2. Learning Outcomes 1. Discuss factors contributing to anxiety and explain some nonpharmacologic therapies used to cope with this disorder. 2. Identify the three classes of medications used to treat anxiety and sleep disorders. 3. Explain the pharmacological management of anxiety and insomnia. 4. Describe the nurse’s role in the pharmacologic management of anxiety and insomnia. 5. Categorize drugs used for anxiety and insomnia based on their classification and mechanism of action. 6. Use the nursing process to care for patients receiving drug therapy for anxiety and insomnia.

3. Antidepressant / Anxiolytic Antidepressant / Anxiolytic escitalopram (Lexapro) Tri-Cyclic Antidepressant MAOIs Benzodiazepines lorazepam (Ativan) diazepam (Valium) GABA Antagonist A zolpidem (Ambien) Phenytoin-Like Drugs Phenytoin-Like Drugs Succinimides Barbiturates phenobarbital (Luminal) phenytoin (Dilantin) valproic acid (Depakote) ethosuximide (Zarontin) Phenothiazines chlorpromazine (Thorazine) Non-Phenothiazines halperidol (Haldol) Atypical Antipsychotics risperidone (Risperdal) Opioids Opioid Antagonists naloxone (Narcan) morphine (Infumorph) Salicylates aspirin (ASA) NSAIDs ibuprofen (Motrin) Non-Opioid acetaminophen (Tylenol) Central Acting tramadol (Ultram) Anti-Migraine ergotamine (Cafergot) Sumatriptan (Imitrex) OVERVIEW: Neuro System Drugs

4. Major Types of Anxiety Disorders Situational anxiety Generalized anxiety disorder (GAD) Panic disorder Phobias Social anxiety Obsessive-compulsive disorder Post-traumatic stress disorder

5. Pharmacotherapy Illustrated

6. Common Causes of Anxiety Phobias Post-traumatic stress Generalized anxiety Obsessive-compulsive feelings Panic Roseman University of Health Sciences

7. Nonpharmacologic Therapies to Cope with Anxiety Cognitive behavioral therapy Counseling Biofeedback techniques Meditation

8. ‘Anxiolytics’ Drugs having the ability to relieve anxiety Quite effective Used when anxiety begins to significantly affect daily activities

9. Classes of Medications Used to Treat Anxiety and Sleep Disorders Antidepressants Benzodiazepines Barbiturates Non-benzodiazepine / nonbarbiturate CNS depressants

10. Treating Anxiety and Insomnia with CNS Agents Antidepressants frequently used to treat anxiety Two major classes Benzodiazepines Barbiturates CNS depression - a continuum ranging from relaxation, to sedation, to the induction of sleep and anesthesia

11. Sedatives and Hypnotics CNS depressants called sedatives due to ability to sedate or relax a patient, or hypnotics because of their ability to induce sleep sedative–hypnotic: calming effect at lower doses and sleep at higher doses Most CNS depressants can cause physical and psychological dependence

12. Monitor Client’s Condition and Provide Education Obtain vital signs, medical and drug history Discuss lifestyle and dietary habits What precipitated the feelings of anxiety?

13. Assess Client’s Need for Antianxiety or Insomnia Drugs Assess intensity and duration of symptoms Identify precipitating factors Identify coping mechanisms Assess for sleep disorder

14. Obtain Drug History Hypersensitivity Use of alcohol and other CNS depressants Drug abuse and dependence

15. Use Cautiously for Certain Clients Those who are elderly Those with suicidal potential Those with impaired renal or liver function

16. Insomnia Acts of sleeping and waking synchronized to many different bodily functions Insomnia sometimes associated with anxiety Short-term or behavioral insomnia sometimes attributed to stress Food or beverages with stimulants may disturb sleep Long-term insomnia often caused by depression, manic disorders, chronic pain Nonpharmacologic means should be attempted prior to drug therapy Rebound insomnia – caused by discontinuation of long-used sedative drug Older patients more likely to experience medication-related sleep problems

17. Antidepressants Treat major depression and a range of anxiety conditions Primary medications to reduce symptoms of panic and anxiety: TCAs, MAOIs, and SSRIs Atypical antidepressants do not fall conveniently into the other categories Adverse reactions make antidepressants unusable for some patients

18. Antidepressants (cont'd) Prototype drug: Escitalopram oxalate (Lexapro) Mechanism of action: increases availability of serotonin at specific postsynaptic receptor sites located within the CNS Primary use: generalized anxiety and depression Adverse effects: dizziness, nausea, insomnia, somnolennce, confusion, seizures

19. Prototype Drug: Escitalopram oxalate (Lexapro)

20. Escitalopram Oxalate Animation Click here to view an animation on the topic of escitalopram oxalate.here

21. Antidepressant Class Information TCAs (partial list information/conditions): Not for use for patients with heart attack, heart block, or arrhythmia Potential side effects: dry mouth, blurred vision, urine retention, and hypertension concurrent use with alcohol or other CNS depressants should be avoided

23. Antidepressant Class Information (cont'd) SSRIs (partial list information/conditions): Safer than other classes Less common sympathomimetic effects (increased heart rate and hypertension) Fewer anticholinergic effects can cause weight gain and sexual dysfunction

25. Antidepressant Class Information (cont'd) SNRIs (partial list information/conditions): Many possible side effects: abnormal dreams, sweating, constipation, dry mouth, loss of appetite, weight loss, tremor, abnormal vision, headaches, nausea and vomiting, dizziness, and loss of sexual desire

26. Antidepressant Class Information (cont'd) MAOIs (partial list information/conditions): avoid foods containing tyramine potentiate the effects of insulin and other diabetic drugs common adverse effects include orthostatic hypotension, headache, and diarrhea

27. Benzodiazepines Prototype drug: lorazepam (Ativan) Mechanism of action: binds to GABA receptor- chloride channel molecule, which intensifies GABA effects Primary use: for anxiety disorders and insomnia Adverse effects: drowsiness, dizziness, respiratory depression

28. Prototype Drug: Lorazepam (Ativan)

29. Benzodiazepines Some treat short-term insomnia Others treat various anxiety disorders Most benzodiazepines given orally Drugs of choice for short-term treatment of insomnia caused by anxiety – greater margin of safety

31. Benzodiazepines Bind To GABA Receptor-Chloride Channel Molecule Intensify effects of GABA Examples: Xanax, Librium, Tranxene

32. Benzodiazepines Have a number of other important indications Seizure disorders Alcohol withdrawal Central muscle relaxation Induction agents in anesthesia

33. Benzo’s Prototype drug: diazepam (Valium) Mechanism of action: Binds with GABA receptor-chloride channel molecules, intensifying effects of GABA Inhibits brain impulses from passing through limbic and reticular activating systems Primary use: as sedative and hypnotic Adverse effects: tolerance, respiratory depression, psychological and physical dependence

35. Nonbenzodiazepines, Nonbarbiturate CNS depressants Chemically unrelated to either benzodiazepines or barbiturates Used mainly for treatment of social anxiety symptoms Prototype: zolpidem (Ambien) Mechanism of action: binds to GABA receptors Primary use: as hypnotic Adverse effects: mild nausea, dizziness, diarrhea, daytime drowsiness, amnesia, sleepwalking, ingesting carbohydrates while sleepwalking

36. Nonbenzodiazepines, Nonbarbiturate CNS depressants (cont'd) Mechanism of action: binds to GABA receptor Preserves sleep stages III and IV Offers minor effects of REM sleep Other Nonbarbiturate CNS Depressants: Buspar, Noctec, Placidyl

37. Prototype Drug: Zolpidem (Ambien)

38. Zolpidem Animation Click here to view an animation on the topic of zolpidem.here

39. Nonbenzodiazepine, Nonbarbiturate CNS Depressants (cont'd) Assess for common side effects of CNS depression Assess neurological status, level of consciousness Monitor vital signs, observe respiratory patterns particularly during sleep Monitor patient’s intake of stimulants, such as caffeine and nicotine Monitor affect and emotional status

40. NCLEX-RN Review Question 1 The nurse should assess a patient who is taking lorazepam (Ativan) for the development of which of these adverse effects? 1.Tachypnea 2.Astigmatism 3.Ataxia 4.Euphoria

41. NCLEX-RN Review Question 1 – Answer 1.Tachypnea 2.Astigmatism 3.Ataxia 4.Euphoria

42. NCLEX-RN Review Question 1 – Rationale Rationale: CNS side effects for lorazepam (Ativan) include amnesia, weakness, disorientation, ataxia, blurred vision, diplopia, nausea, and vomiting.

43. NCLEX-RN Review Question 2 A patient is receiving temazepam (Restoril). Which of these responses should a nurse expect the patient to have if the medication is achieving the desired affect? 1.The patient sleeps in 3-hour intervals, awakes for a short time, and then falls back to sleep. 2.The patient reports feeling less anxiety during activities of daily living. 3.The patient reports having fewer episodes of panic attacks when stressed. 4.The patient reports sleeping 7 hours without awakening.

44. NCLEX-RN Review Question 2 – Answer 1.The patient sleeps in 3-hour intervals, awakes for a short time, and then falls back to sleep. 2.The patient reports feeling less anxiety during activities of daily living. 3.The patient reports having fewer episodes of panic attacks when stressed. 4.The patient reports sleeping 7 hours without awakening.

45. NCLEX-RN Review Question 2 – Rationale Rationale: The nurse should recognize that this medication is ordered for insomnia. Therefore, the patient should be experiencing relief from insomnia and reporting feeling rested when awakening.

46. NCLEX-RN Review Question 3 A 32-year-old female patient has been taking lorazepam (Ativan) for her anxiety and is brought into the emergency department after taking 30 days’ worth at one time. The antagonist used in some cases of benzodiazepine overdosage is: 1.Epinephrine 2.Atropine 3.Flumazenil 4.Naloxone

47. NCLEX-RN Review Question 3 – Answer 1.Epinephrine 2.Atropine 3.Flumazenil 4.Naloxone

48. NCLEX-RN Review Question 3 – Rationale Rationale: Flumazenil (Romazicon) is a benzodiazepine- receptor blocker which may be used to reverse CNS depressant effects. Naloxone (Narcan) is an opioid antagonist.

49. NCLEX-RN Review Question 4 A patient has been given instructions about the newly prescribed medication alprazolam (Xanax). Which of these statements, if made by the patient, would indicate that the patient needs further instruction? 1.“I will stop smoking by undergoing hypnosis.” 2. “I will not drive immediately after I take this medication.” 3.“I will stop the medication when I feel less anxious.” 4.“I will take my medication with food if my stomach feels upset.”

50. NCLEX-RN Review Question 4 – Answer 1.“I will stop smoking by undergoing hypnosis.” 2. “I will not drive immediately after I take this medication.” 3.“I will stop the medication when I feel less anxious.” 4.“I will take my medication with food if my stomach feels upset.”

51. NCLEX-RN Review Question 4 – Rationale Rationale: Benzodiazepines should not be stopped abruptly. The health care provider should decide when and how to discontinue the medication.

52. NCLEX-RN Review Question 5 A patient has been taking diazepam (Valium) for 3 months. Which of these statements by the patient would indicate that the outcome of medication therapy has been successful? 1.“I will need to take this medication for the rest of my life.” 2.“I feel like I am able to cope with routine stress at my job.” 3.“I like this medication. I know that I needed it to treat my anxiety, which is now better, but I think it just makes me feel good, so I am planning to stay on it for quite a while.” 4.“I thought this medication would make me think clearly, but I don’t feel any change in my feelings.”

53. NCLEX-RN Review Question 5 – Answer 1.“I will need to take this medication for the rest of my life.” 2.“I feel like I am able to cope with routine stress at my job.” 3.“I like this medication. I know that I needed it to treat my anxiety, which is now better, but I think it just makes me feel good, so I am planning to stay on it for quite a while.” 4.“I thought this medication would make me think clearly, but I don’t feel any change in my feelings.”

54. NCLEX-RN Review Question 5 – Rationale Rationale: The statement by the patient needs to show clearly that the expected benefit of the medication therapy has been experienced by the patient.

55. NCLEX-RN Review Question 6 Education given to patients about the use of benzodiazepines should include an emphasis on what important issue? 1.They will be required lifelong to achieve lasting effects. 2.They require frequent blood counts to avoid adverse effects. 3.If the drug is not effective within the first 2 months, it will be stopped immediately. 4.The use of counseling or behavioral techniques in addition to the drug will assist in addressing the underlying disorder.

56. NCLEX-RN Review Question 6 – Answer 1.They will be required lifelong to achieve lasting effects. 2.They require frequent blood counts to avoid adverse effects. 3.If the drug is not effective within the first 2 months, it will be stopped immediately. 4.The use of counseling or behavioral techniques in addition to the drug will assist in addressing the underlying disorder.

57. NCLEX-RN Review Question 6 – Rationale Rationale: Counseling or behavioral techniques such as stress reduction will assist in addressing the underlying problem and help ensure the drug is not taken longer than necessary. Benzodizepines are not stopped abruptly or rebound anxiety or cardiovascular effects may occur.

59. Drugs for Anxiety and Insomnia Assessment Potential nursing diagnoses Reason for drug Monitoring vital signs Cautions and contraindications Possible drug interactions Completing health history Drug history Evaluation of lab reports

60. Drugs for Anxiety and Insomnia (cont'd) Nursing Diagnosis Risk for injury Knowledge deficient, related to drug therapy Ineffective individual coping

61. Drugs for Anxiety and Insomnia (cont'd) Planning: client will Experience therapeutic effects depending on drug Be free of adverse effects Demonstrate an understanding of the drug’s activity Accurately describe drug side effects and precautions Demonstrate proper self-administration technique

62. Drugs for Anxiety and Insomnia (cont'd) Implementation Interventions and rationales Administration of drug Observing for adverse effects Client education and discharge planning

63. Drugs for Anxiety and Insomnia (cont'd) Evaluation Effectiveness of drug therapy Evaluate the achievement of goals and expected outcomes

64. Nursing Process Focus: Patients Receiving Drugs for Anxiety Disorders

69. RECEPTORS Review

70. “Receptors” & The Autonomic Nervous System

72. Beta 1 Receptors