treatment of schizophrenia (329 E1) Flashcards
goals for treatment
-safety in all settings
-physical care
-stabilization on meds
-education to pt & fam
-psychosocial support
failure of pt to take prescribed meds can lead to
-risk of relapse
-risk of suicide or self harm
-risk of violence toward others
-increased mortality rates
-potential for hospital readmission
-decline in quality of life
-social and occupational difficulty
antipsychotic medications are used to treat
schizophrenia
takes 2 to 6 weeks for meds to become effective
antipsychotics
- work better on positive symptoms
- typical have less side effects
- do not have risk for overdose
- are not addictive
what type of medication is best for adherence
long term injectable
common side effects of antipsychotic medications
-extrapyramidal SE
-anticholinergic SE
-neuroleptic malignant syndrome
-metabolic syndrome
extrapyramidal SE (EPS)
-acute dystonic reactions
-akathisia
-pseudoparkinsonism
~the above start w/n a few weeks of starting new med or w/ inc dose
-tardive dyskinesia
worst SE of typical antipsychotics, leads to lack of adherence
first gen typical antipsychotics
-chlorpromazine
-haloperidol
-fluphenazine
-thioridazine
-perphenazine
typical antipsychotics typically treat
the positive symptoms of schizophrenia & little effect on negative symptoms
used less than atypical d/t lack of effect on negative sx
advantages of typical antipsychotics
less expensive than atypical antipsychotics
disadvantages of typical antipsychotics
-EPS
-anticholinergic
-sedation, wt gain, metabolic syndrome, neuroleptic malignant syndrome, sexual dysfunction, endocrine disturbances, cardiovascular issues
-increased risk of seizures
EPS: acute dystonic reactions
-a sudden, sustained contraction of one or several muscle groups, usually of the head & neck areas
-can be painful, frightening & uncomfy (inc anixety)
-not dangerous unless they involve muscles affecting the airway
-an emergency
acute dystonic reactions: torticollis
spasmodic and painful spasm of muscles (head pulled to one side)
acute dystonic reactions: oculogyric crisis
eyes roll back toward the head
acute dystonic reactions: laryngeal dystonia
spasm of throat impairing breathing and swallowing
EPS: akathisia
-motor restlessness manifested as excessive pacing, inability to remain still for any length of time, rocking while seated or shifting from one foot to the other while standing
-can be severe and distressing and can be mistaken for anxiety or agitation (dx correctly bc admin of more of the med will make it worse)
-should go away w/ treatment but can persist despite treatment
Akathisia treatment
-a dose reduction or change in medication
-give anticholinergic agent such as benztropine
-provider may add meds such a propranolol, lorazepam or diazepam (short term use only)
-relaxation exercises
Pseudoparkinsonism
temporary sx that resemble parkinson’s
-stiff & stooped posture
-shuffling gait
-bradykinesia
-pill rolling
-treumulousness
-dysphagia
Pseudoparkinsonism treatments
-ID of the med and slow / safe discontinuation
-dosage reduction
-addition of oral anticholinergic agents such as benztropine or trihexyphenidyl to alleviate sx
EPS: tardive dyskinesia
-involuntary rhythmic movement disorder that can occur w/ long term antipsychotic treatment; varies from mild to severe
-usually involves the oral and facial muscles and progresses to include the fingers, toes, neck, trunk or pelvis (tongue protruding)
-changes may be very slow or gradual and dx can be missed
treatment for tardive dyskinesia
-reduce or discontinue antipsychotic med (sx will continue)
-switch to 2nd gen med
-give med to help with sx if cannot change med (valbenazine or deutetrabenazine)
anticholinergic SE
-dry mouth, blurred vision, dry eyes, constipation, urinary retention/hesitancy, drowsiness, dizziness, confusion, hallucinations, tachycardia, skin flushing
neuroleptic Malignant Syndrome (NMS)
-rare
-usually associated w/ antipsychotics
-early detection increases pt’s chance of survival
NMS S/s
-severe muscle rigidity
-altered mental status
-inc body temp over 103
-htn
-tachycardia
-tachypnea
-diaphoresis
-incontinence
progressive S/s of NMS
-rhado / protein in the blood causing organ failure
-acute resp failure (strongest predictor of mortality)
-acute kidney injury
-sepsis
treatment of NMS
-prompt detection
-immediately stop all antipsychotics
-supportive treatment of sx
-ICU
-meds to treat: dantrolene sodium, bromocriptine mesylate, lorazepam
2nd generation atypical antipsychotics
-clozapine
-riseridone
-olanzapine
-questiapine
-ziprasidone
third generation atypical antipsychotic overview
(subset of 2nd gen)
-dopamine system stabilizers
-may improve positive & negative sx + cognitive functions
-little risk of EPS or tardive dyskinesia
third gen drugs
-aripiprazole
-brexpiprazole
-cariprazine
2nd generation overview
-treat both positive and negative sx
-less likely to cause TD or EPS
-less antipsychotics classic side effects
disadvantages of 2nd gen
-tendency to cause significant wt gain
-risk of metabolic syndrome
-expensive
atypical antipsychotics SE
-sedation
-major wt gain leading to metabolic/endocrine problems
-potential for cardiac dysrhythmias / sudden cardiac death
-sexual dysfunction
-less likely for anti chol SE, orthostatic hypotension, seizures & EPS
if pt is at risk for metabolic syndrome
-monitor wt & girth
-initial glucose tolerance test
-monitor blood glucose
-provide nutrition & activity support
-consider lifestyle
clozapine
-has been effective in treating refractory schizophrenia that doesn’t respond to normal treatment has to have failed success w/ other meds
-results in decreased negative symptoms, inc impulse control, reduced violence to self and others & improved quality of life
clozapine SE
potentially fatal SE of agranulocytosis
agranulocytosis
-a reduction in the number of circulating granulocytes and decreased production of granulocytes that limit one’s ability to fight off infection
-life threatening condition
-particularly risky w/ clozapine; greater risk during first months of treatment
-WBCs drops to dangerous levels
-monitor WBC weekly for first 18 wks of treatment and then based on provider thereafter
agranulocytosis
-discontinue medicine if pt develops leucopenia or neutropenia
-reversible if treated early
long acting injectable medications
-pts that are at risk non adherence to prescribed treatments may take medication that is available in injectable form
-long acting and require administration only once every 2 to 4 wks or even up to months
-must have transportation to receive the injection
long acting drugs
haloperidol decanoate
risperidone microspheres
aripiprazole
additional treatment approaches from meds
-ECT
-cognitive behavioral therapy
-group therapy
-family therapy
-social skills training
-case mgt
-support groups
prognostic consideration of schizophrenia
-meds improve sx
-good quality of life
-some do not fully response to treatment leaving mild to severe residual sx & varying degree of disability
-few require repeated or lengthy inpatient care
factors contributing to repeated or lengthy inpatient care
-slow onset of the disease
-younger age at onset
-longer duration between first sx and first treatment
-longer periods of untreated illness
-more negative sx
