Central Nervous System Medications

Tardive Dyskinesia (TD)

Drug induced involuntary repetitive movements or “tics” (tongue, face)

Long term use of medications (antipsychotics) that block dopamine

Do not take anticholinergic meds (makes worse)

“ReTARDIVE”

Neuroleptic Malignant Syndrome (NMS)

Hyperthermia, unstable vitals, muscle rigidity, alteration in mental status

Strong dopamine blocking antipsychotics (dopamine ⬇)

Brain can’t properly control muscles, temperature, and autonomic functions

Extrapyramidal Symptoms (EPS)

Drug induced movement disorder w/ muscle stiffness, slowed movement, or spasticity

Can be permanent side effects of antipsychotic meds

Blocks too much dopamine = movement becomes abnormal

Hallucinations

Seeing, hearing, tasting, or feeling things not actually there

Senses something not present

Delusions

False beliefs not based reality

Beliefs/thoughts but no evidence to back it up

Paranoia

Feeling people or things are out to get you

Serotonin Syndrome

Medications that increase serotonin availability

Toxicity caused by excessive serotonin levels that results from a drug overdose or interaction

Serotonin Syndrome Symptoms

S- shivering

H- hyperreflexia (overactive reflexes)

I- increased temperature

V- vitals unstable

E- encephalopathy (brain isn’t functioning properly/confusion)

R- restlessness

S- sweating

Rhabdomyolysis

Severe muscle breakdown, myoglobin then damages the kidneys

Common in NMS

Depression

Affects 18% of population

Higher rates in younger adults, lower income clients, and women

Clinical diagnosis: 5 s/s within two week period (at least five symptoms happening during the same two weeks)

Signs/symptoms: Depressed mood, diminished interest, weight loss when not dieting or weight gain, insomnia or hypersomnia, agitation, fatigue or loss of energy

Tricyclic Antidepressants (TCA)

Tricyclic Antidepressants (TCA) : older class of medication that blocks reuptake of serotonin and norepinephrine

⬆serotonin and norepinephrine ⬆

AMITRIPTYLINE (ELAVIL)

TCA antidepressant

Inhibits re-uptake of serotonin and norepinephrine

Treats: depression, neuropathic pain, insomnia

Side effects: sedation, constipation, hypotension, sexual dysfunction, serotonin syndrome

Box warning: Increased suicidal ideation

Nsg Considerations: give at bedtime, monitor for increased seizures, do not stop abruptly, monitor, hypotension, do not give w/MAOI, do not give w/ ETOH or CNS depressants

Selective Serotonin Reuptake Inhibitors (SSRI)

Increases Serotonin levels, Mood stabilizer/antidepressant

More serotonin available in brain

FLUOXETINE (PROZAC)

CITALOPRAM (CELEXA)

More serotonin stays available in brain

Used to tx: depression, OCD, bulimia, panic disorder, PTSD, anxiety, PMS, migraines

Side effects: rash, mania, ⬇appetite/weight, ⬆bleeding w/NSAIDs, hyponatremia, anxiety, insomnia, NMS, serotonin syndrome

Box warning: ⬆ suicidal ideation

Nsg considerations: avoid grapefruit, do not give w/NSAIDs, Do not stop abruptly, monitor hypotension, Do not give w/MAOI, monitor for NMS, do not give w/ETOH, monitor ALT/AST, do not give w/CNS depressants

ONSET TAKES 12 WEEKS

Serotonin Norepinephrine Reuptake Inhibitor (SNRI)

Inhibits reuptake of serotonin, dopamine, and norepinephrine

Mood stabilizer/antidepressant

VENLAFAXINE (EFFEXOR)

Increases/maintains levels of serotonin, dopamine, and norepinephrine

Used to tx: major depressive disorder

Side effects: hypertension, insomnia, anxiety, decreased appetite, weight loss, mania, hyponatremia, increased bleeding w/NSAIDs, elevated cholesterol, nausea, serotonin syndrome

Box warning: increased suicidal ideation

Nsg considerations: do not give with NSAIDs, do not stop abruptly, do not give with MAOI, monitor Na+ labs, do not give with ETOH or CNS depressants

MAY TAKE 8 WEEKS FOR THERAPEUTIC EFFECT

Monoamine Oxidase Inhibitors (MAOI)

Inhibits MAO enzyme- enzyme inactivates/ Stops MAO enzyme

Norepinephrine, dopamine, epinephrine, and serotonin levels rise

TRANYLCYPROMINE (PARNATE)

Stops MAO enzyme, Increases levels of norepinephrine, dopamine, epinephrine, and serotonin

Used to tx: major depression disorder, Parkinson’s disease

Side effects: HTN crisis, mania, seizures, hypoglycemia in DM, decreased appetite, weight loss, serotonin syndrome

Box warning: increased suicidal ideation, hypertensive crisis (from eating Tyramine foods)

Nsg considerations: do not give w/ tyramine foods, do not stop abruptly, do not give W/ ETOH or CNS depressants, monitor ALT/AST, monitor BS

Mania

Abnormally elevated mood paired with increase in energy/activity

Signs and symptoms: Insomnia or decreased need for sleep, racing speech or thoughts, inflated sense of self-esteem or power, shifting attention or easily distracted, impulsive or reckless behaviors, experiencing hallucinations or delusions

LITHIUM (LITHOBID)

Anti-Mania

Alters Na+ transport in nerves and muscle cells depolarizing nerve and releasing serotonin, dopamine, and norepinephrine

Used to tx: manic episodes, bipolar episodes, aggressive behavior

Side effects: hyponatremia, tremors, cardiac arrhythmia, polyuria, dry mouth, metallic taste

Box warning: Lithium toxicity, SERUM LITHIUM (0.8-1.2 mEq/L), N&V, diarrhea, muscle weakness, confusion, slurred speech, blurry vision, tinnitus

Nsg considerations: give after meal or w/ food, encourage normal hydration, monitor Na+ labs (135-145 mEq/L), do not give to clients on diuretics/cardiovascular disease/renal disease

Psychosis

Mental state where client loses contact with reality

Disrupted thoughts and perceptions

Signs and symptoms: Hallucinations, delusions, disorganized thinking or speech, unpredictable or inappropriate behavior, paranoia, social withdrawal, decline in self-care, struggling to focus or think clearly

HALOPERIDOL (HALDOL)

RISPERIDONE (RISPERDAL)

HALOPERIDOL (HALDOL)- blocks dopamine and has higher EPS risk

RISPERIDONE (RISPERDAL) - blocks dopamine and serotonin, has lower EPS risk

used to tx: Schizophrenia, bipolar disorder, Tourette’s, autism related irritability

Side effects: Weight gain, hyperglycemia, gynecomastia, Drowsiness, fatigue, vertigo, muscle stiffness, elevates prolactin hormone levels, TD, NMS, EPS

Box warning: increased risk of death to geriatric clients with dementia related psychosis

Nsg considerations: Monitor client weight and vitals, monitor closely for TD, NMS, EPS

Central Nervous System (CNS)

Brain and spinal cord

Chemical and Electrical synapse

Impulses trigger neurotransmitters in a chemical synapse

Neurotransmitters stimulate or suppress a response

THALAMUS active site of neuron activity

Acetylcholine (Ach)

“Excitatory” neurotransmitter

Binds to nicotinic or muscarinic receptors (PSNS)

BROKEN DOWN BY ACETYLCHOLINESTERASE (AchE) enzyme

Responsible for learning, memory, attention, arousal, motivation, and muscle movements

Low levels- Alzheimer’s disease, myasthenia gravis

Gamma-Aminobutyric Acid (GABA)

“Inhibitory”

Decreases stimulation of nerves in brain or blocks chemical messages

GABA-A or GABA-B receptors

Responsible for anxiety, stress, fear, and sleep

Low levels- epilepsy/seizures, mood disorders, Schizophrenia, autism spectrum disorder, depression

Dopamine

“Excitatory” “fight or flight”

Responsible for motor movement, memory, pleasure, motivation, behavior/cognition, attention, sleep/arousal, mood, learning, and lactation

“Reward system” - junk food, sugar, drugs are so addictive

Low levels- ADHD, Parkinson’s disease, restless legs syndrome

Norepinephrine (Noradrenaline)

“Excitatory” “Fight or flight”

Made from dopamine

Responsible for: alertness, arousal, attention span, sleep/wake cycle, mood, and memory

Txs: septic shock, neurogenic shock, critical hypotension

Lower levels- anxiety, depression, ADHD, HA, hypoglycemia

High levels- nervousness, HYN, pheochromocytoma

Serotonin

“Excitatory”

Responsible- happiness, learning, memory, body temp, sleep, sexual behavior, N&V, wound healing by platelets, hunger/appetite

90% of serotonin found in cell lining GI tract

Hormone made from tryptophan- essential amino acid (found in diet, turkey=tired)

Low levels- depression, anxiety, insomnia, digestive problems, OCD, PTSD, panic disorders, schizophrenia, phobias)

Parkinson’s Disease

Problem with the brains ability to smoothly control muscle movement

Brain cells die > dopamine decreases > movement becomes harder to control

Progressive, debilitating disease NO CURE

Occurs middle-late adulthood

Low dopamine HIGH Ach

Medication is used to slow/control progression not cure

Parkinson’s Disease Symptoms

Bradykinesia- slow movement

Dystonia- involuntary muscle control (twist/contract involuntary)

Akathisia- restlessness (can’t sit still, pacing, urge to move)

Akinesia- loss of muscle control (can’t initiate/make movement)

Tremor- pill rolling (shaking at rest)

Shuffling gait, drooling, mood disorders, muscle rigidity

CARBIDOPA-LEVODOPA (SINEMET)

MAIN MED USED TO HELP TREAT SYMPTOMS OF PD

Dopamine replacement, increases dopamine in brain, slows progression of disease

Used to tx: PD, RLS

Side effects: hypotension, drowsiness, fatigue, somnolence, discolored body fluids, depression, hallucinations, aggression, lack of impulse control

Box Warning: Vitamin B6 deficiency, seizures

Nsg considerations: administer w/meals to improve ADL’s, avoid giving w/ high protein, do not take with MAOI, monitor mood changes/impulse control

SELEGILINE (ELDEPRYL)

Blocks MAO-B inhibitor that breaks down dopamine in brain

Used to tx: PD, depression

Side effects: hypotension, drowsiness, vertigo, hallucinations, aggression, lack of impulse control

Box warning: may cause suicidal ideations

Nsg considerations, monitor mood changes/impulse control, do not give w/meperidine, if giving with high doses- do not give w/tyramine foods

AMANTADINE (SYMMETREL)

ANTIVIRAL

Acts on dopamine receptors to release more dopamine

Used to tx: PD, Drug induced extrapyramidal reactions, influenza A

Side effects: hypotension, vertigo, peripheral edema, impulse control

Box warning: do not stop abruptly, cause neuroleptic malignant syndrome (NMS)

Nsg considerations: do not skip doses or double dose, do not take with OTC cold medicine, avoid ETOH, monitor for NMS, monitor impulse control

NMS

body becomes dangerously hot, stiff, confused because dopamine activity suddenly becomes too low, medications that block dopamine especially antipsychotics, can also happen when PD meds suddenly stop

BENZTROPINE (COGENTIN)

ATROPINE (ATROPEN)

SCOPOLAMINE (TRANSDERMAL SCOP)

ANTICHOLINERGIC / ANTI ACETYLCHOLINE (blocks Ach)

Binds w/ muscarinic receptors to block Ach (allows more dopamine)

Used tx: PD, muscle tremors, rigidity, drooling

Side effects: HTN, dry mouth, blurred vision, constipation, urinary retention, skin flushing

Nsg considerations: do not skip doses/double doses, do not take with OTC cold meds, avoid ETOH