Classification of Epilepsy (p. 227) Partial-onset seizures Simple (formerly known as petit mal seizures) Complex Secondary generalized tonic-clonic Generalized-onset seizures Formerly known as grand mal seizures Unclassified seizures Status epilepticus More than 50% of epilepsy cases are primary, meaning the cause cannot be determined. NURSING APPLICATION: Would the nurse expect Ms. Jackson to have a seizure? Why or why not? Copyright © 2011 by Elsevier Inc. All rights reserved.

Antiepileptic Drugs (AEDs) (p. 228) Also known as anticonvulsants Goals of therapy To control or prevent seizures while maintaining a reasonable quality of life To minimize adverse effects and drug-induced toxicity AED therapy is usually lifelong Combination of drugs may be used An antiepileptic drug is a more appropriate term, because many of these medications are indicated for the management of all types of epilepsy and not necessarily just convulsions. Anticonvulsants, on the other hand, are medications that are used to prevent the convulsive seizures typically associated with epilepsy. Single-drug therapy is tried before multiple-drug therapy is started. NURSING APPLICATION: How would the nurse expect Ms. Jackson to metabolize an AED drug? Copyright © 2011 by Elsevier Inc. All rights reserved.

Mechanism of Action (p. 229) Exact mechanism of action is not known AEDs are thought to alter movement of sodium, potassium, and calcium ions across nerve cells in the brain Reduce nerve’s ability to be stimulated Suppress transmission of impulses from one nerve to the next Decrease speed of nerve impulse conduction within a neuron Therapeutic drug monitoring (see Chapter 2) of serum drug concentrations provides a useful guideline in assessing the effectiveness of therapy. Maintaining serum drug levels within therapeutic ranges helps not only to control seizures but also to reduce adverse effects. AED therapy stabilizes neurons, decreasing the spread of excessive nerve impulses. NURSING APPLICATION: If Ms. Jackson is having renal problems, would you expect her serum drug level to be normal, low, or high? Explain why. Copyright line.

Nursing Implications (p. 238) Teach patients to keep a journal to monitor: Response to AED Seizure occurrence and descriptions Adverse effects Instruct patients to wear a medical alert tag or ID AEDs should not be discontinued abruptly Driving may be impaired until drug levels stabilize Nurses must teach patients that therapy is long term and possibly lifelong; AED therapy is not a cure for epilepsy. Interventions are aimed at monitoring the patient while providing safety measures. It is important to adhere closely to the drug dose and frequency of dosing, as ordered. Close monitoring of dosing is important to maintain therapeutic blood levels. NURSING APPLICATION: If Ms. Jackson were on an AED, how would the nurse assist Ms. Jackson to journal about the effects of the drug? Copyright © 2011 by Elsevier Inc. All rights reserved.

Parkinson’s Disease (PD) (p. 244) Chronic, progressive, degenerative disorder Affects dopamine-producing neurons in the brain Caused by an imbalance of two neurotransmitters Dopamine Acetylcholine (ACh) Symptoms occur when about 80% of the dopamine stored in the substantia nigra of the basal ganglia is depleted. Symptoms include akinesia, bradykinesia, rigidity, tremor, and postural instability. NURSING APPLICATION: Describe pill rolling to Ms. Jackson's family. Copyright © 2011 by Elsevier Inc. All rights reserved.

Copyright © 2011 by Elsevier Inc. All rights reserved. Levodopa Therapy (p. 245) Levodopa is taken up by the dopaminergic terminal, converted into dopamine, and then released as needed As a result, neurotransmitter imbalance is controlled in patients with early PD who still have functioning nerve terminals Levodopa is a precursor of dopamine. Levodopa’s effectiveness diminishes over 5-10 years. NURSING APPLICATION: What nursing assessment is important if PD is suspected? Copyright © 2011 by Elsevier Inc. All rights reserved.

Selective MAOI Therapy: Selegiline (p. 246) MAOIs break down catecholamines in the CNS, primarily in the brain Selegiline is a selective MAOB  inhibitor Causes an increase in levels of dopaminergic stimulation in the CNS Selegiline is a new, potent, irreversible MAOI. Improvement in functional ability and decreased severity of symptoms are common after selegiline is added. Delays development of unresponsiveness to levodopa therapy. NURSING APPLICATION: What sign would the nurse expect to fall if Selegiline is being effective? Copyright © 2011 by Elsevier Inc. All rights reserved.

Presynaptic Dopamine Release Enhancer (p. 250) Amantadine (Symmetrel) Indirect-acting Causes release of dopamine from storage sites at the end of nerve cells that are still intact Blocks reuptake of dopamine into the nerve endings, allowing more to accumulate both centrally and peripherally Does not stimulate dopamine receptors directly Usually effective for only 6-12 months. NURSING APPLICATION: Discuss why amantadine would be recommended if it only is effective for 6-12 months. Copyright © 2011 by Elsevier Inc. All rights reserved.

COMT (Catechol ortho-methyltransferase) Inhibitors (p. 250) Indirect-acting Tolcapone (Tasmar) and entacapone (Comtan) Inhibit COMT, the enzyme responsible for the breakdown of levodopa, the dopamine precursor Prolong the duration of action of levodopa; reduce wearing-off phenomenon Indirect-acting dopaminergic drugs are the catechol ortho-methyltransferase (COMT) inhibitors. Effects can include tachycardia, cardiac dysrhythmias, hypertension. The main positive effect of these drugs is that they prolong the duration of action of levodopa. NURSING APPLICATION: Explain what is meant by reduction of the wearing-off phenomenon. Copyright © 2011 by Elsevier Inc. All rights reserved.

Direct-Acting Dopamine Receptor Agonists (p. 251) Nondopamine dopamine receptor agonists (NDDRAs) Ergot derivatives (bromocriptine and pergolide) Nonergot drugs (pramipexole, ropinirole, apomorphine) Dopamine replacement drugs Levodopa, carbidopa, carbidopa-levodopa (Sinemet) Are a major class of drugs used to treat Parkinson's disease, especially in its later stages Directly stimulate dopamine receptors NURSING APPLICATION: What side effects of indirect action and direct action dopamine receptor agonists would be most difficult for Ms. Jackson? Copyright © 2011 by Elsevier Inc. All rights reserved.

Anticholinergic Therapy (p. 253) Anticholinergics block the effects of ACh Used to treat muscle tremors and muscle rigidity associated with PD These two symptoms are caused by excessive cholinergic activity Does not relieve bradykinesia (extremely slow movements) ACh accumulates because of the imbalance of dopamine, and overstimulation of cholinergic excitatory pathways occurs. Anticholinergics are used as adjunct drug therapy in Parkinson's disease due to their antidyskinetic properties. The purpose of their use is to reduce excessive cholinergic activity in the brain. NURSING APPLICATION: Ms. Jackson's nephew stated that he has a friend who has an arm that is flexed toward the body and then extended at the elbow. Explain cogwheel rigidity to Ms. Jackson's nephew. Copyright © 2011 by Elsevier Inc. All rights reserved.

Nursing Implications (p. 255) Monitor for response to drug therapy Improved sense of well-being and mental status Increased appetite Increased ability to perform ADLs, to concentrate, and to think clearly Less intense parkinsonian manifestations, such as less tremor, shuffling gait, muscle rigidity, and involuntary movements Nursing interventions associated with the various antiparkinsonian drugs will vary somewhat depending on the drug class, but close monitoring and comprehensive patient education are required for all these drugs. Levodopa may darken the patient's urine and sweat. Patient should be taught not to discontinue antiparkinsonian drugs suddenly. NURSING APPLICATION: What nursing diagnosis would be appropriate should Ms. Jackson be diagnosed with Parkinson’s disease? Copyright © 2011 by Elsevier Inc. All rights reserved.