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Adams chap 16 Antipsychotics (2)

Page 1: Introduction to Drugs for Psychosis

  • Topic: Drugs for psychosis

  • Reference: Adams Chapter 16

Page 2: Key Medications

  • Important Drugs to Know:

    • Chlorpromazine / Fluphenazine

    • Clozapine

    • Haloperidol

    • Ziprasidone

    • Dantrolene

Page 3: Understanding Psychosis

  • Definition: Losing contact with reality

    • Collection of symptoms

  • Characteristics:

    • Difficulty in processing information

    • Disorganized thoughts, incoherence

    • Distortion of reality

    • Symptoms include delusions, hallucinations, and catatonia

    • May lead to aggressive or violent behavior

Page 4: Schizophrenia Overview

  • Definition: Chronic psychotic disorder

    • Usually manifests in adolescence or early adulthood

  • Categories of Symptoms:

    • Cognitive

    • Positive

    • Negative

Page 5: Symptoms of Schizophrenia

  • Cognitive Symptoms:

    • Disorganized thought

    • Memory difficulty

    • Decreased ability to focus attention

  • Positive Symptoms:

    • Exaggerated behaviors (agitation)

    • Incoherent speech, hallucinations, delusions, paranoia

  • Negative Symptoms:

    • Decreased or lost functions and motivation

    • Social withdrawal, poor self-care, ‘poverty of speech content’

    • Typically more chronic and persistent

Page 6: Dopamine Imbalance in Schizophrenia

  • Symptoms arise from an imbalance in dopamine in the brain

  • Antipsychotics block dopamine receptors

    • Goal: Improve thought processes and behavior

    • Some antipsychotics may also block the vomiting center

Page 7: Extrapyramidal Symptoms (EPS)

  • Definition: Central nervous system dysfunction caused by blocking dopamine

    • Symptoms begin 5-30 days after initial dose

    • Symptoms include ‘pseudo-parkinsonism’, tremors, masklike facies, rigidity, shuffling gait, bradykinesia

    • Described as feeling ‘frozen’

Page 8: Antipsychotic Side Effects

  • Early Side Effects:

    • Acute Dystonia: Muscle spasms of face, neck, tongue, back, laryngeal spasm

    • Treated with antiparkinsonian medication (benztropine/anticholinergic)

    • Akathisia: Restlessness, pacing, constant motion

    • Treated with benzodiazepines or beta-blockers

Page 9: Late Side Effects of Antipsychotics

  • Tardive Dyskinesia: Occurs after one year

    • Symptoms: Protrusion and rolling of tongue, lip-smacking or sucking, chewing, involuntary movements

    • Not reversible!

    • Discontinuation of the drug required;

    • Treatment options include benzodiazepines, beta-blockers, calcium channel blockers, Vitamin E

Page 10: Neuroleptic Malignant Syndrome

  • Definition: Rare, life-threatening condition

    • Symptoms: Muscle rigidity, sudden high fever, altered mental status, tachycardia, unstable blood pressure, seizures, respiratory/renal failure, coma

  • Treatment:

    • Stop medication, support vital signs, administer benzodiazepines, muscle relaxants, dantrolene

Page 11: Types of Antipsychotics

  • Typical Antipsychotics (Older Drugs):

    • Suppress positive symptoms

    • Phenothiazines: Block norepinephrine, cause sedation and hypotensive effects

    • Non-phenothiazines: Block dopamine

  • Atypical Antipsychotics (Newer Drugs):

    • Addressing both positive and negative symptoms

    • Fewer side effects

    • Often first-line therapy; also used for Tourette’s and Huntington’s chorea

Page 12: Older Antipsychotics' Side Effects

  • Chlorpromazine: Strong sedative effect; used for intractable hiccups

  • Fluphenazine: Moderate EPS

  • Considerations: Antipsychotics should not be used to treat dementia

Page 13: Care Implications for Antipsychotic Use

  • Possible pink/red urine

  • Benefits may appear in days, full effect in 7-8 weeks

  • Strongly protein-bound, use cautiously with patients having liver disease

  • Non-adherence common; using liquids may prevent ‘pill hoarding’

  • Can be administered parenterally

Page 14: Haloperidol Overview

  • Haloperidol: Very potent antipsychotic

    • Blocks dopamine receptors

    • Used for psychoses and schizophrenia; also for ADHD, Tourette’s

    • Can serve as chemical restraint in a hospital setting

Page 15: Haloperidol Side Effects and Interactions

  • Side Effects: Sedation, EPS, orthostatic blood pressure changes, headache, blurred vision, photosensitivity, blood dyscrasias, weight gain

  • Interactions: Alcohol and sedatives increase risk; increased toxicity with anticholinergics

  • Long acting: Haloperidol decanoate given IM every 2-4 weeks

Page 16: General Notes on Antipsychotics

  • Major side effect is drowsiness

  • Anticholinergic effects common

  • EPS symptoms start 5-30 days after initial dose

  • Antiparkinsonian drugs can control symptoms

  • Long-term use considerations include photosensitivity and WBC suppression

  • Be cautious of drug interactions with alcohol, antihypertensive meds, antiseizure drugs.

Page 17: Drug Interactions

  • Sedatives: Use with first-generation antipsychotics can lead to additive sedation, increasing risk for falls and impaired driving

  • Levodopa/Carbidopa: Can counteract antipsychotic effects

Page 18: Toxicity of Antipsychotics

  • First-generation antipsychotics are generally safe; OD rarely causes death

  • Possible symptoms: hypertension, CNS depression, various EPS

  • Physical/psychological dependence is rare; avoid sudden discontinuation to minimize withdrawal symptoms

Page 19: Atypical Antipsychotics Overview

  • Atypical Antipsychotics: Serotonin/dopamine antagonists, introduced in the 1990s

    • First-line therapy for treating both positive and negative symptoms

    • Fewer EPS and tardive dyskinesia

Page 20: Metabolic Effects of Atypical Antipsychotics

  • Common Metabolic Effects:

    • Weight gain, high lipid levels, hyperglycemia

  • Graph: Weight change over time compared to placebo for various antipsychotics

Page 21: Marketing and Drug Sales

  • Important Marketing Note:

    • Abilify, Seroquel, Zyprexa among top-selling medications in the US

    • Second-generation drugs outselling first-generation by 10 times; similar efficacy but with significant risks

Page 22: Specific Atypical Antipsychotics

  • Clozapine: The first atypical antipsychotic; effective for refractory cases

    • Side effects include tremors, rigidity, low WBC count (agranulocytosis), diabetes, high lipids, weight gain

Page 23: Further Atypical Antipsychotic Information

  • Risperidone: Low EPS, doesn’t suppress WBC; monitor blood glucose

  • Olanzapine: No WBC suppression; significant risk of metabolic effects

Page 24: Recent Atypical Antipsychotics

  • Ziprasidone (2002): Blocks multiple neurotransmitters; potential side effects include cardiac rhythm issues, hyperglycemia, somnolence, rash, hypotension

    • Generally well tolerated

  • Aripiprazole (Abilify) (2003): Similar side effects, little change in EPS; possible agitation, anxiety, insomnia, sleepiness

    • May serve as adjuvant for depression and mania

Page 25: Use of Antipsychotics in Dementia

  • May be effective for controlling symptoms of dementia such as agitation and moodiness

    • Important to reduce doses by 25-50%

    • Considerations: Significantly higher incidences of stroke and death, especially with clozapine

Page 26: Improving Adherence with Therapy

  • Non-adherence to therapy is common; strategies to improve include:

    • Encourage family support

    • Provide thorough instructions and education on the medications

    • Develop therapeutic relationships with patients

    • Assure patients regarding the low risk of addiction

    • Consider long-term IM preparations, though they may seem punitive

Page 27: Quiz Question 1

  • Which manifestations does the nurse associate with tardive dyskinesia?

    • A. Pacing and squirming, with an uncontrollable need for motion

    • B. Mask-like face with drooling, tremors, rigidity, and shuffling gait

    • C. Twisting, worm-like movements of the tongue and face

    • D. Sudden high fever, sweating, and blood pressure fluctuations

Page 28: Quiz Question 1 (Continued)

  • Which manifestations does the nurse associate with tardive dyskinesia?

    • Reiterated options for clarity

Page 29: Quiz Question 2

  • What is most important to assess one hour after administering the first dose of an antipsychotic agent?

    • A. Range of motion of extremities

    • B. Orthostatic blood pressure measurements

    • C. Abdominal distention and bowel sounds

    • D. Tympanic membrane with an otoscope

Page 30: Quiz Question 2 (Continued)

  • What is most important to assess one hour after administering the first dose of an antipsychotic agent?

    • Reiterated options for clarity

Page 31: Conclusion

  • Conclusion of key points discussed regarding drugs for psychosis and their management.

Key Medications

Important Drugs to Know:

  1. Chlorpromazine / Fluphenazine

    • Indications: Primarily used for the treatment of schizophrenia and severe behavioral problems.

    • Mechanism of Action: Block dopamine receptors, particularly D2, which helps to control the symptoms of psychosis.

    • Nursing Considerations: Monitor for extrapyramidal side effects (EPS), assess for sedation, and evaluate liver function.

    • Dietary Considerations: Avoid alcohol; moderately high-fat meals can increase absorption.

  2. Clozapine

    • Indications: Effective for treatment-resistant schizophrenia and reducing suicidal behavior in patients with schizophrenia.

    • Mechanism of Action: Atypical antipsychotic that works on both dopamine and serotonin receptors.

    • Nursing Considerations: Monitor white blood cell count due to the risk of agranulocytosis, assess for seizures, and educate about signs of infection.

    • Dietary Considerations: Avoid grapefruit juice as it can increase drug levels.

  3. Haloperidol

    • Indications: Commonly used for managing acute psychosis, schizophrenia, and as a first-line option for agitation.

    • Mechanism of Action: Strong dopamine receptor antagonist, effectively decreases positive symptoms of schizophrenia.

    • Nursing Considerations: Monitor for signs of EPS, orthostatic hypotension, and sedation levels.

    • Dietary Considerations: Take with food to minimize gastrointestinal disturbances; avoid caffeine.

  4. Ziprasidone

    • Indications: Used for schizophrenia and bipolar disorder as well as management of acute manic or mixed episodes.

    • Mechanism of Action: Blocks both dopamine and serotonin receptors.

    • Nursing Considerations: Monitor for potential cardiac side effects, including QT prolongation, and assess metabolic parameters.

    • Dietary Considerations: Should be taken with food to enhance absorption; avoid alcohol.

  5. Dantrolene

    • Indications: Primarily used for managing muscle spasms and treating neuroleptic malignant syndrome (NMS).

    • Mechanism of Action: Skeletal muscle relaxant that works by inhibiting calcium release from the sarcoplasmic reticulum of muscle cells.

    • Nursing Considerations: Monitor liver function tests, assess for muscle rigidity, and check for signs of CNS depression.

    • Dietary Considerations: May not have specific dietary restrictions but ensure patient hydration.