CNS Flashcards by Kristin Godsey

Q

neurotransmitter that causes whole brain arousal, stimulates appetite, and is the neurotransmitter in reinforcement pathways.

A

Norepinephrine

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Q

The most basic neurotransmitter involved in primitive functions that affects biologic drives like sex and anger/rage, coordinates movement, and is also the primary neurotransmitter involved in emotion and reinforcement pathways. There are at least 5 different receptors for this neurotransmitter that, when stimulated, elicit different effects.

A

Dopamine

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Q

The most ubiquitous neurotransmitter in the body that assists with all parasympathetic nerves. In the brain, it plays a major role in attention, learning, and memory. Alzheimer’s disease is a result of degeneration of these neurons.

A

Acetylcholine (Ach)

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Q

neurotransmitter is involved with sleep/wake cycles, mood, chronic pain, and hunger. There are more than 20 different receptors for this one

A

Serotonin (5-hydroxytryptamine or 5-HTseries)

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Q

neurotransmitter that inhibits transmission from one nerve to the next in the CNS

A

Gamma-amino butyric acid (GABA)

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Q

Anxiety, panic, anorexia, excitability, insomnia

A

Norepinephrine

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Q

too much __________= Psychoses, Tourette’s Syndrome

A

Dopamine

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Q

too much _________= Delirium/confusion

A

Acetylcholine (Ach)

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Q

too much ___________= Sleep-hallucinations

A

Serotonin (5-hydroxytryptamine or 5-HTseries)

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Q

too much ___________= CNS depression, Respiratory depression, Sedation

A

Gamma-amino butyric acid (GABA)

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Q

too little ____________=Depression, ADD, or ADHD

A

Norepinephrine

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Q

too little ____________=Parkinson’s Disease, ADD, or ADHD

A

Dopamine

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Q

too little ____________=Alzheimer’s

A

Acetylcholine (Ach)

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Q

too little ____________=Depression-OCD, Increased pain sensitivity, Anxiety

A

Serotonin (5-hydroxytryptamine or 5-HTseries)

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Q

too little ____________=Seizures

A

Gamma-amino butyric acid (GABA)

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Q

Drugs that affect ___________:

SNRIs, Tricyclic Anti-depressants, MAOIs

A

Norepinephrine

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Q

Drugs that affect ___________:

Antipsychotics

A

Dopamine

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Q

Drugs that affect ___________:

ACHEIs

A

Acetylcholine (Ach)

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Q

Drugs that affect ___________:

SSRIs, SNRIs, Atypicals, TCAs, MAOIs

A

Serotonin 5-hydroxytryptamine or 5-HTseries)

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Q

Drugs that affect ___________:

Benzodiazepines, Sedatives, Hypnotics

A

Gamma-amino butyric acid (GABA)

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Q

an activating neurotransmitter associated with learning, thought, and emotion

A

Glutamate

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Q

neurotransmitter that provides relief from pain and promotes feelings of pleasure/well-being.

A

Endorphins

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Q

GAD is treated with:

A

Benzodiazepines, SSRI, Buspirone, psychotherapy

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Q

Acute (Situational) Anxiety is treated with:

A

Benzodiazepines, antihistamines

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Panic Disorder (PD) is treated with:

Benzodiazepines, SSRI

``` Medications for _________: Paroxetine (Paxil) duloxetine (Cymbalta) escitalopram (Lexapro) venlafaxine (Effexor) ```

GAD

Medications for ________: Hydroxyzine (Atarax, Vistaril) Propranolol (Inderal®) Atenolol (Tenormin®)

Acute (Situational) Anxiety

``` Medications for _________: Fluoxetine (Prozac) Paroxetine (Paxil) Sertaline (Zoloft) Venlafaxine (Effexor) ```

Panic Disorder (PD)

MOA of ____________: act by boosting the effect of the neurotransmitter GABA which results in a fast onset of sedation and anxiolytic effect / also work as an anti-convulsant and muscle relaxant

Benzodiazepines

Benzodiazeines treat anxiety and ____________

seizure disorders

Benzodiazepines are Schedule ___ drugs

IV

Benzodiazepines have low potential for abuse when used ___________

short-term

The combination of ________ and benzodiazepines can lead to severe respiratory depression and death!!!!

opioids

routine daily use of Benzodiazepines may lead to _______________ and is highly discouraged

physical dependence

As a cautious prescriber, even if you state the patient could take Benzodiazepines up to _____ PRN severe anxiety, prescribe no more than ___ tablets with no refills

TID; 30

a patient who has chronically used benzodiazepines, abrupt discontinuation can cause _________; therefore, discontinuation should be gradually tapered over many weeks.

seizures

benzodiazepines are often used for immediate relief from an acute anxiety attack until a safer anxiolytic agent (______ or ________) can take effect and/or resolve insomnia

SSRI/SNRI or Buspirone

benzodiazepines with ________ onset of action are associated with the highest potential for abuse.

fastest

Benzodiazepines are metabolized in the ______

liver

Caution with ___________ food and drugs with benzodiazepines

CYP450

``` In the CNS, this drug causes: Sedation Decreased anxiety Muscle relaxation Anti-convulsant action ```

Benzodiazepines

benzodiazepine with a fairly long half-life that effectively treats spasms and decreases seizure activity

Diazepam (Valium)

benzodiazepine with a moderate half-life that acts immediately to resolve symptoms-- so it is the most addictive

Alprazolam (Xanax)

benzodiazepine with slower onset and shorter half-life commonly used for anxiety

Lorazepam (Ativan)

``` Commonly treated with ____________: Post-traumatic stress disorder (PTSD) Obsessive-compulsive disorders (OCD) Panic attacks Social anxiety ```

Selective Serotonin Reuptake Inhibitor (SSRI)

For patient with severe anxiety, Rx __-week course of an intermediate-acting benzodiazepine PRN Q 8 hrs. to provide relief until an SSRI/SNRI can take effect.

2

Safety Concerns for ___________: not for long term treatment of anxiety (up to a year) Levels may be increased by grapefruit juice, erythromycin and ketoconazole

Buspirone (BuSpar)

``` SE of __________: dizziness nausea headache drowsiness ```

Buspirone (BuSpar)

anxiety drug that is not habituating and does not have the side effect profile or abuse potential of the benzodiazepines since it is not a CNS depressant

Buspirone (BuSpar)

buspirone (Buspar) has a high affinity for _________ receptors and a lesser affinity for __________ receptors

serotonin; dopamine

efficacy of this drug is mixed and often the SSRIs that are indicated for anxiety offer better coverage for generalized anxiety disorder (GAD)

Buspirone (BuSpar)

strong antihistamine used for anxiety that will cause side effects consistent with antihistamines but in patients with severe anxiety can offer some relief of anxiety

Hydroxyzine (Atarax, Vistaril)

if the client has performance anxiety (stage fright), consider using a ___________ 1 hour before event to relieve the catecholamine-mediated autonomic symptoms without sedation

beta-blocker (Propanolol)

Ideally, insomnia medications should be given for a ________ duration

short

All __________ are indicated for short-term use--10 days maximum. These drugs can cause dependence. Rapid dose decreases of discontinuation can cause withdrawal symptoms.

Benzodiazepines

EX of __________: estazolam (ProSom) flurazepam (Dalmane) temazepam (Restoril)

Benzodiazepines

Benzodiazepines are not reccommended for the ___________ due to risk of: falls fractures impairment

elderly

____________ Drugs: Eszopiclone (Lunesta) zaleplon (Sonata) zolpidem (Ambien, Ambien CR and Intermezzo).

Non-Benzodiazepine ("Benzodiazepine-Like")

___________ is the only Non-Benzodiazepine ("Benzodiazepine-Like") drug recommended for long-term use (all others are reccomended for max of 35 days)

Eszopiclone (Lunesta)

__________ drug: | Ramelton (Rozerem)

Melatonin Agonist

OTC 3 or 6 mg. No potential for addiction or tolerance and is inexpensive. It should not be taken with ramelteon (Rozerem).

Melatonin Herb

Antidepressants frequently used in treating insomnia in the elderly due to reassuring safety profiles.

Mirtazapine (Remeron) | Trazodone (Desyrel)

Due to significant SE, especially in elderly, _____ Antidepressants are rarely used to treat insomnia

Tricyclic

antihistamines used to treat insomnia (cause anticholinergic effects) ***Caution in: Depression Elderly

Diphenhydramine (Benadryl) | Hydroxyzine (Vistaril)

second-generation antipsychotic that causes sedation but it has multiple side effects and is costly. Avoid off-label use for insomnia.

Quetiapine (Seroquel)

If a patient suffers from mild depression and has difficulty with sleeping, _______________ is often given before bed due to its sedative effects. This medication produces a moderate blockade of 5HT reuptake. Overdose is less of a risk with this drug than with TCAs.

Trazodone (Desyrel)

Two drugs that are recommended for chronic insomnia (duration greater than 6 months)

Lunesta (eszopiclone) and Rozerem (ramelteon)

Patient Teaching for ___________: - Do not take unless you have 7-8 hours to sleep - Take on an empty stomach at least 30 minutes before bedtime - Drugs with long half-lives (eszopiclone) are associated with higher risk of next-day impairment - Sleepwalking, sleep driving, sleep eating, sleep sex have been reported with zolpidem and other "Z-drugs" - Do not use with other CNS depressants or alcohol

Insomnia

the best choice for anxiety treatment during pregnancy when a benzodiazepine is indicated and all other alternatives are ineffective

clonazepam (Klonopin)

a non-benzodiazepine that is used as an anxiolytic that is labeled as pregnancy category B, but use during pregnancy should be avoided due to limited data

Buspirone (BuSpar)

a non-benzodiazepine that is used as an anxiolytic that is labeled as pregnancy category B, but use during pregnancy should be avoided due to limited data

Buspirone (BuSpar)

a pregnancy category C non-benzodiazepine that may be used as a last resort, for short-term treatment of insomnia/anxiety in pregnancy

Zolpidem (Ambien)

benzodiazepines that should be avoided in breastfeeding due to long half-life

Diazepam (Valium) and Clonazepam (Klonopin)

Short-term use of these anxiolytic drugs with a shorter half-life are likely safe with breastfeeding

Midazolam (Versed) and Lorazepam (Ativan)

anxiolytic drug that is contraindicated while breastfeeding due to limited data

Buspirone (BuSpar)

short-term and small-dose use of this anxiolytic drug is likely safe while breastfeeding

Hydroxyzine (Vistaril)

``` Known to cause _______________: Chlorpromazine (Thorazine) Citalopram (Celexa) Donepezil (Aricept) Escitalopram (Lexapro) Haloperidol (Haldol) Thioridazine (Mellaril) ```

QT prolongation

medications that block the reuptake of norepinephrine, serotonin, and some dopamine from the pre-synaptic neuron, thereby increasing the amount of neurotransmitter in the synapse...different ones block specific combinations of these neurotransmitter receptors in an attempt to refine the effects of the neurotransmitters

Antidepressants

Once a patient is in remission the antidepressant treatment should be continued for __ to __ months in order to promote complete recovery.

6-12

first-line most commonly used drugs for depression

SSRI and SNRI

It will take ___ to ___ weeks to see an initial effect of SSRI and up to ___ weeks to achieve a full effect

2-3 | 6

SSRI w/ increased risk of nausea (so reccommend taking them at bedtime)

paroxetine (Paxil) | citalopram (Celexa)

SSRI w/ increased risk of insomnia (so reccommend taking in the morning)

fluoxetine (Prozac)

a serious complication that occurs w/ use of serotonergic agents usually as a result of overdose or D2D interactions (especially MAOIs) Symptoms: confusion agitation clonus fever tremor hyperreflexia -can result in respiratory failure & death *resolves w/ discontinuation of the drug *consider in any patient on these drugs that presents w/ agitation/confucsion

serotinin syndrome

condition caused by abrupt discontinution of SSRIs Symtpoms: dizziness headache nausea sensory disturbances tremor anxiety dysphoria -begins within days to weeks of the last dose and persist for 1-3 weeks -resumption of drug will subside symptoms

withdrawal syndrome

``` Contraindications for __________: Breastfeeding Patients w/ Sodium depletion Diuretics Anticholinergics ```

Lithium

Lithium is metabolized in the _________

kidneys

If hyponatremia occurs while on lithium, this happens

lithium reaches toxic levels

``` Drugs used for _________: Lithium Mood Stabilizers (AEDs) -valproic acid (Depakote) -Iamotrigine (Lamictal) -topiramate (Topamax) Atypical Antipsychotics ```

Bipolar Disorder

``` BBW for ____________: Narrow therapeutic range Hepatotoxicity Panreatitis (children < 6 yo, pt. w/ mitochondrial disorders at higher risk) ```

Lithium

condition often caused by long-term use of Lithium

hypothyroidism

used to treat psychosis, delusions, & bipolar disorder & some have an indication as an adjunct for refractory depression (i.e., aripiprazole (Abilify). The APRN must be familiar w/the many side effects of these drugs & check for D2D interactions for every prescription.

Antipsychotics

class of meds was the first developed to treat schizophrenia with an MOA of blockage of dopamine-2 (D2) receptors (responsible for movement), which reduced the hyperactivity in the mesolimbic dopamine pathway.

1st Generation "Conventional" Antipsychotics

SE of _____________: Negative Extrapyramidal side effects such as tardive dyskinesia (which is sometimes irreversible) Increase in prolactin levels (hyperprolactinemia) causing galactorrhea, amenorrhea, sexual dysfunction, & weight gain

1st Generation "Conventional" Antipsychotics

class of meds with MOA of D2 antagonism & serotonin-2A antagonism. The benefits are fewer negative side effects and they help w/ both the negative & positive symptoms of schizophrenia

2nd Generation "Atypical" Antipsychotics

``` SE of __________: Cardiometabolic risks: weight gain obesity dyslipidemia diabetes accelerated cardiovascular disease. ```

2nd Generation "Atypical" Antipsychotics

2nd Gen Atypical Antipsychotics w/ the lowest risk of SE

ziprasidone | aripiprazole

2nd Gen Atypical Antipsychotics w/ the highest risk of SE

clozapine | olanzapine

``` Indications for _____________: ● Partial Seizures ● Generalized Tonic-Clonic ● Bipolar Disorder ● Trigeminal Neuralgia pain ```

Carbamazepine (Tegretol)

``` Indications for ______________: ● Partial ● Tonic-Clonic (Grand Mal) ● Simple ● Complex ------Prevents seizures after head trauma, neurosurgery, & hemorrhagic stroke ```

Phenytoin (Dilantin)

Indications for ______________: ● Absence (Generalized resulting in Petit Mal)

Succinimides: Ethosuximide (Zarontin) Iminostilbenes: Valproic Acid (Depakote)* Lamotrigine (Lamictal)*

SE of ____________: Bone Marrow Suppression SJS in Asians (Check for HLA-B1502 allele prior to starting)

Carbamazepine (Tegretol)

SE of ___________: | Hepatitis (common hypersensitivity reaction)

Phenytoin (Dilantin)

these Antiepileptics have fewer SE’s and are the preferred meds for absence seizures

``` Valproic Acid (Depakote) Lamotrigine (Lamictal) ```

SE of ____________: | SJS (titrate slowly!)

Succinimides: Ethosuximide (Zarontin) Iminostilbenes: Valproic Acid (Depakote)* Lamotrigine (Lamictal)*

D2D Interactions of ____________: Oral contraceptives Folic Acid

Carbamazepine (Tegretol)

D2D Interactions of ____________: | may reduce the therapeutic effect of Progestin and Estrogen contraceptives

Phenytoin (Dilantin)

drug used in combination w/ other anticonvulsants.

Valproic Acid (Depakote)

anticonvulsant safe in pregnancy but it interacts w/ folic acid so educate patient to take 4 mg Folic Acid daily

Carbamazepine (Tegretol)

BBW for _____________: Hypotension Severe cardiac dysrhythmias can occur with rapid IV infusion

Phenytoin (Dilantin)

``` BBW for ________________: Contraindicated in: Sinus Bradycardia SA Block 2nd and 3rd degree AV block Stokes-Adams Syndrome Pregnancy category D ```

Phenytoin (Dilantin)

Safety for _____________: Obtain platelet counts before initiating therapy and at regular intervals Monitor for bleeding or bruises

Valproic Acid (Depakote)

Most __________ drugs ARE lipophilic

antiepileptic

AAP considers ethosuximide, carbamazepine, phenytoin, & valproic acid to be compatible w/ ____________

breastfeeding

_____________ (anticonvulsant) is associated w/ numerous adverse neonatal effects & should only be used while breastfeeding if there are no alternatives

Lamotrigine (Lamictal)

Breastmilk levels of ___________ (anticonvulsants) are the lowest of the group. However, _______________ may be associated w/ infant hepatotoxicity & thrombocytopenia, so infants must be monitored accordingly.

phenytoin & valproic acid valproic acid

For all ___________ drugs while breastfeeding, the infant should be monitored for jaundice, drowsiness & sedation, appropriate weight gain, & appropriate mental & behavioral development.

antiepileptic

____________ are used for seizures and as mood stabilizers.

antiepileptics

antiepileptic used in adults and children

Carbamazepine (Tegretol)

menopausal women may need ________ supplementation while taking antiepileptic drugs

Calcium

Ideal contraceptive methods while patient is taking ______________ are progestin-only contraceptives (such as progestin-only pills or progestin-based injections, implants or IUDs), in combination w/ a barrier method.

antiepileptics

_____________ is commonly used for contraception during antiepileptic therapy... should be given w/in the shortest time interval possible (every ten weeks as opposed to twelve weeks).

medroxyprogesterone (DMPA) injection

___________ not only alters the metabolism of combined oral contraceptives (COCs) but its metabolism is altered by COCs.

Lamotrigine (Lamictal)

``` ___________ effects: dry mouth urinary hesitancy tachycardia constipation blurred vision ```

Anticholinergic

Drugs that cause ____________: Sedatives/Hypnotics Tricyclic Antidepressants

Anticholinergic Effects

drugs that cause EPS, akathisia, and tardive dyskinesia

Conventional Antipsychotics

ubiquitous/abundant/common neurotransmitter in the body responsible for memory formation ○ Excitatory neurotransmitter for all parasympathetic nerves. ○ In the brain, it plays a major role in attention, learning, & memory formation in the hippocampus ○ Plays role in regulating REM sleep. ○ Alzheimer’s is a result of degeneration of cholinergic neurons. Too much: Delirium/Confusion Too little: Alzheimer’s

Acetylcholine (Ach)

an excitatory neurotransmitter causing cell death | ○ Over excitation is cytotoxic

Glutamate

Neurotransmitters involved in Alzheimer's

Acetylcholine (Ach) and Glutamate

____________ Drugs: donepezil (Aricept), rivastigmine (Exelon), & galantamine (Razadyne) ○ MOA: Prevents breakdown of acetylcholine ○ Excitatory neurotransmitter ○ Involved in learning & memory formation in hippocampus ○ Also, a role in regulating REM sleep cycles (Stahl, 2011) ○ Major SE: GI related - Weight loss, N/V/D, dizziness, muscle cramps, may increase seizure risk (rare) ○ Precautions: bradycardia, conduction defects, asthma, COPD ○ Drug Interactions: anticholinergics- reduce effectiveness NSAIDs- increase risk of GI bleed antifungals- inhibit metabolism, increasing levels

Cholinesterase Inhibitors (mild to moderate Alzheimer's)

______________ Drugs: ○ MOA: Blocks excessive excitation of NMDA receptors by glutamate as over excitation by glutamate is cytotoxic. ○ Plays a role in cognition, memory, learning. ○ Major side effects include dizziness, HA, constipation ○ Use cautiously in pts w/ renal impairment ○ Drug Interactions:drugs that raise urine pH (causes elevated levels) other NMDA antagonists (amantadine, ketamine, & dextromethorphan)

N-methyl-D-aspartic acid (NMDA) Receptor Antagonist (moderate to severe Alzheimer's)

First line ADHD drugs: ○ Methylphenidate ○ Dextroamphetamine Slow-dose & pulsatile drugs that amplify (NE) norepinephrine & (DA) dopamine signals that are low. Studies do not demonstrate a difference in efficacy among these drugs

Stimulants

these antidepressants are contraindicated in the elderly

TCAs and MAOIs

Due to decreased renal clearance, reduced hepatic function and frequently reduced albumin levels, the dose of ____________ is started at one-third to one-half of the usual starting adult dosage in the elderly

SSRIs and SNRIs

these drugs are frequently used in treating insomnia in the elderly d/t reassuring safety profiles

Mirtazapine (Remeron) and Trazodone (Desyrel)

this atypical antidepressant is often given at bedtime to elderly patients with insomnia and weight loss as it stimulates appetite, is sedating and exerts an antidepressant effect

Mirtazapine (Remeron)

vast majority of benzos are contraindicated in ________ except in rare instances where benefits outweigh the risk

pregnancy

conflicting studies surround _________ use in pregnancy...some studies show: oral cleft preterm labor fetal growth restriction “Floppy baby syndrome” (lack of tone, sluggishness, & difficulty w/ the sucking reflex) immediately after birth & newborn withdrawal up to three months

benzo

Short-term use of these benzos w/ a shorter half-life is likely safe w/ breastfeeding.

Midazolam (Versed) & Lorazepam (Ativan)

avoid these benzos w/ longer half-life in breastfeeding

Diazepam (Valium) & Clonazepam (Klonopin)

When all alternatives are ineffective, and a Benzo is indicated in pregnancy, short-term use of ____________ is the safest option

clonazepam (Klonopin)

While it is labeled as pregnancy Cat B, this non-benzo during pregnancy and breastfeeding should be avoided due to limited data

busipirone (BuSpar)

non-benzo that is considered safe in breastfeeding due to low breastmilk levels and short half-life

zolpidem (Ambien)

these durgs are indicated for short-term use ONLY-- 10 days max b/c they can cause dependence. Rapid dose decreases or discontinuation can cause w/drawal symptoms, including anxiety & insomnia.

Estazolam (ProSom)flu razepam (Dalmane) temazepam (Restoril)

If a pt suffers from mild depression & has difficulty w/ sleeping, _________ is often given before bed due to its sedative effects. This med produces a moderate blockade of 5HT reuptake. Overdose is less of a risk w/ this drug than w/ TCAs.

Trazodone

a unique agent that has been used as an aid for smoking cessation called ______. DO NOT give to anyone who has a history of seizure risk!!! Benefits: less sexual dysfunctio/ mild weight loss

Bupropion/ Zyban

When choosing an antidepressant therapy: pts w/ pain may achieve some pain relief w/ the use of these drugs

Duloxetine or TCA

the most studied antidepressant for use w/ children and is the only antidepressant recommended for use in children 8 yrs & above

fluoxetine (Prozac)

these drugs are first-line choice for breastfeeding mothers with PPD due to their low excretion into breastmilk

SSRIs: sertraline (Zoloft) paroxetine (Paxil) fluvoxamine (Fluvox)

this drug is NOT first line for breastfeeding mothers w/ PPD

fluoxetine (Prozac)

this drug for bipolar disorder to contraindicated in pregnancy (Cat D) due to risk of CV defects so it may be temporarily discontinued until postpartum

Lithium

most significant SE that should be monitored during Atypical Antipsychotic therapy

cardiometabolic risks (weight gain, obesity, dyslipidemia, diabetes, accelerated cardiovascular disease)

``` Major SE of ___________: GI related: Weight loss, N/V/D izziness muscle cramps may increase seizure risk (rare) ```

Cholinesterase Inhibitors

a woman w/ a history of birthing a child w/ a neural tube defect (NTD) or Diabetic woman, supplementation of _______should increase to ten times the daily recommended amount for pregnancy, to 4 mg/day for 3 months prior to conception

B9 and Folic Acid

``` Potential interactions of _____________: SSRIs (really, all antidepressants) Triptans Benzos Contraceptives some ABXs Digoxin. ```

St. Johns Wort

1 hourr of __________ is equivalent to 3 hrs of sleep. However, it is not recommended instead of sleep, but rather in addition to sleep.

Yoga Nidra

``` CNS Drugs that _____________: Chlorpromazine Citalopram Donepezil Escitalopram Haloperidol Thioridazine Trazodone ```

prolong QT interval