Exam 3 Flashcards

1
Q

Naloxone (Narcan)- class, indication, when to rx, half life

A

Potent opioid
antagonist
* Treatment of choice for
opiate overdose
* Routinely prescribe for
all patients with opioid
use disorder
* Very short half life
Length of effects 30-90 min

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Methadone (Dolophine)- class, administration, federal restrictions, monitoring for adverse effects

A

Long-acting full opioid
receptor AGONIST at mu
receptor
* 1x/daily
* Restricted federally licensed
substance abuse treatment
programs
* Monitor for QTC prolongation
(cardiac abnormalities)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Buprenorphine (Buprenex, Sublocade)
Buprenorphine/Naloxone(Suboxone)- class, effect, indication, med forms

A
  • Partial Opioid receptor agonist/ opioid
    antagonist
  • Decreases cravings; *** Opioid Use disorder w/ comorbid pain= Suboxone can be used in managing pain
  • Can precipitate withdrawal if used too soon after full opioid agonist – it will displace any residual opioids from the mu receptors.
  • Sublingual preparation that is safer= Suboxone: Waiver needed to prescribe in outpatient settings
  • Suboxone= available Buccal film, sublingual film, sublingual tab
  • Buprenorphine= Available sublingual tab; subdermal implant, SQ injection
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

naltrexone-
class, administration including forms, what patients is this good for? Adverse effect/monitoring

A

Competitive opioid antagonist
* Precipitate withdrawal if used
within 7 days of heroin use
* Available orally or monthly depot
injection.
Pill works approx. 24 hours; Injection may last up to 30 days.
* **Treatment of choice for highly
motivated patients.
* Risk for LFT elevation
- Available PO (Revia)
- Available IM (Vivitrol)

***NO LIQUID

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

What could inappropriate use of opioids indicate?

A

may be an indication that the patient’s pain is uncontrolled

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Opioid intoxication sx and management

A

Drowsiness
N/V
↓GI motility (Constipation; abdominal cramps)
Sedation
Slurred speech
Miosis(constricted pupils)
Seizures
Respiratory depression
Arthralgia/myalgia

Mgt:
Airway support
In overdose, give Naloxone (opioid antagonist)
Ventilator if required
Patients art risk of overdose should be prescribed a naloxone (Narcan) kit to keep at home for emergencies.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Opioid withdrawal- sx, management, buprenorphine or methadone for withdrawal?

A

Flu-like symptoms (body aches, anorexia, rhinorrhea, fever)
Diarrhea
Anxiety
Insomnia

Mgt: Buprenorphine/naloxone; Clonidine, dicyclomine (Bentyl)

Moderate symptoms= Symptomatic treatment with;
Clonidine for autonomic s/s
NSAIDs for pain, Baclofen for muscular spasms
Benzos for anxiety & agitation
Loperamide for diarrhea
Dicyclomine for abdominal cramps
Promethazine for nausea
Antinausea medications
Hypnotics for insomnia (e.g. trazodone, low dose quetiapine, diphenhydramine)

NOTE: In clinical experience, when administered for detoxification and not maintenance, buprenorphine is more effective at suppressing and controlling withdrawal symptoms as the taper nears completion compared with methadon

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

cocaine intoxication- sx & tx

A

Euphoria
Heightened self esteem
Decrease BP
Tachycardia or bradycardia
Nausea
Dilated pupils
Psychomotor agitation or depression
Chills and sweating
Dangerous/Deadly: Seizures, cardiac arrythmias, paranoia, hallucinations
**NOTE: Cocaine has vasoconstrictive effects= can cause MI, stroke

Txt: Lorazepam

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

cocaine withdrawal- disulfiram (Antabuse) use, meds for sx, contraindicated med

A

disulfiram/Antabuse use in Cocaine use disorder = increase synaptic dopamine in the brain reward circuit and act as an agonist treatment in the setting of cocaine use disorder

NOTE: Medications for cocaine-induced chest pain and myocardial infarction = Nitroglycerin, Aspirin

**No Metoprolol
(Beta blockers are contraindicated in patients with cocaine induced chest pain – further lowers coronary blood flow thereby worsening ischemia)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

ETOH intoxication

A
  • Impaired fine motor control
  • Impaired judgement and coordination
  • Ataxic gait and poor balance
  • Lethargy, difficulty sitting upright, difficulty with
    memory,
  • Nausea/Vomiting
  • Coma = Levels 300mg/dL and over
  • Respiratory depression and death possible

(***Know ETOH Intoxication vs. Withdrawal)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

ETOH withdrawal (mild/mod/severe)

(***Know ETOH Intoxication vs. Withdrawal)

A

Mild: Insomnia, Irritability, Hand tremor

Moderate: Autonomic hyperactivity (diaphoresis, tachy, HTN), Fever

Severe: Seizures (12-48 hours post consumption); Hallucinations; Delirium Tremens (48-96 hours after last drink)
* Anxiety
* Anorexia
* Nausea/Vomiting
* Psychomotor agitation

NOTE: Use the Clinical Institute Withdrawal Assessment(CIWA) to monitor withdrawal

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

CIWA protocol (what does it assess? number scale mild/mod/severe?)

A

Areas assessed – Nausea & vomiting, tremor, paroxysmal sweats, anxiety,
agitation, tactile disturbances, auditory disturbances, visual disturbances,
headaches, orientation
CIWA scoring and what it means.
* < 10= mild;
* 10-15= moderate
* 15+= severe

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

First line txs ETOH use disorder (class, effect, forms, special consideration for OUD)

A

naltrexone (Revia; IM-Vivitrol)

  • Opioid receptor antagonist
  • Can be used for both ETOH and Opioid Use disorders
  • Reduces desire/cravings
  • First line treatment
  • PO or monthly injection (Vivitrol), Implant
  • Will precipitate withdrawal in patients with physical opioid dependence
    *metabolized by the liver

Acamprosate (Campral)

  • Likely modulates glutamate transmission
  • First line treatment in maintaining abstinence after detox
  • Used for relapse prevention (post detoxification)
  • Can be used in liver disease- not metabolized by the liver (not impacted by ETOH use)
  • Can be administered to patients with hepatitis, liver disease and those who continue drinking alcohol
  • Contraindicated in severe renal disease.
  • Decreases craving
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

First line treatment in maintaining abstinence from ETOH after detox (MOA, use, metabolism, contraindication, effect)

A

Acamprosate (Campral)

Likely modulates glutamate transmission
* First line treatment in maintaining abstinence after detox
* Used for relapse prevention (post detoxification)
* Can be used in liver disease- not metabolized by the liver (not impacted by ETOH use)
* Can be administered to patients with hepatitis, liver disease and those who continue drinking alcohol
* Contraindicated in severe renal disease.
* Decreases craving

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Disulfiram(Antabuse)- effect, concurrent ETOH use, what to avoid, contraindications, patient population

A

2nd line tx ETOH use disorder

Blocks enzyme(Aldehyde dehydrogenase) in the liver
*Causes aversion reaction to ETOH(flushing, headaches, n/v, palpitation, SOB, vertigo, hypotension)
**
Do not administer until the person has been alcohol free at least 12 hours
* Educate patients to refrain from using
anything that contains alcohol (vinegar,
aftershave, perfumes, mouthwash, cough medicine) while taking and up to 2 weeks after discontinuation.
* Contraindicated in severe cardiac disease, pregnancy, psychosis
* For highly motivated patients

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

bupropion/Wellbutrin in ETOH use disorder

A

Bupropion increases the risk for withdrawal seizures in ETOH patients

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Tx for ETOH withdrawal

A

Benzos(Lorazepam,
Diazepam, Chlordiazepoxide-
Librium)= To keep patient calm and lightly sedated
MOA: Enhance the effects of GABA

Tegretol, Valproic or Gabapentin= use in mild withdrawal

Thiamine, folic acid and
multivitamin= for nutritional deficiencies

Thiamine (to prevent or
treat Wernicke’s encephalopathy= B1 deficiency) and Folate

Fluid and electrolyte balance

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

leading causes of death in patients with serious mental illness

A

The leading causes of death in patients with serious mental illness are heart disease, cancer, and cerebrovascular or respiratory disease, which can all be linked to smoking

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

tobacco use disorder tx options (3)

A

VARENICLINE(CHANTIX)
* Mimics action of Nicotine
* ***The most effective tobacco cessation
* Reduces rewarding aspects
* Prevents withdrawal symptoms

BUPROPION
(ZYBAN)
* Inhibits reuptake of dopamine and norepinephrine
* Helps reduce craving and withdrawal symptoms

NICOTINE
REPLACEMENT
THERAPY(NRT)
* Available as transdermal patch, gum, lozenge, nasal spray and inhaler
* Nicotine patch- watch for vivid dreams or sleep disruptions

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

WELL KNOWN METHODS TO PROVIDE BRIEF STOP
SMOKING ADVICE

A

5A’s:
1. Ask for the smoking status
2. Brief advice to quit
3. Assess the motivation to quit
4. Assist by providing evidence-based
treatment
5. Arrange Follow-up

ABC method/Ask and Act:
1. Ask
2. Brief advice
3. Cessation support
** Every smoker would receive an offer for treatment regardless of their motivation to treat status**

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Substances r/t sexual dysfunction

A

Overall, substances such as alcohol, Cocaine and opioid use disorder can lead to sexual dysfunction.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

What med is good for insomnia in substance use disorders?

A

Gabapentin has been considered as a treatment for insomnia in patients with substance use disorders - also helps with anxiety ( No sedative effects, not metabolized by the liver, does not lower seizure threshold, no blood monitoring)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

For geriatric pt, if TCA needed, which is safest?

A

If TCA is indicated = consider Nortriptyline(fewer anticholinergic side effects)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

Tx for elderly with MDD and decreased appetite

A

Consider mirtazapine (Remeron) = MDD w/ symptoms of insomnia and decreased appetite

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Med that can be used as adjunct w/ antidepressants in elderly if severe depression and/or psychomotor retardation
Methylphenidate= can be used in low doses as an adjunct to antidepressants for patients with severe depression and/ or psychomotor retardation.
26
Delirium in elderly (what it is, acute/chronic?, subtypes, causes)
* Medical Emergency * Reversible * 40% mortality * Commonly experienced by patients in the ICU and post-op A person with delirium may experience changes in their awareness of where they are. They may seem “out of it,” lethargic or uninterested in their surroundings. They may be confused, anxious, or see or hear things that are not there. Thinking and remembering are impaired, and anxiety, euphoria or fear may occur * Develops over hours to days = Acute * Subtypes: Hyperactive (agitated, restless, hyperalert); Hypoactive(lethargic, slowed, apathetic); Mixed(cycles between hyperactive and hypoactive * Causes: DELIRIUM(Drugs, Electrolyte imbalance, Low oxygen sat, Infection, Reduced sensory input, Intracranial(strokes), Urinary retention, Myocardial)
27
Types of Dementia
* Group of disorders characterized by gradual development of cognitive deficits * Irreversible Types: 1. *Alzheimer's disease (AD)= most common 2. *Vascular disease = 2nd most common 3. *Lewy body disease (LBD) 4. *Frontotemporal degeneration (FTD) 5. HIV infection 6. Huntington disease (HD)
28
Etiology of SUD (neurotransmitter/pathway, etc)
- Positive rewards of reinforcement= mediated by DA pathways - Reinforcement occurs in the Ventral tegmental area (VTA) and the Nucleus accumbens (Reward center) - DA release within the reward center is enhanced = by the release of natural morphine-like neurotransmitters(Neuropeptides- enkaphalins, beta endorphins) - Repeated drug use= DA system becomes increasingly sensitized
29
Acamprosate (Campral)- MAO, indication, contraindication, effect
Likely modulates glutamate transmission * First line treatment in maintaining ETOH abstinence after detox * Used for relapse prevention (post detoxification) * Can be used in liver disease- not metabolized by the liver (not impacted by ETOH use) ****** Can be administered to patients with hepatitis, liver disease and those who continue drinking alcohol * Contraindicated in severe renal disease. ***** Decreases craving
30
When to consider Acamprosate?
after ETOH detox to prevent relapse ?
31
Topiramate(Topamax)- indication, MAO, effect, SEs
2nd line for ETOH use disorder anticonvulsant - Potentiates GABA and inhibits Glutamate - Reduces cravings - For SE remember DOPE-a-max (impaired cognition, nausea, weight loss, metabolic acidosis.
32
withdrawal tx for ETOH use disorder (mild vs mod/severe)
- Benzos(Lorazepam, Diazepam, Chlordiazepoxide-Librium)= To keep patient calm and lightly sedated MOA: Enhance the effects of GABA - Tegretol, Valproic or Gabapentin= use in mild withdrawal - Thiamine, folic acid and multivitamin= for nutritional deficiencies - Parenteral Thiamine (to prevent or treat Wernicke’s encephalopathy= B1 deficiency) and Folate - Fluid and electrolyte balance
33
Banana Bag ingredients/What are we trying to prevent?
thiamine, multivitamin, folic acid, magnesium sulfate in a saline solution to prevent or treat Wernicke’s encephalopathy= B1 deficiency
34
Cocaine withdrawal sx
Post intoxication depression “Crash” - Fatigue - Malaise - Hypersomnolence - Depression - Anhedonia - Hunger - Constricted pupils - Vivid dreams
35
Tx options for cocaine use disorder
NO FDA approved med Off-label= Naltrexone, modafinil, Topamax Supportive care (control HTN, arrhythmias) Mild-moderate agitation= Benzodiazepines Severe agitation or psychosis – antipsychotics
36
amphetamines (intoxication/withdrawal/tx)
- Classic amphetamines vs. Substituted (designer , club drugs, MDMA – ecstasy, MDEA- eve) - Often used in dance clubs and raves - Have both stimulant and hallucinogenic properties - Intoxication is similar to cocaine - Can cause ongoing psychosis - Withdrawal can cause prolonged depression Txt: Rehydrate, correct electrolyte and treat hyperthermia
37
Phencyclidine (PCP) intoxication/tx
Rage Erythema Dilated pupils Delusions Amnesia Nystagmus Excitation Skin dryness Txt: Supportive care (rehydration, electrolyte balance etc.) Benzos for agitation, anxiety, muscle spasms Haldol for severe agitation and psychosis
38
Phencyclidine (PCP) withdrawal
No withdrawal Recurrence of intoxication due to release of the drug from body lipid stores.
39
Sedative hypnotic intoxication
Benzos, barbiturates, Zolpidem, zaleplon, GHB(date rape drug), etc Intoxication: Drowsiness Confusion Hypotension Slurred speech Incoordination Ataxia Mood lability Impaired judgment Respiratory depression or death in OD
40
Biggest risk of sedative hypnotic withdrawal
Abrupt abstinence after chronic use can be life-threatening/seizures
41
Sedative hypnotic intox. tx
Intoxication Treatment: Maintain airway, breathing and circulation Supportive care (improve respiratory status, control hypotension) Activated charcoal and gastric lavage to prevent further GI absorption= in Overdoses ***Benzos= Flumazenil in OD (Benzo antagonist)
42
Sedative hypnotic withdrawal tx
Withdrawal Treatment: Benzodiazepines (stabilize patient and taper gradually) Carbamazepine or valproic acid (taper not as beneficial)
43
Marijuana (cannabis, pot, weed, grass) benefits and intoxication
Contains THC(tetrahydrocannabinol) which produces the “high” Benefits: N/V; increasing appetite in AIDS patients, chronic pain from cancer and lowering intraocular pressure in glaucoma Intoxication: Euphoria, anxiety, impaired motor coordination, mild tachycardia, Conjunctival injection “red eyes”, dry mouth, Munchies= increased appetite Cannabis induced Psychotic d/o= paranoia, hallucinations and delusions
44
Marijuana (cannabis, pot, weed, grass) withdrawal/tx
Withdrawal: Irritability, anxiety, restlessness, aggression, strange dreams, depression, headaches, insomnia, low appetite Supportive care Based on symptoms
45
Nicotine effect and withdrawal
Effects: Restlessness Insomnia Anxiety Increased GI motility Withdrawal: Intense craving Dysphoria Anxiety Poor concentration Increased appetite Weight gain Irritability Restlessness Insomnia
46
Opioids effect on body
Opioid medications/drugs stimulate mu, kappa and delta opiate receptors Effects on the dopaminergic system which mediates their addictive and rewarding properties
47
Opioid agonist therapy effect on mortality
Opioid Agonists (Buprenorphine/Methadone) Decreased mortality d/t overdose
48
Opioid antagonists and considerations with substance use
Opioid Antagonists (Naltrexone) Precipitates withdrawal in patients actively using opioids Need to successfully complete opioid withdrawal prior to treatment (at least 7 days w/o opioids)
49
buprenorphine vs methadone
Buprenorphine Preferred as initial treatment Lower risk of death in overdose – lower potential of causing respiratory depression. Providers can prescribe this in outpatient settings – no waiver required. Fewer drug-drug interactions. Methadone For individuals with high tolerance Appropriate for patients with higher level o f physical dependance or prior misuse/diversion of buprenorphine Requires daily visits to a licensed opioid treatment program (OTP)
50
What med for OUD w/ comorbid pain
Suboxone can be used in managing pain
51
What can happen if buprenorphine started too soon after last opioid use
If buprenorphine is used too soon after a patient’s last opioid use, Buprenorphine will displace any residual opioids from the μ receptors and can precipitate withdrawal symptoms
52
Hallucinogen intoxication sx/tx
Illusions Hallucinations Body image distortions Labile affect Dilated pupils Tachycardia HTN Hyperthermia Tremors Incoordination Sweating Palpitations Txt: May use Benzos and antipsychotic medications for agitation
53
Hallucinogen withdrawal
Does not cause physical dependence or withdrawal
54
Inhalant (what are they?) & intoxication sx/tx
Inhalants generally act as CNS depressants Most common in preadolescents or adolescents E.g. solvents, glue, paint thinners, fuels, isobutyl nitrates (“huffing” “laughing gas” “rush”) Intoxication Perceptual disturbances Paranoia Lethargy Dizziness Nausea/vomiting Headache Nystagmus Tremor Muscle weakness Ataxia Slurred speech Euphoria Clouding of consciousness Stupor or coma Txt: Airway monitoring; Chelation depending on solvent
55
Inhalant withdrawal & tx
Does not usually occur Irritability Sleep disturbance Anxiety Depression Nausea/vomiting Craving No specific tx (I guess tx sx/emergencies?)
56
Inhalant and other Psychoactive Substance Use disorders
Loss of ability to control the use of inhalants Compulsivity to use inhalants Negative emotional state when not sniffing/breathing inhalants Common among teenagers E.g., volatile solvents, aerosols, gases, nitrites Methods: Sniffing, spraying into nostrils or mouth, bagging, huffing- breathing in from rag soaked with the chemical; inhalation from balloons
57
Clinical presentation inhalant/psychoactive use disorder
Ataxia Smell of chemicals on body or clothing Sores and scabs around nose and mouth (Glue Sniffer’s rash) Slurred speech Drowsiness Headaches
58
Emergency effects inhalant/psychoactive use disorder
Agitation Fever Seizures Hallucinations Confusion Loss of consciousness Coma Fatal accidental injury
59
treatment/management inhalant/psychoactive use disorder
Treat presenting symptoms Benzodiazepines for managing withdrawal and emergency symptoms (e.g., Valium, Lorazepam.
60
Caffeine use disorder/ intoxication & tx
Caffeine is Most used psychoactive substance in the United States Coffee, tea or energy drinks Intoxication Anxiety Insomnia Muscle twitching Rambling speech Flushed face GI disturbance Restlessness Excitement Tachycardia More than 1g= tinnitus, severe agitation, cardiac arrhythmias More than 10g = Death can occur secondary to seizures and respiratory failure Txt: Supportive and symptomatic
61
Caffeine withdrawal
Occurs if cessation is abrupt Headache Fatigue Irritability Nausea Vomiting Drowsiness Muscle pain Depression
62
Geriatric considerations w/ SUD
When assessing and treating older adults, clinicians not only need to take the above factors into account but also need to consider the potential interaction between alcohol and both prescribed and over-the-counter medications, especially psychoactive medications such as benzodiazepines, barbiturates, and antidepressants. The Alcohol Use Disorders Identification Test (AUDIT) and the CAGE often a`re used to screen for at-risk substance use or misuse among older adults Alcohol problems are common among older adults. The use of pharmaceutical drugs is prevalent in older adulthood, and the risk of misusing prescription and over-the-counter medications, which include substances such as sedatives/hypnotics, narcotic and nonnarcotic analgesics, diet aids, and decongestants, also increases with age. Incidentally, benzodiazepines also tend to be one of the most inappropriately prescribed psychotherapeutic medications among older adults
63
Screening tool for alcohol use disorder in geriatric population
The Alcohol Use Disorders Identification Test (AUDIT) and the CAGE often are used to screen for at-risk substance use or misuse among older adults
64
Tx considerations in geriatric population
Clinicians should be cautious when prescribing or recommending a treatment, take both risks and benefits into account when determining a treatment plan, and clearly communicate guidelines for appropriate use to patients. Clinicians also should carefully consider discontinuing medications that do not prove effective Illicit drug use among older adults is rare. Thus, rates of illicit substance use and abuse among older adults will likely continue to rise in the next several decades because of the aging of the baby boom cohort. When assessing and treating older adults, clinicians not only need to take the above factors into account but also need to consider the ******potential interaction between alcohol and both prescribed and over-the-counter medications, especially psychoactive medications such as benzodiazepines, barbiturates, and antidepressants.******
65
Alcohol, Cocaine and opioid use disorder can lead to sexual dysfunction T/F
true
66
Withdrawal seizures are commonly associated with which substances?
Bzo's, etoh
67
If a TCA is indicated in geriatric patient, what TCA & why?
consider Nortriptyline(fewer anticholinergic side effects)
68
Med for geriatric pt with MDD + sx insomnia and/or decreased appetite
mirtazapine/Remeron
69
methylphenidate use in geriatric population
can be used in low doses as an adjunct to antidepressants for patients with severe depression and/ or psychomotor retardation
70
Delirium in elderly tx
Txt: Symptom treatment 1:1 sitter Agitation and Psychotic symptoms * Haldol (PO, IM, IV); Atypical antipsychotics
71
Timeframe of development of delirium in elderly
Develops over hours to days = Acute
72
Subtypes of delirium in elderly
Hyperactive (agitated, restless, hyperalert); Hypoactive(lethargic, slowed, apathetic); Mixed(cycles between hyperactive and hypoactive
73
Causes of delirium in elderly (pneumonic)
DELIRIUM: Drugs Electrolyte imbalance Low oxygen sat Infection Reduced sensory input Intracranial(strokes) Urinary retention Myocardial)
74
Dementia vs delirium
dementia = irreversible,chronic, gradual onset delirium = reversible, fast onset, acute
75
Alzheimer's disease characteristics (3 A’s)
- Gradual progressive decline - Most common type - Affects memory, learning and language - Aphasia (difficulty with speech) - Apraxia (inability to perform previously learned tasks - Agnosia (inability to recognize an object)
76
Alzheimer's disease etiology & tx
Etiology: Accumulation of beta-amyloid plaques and intraneuronal tau protein tangles Txt: Cholinesterase inhibitors NMDA receptor antagonists
77
Vascular disease dementia (cause & risk factors)
2nd most common * Cognitive decline secondary to large vessel strokes * Risk factors: HTN, DM, Smoking, obesity, HLD, A-fib, Age
78
Lewy Body Disease (LBD) characteristics
Characterized by waxing and waning cognition * Visual hallucinations (well formed images of animals and small people) * Develop EPS (Parkinsonism) @ least 1 year after cognitive decline
79
Lewy Body Disease etiology & tx
Etiology: Lewy bodies and Lewy neurites in brain (primarily basal ganglia) Txt: Cholinesterase inhibitors - Seroquel and Clozaril (low doses/short termfor agitation) - Levodopa/Carbidopa (parkinsonism sx) - Melatonin and/or Clonazepam (REM sleep disorder)
80
Kluver-Bucy Syndrome
hypersexual, hyperorality seen in Frontotemporal Degeneration (FTD)
81
What med to tx agitation in Lewy body disease & what risk should you consider
tx can be Seroquel and Clozaril (low doses/short term) There is potential for severe sensitivity reactions, including exacerbation of parkinsonism, confusion, or autonomic dysfunction, which limits the usefulness of antipsychotic medications in these patients = Sensitive to antipsychotics
82
Frontotemporal Degeneration (FTD)- presentation & tx
40% familial Individuals with frontotemporal dementia usually present before age 65, and have behavior symptoms early on, with relative sparing of memory. Symptoms include personality changes, impaired judgement, apathy, and disinhibition * Atrophy of the frontal and temporal lobes Personality/Behavioral: * Disinhibition (verbal, physical sexual) Language: * Difficulty with speech and comprehension Kluver-Bucy Syndrome: hypersexual, hyperorality Txt: * Symptom focus * SSRI to help with disinhibition *atypical antipsychotics can be used for psychosis.
83
List of Cholinesterase Inhibitors
Treat dementia Donepezil (Aricept), Rivastigmine (Exelon), Galantimine (Razadyne)
84
Donepezil (Aricept)- class, indication, SE, benefit, SE that warrants d/c
Cholinesterase Inhibitor Slows clinical deterioration by 6-12 months - Once daily dosing * **** For mild-moderate NCD (is approved for ALL stages including severe) **** - Not effective in severe, end-stage disease ****** Should STOP if side effects of nausea/vomiting develop ***** S/E: diarrhea, weight loss, abnormal dreams, insomnia, dizziness
85
Galantimine (Razadyne)
Cholinesterase Inhibitor * Twice daily dosing * GI side effects * For mild –moderate NCD
86
Rivastigmine (Exelon)
Cholinesterase Inhibitor - Twice daily dosing * For mild-moderate AD & Parkinson’s disease dementia **** Transdermal patch available – daily form with fewer side effects**** * For Mild to moderate NCD *****Highest GI side effects******
87
Tx mood sx in dementia
SSRIs
88
Tx Aggression/Agitation/Psychosis in dementia
Consider atypical antipsychotics (Zyprexa, Seroquel, Risperdal, Haldol) *****Note: Reserve Benzos for short term and acute episodes*****
89
Memantine(Namenda)
NMDA receptor antagonist ***** Moderate – severe dementia * Fewer side effects as compared to the Cholinesterase inhibitors ****** Promotes synaptic plasticity * May be used in conjunction with cholinesterase inhibitors e.g. Namzric (Mamantine/Donepezil) **May cause hallucinations
90
Anticholinergic SE in elderly
blurred vision, dry eyes dry mouth constipation skin flushing, unable to sweat, overheating drowsiness, dizziness, confusion, hallucinations rapid HR urinary retention
91
Intellectual Disability Disorder (IDD)- what is it/effect, causes, management, caution
Impaired cognitive and adaptive/social functioning. * Deficits in intellectual functioning (i.e. reasoning, problem solving, planning, abstract thinking, judgement and learning) * Deficits in adaptive functioning i.e. communication, social participation and independent living. * Severity is mild, moderate, severe and profound Causes: Genetic (Down syndrome); Prenatal (rubella, herpes simplex etc.) Perinatal (Anoxia, prematurity, birth trauma) and Postnatal (malnutrition, toxin exposure, trauma) Management: Behavioral Therapy ****Caution with patients with IDD as they may not be able to self-report drug-related problems.
92
ADHD first line tx/MOA
* The first-line pharmacological tx are stimulants which help to increase DA in PFC * These also, notably, can increase DA in the nucleus accumbens and reward circuitry * Treatment: Multimodal(i.e., Medications + educational and behavioral interventions) * 1st line med: Stimulants (methylphenidate compounds, dextroamphetamine, mixed amphetamine salts)= Ritalin, Concerta, Adderall (Scchedule II) ***MOA: Increase DA in the prefrontal cortex, nucleus accumbens and reward circuitry
93
Monitoring/concern w/ stimulants especially in children
* ****Monitor Height, weight, BP, CBC w/ diff; Pulse quarterly (Height and weight d/t risk of growth restriction)*** * In healthy individuals, it is not necessary to obtain an EKG prior to initiating a stimulant * Prescription Monitoring Program should be checked * Note: With stimulants, evidence of growth suppression is not clear, seems transient and resolves in mid-adolescence * Note: If a child is taking their medication twice daily (i.e. at home and school) and parents request to solely administer the medication= consider switching to an extended release form (e.g. Methylphenidate CD= extended release)
94
2nd line ADHD in children
2nd line: Alpha-2 agonists (Clonidine, guanfacine)
95
When to consider non stimulant in ADHD
Atomoxetine (Strattera); Bupropion (Wellbutrin) ; Alpha 2 adrenergic agonist (Clonidine, Guanfacine) * Stimulants are not working well to control ADHD symptoms * Stimulants cause too many side effects (often intolerable) – e.g. anxiety * The child or teen has problems with substance abuse * The child or teen has a medical condition for which stimulants cannot be used - e.g. tic disorder * Adjunctive therapy for stimulants.
96
Autism
* Characterized by impairments in social communication/interaction and restrictive, repetitive behaviors/interests * 4:1 ration (male/female) * Recognized ages 12-24 months
97
Tx approach to autism
* Early intervention, behavioral therapy, psychoeducation * Alpha-2 agonists (clonidine, guanfacine) and low dose atypical antipsychotics (Risperidone, Abilify)= to help reduce disruptive behaviors, aggression and irritability * Melatonin for sleep, * Remeron for sleep, anxiety
98
Risperidone for autism (indication/age)
Indication: Autism associated irritability, aggression, temper tantrums, self-injurious behaviors, mood lability Age range: Children 5+ and Adolescents less than 18 (weight based)
99
aripiprazole for autism (indication/age)
Indication: Autism associated irritability, aggression, temper tantrums, self-injurious behaviors, mood lability Age range: Children and Adolescents 6- 17 years old
100
What antidepressants cause sexual SE and what are they
Most of the antidepressants EXCEPT Bupropion (Wellbutrin) & Mirtazapine (Remeron) cause sexual problems * Desire (libido) * Frequency of sexual activity * Arousal (lubrication in females and erectile function in males) * Orgasm (delayed orgasm and anorgasmia)
101
How to manage sexual SE from antidepressants
Watchful waiting; if sexual impairment persists: * Decrease the dose of the SSRI within the therapeutic range. * Switch to Bupropion (Wellbutrin) * phosphodiesterase-5 inhibitor (ie sildenafil and tadalafil) cause the blood vessels to relax.
102
If a woman with a distressing sexual problem greatly desires a pharmacologic intervention, after non pharmacologic treatments have been tried, what med is first line
bupropion
103
premature ejaculation- what is it? Tx?
* Recurrent pattern of ejaculation during sex within 1 minute and before individual wishes it Treatment: * Prolong time from SSRI and TCAs stimulation to orgasm * *****(e.g. Clomipramine- 15mg – 30 mg – take 2 hours before intercourse is effective and a safe treatment , Fluoxetine, Paroxetine)
104
Phosphodieterase-5 inhibitors (PDE-5)- ex, what to avoid, caution w/ what med class?
Sildenafil (Viagra)- take 30 min to 4hours before sexual activity Tadalafil (Cialis)- take 30-60 min before sexual activity Note: Avoid concomitant use w/ nitrates (e.g. nitroglycerine, isosorbide dinitrate, amyl nitrate "poppers”) - can cause an unsafe drop in blood pressure Caution with patients taking alpha-adrenergic blockers
105
Cluster A personality disorders
❖ Familial association with psychotic disorders ❖ Patient seem eccentric, peculiar or withdrawn * Schizoid * Schizotypal * Paranoid
106
Cluster B personality disorders
❖ Familial association with mood disorders ❖ Patients seem emotional, dramatic or inconsistent * Antisocial * Borderline * Histrionic * Narcissistic
107
Cluster C personality disorders
❖ Familial association with anxiety disorders. ❖ Patients seem anxious or fearful * Avoidant * Dependent * Obsessive-compulsive
108
General tx personality disorders
Personality disorders are generally very difficult to treat especially since few patients will acknowledge they need help These disorders tend to be chronic and lifelong Pharmacologic treatments have limited usefulness except when treating co-morbid mental conditions (e.g. MDD)
109
Borderline personality disorder (BPD)
* Fear of abandonment * Aggression * Impulsive * Repeated SI attempts/gestures/self-mutilation * “Splitting” * Txt: *****Gold standard=Dialectical behavior therapy(DBT) * Pharmacotherapy as adjunct to psychotherapy. * . Mood stabilizers and low dose antipsychotic meds have been found to be effective for mood swings and lability * Avoid the use of Benzodiazepines
110
Antisocial personality disorder
* Failure to conform to social norms * Deceitful, manipulative for personal gain * Reckless, irritable * Lack remorse * ***NOTE: Begins as conduct disorder in childhood * Txt: * Psychotherapy is ineffective * Treat symptoms of anxiety, depression or aggression but with caution d/t high comorbidity with substance use disorders.
111
General tx guidelines personality disorders
* First-line treatment for personality disorders is psychotherapy. * Symptom-focused, medication treatment of personality disorders is generally considered to be an adjunct to psychotherapy. * Avoid prescribing medications that can be fatal in overdose, such as tricyclic antidepressants. * Avoid prescribing medications that can induce physiological dependence and tolerance, including benzodiazepines. * Avoid changing medication each time there is a crisis or change in mood symptoms, which may occur frequently and suddenly, and also remit suddenly in some people with personality disorders. * Symptom expression in patients with personality disorders often waxes and wanes in relationship to life circumstances.
112
Targeted sx domains in personality disorders & what meds for what sx/how dosed
* Cognitive and perceptual disturbances * Impulsivity or behavioral dyscontrol * Affective dysregulation Antidepressants and mood stabilizers are dosed as they would be for major depressive disorder and bipolar disorder (e.g. Lithium, Lamictal) Antipsychotics are in general used at a lower dosing range compared with doses used in the treatment of schizophrenia (e.g. Abilify, Risperdal, Seroquel)
113
Role of basal ganglia & what type of dementia primarily occurs here
The “basal ganglia” refers to a group of subcortical nuclei responsible primarily for motor control, as well as other roles such as motor learning, executive functions and behaviors, and emotions. Lewy body dementia
114
Oppositional defiant disorder description/general tx
Enduring pattern of anger or irritable mood, argumentative, defiant or vindictive behavior Common in males TX Target symptoms= mood and aggression Treat comorbid conditions (such as ADHD) Behavior modification
115
Conduct disorder description/general tx
Violates the rights of other humans and animals Inflicts cruelty and harm through physical and sexual violence May lack remorse TX Behavioral modification, family and community Meds used to target comorbid symptoms and aggression (SSRIs, guanfacine, propranolol, mood stabilizers, antipsychotics)
116
Autism spectrum disorder description & tx
Characterized by impairments in social communication/interaction and restrictive, repetitive behaviors/interests 4:1 ration (male/female) Recognized ages 12-24 months Early intervention, behavioral therapy, psychoeducation Alpha-2 agonists (clonidine, guanfacine) and low dose atypical antipsychotics (***Risperidone, Abilify***)= to help reduce disruptive behaviors, aggression and irritability Melatonin for sleep, Remeron for sleep, anxiety
117
Tic disorder (Tourette's) description/tx
Sudden, rapid, repetitive, stereotyped movements or vocalizations Anxiety, excitement and fatigue are aggravating factor for tics Tourette’s disorder: most severe characterized by multiple motor tics (face, head, eye blinking, throat clearing) an at least one vocal tic lasting for at least 1 year - Vocal tics( Copralalia/Echolalia) Behavioral interventions Consider meds if tics become severely impairing. *****1st choice: Guanfacine (alpha-2 agonist)**** Clonidine (more sedating) Severe cases, consider atypical (e.g. risperidone)
118
What is one of the biggest things to monitor w/ antipsychotic tx for ASD
sedation r/t risperidone or aripiprazole *also metabolic SE
119
Youngest age for risperidone & aripiprazole rx in children for ASD
risperidone= Children 5+ and Adolescents less than 18 (weight based) aripiprazole= Children and Adolescents 6-17 years old
120
Enuresis tx
*Recurrent urination into clothes or bed wetting Treatment: Psychoeducation, behavioral program ***1st line: Desmopressin (DDAVP) an antidiuretic *** ***2nd line: Imipramine (TCA) at low doses ***
121
Encopresis tx
*Recurrent defecation into inappropriate places (e.g. clothes, floor) *Treatment: Psychoeducation, bowel retraining
122
Intellectual disability disorder (IDD) - sx, cause, tx
Impaired cognitive and adaptive/social functioning. Deficits in intellectual functioning (i.e. reasoning, problem solving, planning, abstract thinking, judgement and learning) Deficits in adaptive functioning i.e. communication, social participation and independent living. Severity is mild, moderate, severe and profound Causes: Genetic (Down syndrome); Prenatal (rubella, herpes simplex etc.) Perinatal (Anoxia, prematurity, birth trauma) and Postnatal (malnutrition, toxin exposure, trauma) ***Management: Behavioral Therapy***
123
Important caution/consideration in IDD r/t meds
they may not be able to self-report drug-related problems.
124
ADHD presentation & etiology
Characterized by ***inattention, hyperactivity and impulsivity*** inconsistent with the patient’s developmental stage. Males > females Etiology: Abnormalities of fronto-subcortical pathways (i.e. frontal cortex and basal ganglia) Dopamine dysfunction NE dysfunction
125
Does response to stimulant prove dx ADHD
No
126
First line tx ADHD & MAO
Meds & educational/behavioral interventions The first-line pharmacological tx are stimulants (methylphenidate & amphetamine) which help to increase DA in prefrontal cortex MOA: Increase DA, NE, 5HT in the prefrontal cortex, nucleus accumbens and reward circuitry
127
SE stimulants
Side effects: GI upset, anorexia, weight loss, BP changes, ↑ HR, Growth suppression(rare),sleep disturbance, jitteriness, headaches, dizziness, mood lability -irritability, psychosis (rare), social withdrawal
128
2nd line and other tx of ADHD
2nd line: Alpha-2 agonists (Clonidine, guanfacine) Can be used instead or as an adjunctive therapy to stimulants Used in children who respond poorly to other meds, experience side effects or have coexisting conditions such as tics. Atomoxetine (Strattera)- NE reuptake inhibitor (consider when a hx or family hx of illicit substance use is present) Bupropion= Wellbutrin (NDRI)
129
What's important to monitor with stimulant tx
****Monitor Height, weight, BP, CBC w/ diff (risk leukopenia or anemia); Pulse quarterly (Height and weight d/t risk of growth restriction)**** In healthy individuals, it is NOT necessary to obtain an EKG prior to initiating a stimulant Prescription Monitoring Program should be checked
130
Contraindication to stimulants
DO NOT USE WITH PREEXISTING CARDIAC CONDITIONS & SYMPTOMS Symptomatic cardiovascular disease Moderate to severe hypertension Hyperthyroidism Known hypersensitivity or idiosyncrasy to sympathomimetic amines Motor tics or Tourette syndrome Glaucoma Agitated states Anxiety History of drug abuse Concurrent use or use within 14 days of the administration of monoamine oxidase inhibitors
131
Methylphenidate (Ritalin, Concerta)- what schedule, SE, how to help SE
- Schedule II - Watch for Leukopenia or anemia - Common side effects(loss of appetite, headache, stomachaches, nausea, weight loss, insomnia) - Taking AM dose after eating breakfast can also help manage s/e of nausea or decreased appetite Long-acting forms help with convenience and reduce the rebound side effects. Long acting avoids dosing in school
132
Dextromethylphenidate (Dexedrine, Adderall)- schedule, indication, age, SE
Schedule II d/t high potential for abuse/diversion May help reduce adverse effects in those who had good response to methylphenidate, but dosing limited because of adverse effects. Short Acting (Dexedrine, Adderall; Focalin)= 4-6 hours duration Long Acting (Adderall XR, Vyvanse)= 8-12 hours FDA approved for children 3+ Side effect: Loss of appetite, headaches, ↑BP; stomachaches, nausea, weight loss, insomnia, anticholinergic, tics/repetitive movements, psychosis
133
How to choose stimulant for ADHD
Choice often driven by insurance formularies: general rule of thumb is to pick either a methylphenidate or an amphetamine formulation and then switch if not responding after titration to reasonable dose
134
When to consider non stimulant meds for ADHD
Stimulants are not working well to control ADHD symptoms Stimulants cause too many side effects The child or teen has problems with substance abuse The child or teen has a medical condition for which stimulants cannot be used - e.g. tic disorder
135
Growth suppression & stimulants
With stimulants, evidence of growth suppression is not clear, seems transient and resolves in mid-adolescence
136
atomoxetine (Strattera)- black box, class, age, indication
**Black box warning for SI thinking in children/adolescents A Selective Norepinephrine Reuptake Inhibitor FDA approved in children 6+ Not classified as a controlled substance (less abuse potential) Alternative to stimulants for children and adolescents who have a substance abuse problem, household member with substance abuse problem, tics or severe side effects from stimulants. Less effective Rare liver toxicity
137
Alpha 2 adrenergic agonists for ADHD (when each indicated; how long until effective; how to d/c them/why)
can be used alone or as adjunctive txt. Clonidine = helps with over aroused, easily frustrated, highly active, aggressive impulsivity and hyperactivity ; Monitor BP Guanfacine (Tenex/Intuniv- Long acting): Rarely but can cause low BP and cardiac arrhythmias. FDA approved for children 6-17years Can take up to 2 weeks to see clinical response Often used if stimulant not effective enough or not tolerated Tends to best target sx of children/adolescents including hyperarousal, hyperactivity, aggression, low frustration tolerance No tics reported Must be tapered to avoid rebound hypertension
138
Qelbree (viloxazine)
Relatively new (approval 2021) for ADHD Approved for children ages 10+ Non-stimulant Norepinephrine reuptake inhibitor Common s/e: nausea, decreased appetite, insomnia, GI upset, diarrhea/constipation, tremor, dizziness, orthostatic hypotension Rare but serious suicidal thoughts/behaviors, seizure
139
First line tx for personality disorders
psychotherapy
140
What does antisocial personality disorder start as in childhood**
conduct disorder
141
Gold standard tx BPD
**dialectical behavior therapy Pharmacotherapy as adjunct to psychotherapy. Mood stabilizers and low dose antipsychotic meds have been found to be effective for mood swings and lability.
142
Should BZO be used in personality disorders
NO Avoid meds that can lead to dependence/tolerance or fatal in OD like TCAs
143
Dopamine & serotonin impact on sexual function
Dopamine enhances libido Serotonin inhibits sexual function
144
Sildenafil (Viagra) tx, SE
erectile disorder/dysfunction/impotence= Difficulty obtaining or maintaining an erection Most common sexual dysfunction in men *Phosphodieterase-5 inhibitor (PDE-5) *Enhances blood flow to the penis S/E: headaches, flushing, dizziness, hypotension **May cause prolonged erection and priapism**
145
TX premature ejaculation
Prolong time from SSRI and TCAs stimulation to orgasm (e.g. Clomipramine, Fluoxetine, Paroxetine)
146
* When to use benzos in pt w/ dementia
Reserve Benzos for short term and acute episodes
147
Black box warning antipsychotics in pts w/ dementia
Black box warning for antipsychotic use in dementia patients= ↑ risk of death = low doses for short periods if necessary ( consider Zyprexa, Seroquel, Risperdal) ESPECIALLY in Lewy Body dementia
148
Leqembi
new treatment for mild cognitive impairment (MCI) Anti-Amyloid Monoclonal Antibody; Immune Globulin; Monoclonal Antibody; targets harmful amyloid proteins; reducing existing amyloid brain plaque. SE: Amyloid Related Imaging Abnormalities or “ARIA”, HA, confusion, dizziness, vision change, nausea, difficulty walking, seizures
149
Normal aging in geriatric patients impacting med choices
- Decreased brain weight/enlarged ventricles - Decreased muscle mass/increased fat - Impaired vision and hearing - Decreased renal function - Decreased ability of liver to metabolize drugs ***Decreased protein levels = more free meds in the body= risk for toxicity ***
150
Safer option for sedative hypnotic in elderly
trazodone
151
What "criteria" used for inappropriate prescribing in elderly
BEERS criteria
152
Side effect of benztropine/Cogentin use in the elderly
Anticholinergic (dry mouth, confusion, blurred vision, urinary retention, constipation etc.)
153
Sx & age of onset frontotemporal dementia
Individuals with frontotemporal dementia usually present before age 65, and have behavior symptoms early on, with relative sparing of memory. Symptoms include personality changes, impaired judgement, apathy, and disinhibition
154
Difference between Lewy body dementia & parkinsons demetia
both irreversible, the main difference between the two is the sequence of events In Parkinson’s disease, the symptoms of parkinsonism usually come first followed by dementia. On the other hand, in Lewy body dementia, dementia comes first, followed by parkinsonism and individuals are “dopamine-sensitive”, meaning it can cause them to hallucinate, become agitated, and be confused.
155
How to mitigate GI SE of rivastigmine (cholinesterase inhibitor)
** Transdermal patch available – daily form with fewer side effects****
156
Only cholinesterase inhibitor approved for all stages of dementia (mild-severe)
Donepezil
157
Disulfiram MOA
It acts by inhibiting aldehyde dehydrogenase (ALDH), leading to high blood levels of acetaldehyde. (causing aversion rxn)
158
To administer Disulfiram, a patient must be alcohol free for at least..... hours
AT LEAST 12 hrs but preferably 24h & can cause aversion reaction for 2 weeks
159
S/S of aversion reaction associated with Disulfiram
flushing, headaches, n/v, palpitation, SOB, vertigo, hypotension
160
Marketed as Zyban and helps reduce tobacco related craving and withdrawal symptoms
bupropion SR
161
Various medications available for Opioid withdrawal s/s * Muscle spasms =__________ * Anxiety and agitation =____________________ * Diarrhea =_____________ * Abdominal cramps =________________ * Nausea =___________ * Insomnia =________ * autonomic ssx
* Muscle spasms = baclofen * Anxiety and agitation = benzo * Diarrhea = Loperamide * Abdominal cramps =dicyclomine * Nausea = promethazine * Insomnia = sedative hypnotics (trazodone, quetiapine, Benadryl) * autonomic ssx= clonidine
162
Most used psychoactive substance in the United States
Caffeine
163
Target symptoms when medications are used in conduct disorder
Meds used to target comorbid symptoms and aggression (SSRIs, guanfacine, propranolol, mood stabilizers, antipsychotics)
164
ADHD symptoms result from a dysfunction of ____________ and ___________
DA & NE
165
This medication commonly prescribed to ADHD has a Blackbox warning for SI in children and adolescents =
atomoxetine
166
Psychopharmacologic management of delirium
antipsychotics haldol has least anticholinergic SE
167
Cholinesterase inhibitors work by reversible inhibition of
acetylcholinesterase, the enzyme that breaks down acetylcholine, thereby increasing the duration of action of acetylcholine
168
Common side effects of Cholinesterase inhibitors
*GI symptoms of overstimulation of the parasympathetic nervous system, such as increased hypermotility, hypersecretion, bradycardia, miosis, diarrhea, and hypotension
169
This criteria has a list of medications considered potentially inappropriate for use in older patients mostly due to high risk for adverse events
Beers
170
Neurotransmitters most commonly associated w/ dementia
decreased NE and acetylcholine