central nervous system meds

function of CNS drugs

• pain relief

• suppress seizures

• produce anesthesia

• for psychiatric disorders

acetylcholine

can be both excitatory or inhibitory

involved with cognitive function - learning, memory; also muscle movement

alzheimer’s is a loss of this neurotransmitter and parkinson’s is an increase

glutamate

main excitatory neurotransmitter in the brain and CNS

involved with memory, learning, development

GABA (is grandma)

main inhibitory neurotransmitter

reduces excitability and improves sleep

dopamine (Determination, Obsession, Pleasure)

excitatory neurotransmitter that is involved in memory, motor control, and pleasure

schizophrenia is caused if its overactive, and Parkinson’s is caused by its loss

serotonin

inhibitory neurotransmitter involved with mood, happiness, anxiety, sleep, appetite, and memory (Sleep, Emotion, Remember)

endorphins

inhibits pain signals and triggers sense of well-being

first approach/treatment for anxiety and trauma disorders

try non-drug approaches like training, support therapy, etc.

then add drugs to the treatment for better efficacy

what are sedative-hypnotic drugs primarily used for?

anxiety and sleep

benzodiazepines

sedative hypnotic anxiolytics; makes GABA work better but affects are limited depending on how much GABA is in the body

• Alprazolam (Xanax)

• Diazepam (Valium)

• Lorazepam (Ativan)

• Clonazepam

• Clorazepate

• Oxazepam

as the dose of sedative hypnotic anxiolytic (ex. Benzos) increases, what happens to the patient?

they go from being sedated (less anxious) → hypnotic (sleepy) → stupor (almost unconscious)

what are benzodiazepines (xanax, -azepam) used for?

used for anxiety (short term)

also used for:

• anesthesia (high doses)

• seizure disorders

• muscle spasms

• alcohol withdrawal

• anxiety attack

adverse effects of benzodiazepines (-azepam, xanax)

• CNS depression = lightheadedness, ataxia (loss of balance), sedations

  • do NOT use with alcohol

  • do NOT cook, drive, or operate heavy machinery

• anterograde amnesia - forgets what happened after taking medication

• paradoxical response - opposite effect = stop drug

  • euphoria

  • rage

  • insomnia

• taper them off or → tremors, insomnia, anxiety

if benzos are given IV, what can be some complications and interventions?

respiratory depression + severe hypotension → cardiac/respiratory arrest

monitor RR before that happens, might need an airway, and give fluids

give Flumazenil (antidote)

Flumazenil

is a competitive benzodiazepine agonist

reduces sedation effects only but does not improve respiratory arrest so continue to monitor RR

(i FLU fast in my mercedes BENZ)

benzodiazepine nursing considerations and interactions

• BAD for pregnancy/lactation

• schedule IV drug

• do NOT give

  • sleep apnea

  • respiratory depression

  • glaucoma

• caution: older adults, liver/kidney impairment, history of substance use

• grapefruit juice

• fatty meals - decrease absorption

• give at BEdtime

Buspirone

is an atypical anxiolytic / nonbarbiturate = can still drive the BUS but its slow (slow onset)

safer alternative to benzos due to less risk of abuse/dependency and does not cause CNS depression

takes time to start effect = not for short term; take with benzos in the beginning and then taper off when this medication starts working

can cause: dizziness, nausea, lightheadedness, constipation, and suicidal ideation

do NOT take with MAOIs (wait 2 weeks), erythromycin (antibiotic), St. John’s wort or grapefruit juice

PHQ-9

patient health questionnaire used to screen for depression

treatment for depression

• antidepressants; sometimes with benzos and antipsychotics

• psychotherapy (CBT)

• supportive interventions: yoga, exercise, music, acupuncture

when should patients on antidepressants start showing a full response to drug therapy?

about 4 weeks = mood should be improved

do a follow up to decide if dose needs to be increased or if they need to be switched to another drug

after no response within a month of taking antidepressants, what is that considered?

failure

early treatment with antidepressants increases the risk of?

suicide

selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) drugs

-lopram: Citalopram (Celexa), Escitalopram (Lexapro)

-xetine: Fluoxetine (Prozac), Paroxetine

Sertraline

-faxine: Desvenlafaxine, Venlafaxine

Sertraline, Duloxetine

adverse effects of SSRIs and SNRIs

• first few days = nausea, diaphoresis, tremor, fatigue, drowsiness

• sexual dysfunction

• CNS stimulation → insomnia, anxiety, agitation

• neuroleptic malignant syndrome (NMS)

  • fever, respiratory distress, tachycardia, seizures, sweating, rigidity

  • different from serotonin syndrome

• suicidal thoughts

• weight loss then weight gain

• withdrawal symptoms

serotonin syndrome (H.A.R.M.F.U.L) or (S.R.I)

build up of serotonin in the body (SHAKY SEROTONIN)

abrupt adverse effect of SSRIs and SNRIs, 2-72 hours after starting it, causing:

• hyperthermia

• altered mental status - confusion

• reflexes (hyper)

• myclonus (jerking)

• fast heart rate

• unconsciousness

• loss of GI control

• sweating

immediately stop drug

• sweaty and hot + fever

• rigid muscles, restlessness, agitation

• increased HR

nursing interventions with SSRIs and SNRIs

• okay for pregnant/lactating women

• do NOT take with TCAs or MAOIs (wait 2 weeks before starting)

• do not give to someone with liver/kidney dysfunction, cardiac disease, seizure, diabetes

• interacts with St. John’s wort

Bupropion

atypical antidepressant

used to treat depression, especially in combination with SSRI/SNRI to treat sexual dysfunction and prevent weight gain

also used for smoking cessation

adverse effects:

• headache, dry mouth, GI upset, constipation, increased HR, HTN, insomnia

• N/V, anorexia, weight loss

• avoid taking if you have seizures

Mirtazapine

atypical antidepressant

causes less sexual dysfunction and taken with SSRIs

is well tolerated but may cause sleepiness (take at night), weight gain, and elevated cholesterol

Trazodone ER (TraZZZadone)

atypical antidepressant taken with SSRIs

is very sedating; avoid taking with ETOH or other sedatives

extended release

Tricyclic antidepressants (TCAs) drug

-apramine: Desipramine, Imipramine, Trimipramine

most common: Amitryptyline and Nortriptyline

Tricyclic antidepressants (TCAs) uses and adverse effects

alternative to SSRIs but can be toxic unlike SSRIs

used for depression, bipolar, fibromyalgia, pain, anxiety, OCD, insomnia, ADHD

can cause:

• orthostatic hypotension

  • amy trips on things = slow position changes

• anticholinergic effects

  • cant pee (retention), cant see (blurred), cant spit (dry mouth), cant shit

  • sip water, increase fiber, chew gum, exercise

• sedation

  • take at night, do not drive

symptoms caused by toxic levels of Tricyclic antidepressants (TCAs)

• cardiac toxicity → dysrhythmias, confusion, agitation, seizures, coma, death

  • do not use if person has had a recent MI

• decreased seizure threshold

  • do not use if person has a history of seizures

• excessive sweating

Tricyclic antidepressants (TCAs) interactions

• serotonin syndrome if mixed with MAOIs or St. John’s wort

• hypertensive crisis with MAOIs

• increased effect with epi. and dopamine

• decreased effects with ephedrine and amphetamine

Monoamine Oxidase Inhibitors (MAOIs) drugs (not popular meds so heres a TIP)

• Nardil - Phenelzine

• Parnate - Tranylcypromine

• Marplan - Isocarboxozid

Monoamine Oxidase Inhibitors (MAOIs) uses and adverse effects

inhibits monoamine oxidase, an enzyme that inactivates norepi., serotonin, and dopamine and inactivates tyramine which promotes norepi. release → HTN crisis

can cause:

• CNS stimulation (HA, dizziness, insomnia)

  • Morning Administration, Otherwise Insomnia

• orthostatic hypotension

• hypertensive crisis if combined with tyramine foods

has lots of meds interactions, including OTC

(can take with carbidopa and levodopa to increase efficacy)

tyramine foods

• aged cheese (gouda, cheddar, brie)

• red wine and beer

• cured meat (pepperoni, salami, prosciutto, bacon, hot dogs)

• tofu, kimchi, soy sauce

• avocado, figs, bananas

• smoked fish

do not eat while taking MAOIs or it will lead to a hypertensive crisis, severe HTN, HA, nausea, increase HR and BP

bipolar disorder

cycle of recurrent fluctuations in mood - mania/depression

episodes include:

• euphoric mania

• hypomania

• depression

• mixed episodes

how is bipolar disorder treated

treated with a combination of 2-3 drugs

• lithium - mood stabilizer

• mood stabilizing antiepileptics ex. Divalproex

• antipsychotics for manic state

  • promotes sleep, reduces anxiety and agitation

  • - done and -apine drugs

• antidepressants

• anxiolytics

lithium

a mood stabilizer with a low therapeutic index = monitor drug levels before giving next dose

adverse effects:

• GI distress → nausea, diarrhea, abdominal pain

• fine hand tremors → take propranolol

• polyuria, mild thirst → take K+ sparing diuretics

• weight pain

• renal toxicity

  • monitor I&Os, Cr clearance, and Na levels

• bradydisrhythmias, hypotension, and electrolyte imbalances

signs of lithium toxicity that we want to catch before it progresses

• N/V/D

• thirst

• polyuria

• muscle weakness

• fine hand tremors

• slurred speech

• lethargy

caused by the 4D’s: dehydration, decreased renal function, diet low in sodium, and drug interactions (NSAIDs and diuretics)

if they begin to look confused, have poor coordination, coarse tremors, and sedation = early signs

nursing considerations when giving lithium

• take 2-3 doses a day and monitor their drug levels and labs

  • electrolytes

  • renal function

• avoid dehydration

  • maintain fluid and sodium intake

  • no salt substitutes

• interacts with NSAIDs, diuretics, and anticholineragics

• not safe for pregnancy and lactation

Carbamazepine

mood stabilizing antiepileptics - used for bipolar; given at night

can cause:

• CNS effects like nystagmus, vertigo, staggering gait

• blood dyscrasias like anemia, or leukopenia

  • (my love for CARBS is in my BLOOD and BONES)

  • watch for sore throat, fever, signs of infection, bruising, fatigue, bleeding gums

  • do NOT take if person has bone marrow suppression or bleeding disorder

• teratogenic

• fluid overload

• hepatotoxicity → watch LFTs

Lamotrigine

mood stabilizing antiepileptics - used for bipolar

adverse effects:

• double vision, dizziness, HA, N/V

• rash

can cause cleft lip/palate

Valproic Acid

mood stabilizing antiepileptic - used for bipolar

can cause:

• indigestion and N/V

• hepatotoxicity (if you VALue your liver)

• pancreatitis

• thrombocytopenia

• teratogenesis

• weight gain

schizophrenia

chronic psychotic illness resulting in:

• disordered thinking

• reduced ability to comprehend reality

• 3 types of symptoms:

  • positive - hallucinations, aggressiveness

  • negative - withdrawal, lack of motivation, reduced speech

  • cognitive - decreased concentration and memory

1st generation aka conventional antipsychotic drugs

• Haloperidol (high potency)

• Fluphenazine (high potency)

• Perphenazine (medium potency)

• Chlorpromazine (low potency)

adverse effects of 1st generation antipsychotic drugs

extrapyramidal side effects (EPSs) - movement disorders***

• acute dystonia

• parkinsonism

• akathisia - unable to stand or sit still; continuous pacing

  • give beta blocker, benzos, or anticholinergic

  • appears months out

• tardive dyskinesia - appears months to years out

  • involuntary lip smacking and face, arms, legs, and trunk movement (cogwheel movement)

• neuroleptic malignant syndrome

• anticholinergic effects

• decreased libido

• seizures

• photosensitivity

• orthostatic hypotension

• sedation

• dysrhythmias

• liver impairment

acute dystonia

spasms of the tongue, neck, face, and back due to 1st generation antipsychotic drugs

watch their airway; have the ability to dislocate joint

give IM/IV diphenhydramine (benadryl), benztropine

Parkinsonism

adverse effect of 1st generation antipsychotic drugs

causes:

• bradykinesia

• lead-pipe rigidity

• shuffling gait

• drooling

• tremors (pill rolling)

give IM/IV diphenhydramine (benadryl), benztropine

neuroleptic malignant syndrome

seen with antipsychotics (DOPEY DOPAMINE) = slow

symptoms: fever, muscle rigidity, altered mental status, tachycardia, diaphoresis, flushing, fluctuating BP

1. stop antipsychotic

2. supportive measures

   1. monitor VS

   2. cooling blanket for fever

   3. antipyretics (aspirin, acetaminophen)

   4. hydration

   5. benzodiazepine to calm down

3. report to HCP

4. Dantrolene and Bromocriptine - muscle relaxers

what can be used to monitor and quantify extrapyramidal side effects (EPS)

Abnormal Involuntary Movement Scale (AIMS)

2nd and 3rd generation aka atypical antipsychotics

better alternative to first generation unless patient is obese, has diabetes, or high cholesterol

has lower risk of extrapyramidal effects

adverse effects:

• hypermetabolic syndrome*

  • diabetes mellitus (can cause exacerbation or new onset)

  • weight gain

  • increased cholesterol

• orthostatic hypotension

• anticholinergic effects

• agitation, dizziness, sedation, sleep disruption

• sexual dysfunction

why are 2nd and 3rd generation antipsychotics given as depot (injections) or PO disintegrating tablets?

due to paranoia, it guarantees the patient takes the drug and does not throw it out

Parkinson Disease

a lack of sufficient dopamine (the neurotransmitter that helps coordinate unconscious muscle movement) and increased Ach affect causing:

• speech changes = difficulty swallowing

• pill rolling tremors

• loss of smell

• slow movement

• forced closure of the eyes

• weakness

• depression/anxiety

• blank expression

• stooped posture

• shuffling gate

drugs alleviate symptoms for a few years so avoid using as much as possible

incurable

1st line drugs for Parkinsons

Carbidopa + Levodopa combination

one increases dopamine and the other makes dopamine last longer

wearing-off effect** vs. on-off syndrome

a loss of drug effect during prolonged course of therapy; adjust dose or frequency. or change/add another drug

vs.

symptom-free periods and times when drugs stop working briefly (15 minutes to hours)

Carbidopa + Levodopa

most effective drug for PD but has the wearing-off effect = helps for 5 years before drugs become ineffective

if they do not work = wrong diagnosis; they should alleviate symptoms

nursing considerations:

• too much vitamin B6 (pyridoxine) turns medications to dopamine too fast and breaks them down faster

• space out protein intake and NO high protein meals

  • inhibit medications

• dyskinesias - toxicity sign; twitching, grimacing

• orthostatic hypotension and beta 1 stimulation

• psychosis

• discoloration of sweat and urine (darker)

• impulsive = gambling, alcohol

vitamin B6 (pyridoxine) containing foods

• wheat germ

• green vegetables

• bananas

• whole-grain cereal

• liver

• legumes

avoid if taking Carbidopa + Levodopa

malignant melanoma

adverse effect of Carbidopa + Levodopa IF someone has or had this type of cancer before

do skin tests and ask how their history with cancer

dopamine agonists and its adverse effects

2nd line drugs for PD; activate dopamine receptors

adverse effects:

• sudden inability to stay awake (“sleep attacks”)

  • daytime drowsiness

• orthostatic hypotension

• psychosis

• impulsiveness (gambling, shopping, binge eating)

• dyskinesias

  • head bobbing

  • tics

  • grimacing

  • tremors

MAO-B inhibitors and its adverse effects

3rd line drugs for PD; prevent break down of dopamine

• insomnia

• hypertensive crisis if combined with tyramine foods

• N/V/D

antiCholinergics and its adverse effects (anti seCretions)

3rd line drug for PD; used in younger patients with mild tremors

ex. Trihexyphenidyl, Benztropine*, atropine

• N/V

• anticholinergic effects

  • blurred vision

  • urinary retention

  • dry mouth

  • constipation

• antihistamine effects

• increased confusion in older adults

(treats TRemors and extrapyramidal symptoms)

levido reticularis

mottled, discolored skin

adverse effect of dopamine releaser

Alzheimer Disease

chronic, progressive neurodegenerative disorder characterized by nonreversible impairment of cerebral function

characterized by memory loss, diminished function, speech, personality, behavior, etc

5As:

• anomia - cant remember names

• apraxia - misuse of objects

• agnosia - inability to recognize familiar objects, tastes, sounds

• amnesia - memory loss

• aphasia - inability to express oneself

Cholinesterase inhibitors

used for Alzheimer’s

adverse effects:

• excessive muscarinic stimulation

  • increased GI motility, diaphoresis, salivation, bradycardia

• cholinergic crisis (DUMBBBELS)

  • diarrhea, urination, miosis, bradycardia, bronchospasm, bronchorrehea, emesis, lacrimation, salivation

  • need mechanical ventilation, oxygen, and atropine

barbiturates (Phenobarbital, Primidone)

“ climbed over BARBed wire to reach the PENTagon and they knocked me out “

antiepileptic with high abuse for potential (tolerance and addiction)

adverse effects:

• CNS effects: drowsiness, sedation, confusion

• toxicity - uses up GABA and acts like it

  • respiratory depression, coma, and pinpoint pupils = overdose

  • monitor VS, oxygen, ventilatory support

• decreases synthesis of vitamin K and D

Phenytoin*** adverse effects (pheny-Toxic)

• CNS effects: nystagmus, ataxia, cognitive impairment

  • cant Talk, cant walk (ataxia)

• gingival hyperplasia

  • floss, gum massagers, brush teeth with soft toothbrush

• skin rash - new and painful

• if IV, can cause dysrhythmias and hypotension

• endocrine effects

for long term antiepileptic treatment

Carbamazepine***

antiepileptic

adverse effects:

• CNS effects

• blood dyscrasias (bruising, bleeding, sore throat)

• hypo-osmolarity (edema, HTN)

• skin effects

  • morbilliform rash looks like measles

antiepileptic therapy nursing considerations

• monitor therapeutic plasma levels

  • shows if they are taking the drug

• NO cure

• do not stop abruptly

• do not give to pregnant/lactating women

• suicide risk

CNS stimulants for ADHD

• methylphenidate

• dextroamphetamine

• amphetamine (meth)

• Lisdexamfetamine

adverse effects of CNS stimulants

• CNS stimulation: insomnia, restlessness

  • give in the morning AFTER breakfast and before school

• decreased appetite and weight loss

• growth suppression

  • check height and weight every visit

• dysrhythmias, chest pain → lower dose

• psychosis

• tolerance and withdrawal

• do not give with MAOIs, caffeine, phenytoin, or OTC cold/decongestants

Atomoxetine

non-stimulant drug given for ADHD; also not a controlled substance = hard to abuse

adverse effects:

• decreased appetite, weight loss, growth suppression

• suicidal ideation

• hepatotoxicity

• seizures

alpha 2 adrenergic agonists (guanfacine, clonidine)

used for side effects of other ADHD drugs

• sedation, drowsiness, fatigue

  • helps with sleep

• hypotension, bradycardia

• weight gain

do not give with high fat foods

drugs used for insomnia

used for 2-3 weeks max

• Zzz drugs - Zolpidem, Zaleplon, Eszopiclone

  • can cause daytime sleepiness, lightheadedness

• melatonin agonist if chronic- Ramelteon

  • do not give if lactating, has liver disease, depression, apnea, or COPD

  • no high fat meals

• Orexin antagonist - Suvorexant, Lamborexant

  • promotes wakefulness

gabapentin effects

• somnolence

• dizziness

• ataxia

• fatigue

• nystagmus

• peripheral edema

used for epilepsy and peripheral neuropathy

MAOOI mnemonic

Massive HTN crisis risk

• Avoid tyramine

• OTC drugs (CAAN)

  • calcium

  • antacids

  • acetaminophen

  • NSAIDs

• Other antidepressants (TCAs, SSRIs, SNRIs)

Increased suicide risk

LITH mnemonic

Levels over 1.5 = toxicity

Increase fluid and sodium

Toxic signs = excessive urination and extreme thirst → dehydration

Hold the NSAIDs

OR

Low GI problems

Increased urination and thirst

Tremors

High weight gain

4S’s of SSRIs side effects

• Serotonin syndrome

• sexual dysfunction

• stomach issues

• swollen (weight gain)