Chapter 26: Drug Therapy for Alzheimer's and Parkinson's Diseases

ANS: C Assess a patient's ability to swallow before giving drugs for Alzheimer's disease because he or she may be at risk for aspiration.

A patient diagnosed with probable Alzheimer's disease is having his swallowing ability tested. His wife asks you why this is necessary. What is your best response? a. "This is a routine assessment that is completed for every patient." b. "The prescriber ordered this test to be done to prevent side effects of a new drug for your husband's disease." c. "This test tells us where your husband's swallowing is now, because it may get worse as his disease progresses." d. "We are concerned about whether we will need to place a feeding tube to give his medications."

ANS: B, C, E Rasagiline is an MAO-B inhibitor. Patients must be taught to avoid foods with tyramine, an amino acid that can cause a hypertensive crisis when patients are taking these drugs. Examples of such foods are aged cheeses, sour cream, and soy sauce (see Box 23-2 in the text).

A patient has been prescribed rasagiline (Azilect). Which foods should you teach the patient to avoid? (select all that apply) a. Green leafy vegetables b. Aged cheeses c. Sour cream d. Fresh apples and pears e. Soy sauce f. Chicken and beef

ANS: D Donepezil is an acetylcholinesterase inhibitor. This drug may cause GI bleeding. Monitor the patient carefully for any signs of bleeding. Monitor emesis and stools for blood.

A patient is prescribed donepezil (Aricept) for Alzheimer's disease. What assessment is most important after giving this drug? a. Blood pressure b. Bowel sounds c. Peripheral pulses d. Signs of bleeding

ANS: B Have 200 mg/1 tablet, Want 800 mg/X tablets; 800/200 = 4 tablets.

A patient is prescribed entacapone (Comtan) 800 mg/day. The drug is available in 200 mg tablets. How many tablets should you give? a. 2 b. 4 c. 6 d. 8

ANS: A Donepezil (Aricept) is a cholinesterase inhibitor, therefore likely to increase succinylcholine-type muscle relaxation during anesthesia. If used during surgery, continued respiratory depression may occur due to prolonged neuromuscular blockade. Teach patients and families to discuss the risks associated with these drugs if the patient needs any type of surgery requiring general anesthesia. Those with dementia are at an increased risk for complications following surgery. They may awaken more slowly and are more likely to experience confusion and delirium. This might lead to longer stays in the postsurgical recovery room (PACU) and longer hospitalization.

A patient prescribed donepezil (Aricept) is to have surgery requiring general anesthesia. Her husband tells you that he read that taking this drug while having surgery can be dangerous. What is your best response? a. "Because of the action of donepezil, she may awaken more slowly and may need to remain in the postanesthesia care unit for a longer period of time." b. "Let me contact your surgeon because the danger of taking donepezil and having general anesthesia is that she may have a massive heart attack." c. "I don't think there is any danger because if there was your surgeon would certainly have discontinued use of this drug until after the surgery." d. "The most dangerous risk is that after the surgery your wife may lose her ability to swallow and aspirate food or medications, ending up with aspiration pneumonia."

ANS: B Rasagiline is a monoamine oxidase B (MAO-B) inhibitor. These drugs inhibit the enzyme that breaks down dopamine in the brain. As a result, more dopamine is available, and the progression of Parkinson's disease is slowed.

A patient prescribed rasagiline (Azilect) for Parkinson's disease asks you how this drug will help his disease. What is your best response? a. "This drug works by increasing the amount of dopamine activity in the brain and reducing tremor and muscle rigidity to improve movement." b. "This drug works by allowing a larger amount of levodopa to reach the brain, which raises dopamine levels in the brain." c. "This drug works by blocking cholinergic nerve impulses that help control the muscles of the arms, legs, and body." d. "This drug works by helping provide a more stable, constant supply of levodopa, which makes its beneficial effects last longer."

ANS: A Entacapone may discolor a patient's urine brownish-orange. This is an expected side effect and is not harmful.

A patient taking entacapone (Comtan) for Parkinson's disease informs you that his urine is now brownish-orange in color. What is your best action? a. Explain that this is an expected side effect and is not harmful. b. Collect a urine sample and send it to the laboratory for urinalysis. c. Hold the drug and immediately notify the prescriber. d. Instruct the patient to increase his intake of fluids.

ANS: D Carbidopa-levodopa can activate malignant melanoma. Patients should be instructed to report any changes in skin lesions immediately to their prescriber.

A patient who has been prescribed carbidopa-levodopa (Sinemet) informs you that a dark spot on his arm is getting larger. What is your best action? a. Measure the size of the spot and document the finding. b. Inform the patient that this is an expected side effect of the drug. c. Administer the drug as ordered by the prescriber. d. Hold the drug and contact the prescriber about this change.

ANS: C Symptoms of drug overdose for memantine include upset stomach, vomiting, drooling, sweating, slow heart rate, difficulty breathing, muscle weakness, and seizures. The drug dose should be held and the prescriber notified immediately.

A patient with Alzheimer's disease has been prescribed memantine (Namenda). The patient has developed the symptoms of vomiting, drooling, heart rate of 56 beats/minute, and muscle weakness. What is your best action? a. Contact the prescriber and ask for an order for an as-needed antiemetic drug. b. Place the patient on a heart monitor and check the heart rate every 2 hours. c. Hold the drug dose and contact the prescriber immediately. d. Give the drug exactly as ordered.

ANS: B Both rivastigmine and galantamine (Reminyl) commonly cause the side effect of GI upset. Giving these drugs with food twice a day helps to minimize this side effect.

A patient with Alzheimer's disease is prescribed rivastigmine (Exelon). What action should you suggest to prevent a common side effect? a. Give the drug with a full glass of water. b. Administer the drug with meals twice a day. c. Assess the patient's level of consciousness. d. Keep an accurate record of all patient food intake.

ANS: C Patients should be taught to immediately notify their prescriber if symptoms of Parkinson's disease (e.g., shaking, stiffness, or slowness of movement) become worse in a relatively short time period.

A patient with Parkinson's disease informs you that the stiffness and slowness of movements associated with the illness have become worse. What should you teach the patient about this change? a. "These changes are normal and expected as your disease progresses." b. "You will need to use a walker at all times to avoid falls and accidents." c. "Whenever your symptoms worsen, contact your prescriber right away." d. "If your prescriber increases your drug dosage these functions will improve."

ANS: D Entacapone is a COMT inhibitor. These drugs can cause the adverse effect of rhabdomyolysis, a serious and potentially fatal effect involving destruction or degeneration of skeletal muscle. Signs and symptoms of rhabdomyolysis include muscle aches, muscle weakness, and dark cola-colored urine. You should hold the drug and notify the prescriber immediately.

A patient with Parkinson's disease who has been prescribed entacapone (Comtan) tells you he is experiencing muscle aches, weakness, and has dark cola-colored urine. What is your best action? a. Send a urine specimen to the laboratory for urinalysis. b. Help the patient back to bed and instruct him or her to rest. c. Tell the patient that these are expected side effects of the drug. d. Hold the drug and notify the prescriber immediately.

ANS: D The prescriber can order a different form of the drug that is compatible with the patient's abilities. The pharmacy can send the drug but not without a valid order from the prescriber. The drug ordered is an extended release form and opening the capsule would give the patient too much drug quickly placing him or her at risk for side effects or adverse effects.

A patient with advanced Parkinson's disease is prescribed extended-release—50 mg carbidopa/200 mg levodopa capsule twice daily. The patient has difficulty swallowing. What is your best action? a. Open the capsule and mix the contents with apple sauce. b. Open the capsule and dissolve the contents in water. c. Contact the pharmacy to send a liquid form of the drug. d. Ask the prescriber to order a different form of the drug.

ANS: D An adverse effect of ropinirole, a dopaminergic/dopamine antagonist drug, is episodes of falling asleep suddenly (narcolepsy). Neuroleptic malignant syndrome is an adverse effect of COMT inhibitors. Depression with suicidal tendencies is an adverse effect of carbidopa-levodopa (Sinemet). Central nervous system depression is an adverse effect of apomorphine (Apokyn) and can include respiratory depression, coma, and cardiac arrest.

For which adverse effect should you monitor in a patient with Parkinson's disease after administering ropinirole (Requip)? a. Neuroleptic malignant syndrome b. Depression with suicidal tendencies c. Central nervous system depression d. Narcolepsy or sleep attacks

ANS: A The most common side effects of drugs to treat Parkinson's disease are dizziness, nausea, and hypotension.

For which common side effects should you monitor after administering any anti-Parkinson's drug to a patient? a. Dizziness and hypotension b. Diarrhea and nausea c. Hypertension and headache d. Body rash and elevated temperature

ANS: D While whiplash and head injuries, hypertension, smoking, and high cholesterol all increase the risk for Alzheimer's disease, age is the greatest risk factor for development of Alzheimer's disease. A patient with Down syndrome has an increased risk by age 50 to 60 years.

For which patient do you watch most closely for symptoms of Alzheimer's disease? a. 35-year-old with Down syndrome b. 50-year-old with a whiplash injury c. 60-year-old with hypertension d. 75-year-old with a smoking history

ANS: C Donepezil suppresses appetite and causes weight loss. In an individual who is underweight, the usual dosage can lead to toxicity. In addition, some Alzheimer's patients forget to eat and are already underweight. Weighing less than an ideal body weight increases the risk for many complications of old age and poor health.

For which patient should the drug donepezil (Aricept) for Alzheimer's disease be avoided? a. 54-year-old woman with early onset Alzheimer's disease b. 67-year-old man who also takes drugs for type 2 diabetes c. 72-year-old woman who is 20 lb underweight d. 72-year-old man who is unable to sit or stand

ANS: B Cholinesterase/acetylcholinesterase inhibitors reduce the activity of the enzyme acetylcholinesterase that breaks down acetylcholine in the synapses of neurons. This action keeps levels of acetylcholine higher. These drugs are used for early to moderate stages of Alzheimer's disease and their effects are temporary.

How do cholinesterase/acetylcholinesterase inhibitors work for treatment of Alzheimer's disease? a. Protecting the neurons from the changes that occur with Alzheimer's disease. b. Blocking the enzyme that breaks down the neurotransmitter at the neuron synapses. c. Blocking the amino acid glutamate at the N-methyl-D-aspartate receptors in the brain. d. Increasing the amount of white matter surrounding neurons to prevent the formation of "tangles."

ANS: C Memantine (Namenda) blocks the amino acid glutamate at N-methyl-D-aspartate receptors in the brain, preventing overstimulation (overstimulation of these receptors damages neurons and appears to be one cause of Alzheimer's disease). It can be effective in helping modify dementia (temporarily) in some patients with moderate-to-severe Alzheimer's disease.

How does memantine (Namenda) work for treatment of Alzheimer's disease? a. Protecting the neurons from the changes that occur with Alzheimer's disease b. Blocking the enzyme that breaks down the neurotransmitter at the neuron synapses c. Blocking the amino acid glutamate at the N-methyl-D-aspartate receptors in the brain d. Increasing the amount of white matter surrounding neurons to prevent the formation of "tangles"

ANS: A, B, D The goals of treatment for Parkinson's disease are to minimize disability, reduce possible side effects of drug therapy, and help the patient maintain a high quality of life. There is no cure for this illness, which is progressive. Drugs can help slow the progression and control the symptoms.

What are the goals of treatment for Parkinson's disease? (select all that apply) a. Help the patient to maintain a high quality of life. b. Reduce side effects of drug therapy. c. Regain as much function as possible. d. Minimize the patient's disability. e. Prolong the patient's life span. f. Maintain short-term memory

ANS: B, C, D The four major symptoms of Parkinson's disease are tremor at rest, rigidity, bradykinesia (slow movements and difficulty starting movements), and abnormal gait. Lack of facial expression is a symptom of this illness, but not a major symptom.

What are the major symptoms of Parkinson's disease? (select all that apply) a. Bradycardia b. Rigidity c. Abnormal gait d. Tremor at rest e. Lack of facial expression f. Facial swelling

ANS: B The skin site where a rotigotine patch has been removed should be cleansed and not used again for a minimum of 14 days to prevent skin breakdown.

What is the minimum time period needed before reapplying a rotigotine patch to the same skin site? a. 7 days b. 14 days c. 21 days d. 28 days

ANS: A As for any drug delivered by transdermal patch, the old patch should be removed before applying the new one to prevent a drug overdose. The patches can irritate the skin and should not be replaced in the same position as the previous patch. Rotating sites prevents skin irritation and breakdown. Applying the patch closer to the brain does not increase brain absorption of the drug.

What is the most important precaution to teach a patient who is prescribed transdermal rivastigmine (Exelon)? a. Always remove old patches daily and apply the new patch to a different site. b. Report any difficulty starting the urinary stream to your prescriber immediately. c. Place the patch on the neck or forehead so that the drug reaches the brain more quickly. d. For best drug absorption, hold a warm washcloth over the patch for 5 minutes after applying it.

ANS: A Adverse effects of memantine include shortness of breath, seizures, and hallucinations.

What problem is a possible adverse effect of memantine (Namenda) for Alzheimer's disease? a. Seizures b. Tachycardia c. Severe hypertension d. Peripheral neuropathy

ANS: B Benztropine is an anticholinergic drug. These drugs cause decreased perspiration, leading to increased risk for overheating during hot weather. Patients should be taught to stay indoors, preferably in an air-conditioned environment, to avoid this side effect.

What safety precaution should you teach a patient with Parkinson's disease who is prescribed benztropine (Cogentin)? a. Always dress warmly and avoid extended exposure to cold weather. b. Stay indoors in an air-conditioned setting during hot weather. c. Change positions slowly to avoid dizziness or light-headedness. d. Avoid alcohol intake because drowsiness is associated with this drug.

ANS: C Carbidopa-levodopa can suppress bone marrow activity and reduce the circulating levels of WBCs (neutropenia), greatly increasing the risk for infection. More patients with Parkinson's disease are older adults and may already have some age-related decrease in immune function. Neutropenia and infection are more likely when the patient's WBC count is low before treatment with the drug is started.

Which blood laboratory test result is most important to check before administering the first prescribed dose of carbidopa-levodopa (Sinemet) to a patient? a. International normalized ratio (INR) b. Blood urea nitrogen (BUN) level c. White blood cell (WBC) count d. Lactate dehydrogenase (LDH)

ANS: A For many patients with Parkinson's disease, the initial symptom is a coarse, rhythmic tremor of the hand while the hand is at rest, also called pill-rolling tremor.

Which common initial symptom suggests that a patient may be developing Parkinson's disease? a. Pill-rolling tremor b. Muscle rigidity c. Stooped posture d. Stumble-run walk

ANS: B Although Parkinson's disease is very rare in women of childbearing age, bromocriptine (Parlodel) is usually not recommended during pregnancy or breastfeeding. It stops the production of breast milk.

Which drug for Parkinson's disease is not recommended for breastfeeding mothers because it stops the production of breast milk? a. Rasagiline (Azilect) b. Bromocriptine (Parlodel) c. Carbidopa (Sinemet) d. Tolcapone (Tasmar)

ANS: D Tolcapone is a COMT inhibitor. Rasagiline is an MAO-B inhibitor while carbidopa and bromocriptine are dopaminergic/dopamine antagonists.

Which drug used to treat Parkinson's disease is a COMT inhibitor? a. Rasagiline (Azilect) b. Bromocriptine (Parlodel) c. Carbidopa (Sinemet) d. Tolcapone (Tasmar)

ANS: D Trihexyphenidyl is an anticholinergic drug. Tolcapone is a COMT inhibitor. Selegiline is a MAO-B inhibitor. Only rotigotine is a pure dopamine agonist.

Which drug used to treat Parkinson's disease is a pure dopamine agonist? a. Trihexyphenidyl (Artane) b. Tolcapone (Tasmar) c. Selegiline (Zelapar) d. Rotigotine (Neupro)

ANS: C Alzheimer's disease is a form of dementia. Parkinson's disease is a neurodegenerative disease. Both illnesses involve interrupted nerve impulse transmissions.

Which is the common underlying pathophysiology of both Alzheimer's disease and Parkinson's disease? a. Both are neurodegenerative diseases. b. Both are forms of dementia. c. Both involve interrupted transmission of nerve impulses. d. Both are primarily caused and directly related to environmental factors.

ANS: A Sinemet can cause a profound reduction in the white blood cell count (neutropenia), which then greatly increases the risk for infection.

Which precaution should you teach patients prescribed carbidopa-levodopa (Sinemet)? a. Avoid crowds and people who are ill. b. Take this drug with an antacid to prevent ulcers. c. Restrict your fluid intake to less than 1.5 L daily. d. Keep the bottle containing the drug in the refrigerator.

ANS: D The most common side effects of cholinesterase/acetylcholinesterase inhibitors are nausea, vomiting, diarrhea, stomach cramps, headaches, dizziness, fatigue, weakness, insomnia, and loss of appetite (anorexia).

Which problem is a common side effect of donepezil (Aricept) for treatment of Alzheimer's disease? a. Weight gain b. Hypertension c. Constipation d. Nausea/vomiting

ANS: B The most common side effects of drugs to treat Parkinson's disease are dizziness, nausea, and hypotension.

Which problem is a common side effect of most drugs used to treat Parkinson's disease? a. Asthma b. Hypotension c. Constipation d. Weight gain

ANS: C The four major symptoms of Parkinson's disease are tremor at rest, rigidity, bradykinesia (slow movements and difficulty starting to move), and abnormal gait.

Which problem is a major symptom of Parkinson's disease? a. Memory loss b. Urinary retention c. Abnormal gait d. Nausea/vomiting

ANS: D Alzheimer's disease is a progressive and incurable condition that destroys brain cells, with gradual loss of intellectual abilities such as memory and extreme changes in personality and behavior. It is the most feared and common form of dementia. Alzheimer's disease is the most common form of dementia.

Which statement about Alzheimer's disease is true? a. The causes of Alzheimer's disease are known but not treatable. b. Physical deterioration occurs before intellectual deterioration. c. The onset of the disorder is sudden and dramatic. d. It is the most common form of dementia.

ANS: D Dopaminergic drugs increase the amount of dopamine activity in the brain. COMT (catechol-o-methyltransferase) inhibitors allow a larger amount of levodopa to reach the brain, which increases the brain's dopamine levels. MAO-B inhibitors inhibit the enzyme monoamine oxidase B that breaks down dopamine in the brain. Anticholinergic drugs are effective against tremors and rigidity by blocking cholinergic nerve impulses that help control the muscles of the arms, legs, and body.

Which statement is true about how drugs for Parkinson's disease work? a. Dopaminergic drugs decrease the amount of dopamine activity in the brain. b. COMT inhibitors allow a larger amount of levodopa to reach the brain, which lowers the brain's dopamine levels. c. MAO-B inhibitors facilitate the enzyme monoamine oxidase B that breaks down dopamine in the brain. d. Anticholinergic drugs block cholinergic nerve impulses to minimize tremors and rigidity.

ANS: A No drug has been developed that will protect neurons from the changes that occur with Alzheimer's disease. Drug treatments can temporarily slow the progression of symptoms in some patients. The drugs do not cure the disease and a patient should not expect to regain lost function. The only way to definitively diagnose this illness is by seeing the plaques and tangles in the brain on autopsy after death.

Which statement made by a patient with Alzheimer's disease indicates the need for additional teaching? a. "When I have been taking donepezil for 6 weeks I should regain my memories." b. "The only way to be sure that I have Alzheimer's disease is by autopsy after I die." c. "Even with medication, eventually I will need total care to prevent complications." d. "The rivastigmine I am taking may slow down the progression of my symptoms."

ANS: A Because patients with Alzheimer's disease have difficulty with memory and cognition, the individual providing care in the home should be included when doing any teaching about the disease, including drugs and dosages.

Which strategy best supports safe medication administration for patients with Alzheimer's disease? a. Include the patient's care provider when teaching about the patient's drugs. b. Provide written guidelines about each drug to the patient. c. Create a chart listing the drugs, dosages, and times they should be taken. d. Suggest that the patient set up the drugs each week in labeled boxes.

ANS: C Alzheimer's disease symptoms begin very slowly. In the early stage, the first symptom is mild forgetfulness, which is sometimes confused with age-related memory changes.

Which symptom is often the earliest to occur in a patient with Alzheimer's disease? a. Difficulty solving simple math problems b. Problems performing simple tasks c. Mild forgetfulness d. Inability to read

ANS: A Bromocriptine suppresses the secretion and release of prolactin from the pituitary gland. Without secretion of this important hormone, lactation with milk production does not occur.

Why is bromocriptine (Parlodel) not recommended for women who are breastfeeding? a. It stops the production of milk. b. It enters the milk and slows infant growth. c. It enters the milk and causes symptoms of Parkinson's disease in the infant. d. It is a pregnancy category C drug and has been found to cause birth defects in animals.