Psych And Elders Flashcards
(105 cards)
1
Q
What are the 5 uses for antidepressants?
A
- Depression
- Anxiety disorders
- Migraine prophylaxis
- ‘Nerve’ pain
- Low dose for insomnia
2
Q
What drug type is sertraline?
A
SSRI; selective serotonin reuptake inhibitors
3
Q
What drug type is venlafaxine?
A
SNRI; serotonin NorE reuptake inhibitor
4
Q
What type of drug is trazodone?
A
SSRI + 5HT2A antagonist and H1 antagonist
5
Q
What type of drug is vortioxetine and vilazodone?
A
SSRI + 5HT1A agonists and 5HT3 antagonist
SSRI + 5HT1A partial agonist
6
Q
What type of drug is mirtazapine?
A
Serotonin and NE antagonist
7
Q
What type of drug is bupropion?
A
NorE and dopamine reuptake inhibitor
8
Q
What type of drug is amitriptyline?
A
Cyclic or tricyclic and tetracyclic antidepressants
9
Q
What type of drug is phenelzine?
A
Monoamine oxidase inhibitor
10
Q
Where does TCA’s work on neuron?
A
Pre and post synaptic
- alpha1AR
- NET
- SERT
11
Q
Where do SNRIs work on neuron?
A
Pre synaptic neuron at NET and SERT
12
Q
Where do SSRIs work on neuron?
A
Presynaptic neuron at SERT
13
Q
Where do MAOIs work on neuron?
A
Presynaptic neuron
14
Q
What can happen with abrupt discontinuation of antidepressants?
A
Discontinuation syndrome
15
Q
When does discontinuous syndrome begin and how long does it last?
A
Begin within 1-2 days of stopping
Lasts a few days up to 2-3 weeks
16
Q
How can you treat discontinuation syndrome?
A
Re-initiating antidepressant
17
Q
What are the symptoms of discontinuation syndrome:
A
Nausea, abdominal pain, diarrhea
Insomnia
Sweating, lethargy, headache, paresthesias
Low mood, irritability, anxiety
18
Q
TriCyclic antidepressants (TCAs) mechanism?
A
Block reuptake of NE, 5HT, or both
May also affect dopamine
19
Q
What are some other effects of TCAs?
A
Muscarinic block
Histamine 1 receptor block
Alpha 1 block
20
Q
If TCAs are given chronically, what can happen?
A
Decrease stores of NE; ECG changes (wide QRS, ventricular arrhythmia, and reduce contractility)
21
Q
TCA can have additive effects with what drugs?
A
Antimuscarinic drugs
22
Q
What effects can happen if TCA and antimuscarinic drugs are given?
A
More post op confusion, urinary retention, decreased bowel sounds, tachycardia
23
Q
What could happen if on TCA and give direct acting vasopressors (phenylephrine, NE)?
A
Exaggerated BP response
24
Q
What happens if on TCA and given indirect acting vasopressors (ephedrine)?
A
Enhance release of NE from presynaptic terminal and can have exaggerated response
25
What drugs should you avoid with pts on TCA?
Pancuronium
Ketamine
Meperidine
Epi
26
Why should you avoid TCA and pancuronium?
Increase HR, CO, and BP
| -inhibit NE uptake transporter
27
Why should you avoid TCA and meperidine?
Weak serotonin reuptake inhibitor
28
Why should you avoid TCA and Epi?
Exaggerated effects
29
Chronic therapy with TCA may have?
Depleted cardiac catecholamines
| -potentially cardiac depressant with anesthetic
30
If hypotension occurs on TCA, what should be given?
Use direct acting agent (phenylephrine)
| -start lower and titrate
31
SSRIs mechanism?
Inhibit reuptake of 5HT into presynaptic neuron
32
What are some adverse effects of SSRIs?
Lack antimuscarinic effects
Lack hypotensive effects
Lack antihistamine effects
33
Can SSRIs get discontinuation syndrome?
Yes
34
Fluoxetine (SSRI) is a potent what and can do what?
Inhibitor of CYP enzymes and may inhibit clearance of warfarin, phenytoin, benzodiazepines
35
Frequently results from combining serotonergic agents is what?
Serotonin syndrome
36
Severe effects of serotonin syndrome?
Seizures, rhabdomyolysis, renal failure, arrhythmia, coma, death
37
What are 4 serotinergic agents that can cause serotonin syndrome?
1. Serotonin reuptake inhibitors
2. Serotonin releasers (amphetamine, ephedrine)
3. Monoamine oxidase inhibitors
4. Direct 5HT receptor agonists
38
Should you avoid these combinations?
| SSRI + tramadol, CYP inhibitors, sumatriptan, meperidine, fentanyl, dextromethorphan, linezolid, phenelzine
YES
39
Monoamine Oxidase inhibitors (MAOIs) mechanisms:
Enzyme responsible for NT degradation
- impact NE, dopamine, 5HT
- amount of NE and 5HT increase at receptor site
40
What are contraindicated drugs with pts on MAOIs?
Indirect acting as they may cause fatal HTN crisis
| -ephedrine, amphetamine
41
How do direct acting vasopressins affect pts with MAOIs?
May have enhanced effect due to additive effects so start very low dose and titrate
-Phenylephrine, NE
42
What drugs should be avoided with pts on MAOIs?
Pancuronium
Ketamine
Local anesthetics containing Epi
43
What drugs inhibit 5HT uptake with pts on MAOIs?
Opioid analgesics: meperidine, dextromethorphan, propoxyphene, methadone, fentanyl
44
Which opiate drugs are considered safe with pts on MAOIs?
Codeine, morphine, oxycodone
45
Which serotonin transport affinity drugs have the most potent interaction when combined with MAOI?
SSRI
46
Which serotonin transport affinity drugs have fairly potent interaction when combined with MAOI?
SNRI and TCA
47
Management of serotonin syndrome:
5HT2A and 5HT1A receptor antagonists (chlorpromazine, cyproheptadine)
48
Which agents of 5HT2A and 5HT1A are ineffective/worsens serotonin syndrome with pts on MAOI?
Bromocriptine and propranolol
49
Anesthesia in pts on MAOIs may reduce hepatic metabolism of what drugs?
Barbiturates (thiopental, methohexital)
| Opioids; reduce clearance and enhance effects (respiratory depression)
50
What is considered safe in anesthesia in pts on MAOI:
```
Propofol
Etomidate
Dexmedetomidine
Benzodiazepines
Inhaled anesthetics
Antimuscarinics
NSAIDs
```
51
5 therapeutic uses for antipsychotics:
1. Schizophrenia
2. Bipolar disorder
3. Severe/refractory depression
4. Tourette’s
5. Huntington’s syndrome
52
What system deals with dopamine hypothesis of schizphrenia; hypothesis of positive psychotic symptoms (hallucination, paranoia, delusions)
Meso-limbic system
53
Meso-limbic system has what kind of hormones?
Excess of dopamine
54
Which system deals with mediates negative and cognitive symptoms of schizophrenia?
Meso-cortical system
55
What does Meso-cortical system hormones look like?
Deficiency of dopamine and excess 5HT
56
What are the 4 key pathways involved in pathophys of schizophrenia?
1. Mesolimbic
2. Mesocortical
3. Nigrostriatal
4. Tuberoinfundibular
57
Therapeutic for mesolimbic pathway?
Decrease dopamine with D2 receptor antagonism
58
Therapeutic for mesocortical pathway?
Increase dopamine with 5HT receptors)
59
Which antipsychotic pathway deals with control of motor movements?
Nigrostriatal
60
Which antipsychotic pathway deals with temp regulation, prolactin secretion?
Tuberoinfundiular pathway
61
What is D2 good to combine with for antipsychotic?
5HT2A
62
What is first generation of antipsychotic agents?
Typical antipsychotics; D2 receptor antagonists
63
What is second generation of antipsychotic agents?
Atypical antipsychotics; D2 + 5HT2A receptor antagonists
64
What does antipsychotic agents - first generation D2 receptor block cause?
Extrapyramidal side effects of Parkinson’s like adverse effects, dystopia, akathisia
65
How does antipsychotic agents -first generation have other receptors and effects?
```
Muscarinic receptor antagonists
Alpha1 receptor antagonists (hypotension)
Histamine1 receptor block (sedation)
Lower seizure threshold
QT prolongation
```
66
How does antipsychotic agents -second generation affect the pathways?
Mesolimbic: weaker but adequate D2 receptor block
| Mesocortical, NS, TIF: weake D2 and block of 5HT2A that enhances dopamine release
67
What are some side effects to antipsychotic agents - second generation?
Wt gain, hyperlididemia, glucose intolerance/DMT2
68
What drug should you avoid for a pt on antipsychotic agents and why?
Ketamine due to decrease in seizure threshold
69
Common side effects of pts on antipsychotic agents? (7)
Tachycardia, hypotension, increase body wt, DM, impaired temp regulation, decreased stress response, neuroleptic malignant syndrome
70
Rare, potentially life-threatening neurological disorder associated with first generation agents - related to D2 receptor potency
Neuroleptic malignant syndrome
71
What does neuroleptic malignant syndrome look like:
Hyperthermia, muscle rigidity, altered mental status, autonomic dysfunction, elevated CK
72
What is a supportive therapy for neuroleptic malignant syndrome?
Dantrolene
73
What are 4 pharmacotherapy of Parkinson’s disease?
1. Antimuscarinic agents (benztropine, trihexphenidyl)
2. Dopamine replacement (levodopa)
3. Inhibitors of dopamine metabolism (dopa decarboxylase inhibitor, COMT inhibitor, MAO inhibitor)
4. Dopamine receptor agonists (pramipexoole, ropinrole)
74
Is levodopa transported across BBB?
Yes
75
What drug is a Peripheral decarboxylase inhibitor that increases amount of levodopa to reach brain and decrease peripheral dopamine related adverse effects
Carbidopa
76
What is a dopamine agonists for PD with DQ administration?
Apomorphine
77
What is a severe side effect of apomorphine?
Nausea
78
What are selective D3 agents for PD?
Pramipexole and ropinrole
79
What are COMT inhibitors for PD and side effect?
Tolcapone, entacopone
| Nausea and diarrhea
80
MAOI for PD and side effect?
Selegiline, rasagiline
| Nausea and vomiting
81
Do PD pts continue usual meds?
Yes
82
When do you administer levodopa for PD pts?
20 min before induction, repeat intra, and postop
83
What is the exception for PD pts to take their med prior to surgery?
Deep brain stimulator implantation (treatment for PD)
84
What should be avoided in PD pts for normal surgery?
Dopamine antagonist antiemtics (chlorpromazine, promethazine)
85
What should be avoided in PD pts undergoing brain stimulator transplantation?
Agents that affect GABA (benzodiazepines, propofol)
86
Which meds are safe for PD pts undergoing brain stimulator transplantation?
Dexmedetomidine
87
Alzheimer’s disease pharmacotherapy?
```
Cholinesterase inhibitors (donepezil, rivastigmine, galantamine)
NMDA receptor antagonist (memantine)
```
88
What drug interaction with neuromuscular blockers in Alzheimer’s disease pts?
Prolongation of Sux and resistance to non-depolarizing agents so need larger dose
89
Do you use shorting acting sedatives, hypnotics, anesthetics, opioids for Alzheimer’s disease pts?
Yes
90
How do you handle acetylchoinesterase inhibitors prior to elective surgery for Alzheimer’s pts?
Hold
91
If not able to hold acetylcholinesterase inhibitors prior to surgery, what kind of interactions can there be? (4)
1. Avoid NMB
2. If using nondepolarizing NMB then need larger dose
3. Sux has prolonged block (phase II block)
4. Monitoring peripheral nerve stimulator a must
92
What drugs to avoid for post op delerium in Alzheimer’s disease pts?
Benzodiazepines
| Drugs with antimuscarinic profile
93
4 CNS changes with elders:
1. Reduction in NTs and receptors
2. Increased sensitivity to IV agents that act in CNS (propofol, opioids, benzodiazepines but decrease MAC)
3. Exaggerated respiratory desires ant affects (impaired response to hypercapnia and hypoxemia)
4. Pain perception (higher thresholds, delay)
94
3 cardiovascular changes in elders:
1. Vascular stiffening
2. Dysautonomia (impaired beta receptor response to increase CO )
3. More BP liability, hypotension
95
4 respiratory changes in elders:
1. Reduced pulmonary reserve
2. Increased stiffening of chest wall and decreased elasticity of lung, increased work of breathing (risk of atelectasis and hypoxemia)
3. Impaired pharyngeal function, aspiration
4. Exaggerated respiratory depressant (opioids, benzodiazepines, volatiles anesthetics)
96
3 hepatic and renal changes in elders:
1. Reduced liver function
2. Decline GFR, creatinine clearance
3. Volume of distribution (decreased TBW, increased adipose tissue)
97
What are the anesthetic drugs to avoid for elders:
Benzodiazepines
NSAIDs (ketorolac)
Opioids
Antimuscarinic
98
3 general approaches for anesthesia in elders:
1. Reduce initial dose
2. Increase interval between repeated doses
3. Use shorter acting agents
99
What 2 benzodiazepines not recommended?
Lorazepam and diazepam
100
What do you reduce propofol to?
40-50% for induction (1.-1.75mg/kg IV over 30 sec)
| 30-40% for infusion
101
Ketamine with elders:
Rarely used but could be used if pt has hypovolemia and need bronchodilation
-use for potent analgesic to avoid opioids
102
How much do you reduce opioids for elders?
25-50%
103
What is recommended longer or shorter acting agents for elders?
Shorter
104
Reduction in hepatic metabolism prolong duration of what drugs?
Pan, vec, and rocuronium
105
How is sugammadex affected in elders?
Recovery is slower
