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Antipsychotic Medications
A. Introduction:
This lab focuses on antipsychotic medication, the AIMS exam, and utilizing the
Mental Status Exam to assess the effects of the medication treatment.
B. Learning Objectives:
Upon completion of this lab the student will be able to:
1.
2.
3.
4.
List 5 "Typical" anti-psychotic medications
List 4 "Atypical" (new generation) anti-psychotic medications
Compare and contrast the "old" and "new" generation anti-psychotics
Identify the 4 EPS side effects that can occur with anti-psychotic
medication
5. Discuss the anticholenergic side effects that may occur with these
medications
6. Describe the role of antiparkinsonian medications to cope with side effects
7. Discuss the symptoms of psychosis that are typically present on the
Mental Status Exam
8. Identify the symptoms that respond best to treatment with medication
9. Identify the purpose of the AIMS exam
10. Discuss the importance of the AIMS exam and the nursing implications
C. Learning Resources
1. Keltner, N.L., Schwecke, L.H., & Bostrom, C.E. (2003). Psychiatric
Nursing (4th edition) St. Louis: Mosby, pp. 188-232.
2. Review the Psychotropic Medications (attached)
3. Review the AIMS Exam Form
4. View the films:
 "I'm Still Here: The Truth About Schizophrenia"
 "AIMS: The Abnormal Involuntary Movement Scale"
PSYCHOTROPIC MEDICATIONS
The purpose of psychotropic medication is to help balance the Neurotransmitters in the
brain. Studies have shown that brain neurotransmission is effected by many different
things: genetics, diet, exercise, connecting emotionally with another human being, learning
about your self and new coping behaviors. We are studying all of these, but this particular
handout focuses on the effects of biochemistry to alter neurotransmission in a way that is
helpful to your patients. You will see that the neurotransmitters are everywhere in the
body, which means that while we are altering the brain chemistry, other systems of the
body are affected, thus causing “side effects.”
Neurotransmitters: There are over 30 presently discovered. This handout will focus on 5 of
these.
1. Definition: Neurotransmitters are chemical messengers that release chemicals in the
synapse (junction between two nerve cells). These transmitters are only in the synapse
for a certain length of time to be either used again or degraded.
2. Receptors: the site of binding for the neurotransmitter. This binding elicits a response.
Then the chemical is passed onto the next nerve cell.
3. Mode of action of medication:
A. Blocking the re-uptake in the synapse, so that more of the chemical can be
absorbed (Prozac).
B. Blocking a receptor or binding to prevent absorption.
C. Altering a receptor.
D. Providing chemicals that help produce more of a substance.
4. Therapeutic Effects:
A. Target symptoms: each class of medications has certain symptoms they target.
B. Onset of Action: Varies, but usually takes 2 to 3 weeks before you get the
maximum effect.
C. Long term maintenance: Since mental illness is a chronic disease, like diabetes,
some patients need to stay on their medications.
D. Patient education is a great need. Or you may need to assess for compliance
problems.
5. Types of neurotransmitters:
A. Dopamine: Mental alertness, thinking and decision making, pleasure cascade,
psychosis.
B. Norepinephrine: Alertness, stimulate heart rate, ability to focus.
C. Serotonin: Mood - both excitatory and inhibitory, regulates sleeping and eating. An
imbalance can cause depression, eating disorders, OCD and migraine headaches.
D. GABA: Inhibitory, calming.
E. Acetylcholine: Memory, lots of medications cause a decrease; therefore
“anticholinergic side effects.”
6. Antipsychotic Medication: Typical and Atypical
A.
B.
Typical - the “old” ones that primarily block dopamine from the receptors and have
serious side effects. They only affect the “positive symptoms” of schizophrenia.
Atypical – “new” medications that effect dopamine and serotonin. Also, they have a
much better side effect profile and decrease the “positive” and “negative”
symptoms. They are very expensive.
7. Typical antipsychotics:
A.
B.
C.
High Potency - 1 to 20 mg-High EPS, low anticholinergic side effects
1. Haldol
2. Prolixin: both these meds come in PO, IM and Depo IM
In-betweens - 4-20 mg
1. Stelazine
2. Trilaphon
3. Navane
4. Loxitane
5. Moban
Low Potency - 50 to 1000 mg
1. Thorazine
2. Mellaril
3. Serentil
8. Atypical Antipsychotics: less EPS side effects, decrease both positive and negative
symptoms
A. Clozaril - 300 mg
B. Risperdol - 6-12 mg – Note: On April 16, 2003, Janssen Pharmaceutica Products,
Inc., published the following warning: Cerebrovascular adverse events (e.g.,
stroke, transient ischemic attack), including fatalities, were reported in patients
(mean age 85 years; range 73-97) in trials of risperidone in elderly patients with
dementia-related psychosis. In placebo-controlled trials, there was a significantly
higher incidence of cerebrovascular adverse events in patients treated with
risperidone compared to patients treated with placebo. RISPERDAL has not been
shown to be safe or effective in the treatment of patients with dementia-related
psychosis.
C. Zyprexa - 10 mg (Olanszapine)
D. Seroquel - .150-300 mg (Quetiapine)
E. Geodon - 20- 80 mem BID (Zprasidone)
9. Antiparkinsonian Agents
A.
B.
C.
D.
Cogentin 1-2 mg (benztropine)
Artane 1-2 mg
Benadryl 50 mg
Symatrel 100 mg
10. Side Effect of Typical Antipsychotics
A. Drowsiness: common during the first few days of treatment; usually disappears in
one to two weeks. Patients should avoid alcohol and medications such as
antihistamines and sleeping aids.
B. Extrapyramidal side affects (EPS):
1. Dystonias: usually occur during the first 5 days of treatment, almost never after
the first 3 months of treatment. They can occur after each injection of IM
medication. Risk factors include high potency agents, large doses, and parental
(IM or IV) route of administration. These affects are readily reversible with
intramuscular injections of diphenhydramine (Benadryl), or benztropine
(Cogentin). Oral antiparkinson agents may need to be continued for a few
weeks to prevent recurrence of the reaction. Patients will often times refer to
allergic or epileptogenic in nature, and do not preclude continued use of the
agent. These reactions include spasms of the:
eye-oculogyric crisis
neck-torticollis
back-retrocollis/opisthotonus
tongue-glossopasm
or other muscles
2. Pseudoparkinsonism: Due to an imbalance of acetylcholine and dopamine in
pseudoparkinsonism this effect is reversible. Treatment consists of reducing the
dose, changing to a different agent, or using oral antiparkinson agents such as
benztropine (Cogentin), trihexyphenidyl (Artane), diphenhydramine (Benadryl),
biperiden (Akineton), or amantidine (Symmetrel). Symptoms include: decrease
movements (bradykinesia, akinesia), muscle rigidity (cogwheel and lead pipe),
resting hand tremor, drooling, mask-like face, and shuffling gait.
3.
effect as a feeling of inner restlessness. This effect can easily be confused with
anxiety and agitation. Differences between akathisia and anxiety/agitation
improves with increases in antipsychotic doses, and vice-versa; and the patient
can usually control anxiety/agitation for a period of time whereas the patient
cannot typically control akathisia. This effect can be treated by changing to a
different agent, reducing the dose if possible, or by the use of an antiparkinson
agent or benzodiazepine.
4. Tardive Dyskinesia: symptoms consist of involuntary lip and tongue movements,
and writhing movements (choreoathetoid) of the arms and legs. Movements
disappear during sleep. Risk factors include increased age, long duration of
therapy, use of high potency agents, and large doses. There is no effective
treatment for tardive dyskinesia. Reducing the dose of the antipsychotic agent
and addition of an antiparkinson agent result in worsening of the symptoms.
C. Anticholinergic side affects: tolerance usually develops to these side affects over 12 months.
- dry month - use of ice chips, sugarless gum, or sugarless sour candy may be
helpful
- blurred vision - reading in well lighted areas and varying the distance of the
material being read may be helpful
- constipation - exercise, drinking plenty of fluids daily, and increasing the
amount of bulk food (bran, salads) intake may relieve this effect. Chronic
problems may require short term use of topical nasal decongestant.
- increase in heart rate
- ejaculation inhibition - most common with mellaril
D. Cardiovascular side effects: most common with low potency agents.
- postural hypotension (dizziness or fainting) - commonly occurs with sudden
changes in position e.g. laying or sitting to standing position, or in hot
temperatures such as hot showers, saunas, and summer heat. Patients
should be told to change positions slowly, and use good judgement in
extreme heat.
- arrhythmias/palpitations (changes in heart rhythm)
E. Miscellaneous side effects:
- skin rash: usually 2 to 8 weeks after initiation of treatment
- photosensitivity: severe sunburn, most common with Thorazine. Patients
should be instructed to wear hats, and long sleeve clothing until the effects
from the sun are determined for that patient. A sunscreen is also useful. A
Sun Protection Factor (SPF) number 15 sunscreen is best. Good choices are
Presun 15, and Solbar 15 plus.
Rare side effects
- agranulocytosis
- jaundice
- lowered seizure threshold
- galactorrhea, gynecomastia
- menstrual irregulations
- body temperature alterations
- pigmentary retinopathy
- increase in blood sugar
- weight gain
11. Side effects of atypical antipsychotics
A. Clozaril-used for refractory, chronic schizophrenia
1. Drowsiness and other anticholinergic effects
2. Drooling
3. Agranulocytosis; can be severe, due blood tests weekly for 6 months, then biweekly
4. Blood tests make drug costly and inconvenient- about $9,000 per year.
B. Risperdone/Resperdol
1. First line for any psychotic patient
2. Sleep disturbance; both insomnia and drowsiness
3. Headache-orthostatice hypotension
4. Constipation, nausea, and dyspepsia
5. EPS at higher doses> 8 mg daily
C. Olanzapine/Zyprexa
1.
First line for psychosis
2. Drowsiness, constipation, dry mouth, headache, weight gain
3. Rare EPS
D. Quatiapine/Seroquel
1. Lowest side effects
2. Drowsiness and orthostatic hypotension
E. Zprasidone/ Geodon
1. Fatigue drowsiness GI Disturbance, EPS cold symptoms
2. Potential medical problem due to prolonging the QT interval
3. Check for dug interactions especially with any cardiac medications