Chapter 3. Neurobiology and Pharmacotherapy-1 Flashcards
(140 cards)
1
Q
Psychiatric illness results in
A
an alteration in neurotransmitters that are the targets of psychotropic drugs
2
Q
Functions of the Brain
A
Maintenance of homeostasis
Regulation of autonomic nervous system (ANS) and hormones
Control of biological drives and behavior
Cycle of sleep and wakefulness
Circadian rhythms
Conscious mental activity
Memory
Social skills
All of these are carried out by interactions of neurons
3
Q
An essential feature of neurons
A
is their ability to initiate signals and conduct an electrical impulse from one end of the cell to the other called neurotransmission.
**get a message and conduct it along, along the way they encounter different chemicals
4
Q
Neurotransmitters
A
Norepinephrine
Serotonin
Glutamate
Y Aminobutyric acid (GABA)
5
Q
Cellular Composition of Brain
A
Presynaptic neuron ==> synapse ==> postsynaptic neuron
When a nerve impulse reaches the end of the axon, the axon releases chemicals from the vesicles and those chemicals are called neurotransmitters
The neurotransmitters then travel across the synapse between the axon and the dendrite of the next neuron which is also called the postsynaptic neuron
These neurotransmitters bind to the membrane of the dendrite and this binding of the neurotransmitters to the receptor can trigger an action potential in the postsynaptic neuron
6
Q
Define insufficient transmission
A
An insufficient degree of transmission may be caused by a deficient release of neurotransmitters from the presynaptic cell or by a decrease in receptors.
7
Q
What causes excessive transmission?
A
may be due to excessive release of a transmitter or to increased receptor responsiveness, as occurs in schizophrenia.
8
Q
What does the core of the brain do?
A
regulates internal organs and vital functions
9
Q
What is the function of the hypothalamus?
A
basic drives and link between thought and emotion and function of internal organs
10
Q
What is the function of the brainstem?
A
Processing center for sensory information
11
Q
Where does brainstem pathways project to?
A
areas of the cerebrum collectively known as the limbic system
12
Q
Key functions of the limbic system
A
plays a crucial role in emotional status and psychological function using norepinephrine, serotonin, and dopamine as its neurotransmitters.
13
Q
Function of the cerebellum
A
Regulates skeletal muscle
Coordination and contraction
Maintains equilibrium
Coordinates smooth muscle movement and balance
14
Q
Function of Cerebrum
A
Mental activities
Conscious sense of being
Emotional status
Memory
Control of skeletal muscles – movement
Language and communication
15
Q
What does an EEG do?
A
Electroencephalography (EEG)
Shows the state a person is in, supports identification of brain abnormalities
16
Q
What does Structured Imaging Techniques show?
A
provide overall images of the brain and layers of the brain.
Shows gross anatomical detail of brain structures
Can reveal schizophrenia and cognitive disorders
17
Q
What does a CT (Computerized Tomography) of the brain show?
A
Urgent, Fast (2.5 min.); Large mass or bleed, lesions, infarcts
18
Q
What does a MRI (Magnetic Resonance Imaging) show?
A
Longer study (~30-60 min.); Detailed brain imaging from application of magnetic field, shows edema, trauma, ischemia, neoplasm
19
Q
What does Functional Imaging Techniques reveal?
A
reveal physiological activity in the brain.
Can detect physiological and biochemical changes in living tissue
Ex: Schizophrenia, mood disorders, adult ADHD
20
Q
What does functional magnetic imagining (fMRI) show?
A
brain activity through blood O2
21
Q
What does Positron Emission Tomography (PET) show?
A
injected tracer shoes activity of the brain and 3D brain imaging
22
Q
What does single photon emission computer tomography (SPECT) show?
A
like PET but shows activity of the brain and brain layers
23
Q
Define disturbances of mental functions that interplay between environment and genetics
A
evidence when talking about concordance in identical twins that grew up in separate environments however still affected by the same mental illness
24
Q
The Biopsychosocial Hypothesis
A
Psychological Factos - traits, coping, defenses
Biological Contribution - often genetically related
Environmental Factors - family, social, cultural, substances, adverse life events
All contribute to a mental illness
25
Dopamine
Too much:
Schizophrenia and mania
Too little:
Some forms of depression, ADHD (frontal cortex) , muscular rigidity and tremors found in Parkinson's disease
26
Function of Dopamine
involved in fine muscle movement
Involved in integration of emotions and thoughts
Involved in decision making (frontal lobe)
Stimulates hypothalamus to release hormones (sex.
Thyroid, adrenal)
27
Norepinephrine
Too much: Schizophrenia, anxiety states, mania
Too little: Depression
28
Functions of Norepinephrine
Level in brain affects mood
Attention and arousal
Stimulates sympathetic branch of autonomic nervous
system for “fight or flight” in response to stress
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Serotonin
Too much: Anxiety states
Too little: Depression and some anxiety disorders especially OCD
30
Functions of serotonins
Plays a role in sleep regulation, hunger, mood states and pain perception
Hormonal activity
Plays a role in aggression and sexual behavior
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GABA
Increase reduces anxiety
Too little: anxiety and anxiety disorders, schizophrenia, Mania, huntington’s decease.
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Functions of GABA
Plays a role in inhibition, reduces aggression, excitation, and anxiety.
May play a role in pain perception
Has anticonvulsant and muscle-relaxing properties
May impair cognition and psychomotor functioning
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Glutamate - NMDA
Decrease NMDA in psychosis. Increased NMDA for prolonged period is neurotoxic and causes neurodegeneration in Alzheimer’s disease.
Incease of AMPA improvement in cognitive performance in behavioral tasks
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Functions of Glutamate - NMDA
Is excitatory
AMPA plays a role in learning and memory
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Cholinergics
Increased in depression
Decrease in alzheimer’s disease, Huntinington’s, and Parkinsons
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Acetylcholine
Too much: Depression
Too little in hippocampus: dementia
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Functions of Acetylcholine
Plays a role in learning, memory
Regulates mood: mania, sexual aggression
Affects sexual and aggressive behavior
Stimulates parasympathetic nervous system
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Adrenaline
Too much: anxiety and anxiety disorders
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Epinephrine
Too little: Depression
40
Define Pharmacodynamics
What drugs do and how they do it
Drug action and drug responses
41
Define Pharmacokinetics
Actions of the body on the drugs (movement of a drug through the body)
ADME
Absorption
Distribution
Metabolism
Excretion
42
Define Pharmacogenetics
Effects of genetic variation on drug responses
43
True or False
Ideal drugs do not have side effects
FALSE
NO ideal drugs, they ALL have side effects
44
Define Absorption
How is the drug absorbed into the body?
45
Define Distribution
How id the drug distributed throughout the body?
46
Define Metabolism
How is the drug transformed for use and eventual excretion?
47
Define Excretion
How is the drug excreted from the body?
48
Define agonists
Mimic the effects of neurotransmitter naturally found in the human brain
- Bind to and stimulate the neurotransmitter's receptor
49
Define antagonists
Block neurotransmitters from binding to its receptors
- obstruct the neurotransmitters action
50
What are Anxiolytic Agents?
Anti-Anxiety drugs
51
List Benzodiazepines
Diazepam (Valium)
Clonazepam (Klonopin)
Alprazolam (Xanax)
Lorazepam (Ativan)
**all addictive and scheduled CONTROLLED medications
52
Function of Benzodiazepines
Promote activity of GABA by binding to receptor on GABAa which increases frequency of CaCl channel opening
==> hyperpolariztion that inhibits cellular excitability which results in a calming effect
possess antianxiety, hypnotic (sleep-inducing), anticonvulsant, amnestic (loss of memory), and muscle relaxant properties.
53
Define SWICKIR
Somatic Symptoms
Worries
Irritability
Concentration
Keyed up/on edge
Initial Insomnia
Relaxation difficulties
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Patients with a SWICKIR score of worries of __ have a significant probability of a clinically important anxiety disorder
Patients with a SWICKIR Anxiety Scale score of worries plus 3 other symptoms for at least 6 months are assumed to have a significant probability of a clinically important anxiety disorder.
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Benzodiazepines for insomnia
Flurazepam (Dalmane)
Temazepam (Restoril)
Triazolam (Halcyon)
**These are for treatment of insomnia because they have a predominantly hypnotic (sleep-inducing) effect.
56
Benzodiazepines for alcohol withdrawal
Chlordiazepoxide (Librium)
Diazepam (Valium)
Lorazepam (Ativan)
57
Short-acting sedative-hypnotic sleep agents (Z-Hypnotics)
Zolpidem (Ambien)
Zaleplon (Sonata)
Eszopiclone (Lunesta)
Help to induce short-term sleep without the antianxiety, anticonvulsant, or muscle relaxant effects of benzodiazepines.
**The FDA has issued warnings on all approved hypnotic medications regarding complex sleep-related behaviors.
58
Nonbenzodiazepine receptor agonists, or Z-hypnotics, include
Zolpidem (Ambien)
Zaleplon (Sonata)
Eszopiclone (Lunesta)
*** They possess hypnotic and amnestic effects without the antianxiety, anticonvulsant, or muscle relaxant effects of benzodiazepines. This is due to their selectivity for GABAA receptors containing an alpha ()-1 subunit.
59
Eszopiclone (Lunesta)
causes an unpleasant taste in the mouth when you wake up.
60
What is Melatonin
a hormone that is excreted at night as part of the circadian rhythm.
61
Function of Ramelteon (Rozerem)
Melatonin Receptor Agonist
acts the same way as naturally occurring melatonin to help with sleepiness and regulation of circadian rhythms
Not classified as a scheduled substance, no abuse potential.
SE: Headache, dizziness
Not restricted to short term use.
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Orexin receptor antagonists (promote sleep)
Suvorexant
Lemborexant
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Suvorexant (Belsomra)
is an orexin receptor antagonist.
64
Buspirone (BuSpar)
thought to work as a partial serotonin agonist
often better tolerated than benzos
Relieves anxiety with no sedative effect
No potential for addiction
Not a CNS depressant
SE: HA, dizziness, lightheadedness, nausea, insomnia
65
What does melatonin receptor agonists stimulate?
the same receptor sites as endogenous melatonin
66
T/F
Many antidepressants have proven to be effective treatments for anxiety disorders.
TRUE
67
What are SSRIs?
Selective serotonin reuptake inhibitors
68
What are SSRIs (Selective serotonin reuptake inhibitors ) used to treat?
OCD, social anxiety disorder (SAD), generalized anxiety disorder (GAD), panic disorder (PD), and posttraumatic stress disorder (PTSD).
69
What is SNRI?
selective serotonin norepinephrine reuptake inhibitor
70
What are SNRI (selective serotonin norepinephrine reuptake inhibitor) used to treat?
GAD, SAD, and PD. Another drug in that classification, duloxetine (Cymbalta), has FDA approval for GAD
71
What is the monoamine hypothesis of depression regarding anti depressant drugs?
Suggests a deficiency in one or more neurotransmitters
72
What is the prolonged use hypothesis regarding anti depressant drugs?
Suggests that prolonged use of antidepressants leads to increased neurotrophic factor production
73
T/F
norepinephrine and serotonin help regulate mood
True
74
T/F
Deficiency of one or both (norepinephrine, serotonin) within the limbic system causes depression
True
75
List Tricyclic Antidrepressants (TCAs)
Amitriptyline (Elavil)
Imipramine (Tofranil)
Nortriptyline (Pamelor
76
T/F
Tricyclic Antidrepressants (TCAs) are first line defense
False
Used to be the first line defense...no longer because they have more side effects, take longer to reach optimal dose, sedation, more lethal in overdose
77
Function of TCAs
Thought to act by blocking reuptake of norepinephrine or both norepinephrine and serotonin
Has anticholinergic side effects: dry mouth, blurred vision, tachycardia, urinary retention, constipation.
May cause sedation and drowsiness
TCA overdose can be fatal.
78
Side effects of TCAs
Orthostatic hypotension (esp. with elderly), confusion, disturbed concentration; anti-cholinergic side effects including blurred vision, dry mouth, constipation, urinary retention
ER/MEDICAL FLOOR TIP: In overdose, may cause fatal arrhythmias, slows AV conduction (consider monitored bed, telemetry)
79
Nursing considerations of TCAs
suicidal precautions, sugarless lozenges for dry mouth, titrate down doses to avoid HA, Vertigo, wt. changes, avoid alcohol, sleeping pills, In bipolar patients, Tx with TCA’s may lead to hypomania or mania.
80
List Monoamine oxidase (MAOIs)
Isocarboxazid (Marplan)
Phenelzine (Nardil)
Selegiline (EMSAM)
Tranylcypromine (Parnate)
81
T/F
MAOIs are organic compounds
True
82
What are Monoamine oxidase Inhibitors?
drug that inhibits action of MAO (enzyme that destroys monoamines) by preventing destruction of monoamines… So synaptic level of neurotransmitters is increased and makes the antidepressant effects possible
83
What must a patient avoid when taking MAOIs?
must avoid tyramine rich foods (aged cheese, pickled or smoked fish, meats, wine) or risk hypertensive crisis
Hypertensive crisis (requiring emergency treatment):
Potentially causing a hemorrhagic stroke.
84
Side Effects of MAOIs
HTN crisis with consumption of high tyramine foods, photosensitivity, weight gain, sexual dysfunction
85
Nursing Considerations for MAOIs
Low tyramine diet; D/C 10 days prior to anesthesia, Monitor for urinary retention, Meds lower seizure threshold, Suicidal precautions.
Dietary restriction of tyramine must be maintained for 2 weeks after stopping MAOIs.
86
What is tyramine found in?
some over-the-counter (OTC) medications, beer, wine, aged cheese, organ meats, avocadoes, and other foods.
87
Adverse Drug Effect: Serotonin Syndrome
Can occur when multiple medications that alter serotonin metabolism are used together (MAOIs + SSRI, etc.)
Can be life-threatening
88
S/S of Serotonin Syndrome
Tachycardia
Sweating (diaphoresis)
Fever progressing to hyperthermia
Shivering, Tremor
Muscle rigidity (myoclonus)
Restlessness/Agitation/Delirium/Coma
89
List Selective Serotonin Reuptake Inhibitors (SSRs)
Fluoxetine (Prozac)
Sertraline (Zoloft)
Paroxetine (Paxil)
Citalopram (Celexa)
Escitalopram (Lexapro)
Fluvoxamine (Luvox)
***Most common class prescribed for depressed mood
90
What is the function of SSRIs?
Block reuptake and destruction of serotonin.
Less anticholinergic and sedating side effects
SE: apathy, low libido, N and V
91
Indication of use for SSRIs
Depression, Anxiety disorders, OCD, Obesity, Bulimia
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S/S of SSRIs
Anti-cholinergic, nausea, headache, painful menstruation, sexual dysfunction, insomnia, rash, taste changes, dry mouth, anxiety, tremor, dizziness, weight loss/gain
93
Nursing Considerations for SSRIs
Suicide precautions, Use in AM, Requires 4 weeks for full effect, monitor weight, good mouth care
94
Indications for Serotonin
Depression, Anxiety disorders, OCD, Obesity, Bulimia
95
Serotonin-norepinephrine reuptake inhibitors (SNRIs)
Venlafaxine (Effexor)
Desvenlafaxine (Pristiq)
Duloxetine (Cymbalta)
Levomilnacipran (Fetzima)
96
T/F
Levomilnacipran (Fetzima) is an SNRI with less effect on norepinephrine reuptake than any of the other SNRIs available for treating depression.
FALSE
Levomilnacipran (Fetzima) is an SNRI with a GREATER effect on norepinephrine reuptake than any of the other SNRIs available for treating depression.
Increasing norepinephrine may be responsible for observed increases in heart rate and blood pressure in some patients.
97
What does SNRIs increase?
Increases both norepinephrine and serotonin.
98
Side effects of SNRIs
HTN is side effect in some pts with higher doses
Side effects include fewer anticholinergic effects.
99
What does Cymbalta work best on?
on nerve pain, limits pain signals ascending to brain
100
Norepinephrine and serotonin-specific antidepressant (NaSSA)
Mirtazapine (Remeron)
101
Norepinephrine dopamine reuptake inhibitor (NDRI)
Bupropion (Wellbutrin) (Zyban)
used for depression
Also used for smoking cessation
No sexual dysfunction as a SE
Can not abruptly stop taking= seizure risk
May cause appetite suppression
102
Mirtazapine (Remeron)
H1 antagonists
2nd or 3rd line antidepressant
useful in patients that experience sexual side effects
risk of elevated lipid levels
commonly used in elder patients
useful in combination therapy
103
Serotonin antagonists and reuptake inhibitors (SARI)
Nefazodone (formerly sold as Serzone)
Trazodone (formerly sold as Desyrel) (Oleptro)
Brexpiprazole (Rexulti)
104
T/F
trazodone (Desyrel) is NOT first choice for antidepressant treatment, but useful for insomnia. Can cause priapism.
True
105
What does Rexuli cause?
weight gain
106
Serotonin partial agonist reuptake inhibitor (SPARI)
Vilazodone (Viibryd)
107
Function of Vilazodone (Viibryd)
Dual activity makes this a SPARI
Enhances serotonin by inhibiting the transporter and by stimulating serotonin
SE: Diarrhea, Nausea, vomiting, insomnia
108
Serotonin Modulator and Stimulator
Vortioxetine (Trintellix)
109
Function of Vortioxetine (Trintellix)
Inhibits serotonin reuptake (like SSRIs), and partially agonizing or antagonizing the 5-HT receptors
May also improve cognitive deficits in the elderly
SE: Constipation, Nausea, Vomiting
Serious SE: hyponatremia, induction of hypo(mania)
110
Mood Stabilizing Agent - Lithium
lithium (Eskalith, Lithobid)
“The Gold Standard”
Stabilizes depression and mania (bipolar disorder).
Narrows the therapeutic index.
Has a potential for toxicity.
Toxic effects can include tremor, ataxia, confusion, convulsions, and N/V.
mechanism of action unknown. May act by affecting electrical conductivity in neurons bc it is a positively charged ion
Affects cardiac contraction can lead to sinus bradycardia
111
Function of Valproate (Depakote/Depakene)
very effective in managing impulsive aggression.
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Function of carbamazepine (Tegretol)
Is administered for acute mania.
113
Function of lamotrogine (Lamictal)
Is administered for maintenance therapy (most commonly used for patients with frequent depressive episodes).
***Watch for rash; may indicate Stevens-Johnson syndrome.
114
Anticonvulsant Agents
Carbamazepine (Tegretol)
Divalproex (Depakote)
Lamotrigine (Lamictal)
Oxcarbezepine (Trileptal)
115
Side Effect Profiles of Mood Stabilizers
Weight gain
Somnolence
Agranulocytosis
Thrombocytopenia
Hepatitis
Steven Johnson Syndrome- life threatening rash.
116
T/F
Lithium and most anticonvulsant agents require monitoring of blood levels and organ functions.
117
Therapeutic Blood Level for Lithium
0.8 to 1.4 mEq/L
118
Maintenance Blood level for Lithium
0.4 to 1.3 mEq/L
119
Maintenance Blood level for Depakote (Divalproex )
50 to 100 mcg/mL
120
Maintenance Blood level for Lithium Tegretol (Carbamazapine)
4 to 12 mcg/mL
121
Toxic Blood level for Lithium
1.5 mEq/L and above
122
T/F
Lithium (a salt) competes with Sodium. Our body responds to Lithium in the same way it responds to Sodium.
True
123
What affects Lithium levels?
New blood pressure medication (most of them shift lithium levels)
NSAIDs (non-steroidal anti-inflammatories) can significantly shift Lithium Levels
The most obvious is over-taking Lithium or continuing to take Lithium while losing a lot of water due to the flu, diarrhea, vomiting or excessive exercise without replenishing fluid.
124
Signs of Lithium Acute Toxicity
Diarrhea; Nausea; Vomiting, Stomach Pains
Dizziness; Weakness
Confusion; Memory problems; Psychosis
Hand tremors; Muscle twitching; Ataxia (incoordination)
Nystagmus
Seizures; Coma; Kidney Failure
125
Signs of Lithium Chronic Toxicity
Tremors; Slurred Speech; Increase reflexes
126
What to do for Lithium overdose?
Activated Charcoal if overdose suspected; Nasal gastric tube to remove stomach content if lithium overdose, Force fluids through IV
127
Antipsychotic Drugs
Phenothiazines
Thioxanthenes
Butyrophenones
**first generation
128
What does first generation drug mean?
conventional, typical or standard antipsychotic drugs
129
Function of second-generation (atypical) antipsychotic drugs
Produce fewer extrapyramidal side effects (EPS)
Target both the negative and positive symptoms
Predominantly D2 (dopamine) and 5-HT2A (serotonin) antagonists (blockers)
Often chosen as first-line treatment
130
Side effects of second-generation antipsychotic drugs
Increase the risk of metabolic syndrome (increased weight, blood sugar, triglycerides)
Insulin resistance - long term
131
Second-generation (atypical) antipsychotic drugs
Clozapine (Clozaril)
Risperidone (Risperdal)
Quetiapine (Seroquel)
Olanzapine (Zyprexa)
Ziprasidone (Geodon)
Aripiprazole (Abilify)
Paliperidone (Invega)
Iloperidone (Fanapt)
Lurasidone (Latuda)
Asenapine (Saphris)
132
Clozapine (Clozaril)
The first atypical antipsychotic
Highly effective in treating treatment-resistant schizophrenia
Has the least possibility of causing extrapyramidal side effects
compared to traditional antipsychotics.
Requires regular blood monitoring for agranulocytosis
133
What is monitored when taking Clozapine
Requires regular blood monitoring for agranulocytosis
134
Describe extrapyramidal side effects
Extrapyramidal side effects including drug-induced parkinsonism (DIP) and tardive dyskinesia (TD) have been identified as frequent side effects of antipsychotics and have been associated with impaired quality of life1 and depression2 in patients with schizophrenia.
135
Black Box Warning for Clozapine
agranulocytosis
seizures
myocarditis
for "other adverse cardiovascular and respiratory effects",
for "increased mortality in elderly patients with dementia-related psychosis.“ ~ FDA
136
Side Effects of Clozapine
often causes less serious side effects such as hypersalivation and weight
137
What lab is obtained when giving Clozapine?
Obtain an absolute neutrophil count (ANC) for patients in accordance with the clozapine Prescribing Information and aligned with the patient's monitoring frequency.
138
ADHD (Attention Deficit Hyperactivity Disorder) Medication Treatment
Methylphenidate (Ritalin, Concerta)
Amphetamines (Adderall, Vyvanse)
Atomoxetine (Strattera): Nonstimulant: labeled for 6+
Guanfacine (Intuniv)
Clonidine (Kapay)
139
Function of ADHD Medication
For short attention span, impulsivity, and overactivity
Sympathomimetic amines, function as agonists at adrenergic receptor sites
May inhibit overactive part of limbic system
***Due to their norepinephrine and dopamine enhancing effects, psychostimulants cause insomnia and increased blood pressure and heart rate.
140
Medication Treatment for Alzheimers Disease
Cholinesterase inhibitors (slow the destruction of acetylcholine):
- Donepezil (Aricept)
- Galantamine (Razadyne)
- Rivastigmine (Exelon)
Glutamate-blocking agent:
- Memantine (Namenda, Namenda XR)
