Ppt chapter 15

Chapter 15
Drugs Relieving Anxiety and
Promoting Sleep
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Question
• What system in the brain is responsible for emotion?
– A. Amygdala system
– B. Reticular system
– C. Limbic system
– D. Ventricular system

Answer
• C. Limbic system
• Rationale: The limbic system in the brain is known to
be primarily responsible for emotions.

Emotions and Neurotransmitters
• The limbic system in the brain is known to be primarily
responsible for emotions.
• The amygdala receives incoming sensory signals and then
communicates with the frontal lobes of the brain.
• The amygdala can signal the brain that a threat is present
and set off a fear response or anxiety.
• Another part of the brain, the hippocampus, is
responsible for processing threatening or traumatic
stimuli.
• The brain sends its messages to the body by way of the
nervous system.

GABA Cell Receptors

Sleep
• Sleep is a time of bodily rest, although the brain remains
active.
• There are two phases:
– No rapid eye movements (NREM)
– Rapid eye movements (REM)

Sleep (cont.)
• NREM stages of sleep are further divided into
– Stage 1—light sleep; muscles relax; brain waves are
irregular and rapid.
– Stage 2—brain waves are larger than in stage 1, with
bursts of electrical activity.
– Stages 3 and 4—deep sleep, with even larger, slower
brain waves called delta waves.

Sleep (cont.)
• A number of physiologic changes occur during sleep.
• The amount of sleep needed by a person varies
throughout the life span, with infants requiring the most
sleep and adults requiring the least.

Anxiety
• Anxiety is a feeling of unease that something bad or
undesirable may happen.
• Some anxiety is normal; it is a protective mechanism.
• Anxiety becomes pathologic when it is severe and chronic
and interferes with a person’s ability to function in
normal life.
• Anxiety disorders can become progressively worse if they
are untreated.
• Anxiety commonly occurs in combination with other
mental or physical illnesses.

Sleep Disorders
• Between 50 and 70 million Americans have a sleep
disorder.
• These disorders are many and may include the following
problems:
– Narcolepsy—sudden irresistible sleep attacks of
unknown origin lasting from seconds to minutes, two
to six times a day
– Sleep apnea—a group of disorders characterized by
cessation of breathing during sleep
– Sleepwalking—getting up and walking about while
still asleep

Sleep Disorders (cont.)
• These disorders are many and may include the following
problems (cont.):
– Night terrors—occur only in children, with periods of
fright, crying, moaning, or screaming after a brief
time asleep
– Excessive daytime sedation
– Insomnia

Selective Serotonin Reuptake Inhibitors
• Selective serotonin reuptake inhibitors (SSRIs) are a
class of antidepressant drugs, some of which are now
considered first-line therapy for anxiety disorders.
• Low serotonin levels are known to be present in severe
stress and in many mood and anxiety-related disorders.
• SSRIs indirectly increase the amount of the
neurotransmitter serotonin available in the synapses.
• SSRIs are generally well tolerated with few adverse
effects.

Tricyclic Antidepressants
• The tricyclic antidepressants (TCAs) are another class of
antidepressants.
• TCAs are as effective as the SSRIs in treating most
anxiety disorders.
• TCAs work by affecting the regulation of serotonin or
norepinephrine in the brain.
• TCAs have a higher adverse effect profile than SSRIs,
which limits their use as antidepressants.

Monoamine Oxidase Inhibitors
• Monoamine oxidase inhibitors (MAOIs) are the oldest
class of antidepressants.
• The MAOIs used to treat anxiety disorders are phenelzine
(Nardil), tranylcypromine (Parnate), and isocarboxazid
(Marplan).
• These drugs are occasionally prescribed for panic
disorder and social phobia.

Monoamine Oxidase Inhibitors (cont.)
• Monoamine oxidase is the enzyme that degrades
serotonin in the synapse.
• By inhibiting the enzyme, higher levels of serotonin can
remain in the synapse and be active.
• The MAOIs are associated with a significant risk of a
serious drug–food interaction.

Beta-Blockers
• Beta-blockers are adrenergic drugs most frequently used
for a wide variety of cardiac conditions.
• Among other actions, they slow the heart rate.
• This helps the patient with some types of anxiety who
may be uncomfortable and highly aware of the
tachycardia and palpitations.

Benzodiazepines
• Benzodiazepines are used for a number of therapeutic
effects.
• As a class, benzodiazepines appear to potentiate the
effects of GABA.
• The result is more CNS depression than would normally
be found.
• Benzodiazepines bind to specific receptor sites to produce
their effects.
• As a drug class, benzodiazepines have a high margin of
safety.

Question
• Benzodiazepines are used to treat which of the following
condition(s)?
– A. Anxiety
– B. Seizures
– C. Alcohol withdrawal
– D. All of the above

Answer
• D. All of the above
• Rationale: Benzodiazepines are used for the
following: anxiety relief, sleep promotion,
anticonvulsant effects, muscle relaxation, treatment
of acute alcohol withdrawal, induction of general
anesthesia, preoperative sedation, and conscious
sedation.

Lorazepam: Core Drug Knowledge
• Pharmacotherapeutics
– Used in treating anxiety disorders and insomnia
• Pharmacokinetics
– Administered: parenterally or orally. Distribution:
body tissues. Metabolism: liver. Excreted: kidneys.
• Pharmacodynamics
– Increases the effects of GABA

Lorazepam: Core Drug Knowledge (cont.)
• Contraindications and precautions
– Hypersensitivity, psychoses, acute narrow-angle
glaucoma, and use in children younger than 6 months
• Adverse effects
– Mild drowsiness, ataxia, confusion, respiratory
disturbances, bradycardia, and hypotension
• Drug interactions
– Several drug interactions

Lorazepam: Core Patient Variables
• Health status
– Asses for renal and hepatic impairment
• Life span and gender
– Pregnancy Category D
• Lifestyle, diet, and habits
– Assess the patient for the use of other CNS
depressants.
• Environment
– Oral formulation can be given in any environment.
• Culture and inherited traits
– Longer T½ in Asians

Lorazepam: Nursing Diagnoses and
Outcomes
• Risk for Injury related to drowsiness and other adverse
effects
– Desired outcome: The patient will not sustain an
injury while on lorazepam.
• Anxiety related to disease process
– Desired outcome: The patient will achieve symptom
control.
• Deficient Knowledge related to newly prescribed drug
therapy
– Desired outcome: The patient will learn the actions
and adverse effects of lorazepam and how to safely
self-administer the drug.

Lorazepam: Planning and Interventions
• Maximizing therapeutic effects
– Give at scheduled intervals throughout the day.
• Minimizing adverse effects
– If GI distress occurs, administer lorazepam with food.
– Monitor for paradoxical reactions and stop the drug if
they occur.
– Dilute injectable lorazepam with an equal volume of
compatible solution.

Lorazepam: Teaching, Assessment, and
Evaluations
• Patient and family education
– Caution against use of alcohol with this drug.
– Discuss side effects of medication.
• Ongoing assessment and evaluation
– Lorazepam therapy is effective if the patient reports
a reduction in feelings of anxiety.
– Throughout therapy, assess for therapeutic response
and onset of adverse effects.

Question
• Lorazepam has a ________ duration of action?
– A. Short
– B. Intermediate
– C. Long
– D. Varies with route of administration

Answer
• A. Short
• Rationale: Lorazepam has a short duration of action;
therefore, divide the daily dosage for treating anxiety
into two or three doses and administer the drug
throughout the day.

Buspirone
• Buspirone (BuSpar) is an azaspirodecanedione that is not
chemically or pharmacologically related to the
benzodiazepines.
• It is used to treat symptoms of anxiety, although exactly
how it works is unknown.
• Optimum relief of anxiety usually occurs after 3 to 4
weeks of treatment.
• Buspirone is intended for short-term therapy; patients
who have been treated with buspirone for up to 1 year
have not required a dosage increase to maintain
therapeutic effect.

Hydroxyzine
• Hydroxyzine (Vistaril) is a miscellaneous antianxiety
drug.
• It exerts CNS depressant activity in subcortical areas.
• It rapidly produces a feeling of calm and relieves anxiety
without impairing mental alertness.
• It may be coadministered with a narcotic to control pain
while minimizing the nausea that may be an adverse
effect from the narcotic.

Meprobamate
• Meprobamate (Equanil) is also used for short-term
management of anxiety symptoms.
• Meprobamate has selective effects at multiple sites within
the CNS, including the thalamus and the limbic system.
• It may also inhibit multineuronal spinal reflexes.
• It has mild tranquilizing properties and some
anticonvulsant and muscle-relaxant properties.
• Meprobamate can produce several CNS adverse effects.
• Meprobamate is a Pregnancy Category D drug.

Eszopiclone
• Eszopiclone (Lunesta) is a nonbenzodiazepine hypnotic.
• The drug induces sleep quickly, prevents waking during
the night.
• Eszopiclone is believed to achieve its therapeutic effect
from interaction with GABA-receptor/benzodiazepine-receptor
complexes.
• It is the only drug for insomnia that is approved for long-term
use (up to 6 months of use).
• Eszopiclone has a rapid onset (within 1 hour) and is
metabolized in the liver and excreted in the urine.
• The most common adverse effects of eszopiclone after 6
weeks of use were headache, prolonged drowsiness, and
an unpleasant taste.

Zaleplon
• Zaleplon (Sonata) is a sedative for short-term use (up to
28 days).
• Although a nonbenzodiazepine and not chemically related
to the benzodiazepines, it does interact with the GABA–
benzodiazepine (BZ) complex.
• The most common adverse effects of zaleplon are
drowsiness, dizziness, light-headedness, and difficulty
with coordination. Zaleplon is a Pregnancy Category C
drug.
• Zaleplon may lead to dependency, and rebound insomnia
is possible.

Zolpidem
• Zolpidem (Ambien) is used for short-term treatment of
insomnia—generally not for more than 7 to 10 days.
• It induces sleep rapidly and should be taken immediately
before going to bed.
• Although zolpidem is not chemically related to the
benzodiazepines, it does interact selectively with the
GABA–BZ receptor complex and shares some
pharmacologic properties with the benzodiazepines.
• Zolpidem generally preserves all of the sleep stages and
has only minor effects on REM sleep.
• The most common adverse effects from zolpidem are
headache, prolonged drowsiness, and dizziness.

Ramelteon
• Melatonin receptor agonists stimulate the same receptor
sites as endogenous melatonin.
• Ramelteon (Rozerem) is used in the treatment of
insomnia when the patient has difficulty falling asleep.
• Ramelteon has high affinity at two specific melatonin
receptors.
• Common adverse effects of ramelteon include headache,
daytime sleepiness, dizziness, tiredness, nausea,
worsening insomnia, and colds.

Trazodone
• Trazodone (Desyrel) is an atypical antidepressant.
• This drug causes significant sedation as an adverse
effect.
• Trazodone is most commonly used to promote sleep.

Chloral Hydrate
• Chloral hydrate is a nonbarbiturate hypnotic used to
induce sleep and to cause preoperative sedation.
• It can be used as an adjunct to opiates and analgesics in
pain control.
• In therapeutic doses, chloral hydrate has little effect on
respirations, blood pressure, or reflexes.
• It does produce numerous adverse effects in the CNS.

Barbiturates
• Barbiturates such as phenobarbital (Bellatal),
secobarbital (Seconal), and pentobarbital (Nembutal)
were used to treat insomnia before the availability of the
benzodiazepines.
• Although they are effective for short-term treatment of
insomnia, they are also highly habit forming.
• Patients can develop tolerance and physical and
psychological dependence on the drugs.

Ppt chapter 15

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