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nerve fibers.
Physiological Actions:
2
A. BIOAMINES
1. Dopamine ( brainstem)
◦ Excitatory
controls complex movements,
motivation
Cognition
regulates emotional response
2. Norepinephrine (noradrenaline)– Brain stem
◦ Excitatory –
attention * memory
mood regulation * sleep, and wakefulness
learning,
C. CHOLINERGICS
1. Acetylcholine ( brain, spinal cord,
PNS, neuromuscular junction of skeletal
muscle) from dietary choline in red meat,
vegetables.
Excitatory or inhibitory
Sleep and wakefulness cycle, signals
muscles to become alert.
D. AMINOACIDS
1. GABA – Gamma- Aminobutyric ACID -
amino acid
◦ Major inhibitory , modulate other
neurotransmitters
◦ Increases – Benzodiazepines induce sleep.
2. Glutamate – excitatory
◦ High levels – major neurotoxic effects
◦ Disorder: brain damage – stroke,
hypoglycemia, sustained hypoxia or ischemia,
degenerative diseases i.e. Huntington’s and
Alzheimer’s.
1. Brain
A. Cerebrum ( cortex)
- conscious sensation and the initiation of
movement.
Patient Teaching
Adhering to medication regimen
Reducing sugar and caloric intake
Clozaril
Weekly WBC monitoring
Discontinue medication and seek care at first sign of
infection
Action: Mechanism of Actions:
block receptors to dopamine
◦ Calms an excites patients without producing
impairment of motor function sleep.
Effects:
Treatment for psychotic symptoms
( hallucinations and delusions)
or positive symptoms—schizophrenia, bipolar,
major depression, and delusional disorders.
Treatment of tics and vomiting – intractable
hiccups.
Reduction of aggressive behavior
◦ Side Effects:
EPS Sedation
Anticholinergic effects
Skin rash
Weight gain
Photosensitivity
Reduction of seizure thresholad
Orthostatic hypotension
Galactorrhea/ amenorrhea
Sexual dysfunction
◦Teaching:
Failure to take antipsychotic
medication -- lead to relapses
and repeated hospitalization.
It should be lowered to elderly
Side Effects:
1. Extrapyramidal effects (EPS) Management:
Mgt:
Lowering the dosages
Changing to another antipsychotic drugs
Administering anticholinergic drugs
Acute dystonia
Torticollis
Opisthotonus
Oculogyric
Management:
Anticholinergic drugs i.e. muscular benztropine
(Cogentin), or dipenhydramine.
Recurrent lowering or change of drugs.
2. Pseudoparkinsonism – drug induced parkinsonism;
◦ Akinesia – absent or slowed movement
◦ Stiff, stooped posture
◦ Masklike facies
◦ Decreased arm swing
◦ Shuffling, festinating gait ( with small steps)
◦ Cogwheel rigidity ( ratchet like movements of joints)
◦ Drooling
◦ Tremor
◦ Bradycardia
◦ Coarse pill rolling movements of the thumb and fingers while at
rest.
Management:
Change of drugs
Adding anticholinergic drugs e.g. Amantadine ( Symmetrel)
3. Akathisia – an intense need to move
about.
Restlessness
anxious and agitated,
rigid posture/gait lack of spontaneous gestures.
Internal restlessness, inability to sit still ( leads to
discontinue drugs).
Management:
◦ Change of antipsychotic drugs
◦ Beta blocker
◦ Anticholinergic or benzodiazepines
4. Neuroleptic Malignant Syndrome (NMS)
- Potentially fatal, idiosyncratic reaction of
antipsychotic or neuroleptic drugs
Signs and symptoms:
Rigidity
High fever
Autonomic instability ( unstable BP, diaphoresis, pallor, delirium,
elevated CPK enzyme
Confused or mute
Dehydration, poor nutrition, concurrent medical illness ( high risk)
◦ Management:
Discontinuance of all antipsychotic medications
Supportive medical care – rehydration and
hypothermia
5. Tardive Dyskinesia (TD)
A syndrome of permanent, involuntary movements
Tongue thrusting and protrusion, lip smacking,
blinking, grimacing , unnecessary facial movements.
Management:
Maintenance dosages as low as possible
Changing medications
Monitoring periodically
NEW-GENERATION ANTIPSYCHOTIC
DRUGS aripiprazole (Abilify)
Side Effects
Headache
Anxiety
Nausea
Patient Teaching
Adhering to medication regimen
Antidepressant Drugs
SSRIs; TCAs; MAOIs
Uses:
Major depression, panic disorder and other anxiety
disorders, bipolar depression, psychotic depression
Drink sugar free fluids and hard candies to ease
dry mouth.
avoid calorie-laden beverages and candies –to
avoid dental caries, weight gain
increase fluid and bulk forming food, exercise –
prevent constipation.
Stool softeners but no laxative.
Use of sunscreen – prevent burning.
rising slowly – prevent hypotension or dizziness.
Monitor drowsiness or sleepiness. Avoid driving.
Medication can be taken 3-4 hrs. late. If more
than 4 hrs.late omit the dose.
USES: major depressive illness, panic,
anxiety, bipolar, and psychotic
depression.
Used primarily to treat the related
symptoms of dysphoria, anhedonia,
reduced energy level, change in appetite
and sleep, hopeless feelings, and suicidal
ideations.
Interact with two monoamine
neurotransmitters:
Norepinephrine
Serotonin
Tricyclic and the related cyclic
antidepressants.
Selective serotonin reuptake inhibitors
( SSRIs)
Monoamine oxidase inhibitors (MAOIs)
Other antidepressants or non tricyclic
Effects:
Decreased symptom of depression
Sedative/ hypnotic
Treatment of depression associated with organic
illness and addiction
Amoxapine – with neuroleptic effects
Clomipramine – OCD
Contraindications:
◦ Alcohol intake
◦ Dementia
◦ Suicidal clients ( toxic in overdose)
◦ Cardiac disease
◦ Multiple concominant medications ( TCA drug
indications)
◦ Daytime sedation, urinary retention, or
constipation
Teachings:
◦ Elderly – ½ of adult dosage.
◦ Alcohol – sedation and ataxia
◦ Suicidal precaution
2. MAOIs – has also positive effects on depression
Low incidence of sedation and anticholinergic
effects,
◦ Effects:
Reduces atypical depression ( with weight gain
and hypersomnia) or refractory depression in
compliant patients.
Side effects:
1. hypertensive crisis - if taken with foods
containing tyramine ( amino acids) or
sympatomimetics.( severe hypertension, high
temperature, tachycardia, diaphoresis,
arrhythmias.
Drug interactions: potentially fatal with
Other MAOIs
SSRIs – serotonin syndrome
Meperidine ( Demerol)
Buspirone (Buspar)
Dextromethorpan
General anesthetics
◦ Toxic effects:
Cardiac toxicity, and are toxic in overdose
◦ Contraindications:
Noncompliant or poorly motivated patients,
insomnia, agitation.
Teachings:
◦ Avoid foods with tyramine: (cheese, liver,
avocados, figs, anchovies, yeast extract, deli
meats, herring, beer, red wine, ale, chocolate,
protein extracts, and stimulants, diet pills, cold
and decongestant medications, nasal sprays.)
◦ Never Combine with SSRI
fluoxetine (Prozac), paroxetine (Paxil), sertraline
(Zoloft), citalopram (Celexa), escitalopram
(Lexapro)
Have replaced the cyclic drugs as the first
of choice in treating depression.
Drug of choice for highly suicidal and
impulsive, no risk for lethal overdose.
Suicide precautions: feel energized;
feels frustrated on peak effects of drugs.
◦ Treatment for anxiety disorders: OCD,
PTSD, and panic disorder, eating disorder,
enuresis
Teachings:
◦ Effects not seen for 10-21 days- it will take
weeks longer.
◦ Relief not immediate but will be experienced –
do not discontinue prematurely.
SEROTONIN NOREPINEPHRINE REUPTAKE INHIBITORS
(SNRIs)- decreased activity of norepinephrine
◦ Venlafaxine ( effexor)- mild sedation and anticholinergic
symptoms- depressed, sleeping excessively and little
energy
◦ Nefazodone(Serzone) -
◦ duloxetine ( Cymbalta)
NOREPINEPHRINE DOPAMINE REUPTAKE INHIBITOR (NDRI)
◦ )- inhibits norepinephrine, serotonin, and dopamine
◦ Bupropion (wellbutrin, Zyban) – depression
◦ Zyban – nicotine addiction
ALPHA 2 ANTAGONIST ( NaSSA)
Mirtazapine (Remeron) boosts
norepinephrine/noradrenaline and serotonin by
blocking the a2adrenergic presynaptic receptors,
histamine receptor is also blocked – sedative
effect. Indicated for depression
SEROTONIN 2 ANTAGONIST/REUPTAKE
INHIBITORS (SARI)
Trazadone ( Desyrel)- blocks serotonin 2A
receptor potentially and blocks serotonin reuptake
pump less potentially.
Indication: insomnia, anxiety, depression
USE: Bipolar Affective Disorder by
stabilizing mood and treating acute mania.
◦ A mood disorder - characterized by an
expansive emotional state, extreme excitement
and elation, flight of ideas, increased
psychomotor activity, violent and self
destructive behavior.
Drugs used:
◦ Lithium
◦ Other drugs:
ANTICONVULSANT – Carbamazepine ( Tegretol),
Valproic acid ( Depakote, Depakene) are effective
mood stabilizer.
Lithium normalizes the reuptake of neurotransmitter.
Effects:
◦ Mood disorders: mood swings, excitement, elation, flight of
ideas, violent/self destructive behavior.
◦ Manic episodes – Bipolar disorder –maintenance
◦ Daily dosage: 900-3,600 mg; serum lithium level @ 1.0 -1.2
mEq/L.
◦ Effects:
Treatment of bipolar disorder, acute mania, aggressive
behavior
Reduction in mood swings
Maintenance – bipolar and seizure disorder
short term basis to decrease anxiety
,insomnia, OCD, PTSD, and alcohol
withdrawal.
Used to reduce the manifestations of
person's knowledge
Cultural Considerations
St John’s Wort and Kava – hypericum perforation L –
used for depression, pain, anxiety, insomnia and
premenstrual syndrome.
◦ Modulate serotonine, dopamine, and norepinephrine.
KAVA – PIPER Methysticum Plant - anxiety reduction
Nutritional Therapies and Supplements:
Melatonin – (pineal gland) – treatment of insomnia and
jetlag.
, Dimethylaminoethanol (DMAE)- ADHD, Alzheimer’s d.,
Huntinggton’s chorea, & Tardive Dyskinesia
lecithin – precursor of acethylcholine – improve memory
and treat dementia.
OTHERBIOLOGIC
TREATMENTS:
an electrical current - produce a gradmal seizure
It causes changes in monoamine neurotransmitter systems
– similar to anti- depressants.