Download Antipsychotic Medication

Antipsychotic Medication
Mary Knutson, RN
3-7-12
Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc.
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Clinical Uses of Antipsychotics
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Short-term: in severe depression and in
substance-induced psychosis
Treatment of aggressiveness and behavioral
problems with pervasive developmental
disorders
Useful in elderly patients with dementia;
delirium with agitation and psychosis
Decrease vocal tics in Tourette syndrome
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Typical Antipsychotics
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Phenothiazines
 Chlorpromazine (Thorazine), thioridazine
(Mellaril), mesoridazine (Serentil),
perphenazine (Trilafon), trifluoperazine
(Stelazine), fluphenazine (Prolixin)
Thiothixene (Navane)
Butyrophenone: haloperidol (Haldol)
Dibenzoxazepine: loxapine (Loxitane)
Dihydroindolone: molindone (Moban)
Diphenylbutylpiperidine: pimozide (Orap)
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Atypical Antipsychotics
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Aripiprazole (Abilify)
Clozapine (Clozaril)
Paliperidone (Invega)
Risperidone (Risperdal, Consta, M-Tabs)
Olanzapine (Zyprexa, Zydis)
Quetiapine (Seroquel)
Ziprasidone (Geodon)
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Target Symptoms for
Antipsychotics
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Positive symptoms: excess or distortion of
normal function
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Psychotic disorders of thinking: delusions or
hallucinations
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Disorganization of speech and behavior: thought
disorder (incoherence, derailment, illogicality), bizarre
behavior
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Target Symptoms for
Antipsychotics
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Mood symptoms
Cognitive impairment
Difficulty with socialization
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Target Symptoms for Atypical
Antipsychotics
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Negative symptoms: decrease or loss of normal
function
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Flattened affect
Alogia (restricted thought and speech)
Avolition/apathy
Anhedonia/asociality
Attentional impairment
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Treatment Plan
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Initial nursing treatment plan should address
target symptoms; selection of drug, dose,
response, observed side effects and their
treatment; patient safety, education, reassurance
Nurse-patient relationship forms basis for ongoing
therapeutic alliance
Nonpharmacological treatment of residual
symptoms of psychosis more successful when
patient’s behavior, mood, and thought processes
begin to improve with medications
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Drug Action of Atypical
Antipsychotics
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Block at dopamine2 (D2) and serotonin2 (5-HT2)
postsynaptic receptors; thus they are DA and 5HT antagonists
Aripiprazole: new generation of atypical
antipsychotics, a dopamine-serotonin stabilizer;
partial agonist (enhancer) at D2 and 5-HT1A
receptors and has antagonistic (blocking) activity
at 5-HT2A receptors
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Advantages of Atypical
Antipsychotics
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Improve positive symptoms of schizophrenia, but
unlike typical drugs, they also improve negative
symptoms
Atypical drugs reported to treat mood symptoms,
hostility, violence, suicidal behavior, difficulty
with socialization, cognitive impairment seen in
schizophrenia
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Disadvantages of Atypical Drugs
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Can result in metabolic syndrome
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Problems with this syndrome: weight gain,
diabetes, and dyslipidemia, often resulting in
cardiovascular disease
Higher cost compared with typical
antipsychotics
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However, cost/benefit analyses show cost
outweighed by improved effectiveness and quality
of life of patients taking these drugs
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Side Effects of Atypical
Antipsychotics
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Risperidone: elevate serum prolactin levels;
may cause extrapyramidal symptoms (EPS)
at higher doses
Weight gain and metabolic disturbances; side
effects (except ziprasidone and aripiprazole);
olanzapine and clozapine highest likelihood
of causing problems
Sedation commonly observed in patients
taking quetiapine, olanzapine, or clozapine
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Side Effects
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Because ziprasidone associated with
mild/moderate prolonged Q-T interval, may
need monitoring of ECGs and cardiac
functioning
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Side Effects
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Clozapine often reserved for patients with
treatment-resistant illness because of side
effects: agranulocytosis, seizures, myocarditis
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Prescribers must follow treatment protocol,
entering patients in national registry, monitoring
WBC count every 1-2 weeks, and writing
prescriptions for maximum of 2 weeks
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Drug Action of Typical
Antipsychotics
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Dopamine (DA) antagonists: they block
postsynaptic D2 receptors in several DA tracts in
brain; decrease in positive symptoms of
schizophrenia and EPS
Have synaptic effects in other transmitter
systems; broad side effect profile
Selection of drug determined by extent, type,
severity of side effects
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Drug Action
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A low-potency drug (chlorpromazine) reduces
risk of EPS; high-potency drug (haloperidol)
minimizes sedation, postural hypotension,
anticholinergic effects
Have not been particularly effective in treating
cognitive impairment and mood symptoms,
the other dimensions of schizophrenia
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Side Effects of Antipsychotics
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Discomfort to life-threatening emergency
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EPS
• Acute dystonic reactions
• Akathisia
• Parkinson syndrome
Neuroleptic malignant syndrome (NMS)
Seizures
Agranulocytosis
Photosensitivity, anticholinergic effects, or metabolic
syndrome
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Extrapyramidal Symptoms
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EPS and tardive dyskinesia: side effects of
typical antipsychotics
Result in patient nonadherence with drug
EPS common and often painful, disabling
Also stigmatizing but usually can be
prevented or minimized and effectively
treated, except for tardive dyskinesia, which
may remain
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Extrapyramidal Side Effects
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Mimic extrapyramidal disease by causing:
 Involuntary movement
 Changes in muscle tone
 Abnormal posture
May resemble Parkinson disease
Caused by drugs that block dopamine receptor
sites
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Acute Dystonic Reactions
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Sudden spasms of major muscle groups that
are frightening and painful
They may need treatment with medication
Occur mostly with high-potency drugs or with
abrupt withdrawal
Oculogyric crisis is when eyes stay in an up
or sideways position for minutes or several
hours
Torticolis is when head is inclined to one side
involuntarily because of muscle contractions
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Akathisia
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Inability to remain still
 Pacing
 Inner restlessness
 Leg aches relieved by movement
Need to rule out anxiety or agitation, then
medicate patient
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Parkinson Syndrome
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Akinesia: abnormal state of hypoactivity or
muscle paralysis
Cogwheel rigidity: abnormal rigor in muscle
tissue, including jerky movements when
muscle passively stretched
Fine tremor: quick, rhythmic, quivering
movements that sometimes disappear during
purposeful movements
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Tardive Dyskinesia (TD)
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Can occur after use (usually long use) of
conventional antipsychotics
Involuntary movements: tongue protrusion, lip
smacking, chewing, blinking, grimacing,
choreiform movements of limbs and trunk, foot
tapping
Use preventive measures, and assess often
Consider changing to atypical antipsychotic
because there is no treatment for TD
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Treatment Principles
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Tolerance to side effects usually develops by
third month
Decrease dose of drug
May add a drug to treat EPS, then taper after
3 months on antipsychotic
Use a drug with lower EPS profile
Give patient education, support
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Drug Strategies to Treat EPS
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Administer one of these drugs:
 Anticholinergics: benztropine (Cogentin),
trihexyphenidyl (Artane), biperiden
(Akineton), procyclidine (Kemadrin)
 Antihistamine: diphenhydramine (Benadryl)
 Dopamine agonist: amantadine
(Symmetrel)
 Benzodiazepines: diazepam (Valium),
lorazepam (Ativan), clonazepam (Klonopin)
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Neuroleptic Malignant Syndrome
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Rare but potentially fatal (14%-30% mortality)
side effect of antipsychotic drugs
Fever, tachycardia, sweating, muscle rigidity,
tremor, incontinence, stupor
Treatment: stop triggering drug, initiate
supportive care
Important reason for nurse to assess carefully
for drug side effects
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Other Side Effects of
Antipsychotics
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Anticholinergic effects
 Constipation, dry mouth, blurred vision,
orthostatic hypotension, tachycardia, urinary
retention, nasal congestion
Metabolic syndrome
 Weight gain, diabetes, and dyslipidemia, often
resulting in cardiovascular disease
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General Pharmacological
Principles
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Dosage requirements for individual patients
vary considerably, must be adjusted as target
symptoms change and side effects monitored
Some patients begin to respond to sedating
effects of typical drugs in 2-3 days, some take
as long as 2 weeks
Full benefits may take 4 or more weeks
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Drug Effects
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Atypical drugs may begin to work in 1 week but
take several months to reach maximum efficacy
Thus patient, family, and clinician must not
increase dose prematurely because this strategy
usually increases side effects and not
effectiveness
Brief course of benzodiazepine may help patient
maintain control during this time
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Changing Drug Therapy
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Patient unresponsive to antipsychotic trial
often responds to another antipsychotic in a
second trial
Clozapine is usually considered only after
second trial failure (when patient is
considered treatment resistant)
When switching from one antipsychotic to
another, gradually decrease one drug while
gradually increasing new drug (cross-titration)
over 2-4 days
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Preparations of Antipsychotics
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Several typical (haloperidol) and atypical
(ziprasidone) antipsychotics have short-acting
injectable preparation, can be administered IM in
acutely agitated patients
Often provides relief for acutely ill patient while
oral formulations begin to work or until acute
crisis resolved
Some in oral disintegrating tablet form
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Maintenance Treatment
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May include injectable preparations if patient
unable to adhere adequately to daily dosing
regimen
 Long-acting (haloperidol decanoate,
fluphenazine decanoate, Risperdal Consta)
typical and atypical drugs available
 Test ability to tolerate first by administering
oral form for several days, then
administering injection that may last for
many weeks
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Antipsychotics
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Taper slowly over days to weeks to avoid
dyskinetic reactions and side effects
Do not cause chemical dependency or tolerance
to antipsychotic effects
Low abuse potential; safe in overdose
Effects on fetus inconclusive, but must consider
what is best for pregnant mother
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Role of Nurse
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Minimize patient’s fears
Decrease any sense of stigmatization
Enhance adherence to drug treatment
Provide effective patient education
Support patient, family
Manage intensive, comprehensive medication
regimen
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References
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Stuart, G. (2009). Principles and practices of
Psychiatric Nursing (9th ed.) St. Louis: Mosby
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