Introduction to Clinical Pharmacology Chapter 19 Cholinesterase Inhibitors

Cholinesterase Inhibitors: Actions and Uses Dementia is slow and progressive; delirium has a sudden onset and sensory impairment occurs Actions: Cholinesterase inhibitors act to increase level of acetylcholine in CNS by inhibiting its breakdown and slowing neural destruction; slows down the progression of the Alzheimer’s Disease SUMMARY DRUG TABLE Uses: Cholinesterase inhibitors are used to treat dementia associated with AD and best when used in early stages of dementia

Cholinesterase Inhibitors: Adverse Reactions Generalized adverse reactions and need priority interventions: Anorexia; nausea; vomiting; diarrhea; dizziness; headache; confusion

Cholinesterase Inhibitors: Contraindications and Precautions Cholinesterase inhibitors are contraindicated in patients with hypersensitivity to drugs and if pregnant or during pregnancy and lactation These drugs are used cautiously in patients with renal disease, bladder obstruction; seizure disorders; sick sinus syndrome; gastrointestinal bleeding; asthma Ginkgo has not been proven or disproven, but if taken,effects may not be evident until after 4 to 24 weeks of treatment. The most common adverse reactions include mild GI discomfort, headache, and rash. Should be avoided if taking selective serotonin reuptake inhibitors or monoamine oxidase inhibitors antidepressants; adverse effects include headache, rash, and GI discomfort and need to be recognized and brought up to healthcare provider; excessive dose of ginkgo may exhibit the following adverse reactions: diarrhea, nausea, vomiting, and restlessness

Interactions Interactant drug Effect of interaction Anticholinergics-like benztropine, glycopyrrolate, and tiotropium Decreased effectiveness of anticholinergics Nonsteroidal anti-inflammatory drugs Increased risk of GI bleeding Thiazide diuretics NMDA receptor antagonist Decreased effectiveness of thiazide drug Theophylline Increased risk of theophylline toxicity

Nursing Process: Assessment #1 Preadministration assessment: Assess patient’s cognitive ability and functional ability before and during therapy in preclinical AD there would be no change in these areas Assess patient regarding orientation, calculation, recall, and language Assess patient for agitation and impulsive behavior Obtain complete medical history and history of symptoms of AD from patient, family member, or patient’s hospital records

Nursing Process: Assessment #2 Preadministration assessment (cont.) Observe patient for what appears to be deviations from normal behavior pattern Ask the family about unusual behaviors, such as wandering or outbursts of angry or frustrated behavior Assess patient’s vital signs and weight

Nursing Process: Assessment #3 Ongoing assessment: Includes both mental and physical assessment Initial assessments will be compared with ongoing assessments to monitor patient’s improvement after taking cholinesterase inhibitors

Nursing Process: Planning Expected outcomes include: Optimal response to drug therapy Support of patient needs related to management of adverse reactions Absence of injury Compliance with the prescribed therapeutic regimen

Nursing Process: Implementation #1 Promoting an optimal response to therapy: Develop care plan to meet patient’s individual needs When the drugs no longer provide memory enhancement, environmental factors may need to change rather than modifying the patient's behavior Monitor vital signs and other assessments in hospitalized patients

Nursing Process: Implementation #2 Monitoring and managing patient needs: Imbalanced nutrition: less than body requirements Attention to dosing of medications can be helpful to decrease adverse GI reactions and promote nutrition Remove oral dosing syringe provided in protective container when rivastigmine is administered as oral solution and can be mixed with water, soda, or fruit juice

Nursing Process: Implementation #3 Monitoring and managing patient needs (cont.) Patient should be offered well-balanced diet with foods that are easy to chew and digest Fluid intake of six to eight glasses of water daily is encouraged to prevent dehydration

Nursing Process: Implementation #4 Monitoring and managing patient needs (cont.) In later stage, patient may be fed through feeding syringe, or the caregiver can encourage chewing action by pressing gently on bottom of the patient’s chin and on the lips

Nursing Process: Implementation #5 Monitoring and managing patient needs (cont.) Risk for injury: Physical decline and adverse reactions of dizziness and syncope place patient at risk for injury Use of side rails; keeping the bed in low position; using night lights; frequent monitoring by nurse or caregiver will reduce risk of injury

Nursing Process: Implementation #6 Educating the patient and family: Explain any adverse reactions that may occur with specific drug and encourage caregiver or family members to contact primary health care provider immediately if serious drug reaction occurs Evaluate patient’s ability to assume responsibility for taking drugs at home

Nursing Process: Implementation #7 Educating the patient and family (cont.) Focus on educating family and major caregiver on patient needs Discuss drug regimen with patient, family member, and/or caregiver

Nursing Process: Evaluation Therapeutic effect is achieved Adverse reactions are identified, reported to the primary health care provider, and managed successfully through appropriate nursing interventions No injury is evident Patient, family member, or caregiver demonstrates understanding of the drug regimen Exelon can be given orally or topically ensure the caregiver is aware of how to give or apply transdermal patch on an area that is hairless to have better contact with skin, rotate sites; if being placed by nurse document site placed and ensure not in area where patient can remove it or pick at it

Question #1 Is the following statement true or false? Alzheimer disease (AD) is one of the conditions where dementia is a major issue.

Answer to Question #1 True Alzheimer disease (AD) is one of the conditions where dementia is a major issue. This occurs due to the buildup of plaques and tangles in the neurons of the brain. Acetylcholine is reduced, resulting in symptoms of dementia.

Question #2 Is the following statement true or false? The progression of memory loss associated with dementia is treated with cholinesterase inhibitors. These drugs cure dementia.

Answer to Question #2 False The progression of memory loss associated with dementia is treated with cholinesterase inhibitors. These drugs slow progression but do not cure dementia.

Question #3 Is the following statement true or false? Patients with dementia may at times experience acute confusion, known as delirium.

Answer to Question #3 True Patients with dementia may at times experience acute confusion, known as delirium.