Respond to the 2 following posts separately with separate reference lists. Citations: At least one high-level scholarly reference in APA per post from within the last 5 years
1. [Amber Maddox] The two classes of medications that are currently available for the treatment of dementia include cholinesterase inhibitors which function to decrease the breakdown of acetylcholine and N-methyl-D-aspartate (NMDA) receptor antagonists which functions to protect brain cells by blocking the effects of excess glutamate (Rosenthal & Burchum, 2020). Cholinesterase drugs include Aricept (donepezil) and have the adverse effects of nausea, vomiting, diarrhea, loss of appetite, dizziness, drowsiness, weakness, trouble sleeping, tremors, and or muscle cramps (Wilkins, 2021). NMDA receptor antagonists include Namenda (memantine) and have the adverse effects of dizziness, confusion, aggression, depression, headaches, sleeplessness, diarrhea, or constipation (Wilkins, 2021).
The behavioral disturbances that I feel can be most upsetting with progressive dementia are agitation or aggression and confusion. Patients may start to develop these behaviors due to not being able to communicate their needs, or not having their needs met. This makes caring for those with dementia very difficult. Non-pharmacological treatment recommendations for these behaviors include but are not limited to frequent reorientation, structured care, validation therapy, pet therapy, multi-sensory stimulation, and massage (Scales et al., 2018). According to the Alzheimer’s Association, antipsychotics should be used very cautiously when prescribed for behavioral or psychological symptoms of dementia, and most come with black box warnings (2022). Patients with dementia should only be prescribed antipsychotic medications if their behavioral symptoms are due to mania or psychosis, they are a danger to themselves or others, or if they are experiencing inconsolable or persistent distress with a significant decline in functioning (Alzheimer’s Association, 2022). I would fully assess all the behavioral symptoms before making an informed decision, but with the little information in this case study stating mild dementia my pharmaceutical treatment recommendation for agitation/aggression would be the selective serotonin reuptake inhibitor (SSRI) citalopram (Celexa) and my pharmaceutical treatment recommendation for increased confusion would be the acetylcholinesterase inhibitor Aricept (donepezil).
In Parkinson’s disease, there is not enough dopamine made for the brain to be able to function properly. Levodopa is a central nervous system agent that is able to replace the missing dopamine in the brain (Rosenthal & Burchum, 2020). By replacing the missing dopamine individuals are able to more easily complete activities of daily living and functioning. Adverse effects of levodopa may include hypotension, constipation, trouble sleeping, decreased muscle coordination, dyskinesia, headache, nausea, vomiting, and or anxiety (Wilkins, 2021). Carbidopa is a decarboxylase inhibitor that is most commonly combined with levodopa because of its ability to prevent levodopa from being broken down before it reaches the brain (Rosenthal & Burchum, 2020). When this happens, it takes less levodopa to reach a therapeutic effect, therefore preventing some of the adverse side effects such as increased nausea and vomiting. These drugs are combined and produced under many brand names, most popularly Sinemet or Rytary. Other drugs that are used in the treatment of Parkinson’s disease include Monoamine oxidase-B inhibitors (MAO-B) inhibitors which block the effect of enzymes that inactive dopamine, dopamine antagonists which directly stimulate the dopamine receptors in the brain, COMT inhibitors which prolongs and enhances the effect of levodopa, anticholinergics which reduce the tremor, amantadine which improves mild symptoms such as rigidity and tremor, and istradefylline which treats motor symptoms (Tarsy, 2021).
Venlafaxine is a newer selective serotonin-noradrenaline reuptake inhibitor (SNRI) which blocks the reuptake of both serotonin and norepinephrine (Rosenthal & Burchum, 2020). Tricyclic antidepressants (TCAs) also inhibit serotonin and noradrenaline reuptake inhibition resulting in decreased depression, however TCAs also bind to several other receptor sites not thought to have antidepressant activity and causing additional unwanted side effects (Rosenthal & Burchum, 2020). Adverse effects of venlafaxine include nausea, headaches, sweating, dry mouth, difficulty sleeping, dizziness, and/or constipation (Wilkins, 2021). Because venlafaxine does not bind to muscarinic cholinergic, histaminergic, and alpha-1 adrenergic receptors, it has demonstrated to be safer than TCAs (Tamblyn, 2020).
References
Alzheimer’s Association. (2022). Treatments for Behavior. Alzheimer’s Disease and Dementia. https://www.alz.org/alzheimers-dementia/treatments/treatments-for-behavior
Antidepressant Use by Class, Drug, and Indication. Journal of the American Geriatrics Society, 68(7), 1494–1503. https://doi.org/10.1111/jgs.16404
Rosenthal, L., & Burchum, J. (2020). Lehne’s Pharmacotherapeutics for Advanced Practice Providers. Elsevier Gezondheidszorg.
Scales, K., Zimmerman, S., & Miller, S. J. (2018). Evidence-Based Nonpharmacological Practices to Address Behavioral and Psychological Symptoms of Dementia. The Gerontologist, 58(suppl_1), S88–S102. https://doi.org/10.1093/geront/gnx167
Tamblyn, R., Bates, D. W., Buckeridge, D. L., Dixon, W. G., Girard, N., Haas, J. S., Habib, B., Iqbal, U., Li, J., & Sheppard, T. (2020). Multinational Investigation of Fracture Risk with Antidepressant Use by Class, Drug, and Indication. Journal of the American Geriatrics Society, 68(7), 1494–1503. https://doi.org/10.1111/jgs.16404
Tarsy, D. (2021). Patient education: Parkinson disease treatment options — medications (Beyond the Basics). UpToDate. Retrieved April 3, 2022, from https://www.uptodate.com/contents/parkinson-disease-treatment-options-medications-beyond-the-basics
Wilkins, L. W. (2021). Nursing2022 Drug Handbook. Wolters Kluwer.
2. [Melissa Salazar] Mrs. William, a 75-year-old patient is with her daughter for a follow-up visit. At her previous office visit, her daughter expressed concerns of her mother’s increasing forgetfulness. You send Mrs. William for neuropsychiatric testing. She is diagnosed with mild dementia, and the patient and family would like to discuss treatment options.
Dementia occurs due to the loss of healthy neurons in the brain. This loss is a contributing factor for mild to severe symptoms such as memory loss and confusion or hallucinations and movement dysfunction (U. S. Department of Health and Human Services, 2021). While there is no cure for dementia, there are some medications to help slow down the process. The loss of acetylcholine, critical to forming memories, or increased beta-amyloid and neuritic plaques are some of the underlying factors that are involved (Rosenthal & Burchum, 2021).
Treatment consists of cholinesterase inhibitors or n-methyl-D-aspartate (NMDA) receptor antagonist. Cholinesterase inhibitors prevent the breakdown of acetylcholine by acetylcholinesterase (AChE), which increases the availability of acetylcholine at cholinergic synapses (Rosenthal & Burchum, 2021). They can be used for mild to severe treatment. Some examples of these include: donepezil (Aricept), rivastigmine (Exelon), and galantamine (Razadyne). NMDA receptor antagonist memantine (Namenda) is only indicated for moderate or severe cases. It works by blocking calcium influx when extracellular glutamate is low but permits calcium influx when extracellular glutamate is high (Rosenthal & Burchum, 2021). Glutamate is the major excitatory transmitter of the central nervous system.
Donepezil can be used for mild and progressive symptoms such as sleep disturbances, wandering or anxiety. Noticeable differences should be seen in approximately 15 days. Adding memantine will assist in the more severe symptoms such as loss of speech, appetite, and bowel and bladder control.
Mr. Lacy is a 65-year-old man diagnosed with Parkinson’s disease (PD) five years ago. His disease has progressed over the years, and it is recommended that he be treated with levodopa.
Levodopa is a dopaminergic drug used for the treatment of Parkinson’s disease by increasing dopamine synthesis. Dopamine is an inhibitory transmitter that releases γ-aminobutyric acid (GABA), a motor control transmitter (Rosenthal & Burchum, 2021). Levodopa coverts to dopamine through a catalytic reaction called decarboxylase to stimulate neurons. Whereas dopamine cannot cross the blood-brain barrier (BBB), levodopa can. Adverse effects include dyskinesia, hallucinations, psychosis, as well as GI disturbances (Gandhi & Saadabadi, 2021).
It is commonly combined with carbidopa to decrease the amount of decarboxylation in the periphery so that more of the drug can enter the central nervous system (CNS). Carbidopa is a dopamine decarboxylase inhibitor that does not cross the BBB. Therefore levodopa cannot convert to dopamine outside the central nervous system (Rosenthal & Burchum, 2021).
Other drugs that can be used for the treatment of Parkinson’s disease include; dopamine-receptor agonists (bromocriptine, pramipexole, and ropinirole), catechol-o-methyltransferase (COMT) inhibitors (entacapone and tolcapone) and monoamine oxidase B (MAO-B.) inhibitors (selegiline and rasagiline)
A 50-year-old man has developed depression after the death of his wife. He is prescribed venlafaxine (Effexor XR) 75 mg PO once a day.
Q6. How does venlafaxine differ from tricyclic antidepressants (TCAs)? What adverse effects might this patient expect with venlafaxine?
Venlafaxine (Effexor) is a serotonin-norepinephrine reuptake inhibitor (SNRI). SNRIs are used for depression, as well as anxiety and panic disorder. SNRIs increase levels of norepinephrine and serotonin by blocking neuronal reuptake of serotonin and NE. Side effects include insomnia, nausea, hyponatremia, sexual dysfunction and possible suicidal ideation (Rosenthal & Burchum, 2021). It should not be taken with benzodiazepines.
Tricyclic antidepressants (TCA) block neuronal reuptake of two monoamine transmitters 5-HT and NE (Rosenthal & Burchum, 2021). They also increase serotonin and norepinephrine. Previously the first drug of choice for depression, they have since been replaced with safer selective serotonin reuptake inhibitors (SSRIs). Cardiac toxicity being the most dangerous effect, as well as more common adverse effects including sedation, orthostatic hypotension, and anticholinergic effects.
References
Gandhi, K., & Saadabadi, A. (2021). Levodopa (L-Dopa). Retrieved from StatPearls: https://www.ncbi.nlm.nih.gov/books/NBK482140/
Rosenthal, L. D., & Burchum, J. R. (2021). Lehne’s Pharmacotherapeutics for Advanced Practice Nurses and Physician Assistants (2nd ed.). St. Louis, Missouri: Elsevier.
U. S. Department of Health and Human Services. (2021). What is dementia? Symptoms, types, and diagnosis. Retrieved from National Institute on Aging: https://www.nia.nih.gov/health/what-is-dementia
