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1 Copyright © 2012, 2009, 2006, 2003 by Saunders, an imprint of Elsevier Inc. Chapter 23 DRUGS FOR NEUROLOGIC DISORDERS: PARKINSONISM AND ALZHEIMER’S DISEASE
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2 Copyright © 2012, 2009, 2006, 2003 by Saunders, an imprint of Elsevier Inc. Parkinsonism Pathophysiology Chronic neurologic disorder Degeneration of dopaminergic neurons Imbalance of the neurotransmitters Less dopamine
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3 Copyright © 2012, 2009, 2006, 2003 by Saunders, an imprint of Elsevier Inc. Parkinsonism (cont’d) Characteristics Tremors of head and neck Rigidity (increased muscle tone) Bradykinesia (slow movement) Postural changes Head and chest thrown forward Shuffling walk Lack of facial expression Pill-rolling motion of hands
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4 Copyright © 2012, 2009, 2006, 2003 by Saunders, an imprint of Elsevier Inc. Parkinsonism (cont’d) Treatment regimen Anticholinergics Block cholinergic receptors Dopaminergics Convert to dopamine Dopamine agonists Stimulate dopamine receptors MAO-B inhibitors Inhibit MAO-B enzyme that interferes with dopamine COMT inhibitors Inhibit COMT enzyme that inactivates dopamine
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5 Copyright © 2012, 2009, 2006, 2003 by Saunders, an imprint of Elsevier Inc. Antiparkinsonism Drugs Anticholinergics Parasympatholytic Benztropine (Cogentin) Trihexyphenidyl HCl (Artane) Action: inhibit release of acetylcholine Decrease tremors and rigidity
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6 Copyright © 2012, 2009, 2006, 2003 by Saunders, an imprint of Elsevier Inc. Antiparkinsonism Drugs (cont’d) Anticholinergics Nursing Interventions Monitor vital signs for increased P. Monitor urine output for early detection of urinary retention. Increase fluid intake, fiber, and exercise to avoid constipation. Observe for involuntary movements. Advise client to avoid alcohol, cigarettes, caffeine, and aspirin to decrease gastric acidity. Encourage client to relieve dry mouth with ice chips, hard candy, or sugarless chewing gum. Suggest use of sunglasses for photophobia.
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7 Copyright © 2012, 2009, 2006, 2003 by Saunders, an imprint of Elsevier Inc. Antiparkinsonism Drugs (cont’d) Dopaminergics Carbidopa-levodopa (Sinemet) Action: converted to dopamine Increases mobility Side effects Fatigue, insomnia Dry mouth Blurred vision Orthostatic hypotension, palpitations, dysrhythmias Urinary retention Nausea, vomiting Dyskinesia, psychosis, severe depression
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8 Copyright © 2012, 2009, 2006, 2003 by Saunders, an imprint of Elsevier Inc. Dopaminergics Carbidopa-levodopa (Sinemet) Drug interactions Decrease levodopa effect with: Anticholinergics Phenytoin Tricyclic antidepressants MAO inhibitors Benzodiazepines Phenothiazines Vitamin B 6
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9 Copyright © 2012, 2009, 2006, 2003 by Saunders, an imprint of Elsevier Inc. Dopaminergics (cont’d) Carbidopa-levodopa Function Advantages A, When levodopa is used alone, only 1% reaches the brain because 99% converts to dopamine while in the peripheral nervous system. B, By combining carbidopa with levodopa, carbidopa can inhibit the enzyme decarboxylase in the periphery, thereby allowing more levodopa to reach the brain.
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10 Copyright © 2012, 2009, 2006, 2003 by Saunders, an imprint of Elsevier Inc. Dopamine Agonists Amantadine (Symmetrel) Also antiviral drug for influenza A Action Stimulates dopamine receptors Taken alone or in combination with levodopa or anticholinergic Use Early treatment of parkinsonism as drug tolerance develops Improvement of symptoms
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11 Copyright © 2012, 2009, 2006, 2003 by Saunders, an imprint of Elsevier Inc. Antiparkinsonism Drugs (cont’d) Nursing interventions Monitor for orthostatic hypotension. Administer drug with low-protein foods. Avoid vitamin B 6, alcohol, other depressants. Do not abruptly discontinue. Warn of harmless brown discoloration of urine and sweat. Assess for suicidal tendencies. Assess symptom status and “on-off” phenomenon. Monitor blood cell counts, liver and kidney function.
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12 Copyright © 2012, 2009, 2006, 2003 by Saunders, an imprint of Elsevier Inc. Alzheimer’s Disease Pathophysiology Progressive, degenerative disease Neuritic plaques form Neurofibrillary tangles are in neurons Cholinergic neurotransmitter abnormality
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13 Copyright © 2012, 2009, 2006, 2003 by Saunders, an imprint of Elsevier Inc. Alzheimer’s Disease (cont’d) Pathophysiology Histologic changes Histologic changes in Alzheimer’s disease. A, Healthy neuron. B, Neuron affected by Alzheimer’s disease showing characteristic neuritic plaques and cellular neurofibrillary tangles.
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14 Copyright © 2012, 2009, 2006, 2003 by Saunders, an imprint of Elsevier Inc. Alzheimer’s Disease (cont’d) Characteristics Loss of memory, logical thinking, judgment Time disorientation Personality changes Hyperactivity Tendency to wander Inability to express oneself Later hostility, paranoia
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15 Copyright © 2012, 2009, 2006, 2003 by Saunders, an imprint of Elsevier Inc. Acetylcholinesterase Inhibitors Donepril (Aricept) Rivastigmine (Exelon) Action Allow more acetylcholine in neuron receptors Increase cognitive function Use Mild to moderate Alzheimer’s disease
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16 Copyright © 2012, 2009, 2006, 2003 by Saunders, an imprint of Elsevier Inc. Acetylcholinesterase Inhibitors (cont’d) Side effects Headache, dizziness Depression GI distress Dehydration, dry mouth, constipation Blurred vision Insomnia Hypertension, hypotension, dysrhythmias Hepatotoxicity
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17 Copyright © 2012, 2009, 2006, 2003 by Saunders, an imprint of Elsevier Inc. Acetylcholinesterase Inhibitors (cont’d) Nursing interventions Monitor vital signs. Maintain consistency in care. Monitor behavioral changes. Safety Provide safety when wandering. Arise slowly to avoid dizziness. Monitor for GI bleeding. Inform family of support groups.
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18 Copyright © 2012, 2009, 2006, 2003 by Saunders, an imprint of Elsevier Inc. Case Study A client who has parkinsonism is taking carbidopa/levodopa (Sinemet). Critical Thinking 1. What laboratory values may be altered in a client who is taking carbidopa/levodopa? 2. Compare the different actions of the drugs used to treat parkinsonism and reduce symptoms.
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19 Copyright © 2012, 2009, 2006, 2003 by Saunders, an imprint of Elsevier Inc. Practice Question #1 Which comment to the nurse indicates more teaching is needed for a client taking carbidopa/levodopa? A.“I know I need to take this drug once a day.” B.“I know I shouldn’t stop taking this drug abruptly.” C.“I understand my urine may become dark and discolored.” D.“I know it may take a few weeks or months to control my symptoms.”
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20 Copyright © 2012, 2009, 2006, 2003 by Saunders, an imprint of Elsevier Inc. Practice Question #1 (cont’d) Answer: A Rationale: A statement from the client such as “I know I need to take this drug once a day” indicates that more teaching is needed because carbidopa/levodopa has a short half-life and must be taken 3 or 4 times per day. The other answers are true.
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21 Copyright © 2012, 2009, 2006, 2003 by Saunders, an imprint of Elsevier Inc. Practice Question #2 Which side effect/adverse effect of carbidopa/levodopa does the nurse realize is most important to monitor? A. Dysphagia B. Increased libido C. Agranulocytosis D. Urinary retention
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22 Copyright © 2012, 2009, 2006, 2003 by Saunders, an imprint of Elsevier Inc. Practice Question #2 (cont’d) Answer: C Rationale: It is most important for the nurse to monitor the client taking carbidopa/ levodopa for agranulocytosis (decreased white blood cells), which is life-threatening. Dysphagia, increased libido, and urinary retention are not life threatening.
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