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Antipsychotics are used to treat schizophrenia, schizoaffective DO, organic brain syndrome with psychosis, delusional DO, Bipolar DO
Side effects of Antipsychotics
- Anticholinergic-dry mouth, urinary hesitancy/retention, constipation, blurred vision, photosensitivity, dry eyes, ejaculatory inhibition
- EPS-pseudoparkinsonism, acute dystonic reaction (spasms of neck, back, and eyes), akathisia, Tardive Dyskinesia (tongue protrusion, lip smacking, chewing, blinking, grimacing, choreiform movement of limbs and trunk, foot tapping)
- CV- hypotension, orthostatic hypotension, tachycardia
- Other- agranulocytosis, seizures, NMS, photosensitivity, sedation/weight gain
- Metabolic Syndrome- weight gain, diabetes, dyslipidemia, CV disease
Target Symptoms of Antipsychotics
- Typical and Atypical-(Positive symptoms) psychotic disorders of thinking (delusions, hallucinations); disorganized speech and behavior (positive formal thought DO-incoherence, derailment, illogicality; bizarre behavior-catatonic motor behaviors, DO of movement, deterioration of social behavior)
- Atypical- (Negative symptoms) affective flattening, alogia, avolition/apathy, anhedonia/asociality, attention impairment
- Mood symptoms, cognitive impairment, difficulty with socialization
- Side effect of typical antipsychotics characterized by dystonia, akathisia, akinesia, parkinsonism, and Tardive Dyskinesia.
- Treatment involves a decrease in drug dose, changing the drug to a drug with lower incidence of EPS, or administering a treating drug.
- Drugs to treat EPS-
- Anticholinergics- benztropine (Cogentin), trihexyphenidyl (Artane), biperiden (Akineton)
- Antihistamines- diphenhydramine (Benadryl)
- Dopamine agonist- amantadine (Symmetrel)
- Benzodiazipines- diazepam (Valium), lorazepam (Ativan), clonazepam (Klonopin)
Neuroleptic Malignant Syndrome
- Adverse reaction to antipsychotic or neuroleptic drug. Symptoms include Fever (>100.4), tachycardia, confusion or altered consciousness, diaphoresis/sweating, rigid muscles, tremor, incontinence, autonomic imbalance, stupor, leukocytosis, elevated CPK, renal failure
- Treatment includes stopping all neuroleptic drugs, treat hyperthermia aggressively (cooling blankets, ice packs to axillae and groin), hydration, renal dialysis, ventilation, BZs, dantolene, and dopaminergic agents.
- Dopamine and Serotonin targeted to treat both positive and negative symptoms
- aripiprazole (Abilify)
- asenapine (Saphris)
- clozapine (Clozaril)
- iloperidone (Fanapt)
- lurasidone (Latuda)
- olanzapine (Zyprexa, Zydis)
- paliperidone (Invega)
- riperidone (Riperdal, Consta, M-Tabs)
- quetiapine (Seroquel)
- ziprasidone (Geodon)
- Elevates serum prolactin levels and can cause EPS
- Comes in Long Acting Injectable Form
- metabolic syndrome, sedation
- reserved for patients with treatment resistant illness because of agranulocytosis, seizures, myocarditis. WBC count weekly for 6 months then biweekly for duration of medication administration; used only if other treatments do not work due to its high rate of EPS and side effects
Long Acting Injectable Antipsychotics
- riperidone (Risperdal, Consta), fluphenazine (Prolixin), fluphenazine decanoate (Prolixin D), haloperidol decanoate (Haldol D)
- Used to treat acutely disturbed patients or those who represent significant compliance risks that are injected every 2-4 weeks.
- Advantages- overcoming noncompliance, circumvention of reduced bioavailability, circumvention of reduced metabolism, achievement of stable plasma levels
- Disadvantages- inability to withdraw drug rapidly, length process to adjust doseage related to extended half-lives
- Dopamine targeted positive symptoms, high incidence of EPS
- chlorpromazine (Thorazine)
- thioridazine (Mellaril)
- mesoridazine (Serentil)
- perphenazine (Trilafon)
- trifluperazine (Stelazine)
- fluphenazine (Prolixin)
- fluphenazine decanoate (Prolixin D)
- thiothixene (Navane)
- haloperidol (Haldol)
- haloperidol decanoate (Haldol D)
- loxapine (Loxitane)
- pimozide (Orap)
Treating patients with Delirium
Assess and provide for basic physiological needs first. Create a calm, comfortable environment, use lights in the room, and if possible, have a family member present. If patient is having hallucinations, try to orient the patient continually, and if needed haloperidol and atypical antipsychotics are used. Provide clear messages and instructions with minimal choices and educate patient and family member. Patient may need multiple teaching sessions.
- Cholinesterase Inhibitors improve memory.
- donepezil (Aricept), galantamine (Razadyne), rivastigmine (Exelon). These drugs work by inhibiting AChE. They allow a greater concentration of ACh in the brain and improve cholinergic function. S/E are nausea, anorexia, and diarrhea.
- tacrine (Cognex) is an ACE inhibitor used.
- memantine (Namenda) is N-methyl-D-aspartate receptor antagonist used in combination with cholinesterase inhibitors.