NUR 3031 Sedatives, Hypnotics, and Mood Stabilizers

Bipolar Disorder (BPD)

Cyclic Disorder

Recurrent Fluctuations in mood

Episodes of mani and depression persist for months without treatment.

Chronic condition, requiring lifelong treatment.

—> May be caused by disruption of neuronal growth and survival.

Mood Episodes pt w/ BPD may experience?

• Pure manic episodes (euphoric mania)

• Hypomanic episode (hypomania)

• Major depressive episode (depression)

• Mixed Episode

What treatments are available to pt’s with BPD?

Psychotherapy

Medications

Bipolar Disorder Medications: Mood Stabilizers

Relieve symptoms during manic and depressuve episodes

Prevent recurrence of manic and depressive episodes

—> Do NOT worsen symptoms of mania and depression

—> DO NOT accelerate the rate of cycling

Bipolar Disorder Medications: Antidepressants

Used to treat depressive episodes

Bipolar Disorder Medications: Antipsychotics

Effective in treating psychotic symptoms associated with mania.

—> Can be given long-term for preventive treatment.

Examples of Mood Stabilizers for pt’s with BPD

• Antiepileptic Drugs

• Lithium

Antiepileptic Agents: Divalproex Sodium (Depakote) MOA

Suppresses sodium channels in rapidly firing neurons

Suppresses calcium influx

Increases inhibitory effects of GABA

Antiepileptic Agents: Divalproex Sodium (Depakote) Adverse Effects

Depakote AE:

• GI Distress: N/V/D and Indigestion

  • Best to give with food or enteric-coated

• Hepatotoxicity: Monitor LFT's

• Pancreatitis

• Highly teratogenic: DO NOT USE IN PREGNANCY

Antiepileptic Agents: Carbamazepine (Tegretol) and Lamotrigine (Lamictal) MOA

Blocks sodium channels in rapidly firing neurons

Antiepileptic Agents: Carbamazepine (Tegretol) and Lamotrigine (Lamictal) Adverse Effects

Tegretol and Lamotrigine AE:

• Neurological: visual disturbances, ataxia, and vertigo

• Blood Dyscrasias: Leukopenia, anemia, & thrombocytopenia

• Dermatologic: Steven Johnson’s Syndrome (rash)

• Teratogenic

• AVOID GRAPEFRUIT JUICE

Medication for Bipolar Disorder: Lithium MOA

MOA unknown: theories suggest altering ion transport

Medication for Bipolar Disorder: Lithium Pharmacokinetics

Administer PO

• Take with food to avoid upset stomach

Short Half-Life

• Must dose SEVERAL times per day, even with long-acting administration

• Teratogenic: DO NOT USE WITHIN FIRST TRIMESTER

Medication for Bipolar Disorder: Lithium/Sodium Considerations

Lithium is structurally similar to sodium

• Toxicity will result with Hyponatremia

• Kidneys try to retain lithium in place of sodium

Medications for BPD: Lithium Side Effects

Lithium SE:

• Increased thirst

• Polyuria

• Fatigue

• Confusion

• Muscle Weakness

• Fine hand tremors

• Cardiac arrhythmias

• Goiter

• Hypothyroidism

Lithium Toxicity:

Lithium has a VERY NARROW THERAPEUTIC INDEX:

• Maintain a Lithium level of 0.4-0.10mEq/L

Draw Lithium levels every 2-3 days at the beginning of therapy

Draw every 3-6 months afterwards.

Lithium Toxicity: Early Symptoms

N/V/D

Thirst/Polyuria

Slurred Speech, Muscle Weakness, Fine Hand Tremor

Lithium Toxicity: Late Symptoms

Coarse Hand Tremor

Confusion

ECG Changes

High output dilute urine

Seizures, Coma, DEATH.

Nursing Considerations: Baseline Assessment

• Pregnancy Test

• Cardiovascular System

• Serum Electrolyte Levels

• Renal Function

• Thyroid Function

Lithium Nursing Considerations: Patient / Family Eductation

• S/S of Toxicity

• Importance of taking as prescribed/recieving blood work

• Consistent sodium intake

• Birth Control Methods

Nondrug Therapy for BPD: Education

Patient and Family education regarding diagnosis and treament

Nondrug Therapy for BPD: Psychotherapy

• Individual

• Group

• And Family therapy

Nondrug Therapy for BPD: Electroconvulsive Therapy

AKA ECT

• Last Resort Treatment

• Stimulation of controlled seizures to “reset the brain”

Sedatives and Hypnotics: Sedatives

Sedatives are medications that calm nervous system overactivity, reduce anxiety, and promote relaxation without inducing sleep.

• Often called anxiolytics or tranquilizers

Sedatives and Hypnotics: Hypnotics

Hypnotics are medications that are specifically designed to induce and maintain sleep

• typically used to treat conditions like insomnia

Anxiety Disorders Overview

An uncomfortable state with physiologic and physical components

• Characterized by fear, apprehension, dread, and uneasiness

• Among the most common psychiatric illnesses

Types of Anxiety Disorders

• Generalized Anxiety Disorder

• Obessive-Compulsive Disorder

• Social Anxiety Disorder

• Post-Traumatic Stress Disorder

Common Treatments for Anxiety Disorders:

Psychotherapy

Pharmacotherapy:

• SSRIs and SNRIs (first-line therapy for long-term management)

Medications for Anxiety Disorders: Buspirone (Buspar)

As effective as a benzodiazepine

• NOT a CNS depressant

• NO abuse potential

(Safest option for individuals who struggle with substance use disorder, alcholol, or other illicit drugs)

—> Well absordbed after oral administration

Medications for Anxiety Disorders: Benzodiazepines Examples and MOA

MOA: Potentiates action of GABA, the major inhibitory neurotransmitter

Examples:

• Lorazepam (Ativan)

• Alprazolam (Xanax)

• Diazepam (Valium)

• Midazolam (Versed)

(end in pam or lam)

What are benzodiazepines most effective for?

• Anxiety

• Seizure Disorders

• Alcohol Withdrawal

• Preoperative adjunct for conscious sedation and balanced anesthesia

Implications of Benzodiazepines:

Benzo’s are a CNS Depressant

• Use caution with other CNS depressants —> overdose

• Respiratory depression when used in combination with other respiratory and CNS depressants (not likely on its own)

• Rebound anxiety if withdrawn too quickly

Antidote for overdose and to reverse anesthesia:

★ (Flumazenil Romazicon)

Antidote for Benzodiazepine OD and to reverse anesthesia:

Flumazenil (Romazicon)

• Antidote for Benzodiazepine OD and to reverse anesthesia

Medications for Anxiety Disorder Treatments: Hypnotics Non-Benzo Z-Drugs

Zolpiden — Ambien, or Ambien CR

Medications for Anxiety Disorder Treatments: Hypnotics Z-Drugs MOA

Z-Drugs: Non-benzodiazepines that selectively bind to GABA-A receptors

Medications for Anxiety Disorder Treatments: Hypnotics Z-Drugs Side Effects

Z-Drug Side Effects:

• Dizziness

• Drowsiness

• Headache

• Next-day drowsiness

• Metallic Taste

Medications for Anxiety Disorder Treatments: Hypnotics Z-Drugs Adverse Effects

Z-Drug Adverse Effects:

• Sleepwalking

• Sleep driving/eating

• CNS depression, —> falls

Patient Teaching for Z-Drugs

Patient Teaching for Z-Drugs includes:

1. Take immediately before bed

2. Only take if 7-8 hours of sleep availbale

3. Avoid alcohol

4. Report abnormal sleep behaviors

Nursing Implications for Z-Drugs:

Z-Drug Nursing Interventions:

1. Monitor complex sleep behaviors

2. Assess Fall Risk

3. Monitor effectiveness

4. Assess the lowest effective dose

ADHD:

Neurodevelopmental disorder characterized by persistent patterns of inattention, hyperactivity, and/or impulsivity that interfere with daily functioning or development.

• Unknown cause: believed to be from genetics, brain structure, imbalances in dopamine and norepinephrine

Presentation of ADHD:

ADHD can present as / a combo of:

• Inattentive Presentation

• Hyperactive-Impulsive Presentation

ADHD: Common Treatments

Stimulants: Methylphenidate (Ritalin, Concerta)

— Mixed Amphetamine Salts (Adderall)

Non-stimulants: Atomoxetine (Strattera)

Treatment of ADHD: CNS Stimulants NTN

Methylphenidate: (Ritalin, Concerta, Metadate CD, Ritalin LA, Daytrana)

Mixed Amphetamine salts: Adderall or Adderal XR

Treatment of ADHD: CNS Stimulants MOA

Increase dopamine and norepinephrine

Treatment of ADHD: CNS Stimulants Side Effects

ADHD CNS Stimulant SE:

• Decreased appetite

• Weight loss

• Insomnia

• Dry mouth

• Headache

• Tachycardia

• Hypertension

Treatment of ADHD: CNS Stimulants Adverse Effects

ADHD CNS Stimulant AE:

• Cardiact Events

• Psychosis/mania

• Growth suppression

• Misuse/dependence

Patient Teaching for ADHD CNS Stimulants

1. Take in the morning, avoid evening doses

2. Monitor appetite/weight fluctuations

3. Swallow ER WHOLE

4. Store Securely

5. MIXED AMPHETAMINE SALTS ARE A SCHEDULE II DRUG

Nursing Interventions for ADHD CNS Stimulants:

Nursing Interventions for ADHD CNS Stimulants

1. Monitor BP/HR

2. Monitor height/weight

3. Obtain Cardiac Hx

4. Assess and Monitor for Misuse

5. Monitor and Assess Response

ADHD: Non-Stimulant Medications

Atomoxetine - Strattera

ADHD: Non-Stimulant Medications MOA

Increases norepinephrine or stimulates central alpha2 receptors.

ADHD: Non-Stimulant Medications Side Effects

ADHD Non-Stimulant SE:

• Drowsiness

• Fatigue

• Dry Mouth

• Dizziness

• Constipation

• Nausea

ADHD: Non-Stimulant Medications Adverse Effects

ADHD Non-Stimulant Medications AE

• Suicidal thoughts (atomoexetine)

• Hypotension

• Bradycardia

• Liver Injury

• Rebound hypertension

Patient Teaching for ADHD Non-Stimulant Medications:

Teaching for ADHD Non-Stimulant

1. Effects take weeks

2. DO NOT STOP CLONIDINE/GUANFACINE ABRUPTLY

3. Rise slowly

4. Report mood changes

Nursing Interventions for ADHD Non-Stimulant Medications:

Interventions for ADHD Non-Stimulant

1. Assess sleep quality

2. Monitor Daytime Drowsiness

3. Low depenence risk

Hypnotics: Melatonin Receptors

Melatonin:

Ramelton — (Rozerem)

• Activates MT1 and MT2 melatonin receptors

Hypnotics: Melatonin Receptors Side Effects

Melatonin SE:

• Dizziness

• Fatigue

• Somnolence

Hypnotics: Melatonin Receptors Adverse Effects

Rare allergic reactions

Hormonal Changes

Patient Teaching for Melatonin

1. Take 30 minutes before bed

2. Avoid high-fat meals

Nursing Interventions for Melatonin

Interventions for Melatonin

1. Assess sleep quality

2. Monitor daytime drowsiness

3. Low dependence risk