Antiparkinsonism Drugs

1 NPN 130 CHAPTER 29

NPN130CH29-30

Parkinsons Disease
2

Most common form of Parkinsonism Parkinsonism is characterized by:

Tremors (described as pill-rolling) Rigidity Slow movement (bradykinesia) Parkinson-like symptoms can be seen with head injuries, certain drugs and encephalitits

Parkinsons Disease is progressive->

symptoms worsen over time

NPN130CH29-30

Parkinsons Disease
3

Symptoms: caused by depletion of

dopamine Slurred speech Facial: Masklike/emotionless expression Difficulty chewing/swallowing Unsteady and shuffled gait Upper body bent forward
NPN130CH29-30

Parkinsons Disease
4

NPN130CH29-30

Parkinsons Disease
5

Symptoms are treated with antiparkinsonism drugs. Supplement the dopamine in the brain Block excess acetylcholine (Ach)

Drugs:
Dopaminergic

agents (MAOI) Dopamine receptor agonists Cholinergic blocking drugs Catechol-O-methyltransferase inhibitors Non-ergot dopamine receptor agents
NPN130CH29-30

Dopaminergic Drugs/ MAOIs

6

Affect dopamine content of brain: Carbidopa/levodopa (Sinemet) Amantadine (Symmetrel) Bromocriptine (Parlodel) Rasagiline (Axilect)

NPN130CH29-30

Dopaminergic Drugs
7

Actions:
Blood-brain
Levodopa

barrier

(dopamine) only reached brain in small quantities. With carbidopa, more levodopa is able to reach the brain
that work to stimulate dopamine receptors (bromocriptine)

Agonist
Drugs

NPN130CH29-30

Uses
8

Parkinsons Disease Parkinson-like symptoms (extrapyramidal) Restless leg syndrome Viral infection (amantadine)

Influenza A prevention

NPN130CH29-30

Adverse Reactions
9

Dry mouth/dysphagia Anorexia, nausea/vomiting Abdominal pain/constipation Increased hand tremor

Headache/dizziness

NPN130CH29-30

Adverse Reactions
10

Serious-levodopa

Choreiform movements

Involuntary muscle twitching of limbs/facial muscles

Dystonic movements

Muscular spasms/tongue, jaw, eyes, neck

If these symptoms occur, withhold the next dose and call PMD immediately; may need to lower dose or discontinue use of drug

Serious-less common

Dementia Depression Psychotic episodes/paranoia/suicidal tendencies

NPN130CH29-30

Contraindications/Precautions
11

Known allergy Narrow-angle glaucoma MAOI antidepressants

Skin lesions-dopamine can activate malignant

melanoma Cautiously: cardiovascular/pulmonary/renal/hepatic disease

NPN130CH29-30

Interactions
12

Foods high in pyridoxine (vitamin B6) can reduce

effect of levodopa. BUT when levodopa is given with carbidopa, Vit B6 may decrease adverse effects

NPN130CH29-30

Cholinergic Blocking Drugs

13

Block excess acetylcholine

(Ach)enhances dopamine transmission Less effective than levodopa r/t peripheral adverse reactions. Older adults-Benadryl fewer adverse effects
NPN130CH29-30

Uses
14

Used as adjunctive therapy in all forms of

parkinsonism and to control drug-induced extrapyramidal disorders

Benztropine (Cogentin) Biperiden (Akineton) Diphenhydramine (Benedryl)

NPN130CH29-30

Adverse Reactions
15

Dry mouth Blurred vision Dizziness Mild nausea

Nervousness
Urinary retention, dysuria
Clients older than 60 years old frequently develop increased sensitivity

to anticholinergic drugs. Monitor these clients carefully for adverse reactions-> may need lower doses

If any adverse reactions are severe, the drug may be d/c for several days

and restarted at a lower dose or changed to a different med

NPN130CH29-30

Contraindications/Precautions
16

Known allergy Narrow-angle glaucoma Pyloric/duodenal obstruction

Peptic ulcers
Prostatic hypertrophy (BPH) Achalasia (muscles of lower esophagus do not relax,

have difficulty swallowing) Myasthenia gravis megacolon

NPN130CH29-30

COMT (Catechol-O-methyl transferase) Inhibitors

17

Theory: prolong the effect of levodopa Blocks COMT, an enzyme, that eliminates dopamine When given with levodopa, COMT inhibitors increase duration and action of levodopa

Entacapone (Comtan)
Tolcapone (Tasmar)
NPN130CH29-30

Uses
18

Adjunct to levodopa/carbidopa Tasmar is associated with liver damage/failure Only given for those not responding to other therapies Liver function tests (LFT) every 2 weeks for first year, every 8 weeks thereafter

Comtan -> milder COMT inhibitor Used to help manage fluctuations in the response of levodopa

NPN130CH29-30

Adverse Reactions
19

Dizziness Dyskinesias (diminished voluntary movements and the

presence of involuntary movements, similar to tics) Hyperkinesias (state of excessive restlessness that affects the ability to control motor movement) Nausea, anorexia, diarrhea Sleep disorders Orthostatic hypotension Somnolence Muscle cramps **Liver failure

NPN130CH29-30

Contraindications/Precautions
20

Known allergy Pregnancy/lactation

Liver dysfunction-Tasmar
Hypertension

Hypotension
Decreased renal/hepatic function

NPN130CH29-30

Dopamine Receptor Agonists

21

Action
Not

understood but theoretically, thought to work by acting directly on the postsynaptic dopamine receptors of nerve cells in the brain, mimicking the effects of dopamine in the brain

NPN130CH29-30

Uses
22

Treatment of signs/symptoms of

Parkinsons Disease
Pramipexole (Mirapex) Ropinirole (Requip)

Used for on-off phenomena.

Apomorphine (Apokyn) Antiemetics must be used

NPN130CH29-30

On-Off Phenomenon
23

On-off phenomenon can occur in pts taking levodopa.

Client alternates btwn improved clinical status and loss of therapeutic effect Occurs with long term use of levodopa If sx occur, MD may order drug holiday in which complete withdrawal of medication is ordered x 5-14 days. Pt will then gradually restart drug at lower dose Monitor pts for complications -> neuroleptic malignantlike syndrome

Muscular rigidity Increased body temp Mental status changes

NPN130CH29-30

Adverse Reactions
24

Mirapex/Requip

Nausea/vomiting Dizziness Somnolence Hallucinations Confusion Abnormal involuntary movements headache

NPN130CH29-30

Contraindications/Precautions
25

Known allergy Cautiously: Dyskinesia Orthostatic hypotension Hepatic/renal failure Cardiovascular disease Hx. Hallucinations/psychosis

NPN130CH29-30

Contraindications/Precautions
26

Increased risk of CNS depression when given with

other CNS depressants When administered with levodopa

Increase effects of levodopa-> will need lower dose of levodopa May have increased risk of hallucinations

NPN130CH29-30

Pre administration Assessment

27

Unreliable history?

Family member history better Length ADLs Current mental condition

Symptoms of disorder

Physical assessment Current neuromuscular status

Tremors Mask-like expression Postural deformities Difficulty swallowing

NPN130CH29-30

Ongoing Assessment
28

Response to drug therapy Therapeutic Improvement Adverse reactions Hallucinations occur more often in older client taking antiparkinsonism drugs. Monitor for visual, auditory or tactile hallucinations How to treat adverse effects?

NPN130CH29-30

Anticonvulsants
29 NPN 130 CHAPTER 30

NPN130CH29-30

Anticonvulsants
30

Convulsions-sudden, involuntary contraction of

muscles of the body with possible LOC Seizures-periodic disturbances of the brains electrical activity

Idiopathic-no known cause Hereditary-genetically passed from parent to child Acquired-have a known cause: high fever, electrolyte imbalances, brain tumors, drug withdrawals

Goal of treatment is to treat underlying pathologic

process to stop seizures If cause is unclear, try to control seizure activity

NPN130CH29-30

Anticonvulsants
31

Epilepsy-Permanent, recurrent seizure disorder Causes include brain injury at birth, head injuries Each type of seizure disorder is characterized by a specific pattern of events, as well as a different pattern of motor or sensory manifestations Partial Seizures- most common type simple-consciousness is impaired and variable motor-uncontrolled stiffening/jerking in one part of the body (e.g., finger, mouth, hand) Can involve area of brain that interpret info; they may present as flashing lights or may have change in taste or speech. This is called a somatosensory seizure.

NPN130CH29-30

Partial Seizure
32

NPN130CH29-30

Anticonvulsants
33

Generalized Seizures-LOC May or may not have convulsive movt Tonic-Clonic Seizure Alternate contraction (tonic phase-The person will quickly lose consciousness, and the skeletal muscles will suddenly tense, often causing the extremities to be pulled towards the body or rigidly pushed away from it, which will cause the person to fall if standing.) and relaxation (clonic phase-The person's muscles will start to contract and relax rapidly, causing convulsions. These may range from exaggerated twitches of the limbs to violent shaking or vibrating of the stiffened extremities. The person may roll and stretch as the seizure spreads ) +LOC Abnormal behavior Myoclonic Seizure Involve sudden, forceful contractions of single or multiple groups of muscles

NPN130CH29-30

Tonic-Clonic Seizure
34

NPN130CH29-30

Electroencephalogram (EEG)
35

NPN130CH29-30

EEG Electrode Placement

36

NPN130CH29-30

Anticonvulsants
37

Drugs used for managing seizures-> called

anticonvulsants Do not cure epilepsy Most drugs treat specific types of seizures, NOT a one-size fits all.

NPN130CH29-30

Actions
38

Depress abnormal nerve impulse discharges in the

CNS.

Hydantoins (tonic-clonic seizures) -Dilantin Carboxylic acid derivatives (epilepsy)-Depakote Succinimides (partial seizures)- Celontin Oxazolidinediones (epilepsy)- Tridione Benzodiazepines (seizure disorders)- Klonopin, Valium, Ativan Barbituates-phenobarbital Miscellaneous-Tegretol, Neurontin, Keppra, Topamax

NPN130CH29-30

Uses
39

Used prophylactically to prevent seizures after trauma,

neurosurgery, tumors Seizures (all types) Neuropathic pain-Neurontin (e.g. diabetic neuropathy) Bipolar Disorders Anxiety disorders

**Status epilepticus-emergency, continual seizure

activity with NO interruptions. May occur from abrupt discontinuation of anticonvulsant- concerned with what?

Ativan

NPN130CH29-30

Adverse Reactions
40

CNS Drowsiness, weakness, headache, dizziness, nystagmus (constnat, involuntary movt of the eyeball), slurred speech

GI Nausea, vomiting, anorexia, constipation, diarrhea, gingival hyperplasia (overgrowth of gum tissue)
Other Rash, itching (pruritus) urticaria, urinary frequency, blood dyscrasias-> monitor for thrombocytopenia (bleeding gums, easy bruising, increased menstual bleeding, tarry stools) or leukopenia (sore throat, fatigue, SOA) and notify PMD
NPN130CH29-30

Adverse Reactions
41

Gingival hyperplasia

NPN130CH29-30

Adverse Reactions
42

Nystagmus

NPN130CH29-30

Dilantin
43

Most commonly prescribed anticonvulsant because of its

effectiveness and low toxicity. Normal levels 10-20 mcg/mL Monitor for signs of toxicity (>20 mcg/mL)

Slurred speech Ataxia (lack of voluntary coordination of muscle movements) Lethargy Dizziness N/V

Give IV over IM-> Can cause muscle damage at injection site If rash occurs call PMD. Usually d/c unless rash is mild

(acne/sunburn); therapy may be resumed after rash disappers

NPN130CH29-30

Tegretol
44

Tegretol: Can cause agranulocytosis (severe, low

amount of WBC)

Notify MD of sore throat, fever, malaise. Pt may not be able to fight off infection without treatment

NPN130CH29-30

Contraindications
45

Known allergy Phenytoin-sinus bradycardia, SA block,

2nd & 3rd degree block Tegretol- not given within 14 days of MAOIs, bone marrow depression, renal or hepatic impairment Pregnancy/lactation
NPN130CH29-30

Precautions
46

Renal/Hepatic disease Neurologic disorders Barbituates Pulmonary disease Hyperactive children Phenytoin (Dilantin) Hypotension Severe myocardial insufficiency

NPN130CH29-30

Pre Administration Assessment

47

Thorough patient history Display 30.1

Description of seizures Daily/weekly frequency Avg length Aura present? Description of impairment of consciousness What brings on seizures?

Family history? Vital signs

PCP may order CT Scan, MRI, CBC, hepatic/renal labs

NPN130CH29-30

Ongoing Assessment
48

Therapeutic? Adverse reactions?

Serum plasma levels

Documentation seizure activity

NPN130CH29-30

Education Patient/Family
49

What should family expect? How to protect patient? Postical state The postictal state is the altered state of consciousness that a person enters after experiencing a seizure. It is characterized by drowsiness, confusion, nausea and other disorienting symptoms. This period is often accompanied by amnesia or other memory defects. This is the time it takes the brain to recover from the seizure.

NPN130CH29-30

Education
50

Never omit or change drug dose unless advised by PMD Must monitor blood levels When seizing, the person should be placed on their side.

NEVER PUT ANYTHING IN THE MOUTH OF A SEIZING PERSON! Anticonvulsant drugs cause drowsiness/dizziness-> use caution Need medical ID: MedicAlert tag or bracelet Notify PMD of all meds: prescription and nonprescription Record all seizures

NPN130CH29-30

Seizure Safety
51

NPN130CH29-30

Seizure Safety
52

NPN130CH29-30