Parkinsonism (Pathophysiology)
Chronic neurologic disorder Degeneration of dopaminergic neurons Imbalance of the neurotransmitters Less dopamine Need to be a balance of ACh and dopamine on and off periods long term once developed
Parkinsonism (Characteristics)
Tremors of head and neck and knees Rigidity (increased muscle tone) Bradykinesia (slow movement) Postural changes Head and chest thrown forward Shuffling walk Lack of facial expression Pill-rolling motion of hands
Parkinsonism (Treatment)
MAO-B inhibitor- increases dopamine
Par. Treatment- Anticholinergic
Dry the person out Confusion Block cholinergic receptors Parasympatholytic- Benztropine (Cogentin) Action: inhibit release of acetylcholine Decrease tremors and rigidity
Par. Treatment- Dopaminergics
Convert to Dopamine
Carbidopa-levodopa (Sinemet)
Action: converted to dopamine
Increases mobility
Side effects
Fatigue, insomnia, dry mouth, blurred vision
Orthostatic hypotension- increased risk of falls
palpitations, dysrhythmias
Urinary retention, nausea, vomiting
Dyskinesia, psychosis (hallucinations, etc.),
severe depression- older white male (> 55yrs) predictable suicide
Carbidopa-Levodopa (Interactions)
Inhibit MAO-B enzyme that interferes with dopamine Decrease levodopa effect with: Anticholinergics Phenytoin- used for seizures Tricyclic antidepressants MAO inhibitors- interacts with food Benzodiazepines Phenothiazines Vitamin B6
Antiparkinosism Drugs (Interventions)
orthostatic hypotension- drink fluids; let feet dangle before standing
administer drug with low-protein foods
avoid vit B6, alcohol, and other depressants
mixed with alcohol increases effects
taper med off
suicidal- plan, where, how, etc < phenomenom
Monitor blood cell counts, liver and kidney (f)
Amantadine (Symmetrel)- Dopamine Agonist
Stimulate dopamine receptors Action: Stimulates dopamine receptors Use: Early treatment as drug tolerance develops Improvement of symptoms
Parkinsonism Treatments- COMT inhibitors
Inhibit COMT enzyme that inactivates dopamine
Parkinsonism Treatments- Dopamine agonists
Stimulate dopamine receptors
Alzheimer’s disease (Pathophysiology)
Progressive, degenerative disease
Neuritic plaques form- make transmission of signals more difficult
Neurofibrillary tangles are in neurons
Cholinergic neurotransmitter abnormality- ACh protects memory
Alzheimer’s disease (Characteristics)
Loss of memory, logical thinking, judgment Time disorientation Personality changes Hyperactivity Tendency to wander Inability to express oneself
Acetylcholinesterase Inhibitors (2 ex’s, action, and use)
Donepril (Aricept), Rivatstigmine (Exelon)
Action
Allow more acetylcholine in neuron receptors
Increase cognitive function
Use
Mild to moderate Alzheimer’s disease
Acetylcholinesterase Inhibitors (Side effects)
Headache, dizziness Depression GI distress Dehydration, dry mouth Blurred vision Insomnia Hypertension, hypotension, dysrhythmias Hepatotoxicity Orthostatic hypotension
Acetylcholinesterase Inhibitors (Interventions)
Monitor vital signs Maintain consistency in care Monitor behavioral changes Provide safety when wandering Arise slowly to avoid dizziness Monitor for GI bleeding
Stages of sleep
Rapid eye movement (REM)
Non–rapid eye movement (NREM)- 4 stages
Insomnia
More common in females
Treatment: sedative-hypnotics
Nonpharmacologic management (Insomnia)
No daytime naps, drink warm fluids
Avoid caffeine 6 hrs before bedtime
Avoid heavy meals/exercise before bedtime
Warm bath, read, listen to music
Sedative- Hypnotics
Sedatives: mildest form of CNS depression Sedative hypnotics: Barbiturates Benzodiazepiness Nonbenzodiazepines Piperidinediones OTC: Nytol, Sleep-Eze, Tylenol PM Diphenhydramine (Benadryl)
Barbiturates
Ultrashort-acting
Used as a general anesthetic
Example: thiopental sodium (Pentothal)
Short-acting
Induce sleep
No residual drowsiness
Examples: pentobarbital (Nembutal), secobarbital (Seconal)
Intermediate-acting
Induce and sustain sleep
Residual drowsiness (hangover effect)
Examples: amobarbital (Amytal), butabarbital (Butisol)
Long-acting
Used to control seizures
Example: phenobarbital
Benzodiazepines
Ex, Action, Use
GABA= calming «targeted in antianxiety and insomnia meds
Temazepam (Restoril)
Action: Interacts with neurotransmitter GABA to reduce neuron excitability
Use: reduce anxiety, treat insomnia
Non benzo’s
Ex, Action
Zolpidem (Ambien), Eszopiclone (Lunesta)
Action: neurotransmitter inhibition
Zolpidem (Ambien)
gets people to sleep; crazy time before sleep- no memory
Eszopiclone (Lunesta)
not as problematic; metallic taste- makes things taste weird
Sedative-Hypnotics (General side effects)
Residual drowsiness (hangover) Drug dependence Drug tolerance Excessive depression Respiratory depression Withdrawal symptoms
Secobarbital (Seconal)
Action, Use, Side-effects, interactions
Barbituate
Action: depression of CNS
Use: short-acting to treat insomnia
Side effects
Hangover, dizziness, paradoxical excitement in elderly, respiratory distress, laryngospasm
Interactions
Decreased respirations with alcohol, CNS depressants, and MAOIs
Sedative- Hypnotics
Interactions, Interventions
Alcohol, CNS depressants Nursing interventions First use nonpharmacologic methods Take 15-45 min before bedtime Report hangover effect Be attentive to safety Avoid alcohol, other CNS depressants Monitor BP, R, withdrawal symptoms
Epilepsy
Seizure disorder
Abnormal electric discharges from cerebral neurons
Epilepsy (Characteristics)
Loss of consciousness
Convulsive movements
Epilepsy (Cause)
Unknown
Secondary to trauma, anoxia, infection, stroke
Isolated seizures due to fever, electrolyte, or acid-base imbalance
Generalized Seizure Classification
Grand mal (tonic-clonic)
Most common
Generalized alternating
muscle spasms and jerkiness
Petit mal Seizure Classification
Brief loss of consciousness (10 seconds or less)
Usually occurs in children
Partial Seizure Classification
Psychomotor Repetitive behavior Chewing or swallowing motions Behavioral changes Motor seizures
Anticonvulsants (Action)
Suppress abnormal neuron firing
Suppress Na influx
Phenytoin (Dilantin)
Suppress Ca influx
Valproic acid (Depakane), divalproex (Depakote)
Enhance action of GABA- inhibitory neurotransmitter: calm; antianxiety
Clonazepam (Klonopin), gabapentin (Neurontin)
Inhibit GABA degradation- inhibit breakdown so there is more; usually enzyme is inhibited
Vigabatrin (Sabril)
Hydantoins
Ex, Contradictions, therapeutic serum level, side effect/adverse reactions
Phenytoin (Dilantin)
Contraindications
Pregnancy (teratogenic)
Therapeutic serum level
10-20 mcg/ml
Side effect/adverse reactions
Gingivitis, gingival hyperplasia, nystagmus
HA, diplopia, dizziness, slurred speech, decreased coordination, alopecia
Thrombocytopenia, Stevens-Johnson syndrome
Steven-Johnson Syndrome
Rash
Phenytoin (Dilantin) Drug interactions
Increased effects with cimetidine (Tagamet), INH, sulfonamides
Decreased effects with folic acid, antacids, calcium, sucralfate, antineoplastics, antipsychotics, primrose, ginkgo
Decreased effects of anticoagulants, oral contraceptives, antihistamines, dopamine, theophylline
Hydantoins Nursing Interventions
Shake suspension well (5 min)
Monitor serum drug levels
Safety: Protect from environmental hazards, driving
Warn females taking oral contraceptives to use additional contraception
Avoid certain herbs, alcohol, and other CNS depressants
Warn client not to discontinue abruptly
Need frequent oral hygiene and dental check-ups
Monitor glucose level in diabetics
Teach client to take drug at same time every day
Warn of harmless pinkish red or brown urine