive function.


QuestionQuestion

• Rivastigmine has been shown to alter the course of Alzheimer disease?

– A. True

– B. False


AnswerAnswer

• B. False

• Rationale: Rivastigmine has not been shown to alter the course of the dementing process; however, it is anticipated that disease effects will lessen as the disease process advances and fewer cholinergic neurons remain intact.

ppt chapter 17

Documents

dementia dementia

prototype drug

alzheimer dementiadiffer

form of progressive

schizophrenia schizophrenia

dysphoria drug interactions

drug life span

memory acquisition