EXAM 3 - pathopharm II - anxiety and insomnia

what does anxiety normally involve?

a perceived threat

what is the most common mental illness in the US?

anxiety

what is anxiety disorder?

severe and prolonged anxiety that impairs daily functioning

what occurs due to an imbalance in inhibitory and excitatory neurotransmitters?

anxiety

what are the manifestations of anxiety?

tension HA, overactivity of autonomic nervous system, muscle rigidity

what does the autonomic nervous system control?

everything involuntary and unconscious (digestion, heart contraction, etc)

what are the two systems within the autonomic nervous system?

parasympathetic and sympathetic nervous system

what manifestations in anxiety does the autonomic nervous system cause?

enteric stimulation - diarrhea (increased gut motility) and increased secretions

how does the noradrenergic system cause anxiety?

excessive norepinephrine causes a hyperarousal state

where is norepinephrine released from?

noradrenergic neurons from the locus coeruleus

what is the locus coeruleus (LC)?

brainstem nucleus

what stimulates the LC?

caffeine

what inhibits the LC?

benzodiazepines

how do the neuroendocrine factors cause the cascade to anxiety?

a perceived threat or stress --> activation of hypothalamic-pituitary-adrenal axis (HPA) and corticotropin-releasing factor --> activation of LC --> release of norepinephrine --> anxiety

what is the center of stress?

the hypothalamic-pituitary-adrenal axis (HPA)

what is GABA?

inhibitory neurotransmitter

what do insufficient amounts of GABA produce?

anxiety, sleep disorders, irritability

how does GABA work?

attaches to GABAa receptors and opens chloride channels to allow chloride to enter, causing the neuron to be less excited (blocking the nerve impulse)

what does benzodiazepine treat?

anxiety, insomnia, seizures, muscle relaxant

what are the drugs called that treat anxiety?

Anxiolytics

what is the prototype benzodiazepine?

Diazepam (Valium)

which anxiety med is considered "second line"?

Diazepam (Benzodiazepines)

what does long term use of benzodiazepines lead to?

dependency

what is the first line treatment for LONG TERM anxiety?

antidepressants

what antidepressant is NOT used for anxiety?

barbituates

what do selective serotonin reuptake inhibitors (SSRIs) do (patho)?

block serotonin reabsorption into brain, leaving more free floating serotonin available

what does serotonin affect?

mood, GI motility, and cardiac cycles

what do AE of SSRIs look like?

anxiety (N/V/D, dry mouth, insomnia, nervousness, appetite changes)

why do patients often abruptly stop SSRIs?

they start to get AE of anxiety

what do serotonin norepinephrine reuptake inhibitors do (patho)?

equalize availability of norepinephrine and serotonin

what is the first line antidepressant drug treatment for anxiety?

tricyclic antidepressants

what results from decreased norepinephrine and/or serotonin?

depression

what results from too much norepinephrine or a decrease in GABA?

anxiety

what do tricyclic antidepressants do (patho)?

blocks reuptake of serotonin

what are the AE of tricyclic antidepressants?

anticholinergic effects (blurred vision, constipation, dry mouth, urinary hesitancy/retention)

what is the criteria of generalized anxiety disorder?

worry about two or more circumstances and multiple symptoms for 6 months or longer

what is an obssession?

a thought or feeling

what is a compulsion?

an act

what is obssessive-compulsive disorder?

repeated performance of an act (compulsion) to relieve the fear and anxiety associated with an obssession

what are the two main stages of sleep?

REM and non-REM

what happens physiologically during REM sleep?

rapid eye movement, increased heart rate, increased breathing, increased BP, and increased temperature

what is insomnia?

prolonged difficulty in going to sleep or staying asleep long enough to feel rested

T/F: a patient with insomnia frequently complains of daytime sleepiness

false

T/F: patients with insomnia struggle with concentration

true

why do we see a higher rate of psychosocial problems in insomnia patients?

they don't get enough REM sleep

what are the causes of insomnia (6)?

1. medical disorders

2. neurological disorders

3. substance abuse

4. environmental factors

5. stress-related factors

6. medications

what are the manifestations of insomnia (5)?

1. fatigue

2. lack of energy

3. irritability

4. difficulty falling asleep and staying asleep

5. concentration impairment

what is important to do when getting off of benzodiazepines?

taper dosage

T/F: overdose on benzodiazepines is extremely common and fatal

false

what are s/s of benzodiazepine overdose (6)?

1. blue/cyanotic lips

2. blurred/double vision

3. labored breathing

4. weakness

5. stupor

6. coma

what is the antidote for all benzodiazepines?

flumazenil

how do benzodiazepines work (patho)?

enhance GABA inhibitor effects

what are the AE of diazepam?

disinhibition, depressed mood, slurred speech

what is disinhibition?

inhibits ability to make sound decisions

how are benzodiazepines administered?

given IV at a rate of 5 mg/min

a patient is receiving 15 mg of diazepam. Over how long should you give the drug?

3 minutes

what groups should avoid receiving diazepam?

- alcohol or drug abuse

- severe respiratory disorders

which benzodiazepine is safest for older adults?

temazepam

what do nonbenzodiazepine sedative-hypnotic agents do (3)?

decrease agitation, promote relaxation, and produce sleep

what drug class is eszopiclone in?

nonbenzodiazepine sedative-hypnotic agents

when is eszopiclone administered?

immediately before going to sleep and on an empty stomach

why is eszopiclone given before bed?

it is rapid acting to produce sleep

what should a patient avoid after taking eszoplicone?

any activity

what type of meal delays the effects of eszoplicone?

high fat meals

how long can a patient be on eszopiclone?

considered long term: less than 1 year

what are the AE of eszopiclone?

anterograde amnesia (short term memory loss), unpleasant taste (educate!!), hallucinations, aggression or bizarre behavior (educate!!)

what drug class is ramelteon in?

nonbenzodiazepine sedative-hypnotic agents

what is the action of ramelteon?

binds to melatonin receptors in the CNS

how long can a patient take ramelteon?

considered long term: less than 1 year

what insomnia med is safe to give an older adult?

ramelteon

ramelteon won't lead to ____________ with longterm use, unlike benzos

dependence

what are the AE of ramelteon?

decrease in testosterone, increase in prolactin, decrease in cortisol, unpleasant taste, alter taste of food

what patients should avoid taking ramelteon?

pts with severe hepatic impairment

what drug class is zaleplon in?

nonbenzodiazepine sedative-hypnotic agents

zaleplon ONLY helps an insomnia patient ________ _________

fall asleep (doesn't help keep them asleep)

what diet should you advise a patient on zaleplon be on?

low fat

what are the AE of zaleplon?

depression, drowsiness, impaired coordination, short term memory loss

how long is the onset of zaleplon?

1 hour

how long should a patient be on zaleplon?

considered short term: 7-10 days

what patients should avoid taking zaleplon?

pts with renal failure

what drug class is zolpidem in?

nonbenzodiazepine sedative-hypnotic agents

how long should a patient be on zolpidem?

considered short term: 7-10 days

what are the AE of zolpidem?

drowsiness, dizziness, amnesia

what patients should take caution when taking zolpidem and why?

pts with s/s of major depression; related to intentional overdose in these pts

what natural hormone induces sleep and where is it produced?

melatonin; pineal gland