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208 Terms

1
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what happens in the brain in a patient with alzheimer's disease (mid 60s+)?

abnormal deposits of protein form amyloid plaques and tau tangles

2
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what happens in the brain in a patient with frontotemporal dementia (45-64)?

abnormal amounts/forms of tau and TDP-43 proteins accumulate inside neurons in frontal and temporal lobes

3
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what happens in the brain in a patient with lewy body dementia (50+)?

abnormal deposits of alpha-synuclein protein ("lewy bodies") affect the brain's chemical messengers

4
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what happens in the brain in a patient with vascular dementia (>65)?

conditions (e.g. blood clots) disrupts blood flow in the brain

5
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symptoms of mild alzheimer's dementia

wandering, getting lost, repeating questions

6
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symptoms of moderate alzheimer's dementia

problems recognizing friends/family, impulsive behavior

7
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symptoms of severe alzheimer's dementia

cannot communicate

8
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type of dementia:

difficulty planning and organizing

emotional flatness or excessive emotions

shaky hands

problems with balance and walking

difficulty making or understanding speech

frontotemporal dementia

9
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type of dementia:

inability to concentrate, pay attention, stay alert

disorganized ideas

muscle rigidity

loss of coordination

reduce facial expression

insomnia

excessive daytime sleepiness

visual hallucinations

lewy body dementia

10
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vascular dementia symptoms

forgetting current/past events, misplacing items, trouble following instructions, hallucinations / delusions, poor judgement

11
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typical antipsychotic drugs

chlorpromazine (thorazine), haloperidol

12
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atypical antipsychotic drugs (2, 2.5, 3)

2: clozapine, risperidone, olanzapine, quetiapine 2.5: aripiprazole (abilify) 3: ziprasidone (geodon), lurasidone (latuda), cariprazine, lumateperone, pimavanserin

13
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regimen for haloperidol (haldol, typical antipsychotic)

start 2 mg, increase by 2 mg every other day

14
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which typical antipsychotic is low potency and has antihistamine and anticholinergic effects? => lower rates of EPS, higher weight gain and sedation

chlorpromazine (thorazine)

15
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regimen for risperidone (risperdal, atypical antipsychotic)

start 1-2 mg, target 2-6 mg (ADR: prolactin elevation)

16
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regimen for olanzapine (zyprexa, atypical antipsychotic)

start 5-10 mg, goal 10-20 mg (smoking increases clearance, female decreases clearance)

17
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which atypical antipsychotic clearance is increased by smoking and decreased by female gender?

olanzaprine (zyprexa)

18
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what is quetiapine (seroquel) used for?

EVERYTHING...schizophrenia (600 mg daily), bipolar (300-600 mg daily), acute mania, depression

19
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side effects of quetiapine (seroquel, atypical antipsychotic)

EKG changes (qtc), metabolism- weight gain, sedation, agitation, insomnia

20
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what is aripiprazole (abilify, atypical antipsychotic) used for?

MDD (goal 5-15 mg), psychosis (goal 10-30 mg)

21
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transitioning from / to aripiprazole (abilify, atypical antipsychotic) rules

from: stop abilify completely and start other antipsychotic at middle dose

to: start abilify at middle dose (10 mg) and taper other antipsychotic x2 weeks

22
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side effects of aripiprazole (abilify, atypical antipsychotic)

lowers QTc, moderate motor SEs (akathisia), weight gain (less than other antipsychotics)

23
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ADR of antipsychotic/antidepressant drugs: a state of agitation, distress, and restlessness, pacing (tx: BB)

akathasia

24
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which atypical antipsychotic causes the most amount of weight gain and dyslipidemia (high TG, high LDL, low HDL)?

clozapine (12 lb in 10 weeks) (next: olanzapine)

25
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which atypical antipsychotic has the highest risk of seizure?

clozapine (atypical antipsychotic)

26
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general indication for typical and atypical antipsychotics

schizophrenia

27
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what is haloperidol (haldol, typical antipsychotic) used for?

psychotic disorders, tourette's, children with behavioral / hyperactive issues (second line)

28
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what is clozapine (atypical antipsychotic) used for?

treatment-resistant schizophrenia, reduction in suicidal behavior in schizophrenia or schizoaffective

29
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dystonia is muscle spasm (twisting movements esp of the face and neck). what is the tx?

benztropine 2 mg BID x 7 days, benadryl

30
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how do typical antipsychotics work?

block dopamine 2 receptors broadly (anti-dopamine)

31
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advantages of high potency first gen antipsychotics (haloperidol)?

disadvantages: high risk EPS, high risk tardive dyskinesia

injectable formulations (include IV), depot form, inexpensive

32
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advantages of low potency first gen antipsychotics (chlorpromazine)?

disadvantages: high risk QTC prolongation, high risk tardive dyskinesia

highly sedating injectable forms (include IV), inexpensive

33
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how do atypical antipsychotics work?

block 5HT2A receptors (serotonin-dopamine antagonists) aka block receptors --> increase dopamine release in striatum (less EPS) and decrease prolactin release

34
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what must you order before starting clozapine (clozaril, atypical antipsychotic)?

WBC, ANC (neutropenia), lipid panel, EKG

35
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which atypical antipsychotic must be avoided with benzodiazepines (poss respiratory depression) and drugs that cause granulocytopenia (eg carbamazepine)?

clozapine (clozaril, atypical antipsychotic)

36
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side effects of clozapine (clozaril, atypical antipsychotic)

sedation, weight gain, sialorrhea, other (less common/rare): seizure, resp depression, myocarditis, neuroleptic malignant syndrome, PE

37
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MOA benzodiazepines

increase GABA

38
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why can benzos lead to all these things: sedation, muscle relaxation, cognitive / psychomotor impair, tolerance, dependence, anxiety reduction, anterograde amnesia?

GABA receptors widely distributed and benzos broadly inhibit brain function

39
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which class of drugs has been shown to increase risk of hip fracture by 50% in the elderly?

benzos

40
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drug interactions with benzos

carbamazepine (decrease metabolism), methadone (over-sedation), clozapine (increase risk cardiopulm depression), opiates (increase risk resp depression)

41
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withdrawal symptoms of benzos

stiffness, weakness, flu-like, visual disturbances, seizure, tachy, HTN, anxiety/insomnia, nightmares, hallucination, depression

42
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what drug class is eszopicione and zolpidem?

non-benzo receptor agonists

43
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what must you order at baseline when starting lithium? can start lithium concurrently unless reason to suspect abnormal labs/EKG

weight, TSH, BMP (Na, Cr, Ca), urine albumin:Cr ratio (proteinuria), EKG (only if cardiac hx or >40 y/o)

44
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regimen for lithium

start 300 mg qhs, titrate by 300 mg Q4 nights to 900 mg, then check level

45
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ADRs of lithium

renal insufficiency (daily is better than BID), tubular effects (nephrogenic diabetes insipidus), nausea, tremor (tx: propranolol), hypothyroidism (tx: levothyroxine), hyperparathyroidism, weight gain, low lethal dose (tx: dialysis)

46
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what if pt on lithium develops nephrogenic diabetes insipidus?

lower dose or start amiloride

47
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toxic level of lithium

symptoms: anorexia, N/D, nystagmus, muscle weakness, drowsy, ataxia, tremor, jerks, sinus brady, heart block

>1.5

48
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toxic level of lithium: >1.5.

what is the tx?

hydration, gastric lavage, cardiac monitor, dialysis (if >6 mEq/L, coma, convulsions, resp failure)

49
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antipsychotic drugs commonly cause weight gain, esp clozapine and olanzapine. what drugs can you consider to help with weight gain in these pts?

metformin, topiramate, liraglutide (victoza), melatonin, zonisamide, reboxetine

50
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how often do you screen for dyslipidemia when starting a patient on olanzapine and clozapine?

baseline, 3 mo after initiation, then yearly

51
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name the SNRI drugs

venlafaxine (effexor), nefazodone (serzone), duloxetine (cymbalta), desvenlafaxine, levomilnacipran

52
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indications for venlafaxine (effexor, SNRI)

depression, GAD, social anxiety disorder, panic disorder

53
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which SNRI is a rare antidepressant that increases REM sleep rather than suppresses it? other drugs included: mirtazapine (atypical antidepressant)

nefazodone (serzone, SNRI)

54
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BBW of nefazodone (serzone, SNRI)

liver injury

55
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what must you check at baseline when prescribing nefazodone (serzone, SNRI)?

LFTs (baseline, Q3-6 months during first year then 6 mo after... avoid in active liver dz or LFTs 3xNL)

56
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which SNRI is indicated for: MDD, GAD acute / maintenance, chronic MSK pain, diabetic peripheral neuropathic pain, fibromyalgia?

duloxetine (cymbalta, SNRI)

57
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side effects of duloxetine (cymbalta, SNRI)

fatigue, constipation, weight gain, HTN

58
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which SNRI has evidence in vasomotor symptoms in perimenopausal women?

desvenlafaxine (pristiq, SNRI)

59
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active metabolite of venlfaxine

desvenlafaxine (pristiq, SNRI)

60
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which drug had been seen to have lower rates of elevated BP: venlafaxine or desvenlafaxine?

desvenlafaxine (pristiq, SNRI)

61
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which SNRI is it a must to avoid alcohol due to alcohol causing accelerated drug release?

levomilnacipran (fetzima, SNRI)

62
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which SNRIs are appropriate for ADHD with prominent depression and/or anxiety? second-line after stimulants

duloxetine (cymbalta), venlafaxine (effexor)

63
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SSRIs vs SNRIs:

upper/lower GI bleeds

tolerability in regard to AEs

overdose risk

risk of hypomania/maina

GI bleeds: MC in SSRIs

AEs: less tolerable in SNRIs

overdose: MC in SNRIs

mania: MC in SNRIs

64
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explain perimenopause in regards to vasomotor symptoms

irreg estrogen --> dysregu neurotransmitter systems in hypothalamic thermoreg center--> neurotransmitter def--> trigger VNS and depression

65
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explain postmenopause in regards to vasomotor symptoms

low estrogen--> low expression of brain glucose transporters--> CNS glucose transport drops--> hypothalamus detects this drop and triggers noradrenergic alarm--> vasomotor response

66
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which SNRI is most sedating?

duloxetine (cymbalta, SNRI)

67
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ADRs SNRIs

sedation, insomnia, headaches, hyperhidrosis, weight gain

68
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name the SSRIs

fluoxetine, sertraline, citalopram, escitalopram, paroxetine, fluvoxamine, vilazodone, vortioxetine

69
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how do SSRIs work?

block serotonin reuptake pump--> increases seotonin in somatodendritic area of serotonin neuron--> somatodendritic 5HT1a autoreceptors down-regulate--> less inhibit of serotonin impulse flow, more 5HT released from axon

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general indications for SSRIs

depression, OCD, panic disorder, bullimia, PMDD

71
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structure to disease

depression

OCD

panic

bullimia

depression: prefrontal cortex (decreased vol)

OCD: basal ganglia (hyperactivity)

panic: hippocampus

bullimia: hypothalamus

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benefits SSRIs vs TCAs / MAOIs

fewer anticholinergic side effects, less cardiac toxicity, low risk overdose, no diet restriction, fewer med interactions

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most sedating SSRIs

paroxetine, fluvoxamine

74
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which SSRI has the worst withdrawal, causing akathisia, dystonia, restlessness, GI symptoms, dizzy, brain zaps?

paroxetine (paxil, SSRI)

75
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why do SSRIs cause bleeding risk?

SSRIs inhibit the uptake of serotonin into platelets (serotonin limit bleeding when released from platelets in response to vascular injury)

76
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symptoms of serotonin syndrome (HARMED)

hyperthermia, autonomic instability, rigidity, myoclonus, encephalopathy, diaphoresis

77
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medications that increase the risk of serotonin syndrome + SSRI

St. John's wort, fentanyl, tramadol, methadone, flexeril, meperidine, ziprasidone

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medications that DO NOT increase the risk of serotonin syndrome + SSRI

triptans, dextromethorphan

79
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which SSRI increases levels of most NSAIDs, warfarin, xanax, valium, clozapine (seizures), haloperidol, imipramine, amitriptyline, fluoxetine?

fluvoxamine (luvox, SSRI)

80
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which SSRI is it not safe to drink alcohol?

vortioxetine (viibryd, SSRI)

81
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general indications for tricyclic antidepressants (TCAs)

MDD, enuresis, antipruritic, neuropathic pain/HA, GI (IBS)

82
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tetracyclic amine: amoxapine (asendin)

tertiary amines: ?

secondary amines: nortriptyline (pamelor), desipramine (norpramin), protryptyline (vivactil)

amitriptyline (elavil, IBS), clomipramine (anafranil, OCD), doxepin (adapin, sinequan), imipramine (tofranil, enuresis)

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ADRs of TCAs (fewer in secondary amines)

anti-muscarinic anticholinergic (blurry vision, dry mouth, constipation, urinary retention, heat intolerance, tachy, cognitive impair), anti-histamine (weight gain, drowsy), alpha 1 adrenergic antagonist (dizzy, decreased BP, ortho hypotension, drowsy)

84
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name affective disorders (aka mood disorders)

depression, dysthymia, mania, hypomania

85
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depression key points (SIG E CAPS)

suicide, interests, guilt, energy, concentration, appetite, psychomotor change, sleep

86
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mania key points (DIG FAST)

distractibility, indiscretion, grandiosity, flight of ideas, activity increase, sleep deficit, talkativeness

87
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GAD key points (WATCHERS)

worry, anxiety, tension in muscles, concentration difficulty, hyperarousal, energy loss, restlessness, sleep

88
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PTSD key points (TRAUMA)

traumatic event, re-experience, avoidance, unable to function, month or more, arousal increased

89
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name personality disorders

paranoid, schizotypal, borderline, antisocial, schizoid

90
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substance dependence key points (ADDICTeD)

activities are given up, dependence (tolerance), dependence (withdrawal), intrapersonal consequences, can't cut down, time-consuming, duration

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substance abuse key points (WILD)

work/school/home obligations, interpersonal consequences, legal problems, dangerous use

92
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alcohol abuse key points (CAGE)

cut down, annoyed, guilty, eye-opener

93
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extrapyramidal symptoms (EPS) are side effects of antipsychotic medications. name the 3 main symptoms

dystonia, pseudoparkinsonism, akathisia

94
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normal QTC

350-460

95
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questions to ask during visit (SMASH DAT)

sleep, mood, appetite, SI, HI, delusions, hallucinations, tolerating meds

96
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increased risk for suicide (SAD PERSONS)

sex (M), age (45-64), depression, previous attempt, ethanol use, rational thinking loss, social support lacking, organized plan, no spouse, sickness

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which atypical antipsychotic is known to modulate dopamine? good use in catatonia pts

aripiprazole (abilify)

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which SSRIs are typically recommended in kids?

fluoxetine (prozac), escitalopram (lexapro)

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BBW for citalopram (celexa, SSRI)

QTc prolongation

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MOA of MAOIs

monoamine oxidase breaks down neurotransmitters (serotonin, norepi, dopamine)--> inhibt MAOs--> more serotonin, norepi, dopamine available