1. Introduction to Clinical Pharmacology Chapter 19 Cholinesterase Inhibitors

2. Cholinesterase Inhibitors: Actions and Uses
Dementia is slow and progressive; delirium has a sudden onset and sensory impairment occurs
Actions:
Cholinesterase inhibitors act to increase level of acetylcholine in CNS by inhibiting its breakdown and slowing neural destruction; slows down the progression of the Alzheimer’s Disease
SUMMARY DRUG TABLE
Uses:
Cholinesterase inhibitors are used to treat dementia associated with AD and best when used in early stages of dementia

3. Cholinesterase Inhibitors: Adverse Reactions
Generalized adverse reactions and need priority interventions:
Anorexia; nausea; vomiting; diarrhea; dizziness; headache; confusion

4. Cholinesterase Inhibitors: Contraindications and Precautions
Cholinesterase inhibitors are contraindicated in patients with hypersensitivity to drugs and if pregnant or during pregnancy and lactation
These drugs are used cautiously in patients with renal disease, bladder obstruction; seizure disorders; sick sinus syndrome; gastrointestinal bleeding; asthma
Ginkgo has not been proven or disproven, but if taken,effects may not be evident until after 4 to 24 weeks of treatment. The most common adverse reactions include mild GI discomfort, headache, and rash. Should be avoided if taking selective serotonin reuptake inhibitors or monoamine oxidase inhibitors antidepressants; adverse effects include headache, rash, and GI discomfort and need to be recognized and brought up to healthcare provider; excessive dose of ginkgo may exhibit the following adverse reactions: diarrhea, nausea, vomiting, and restlessness

5. Interactions Interactant drug Effect of interaction
Anticholinergics-like benztropine, glycopyrrolate, and tiotropium
Decreased effectiveness of anticholinergics
Nonsteroidal anti-inflammatory drugs
Increased risk of GI bleeding
Thiazide diuretics NMDA
receptor antagonist
Decreased effectiveness of thiazide drug
Theophylline
Increased risk of theophylline toxicity

6. Nursing Process: Assessment #1
Preadministration assessment:
Assess patient’s cognitive ability and functional ability before and during therapy in preclinical AD there would be no change in these areas
Assess patient regarding orientation, calculation, recall, and language
Assess patient for agitation and impulsive behavior
Obtain complete medical history and history of symptoms of AD from patient, family member, or patient’s hospital records

7. Nursing Process: Assessment #2
Preadministration assessment (cont.)
Observe patient for what appears to be deviations from normal behavior pattern
Ask the family about unusual behaviors, such as wandering or outbursts of angry or frustrated behavior
Assess patient’s vital signs and weight

8. Nursing Process: Assessment #3
Ongoing assessment:
Includes both mental and physical assessment
Initial assessments will be compared with ongoing assessments to monitor patient’s improvement after taking cholinesterase inhibitors

9. Nursing Process: Planning
Expected outcomes include:
Optimal response to drug therapy
Support of patient needs related to management of adverse reactions
Absence of injury
Compliance with the prescribed therapeutic regimen

10. Nursing Process: Implementation #1
Promoting an optimal response to therapy:
Develop care plan to meet patient’s individual needs
When the drugs no longer provide memory enhancement, environmental factors may need to change rather than modifying the patient's behavior
Monitor vital signs and other assessments in hospitalized patients

11. Nursing Process: Implementation #2
Monitoring and managing patient needs:
Imbalanced nutrition: less than body requirements
Attention to dosing of medications can be helpful to decrease adverse GI reactions and promote nutrition
Remove oral dosing syringe provided in protective container when rivastigmine is administered as oral solution and can be mixed with water, soda, or fruit juice

12. Nursing Process: Implementation #3
Monitoring and managing patient needs (cont.)
Patient should be offered well-balanced diet with foods that are easy to chew and digest
Fluid intake of six to eight glasses of water daily is encouraged to prevent dehydration

13. Nursing Process: Implementation #4
Monitoring and managing patient needs (cont.)
In later stage, patient may be fed through feeding syringe, or the caregiver can encourage chewing action by pressing gently on bottom of the patient’s chin and on the lips

14. Nursing Process: Implementation #5
Monitoring and managing patient needs (cont.)
Risk for injury:
Physical decline and adverse reactions of dizziness and syncope place patient at risk for injury
Use of side rails; keeping the bed in low position; using night lights; frequent monitoring by nurse or caregiver will reduce risk of injury

15. Nursing Process: Implementation #6
Educating the patient and family:
Explain any adverse reactions that may occur with specific drug and encourage caregiver or family members to contact primary health care provider immediately if serious drug reaction occurs
Evaluate patient’s ability to assume responsibility for taking drugs at home

16. Nursing Process: Implementation #7
Educating the patient and family (cont.)
Focus on educating family and major caregiver on patient needs
Discuss drug regimen with patient, family member, and/or caregiver

17. Nursing Process: Evaluation
Therapeutic effect is achieved
Adverse reactions are identified, reported to the primary health care provider, and managed successfully through appropriate nursing interventions
No injury is evident
Patient, family member, or caregiver demonstrates understanding of the drug regimen
Exelon can be given orally or topically ensure the caregiver is aware of how to give or apply transdermal patch on an area that is hairless to have better contact with skin, rotate sites; if being placed by nurse document site placed and ensure not in area where patient can remove it or pick at it

18. Question #1 Is the following statement true or false?
Alzheimer disease (AD) is one of the conditions where dementia is a major issue.

19. Answer to Question #1 True
Alzheimer disease (AD) is one of the conditions where dementia is a major issue. This occurs due to the buildup of plaques and tangles in the neurons of the brain. Acetylcholine is reduced, resulting in symptoms of dementia.

20. Question #2 Is the following statement true or false?
The progression of memory loss associated with dementia is treated with cholinesterase inhibitors. These drugs cure dementia.

21. Answer to Question #2 False
The progression of memory loss associated with dementia is treated with cholinesterase inhibitors. These drugs slow progression but do not cure dementia.

22. Question #3 Is the following statement true or false?
Patients with dementia may at times experience acute confusion, known as delirium.

23. Answer to Question #3 True
Patients with dementia may at times experience acute confusion, known as delirium.