Specific Neurodegenerative Disorders

What baseline labs should be obtained for a patient who has been prescribed carbidopa-levodopa? Select all that apply. CBC LFT BMP Kidney profile Prolactin level Pregnancy test

CBC LFT Prolactin Test Pregnancy Test

When levodopa is used alone, only ___ reaches the brain because ____ converts to dopamine while in the peripheral nervous system. By combining carbidopa with levodopa, carbidopa can inhibit the enzyme decarboxylase in the periphery, thereby allowing more levodopa to reach the brain.

1% 99%

The duration of action for transdermal rivastigmine is _____ hours.

24

A nurse administers oral carbidopa-levodopa to a patient who has tremors from Parkinson's disease. What duration of action does the nurse expect to see for this medication? 1 hour 3 hours 5 hours 8 hours

8 hrs

Pre-Administration Assessment for Carbidopa-Levodopa Determine Baseline Data:

Vital signs Lab: Complete blood count (CBC), liver function test (LFT), prolactin level, pregnancy test Current motor symptoms and any impairment to ADLs

Capidopa-Levodopa: Metabolism

Half Life: 1-2 hours

Where does the excretion of carbidopa-levodopa occur? Liver Urine Gallbladder Oral secretions

Urine

Capidopa-Levodopa:Absorption

PO: Well-absorbed

What information should the nurse include in patient teaching for a patient taking extended-release carbidopa-levodopa? Select all that apply. "Report tremors to your health care provider." "Do not abruptly stop taking this medication." "You may continue to have symptoms for several weeks or months " "If this medication causes GI upset, you can crush the tablets and mix them with food." "You may experience discolored urine or dark perspiration while taking this medication."

"Do not abruptly stop taking this medication." "You may continue to have symptoms for several weeks or months " "You may experience discolored urine or dark perspiration while taking this medication."

The nurse is providing education to a patient taking carbidopa-levodopa. Which statement by the nurse correctly explains why the patient should take this medication with low-protein foods? "A high-protein diet will increase renal excretion of carbidopa-levodopa." "Low-protein foods accelerate the transportation of this medication to the CNS." "Alow-protein diet will help prevent gastrointestinal distress from the medication." "High-protein foods interfere with transportation of this medication to the central nervous system."

"High-protein foods interfere with transportation of this medication to the central nervous system."

What correct statement should the nurse include in patient teaching related to carbidopa-levodopa and symptoms of dyskinesia? "Your dyskinesia will be cured by this medication." "Your dyskinesia will worsen with this medication." "It will take 3 to 5 days for your symptoms to be controlled." "It may take weeks or months before your symptoms are controlled."

"It may take weeks or months before your symptoms are controlled." Symptoms may take weeks or months to be controlled in patients taking carbidopa-levodopa.

Which information related to rivastigmine should the nurse teach Mrs. Hill? "Weight gain can occur." "Avoid grapefruit products." "Take ibuprofen 30 minutes before a meal to prevent GI upset." "Rise slowly from sitting or lying positions, as orthostatic hypotension can occur."

"Rise slowly from sitting or lying positions, as orthostatic hypotension can occur."

A patient who is currently taking an antihypertensive drug for renal artery stenosis has also been prescribed carbidopa-levodopa for the beginning stages of Parkinson's disease. The patient states, "I'm applying for a job where I would be operating a backhoe." What teaching should the nurse provide for the patient? "Perform exercises for lumbar support while sitting." "Your tremors will stop, so you will be able to operate a backhoe." "These medications stimulate your central nervous system, so you will be able to operate heavy machinery." "These medications together may increase your risk for hypotension, so you will need to use caution when operating heavy machinery."

"These medications together may increase your risk for hypotension, so you will need to use caution when operating heavy machinery."

Which instruction ismost important for the nurse to include when teaching a patient who has been prescribed sustained-released carbidopa-levodopa? "Take this medication with food." "Take this medication with low-protein foods." "Watch for adverse effects such as dizziness and drowsiness." "Inform the health care provider when you can walk without shuffling."

"Watch for adverse effects such as dizziness and drowsiness." Adverse effects of carbidopa-levodopa include dizziness and drowsiness, which can lead to orthostatic hypotension and falls. Safety is the highest priority.

Rivastigmine Absorption:

Absorption: PO: GI track (faster on empty stomach)

Drug Class: Dopamine Agonists Mechanism of Action: Examples:

Acts directly on the dopamine receptors of nerve cells in the brain by stimulating them. Exact mechanism of action is not understood. amantadine bromocriptine pramipexole ropinirole HCl

Match the drug class with the mechanism of action: Affect dopamine content of the brain Stimulate dopamine receptors of nerve cells in the brain Inhibit activity of acetylcholine Inhibit activity of monoamine oxidase Mechanism of Action: Dopaminergics MAO-B inhibitors Anticholinergics Dopamine agonists

Affect dopamine content of the brain Dopaminergics Stimulate dopamine receptors of nerve cells in the brain Dopamine agonists Inhibit activity of acetylcholine Anticholinergics Inhibit activity of monoamine oxidase MAO-B inhibitors

Drug Class: Dopaminergics Mechanism of Action: Examples:

Affects the dopamine content of the brain. Levodopa is converted into dopamine by nerve cells in the brain. When combined with carbidopa, more levodopa is permitted to reach the brain and a lower dose is required. carbidopa-levodopa

A nurse is providing a teaching plan for a patient who is taking carbidopa-levodopa and selegiline, an MAOI. Which foods should the nurse tell the patient to avoid? Honey, beer, and apples Boiled peanuts and hot dogs Grapefruit juice and tomatoes Aged cheeses, red wines, and bananas

Aged cheeses, red wines, and bananas Foods high in tyramine such as aged cheeses, red wines, and bananas should be avoided to prevent hypertensive crisis.

Adverse Effects of Cabidopa-Levodopa Common: Life Threatening:

COMMON Involuntary movements Psychosis Palpitations Orthostatic hypotension Depression with suicidal tendencies Urinary retention LIFE THREATENING Cardiac dysrhythmias Thrombocytopenia Hemolytic anemia Agranulocytosis

Pharmacodynamics of Rivastigmine:

Although a cure for Alzheimer's has not been found, there are some medications that can treat the disease symptoms. Some of these medications fall under the classification of acetylcholinesterase (AChE) (or cholinesterase) inhibitors and include rivastigmine, tacrine, and donepezil. These medications stop the breakdown of acetylcholine, allowing more to be available to the neuron receptors. These drugs are currently approved by the Food and Drug Administration (FDA) for the treatment of Alzheimer's disease. There are other drugs that are currently being investigated for use with Alzheimer's disease. Rivastigmine will be discussed as the prototype Alzheimer's drug. Rivastigmine is prescribed to patients with mild-to-moderate Alzheimer's. As an AChE inhibitor, rivastigmine improves cognitive function through its capability to access the CNS and increase cholinergic transmission. Studies have shown that rivastigmine improves memory and slows down the process of the disease.

Neurodegenerative disorders are conditions that continually progress and cannot be cured. Two types of neurodegenerative disorders include _____ and _____. Although these neurodegenerative disorders cannot be cured, there are medications that can treat the symptoms and, in some cases, slow the progression of the disease.

Alzheimer's disease Parkinson's disease

What is Alzheimer's?

Alzheimer's is a type of dementia, usually presenting after the age of 65, that is progressive and, therefore, cannot be cured. Approximately 5% of people with Alzheimer's develop symptoms before the age of 65, some between the age of 30 and 40. This is termed early onset. Alzheimer's disease causes problems with memory, thinking, and behavior due to the loss of neurons. Some of the physiological changes that take place and are thought to cause Alzheimer's include: Acetylcholine deficiency due to cholinergic neuron degeneration Neuritic plaques: Apolipoprotein E4 (apo E4) binds beta-amyloid within the plaques Neuronal injury/death: Contributed by high levels of beta-amyloid protein Neurofibrillary tangles

Drug Class: COMT Inhibitors Mechanism of Action Examples:

Blocks catechol-o-methyl transferase (COMT), an enzyme that breaks down dopamine, and prolongs the effect of levodopa. With a higher concentration in the brain, a lower dose of levodopa is required. entacapone, tolcapone

The nurse is preparing to administer rivastigmine to a patient who has been admitted with worsening symptoms of Alzheimer's disease. The order states to administer 8 mg bid, and the pharmacy sends four 2-mg tablets for the am dose. What should the nurse do first? Administer the medication Call the pharmacy to ask for one 8 mg tablet Call the health care provider for an order change Ask a family member what dosage the patient takes at home

Call the health care provider for an order change

_____ and ______ are dopaminergics which are combined to create a more effective parkinsonism therapy.

Carbidopa Levodopa

Which statement about the mechanism of action of carbidopa is true? Carbidopa has no therapeutic effect on its own. Carbidopa works by crossing the blood-brain barrier. Carbidopa aids in the breakdown of levodopa in the peripheral tissues. Due to periphery loss of the medication, only 2% of carbidopa taken is available to the brain.

Carbidopa has no therapeutic effect on its own.

Which statement correctly explains the action of carbidopa-levodopa? Carbidopa decreases symptoms of parkinsonism. Carbidopa inhibits the breakdown of dopamine at the synapses in the brain. Carbidopa inhibits the catechol-o-methyltransferase (COMT) enzyme, increasing the concentration of levodopa. Carbidopa prevents levodopa decarboxylation in the periphery, resulting in more levodopa being transported to the brain.

Carbidopa prevents levodopa decarboxylation in the periphery, resulting in more levodopa being transported to the brain.

Which statement about carbidopa-levodopa is correct? Carbidopa-levodopa should not be taken with food. Carbidopa-levodopa should not be stopped abruptly. High-protein foods should be consumed with every meal. A decrease in the symptoms of Parkinson's disease occurs within a week of starting medication treatment.

Carbidopa-levodopa should not be stopped abruptly.

Rivastigmine Patient Teaching Side Effects:

Common: Nausea, vomiting, diarrhea, anorexia, abdominal pain, and weight loss Report immediately: Severe nausea/vomiting, increased salivation, diaphoresis, bradycardia, hypotension, respiratory depression, and seizures Teach patients to rise slowly to avoid orthostatic hypotension. Explain to patients the importance of regular liver tests since hepatotoxicity can occur.

Pre-Administration Assessment for Carbidopa-Levodopa Identify High-Risk Patients:

Concurrent use of levodopa and monoamine oxidase (MAO) inhibitors may trigger melanoma; monitor skin for changes. Patients with heart disease or mental disorders or those on MAO-B inhibitor therapy should use with caution. Review the patient's medical history for contraindications or conditions in which this drug should be used with caution. Review the patient's medication history; report possible interactions.

Contraindications of Rivastigmine

Contraindications: History of reactions to rivastigmine at application site; hypersensitivity to drugs with similar compounds (carbamate derivatives) Rivastigmine can cause hepatotoxicity; liver dysfunction can cause cumulative drug effect Cautions: Simultaneous NSAID use Peptic ulcers Urinary obstruction Bradycardia or supraventricular defects COPD Patients under 50 kg Seizure disorders Sick sinus syndrome

Contraindications for Carbidopa-Levodopa

Contraindications: Glaucoma, cardiac issues, kidney disease, liver disease, skin lesions that appear suspicious, orthostatic hypotension Cautions: Psychiatric disorders, suicide ideation, seizures, peptic ulcer

Patient Teaching: Diet for Cabidopa-Levodopa

Diet Inform patients that if GI problems occur, they can take the medication with food; patients should be aware that this will decrease the rate of absorption. Inform patients taking selegiline that eating foods high in tyramine (red wine, yogurt, bananas) can result in a hypertensive crisis. Advise patients to eat a low-protein diet as protein can interfere with the drug reaching the brain, thus decreasing effectiveness.

Rivastigmine Distribution:

Distribution: Protein-binding: 40%

Interactions for Carbidopa-Levodopa

Drug: When used with levodopa: Anticholinergics, antipsychotics may reduce effect of levodopa. Tricyclic antidepressants (TCAs) may cause dyskinesia and hypertension. Methyldopa may cause psychosis. MAOI's can result in severe hypertension. Food: Foods high in protein may reduce levodopa absorption from the intestine. Lab: Blood urea nitrogen (BUN), aspartate aminotransferase (AST), alanine aminotransferase (ALT), alkaline phosphatase (ALP), and lactate dehydrogenase (LDH) levels could show an increase.

What potential side effect of carbidopa-levodopa should the nurse teach the patient and family to report to the health care provider? GI upset Seizures Dyskinesia Elevated temperature

Dyskinesia

Evaluation for Cabidopa-Levodopa

Evaluation Assess for reductions in tremor and rigidity. Assess for improvement in balance, gait, and mobility. Assess for side effects.

Patient General Teaching for Cabidopa-Levodopa

General Teaching Teach patients that if the medication is stopped abruptly, an increase in parkinsonism symptoms may occur. Inform patients that symptoms may persist for weeks or months before a therapeutic goal is reached and they are controlled. Warn patients that extended release tablets should not be crushed or chewed.

Carbidopa-levodopa is available in three different forms. It must be titrated carefully for each patient to determine the optimum daily dosage.

Immediate Release PO: 3-4x a day No more than 8 tablets or 80/800 mg per day Initial dose: 1 tablet of 10 or 25 mg carbidopa/100 mg levodopa Maintenance: 25/250 mg Extended-release capsules PO: 2x a day No more than 1600 mg/day Initial dose: 50 mg carbidopa/200 mg levodopa Enteral Suspension 2000 mg/day over 16 hours

Which nursing diagnosis is highest priority for a nurse who is caring for a patient taking carbidopa-levodopa for Parkinson's disease? Risk for activity intolerance related to tremors Impaired physical mobility related to dizziness Body image disturbance related to shuffling gait Knowledge deficit related to effects of medication

Impaired physical mobility related to dizziness

To evaluate the effectiveness of dopaminergic agents, the nurse should assess for which condition? Weight loss Correction of shuffling gait Increase in drooling and sweating Improvement in balance, gait, and mobility

Improvement in balance, gait, and mobility

Capidopa-Levodopa: Excretion

In urine as metabolites

A patient has been taking carbidopa-levodopa for many years. During assessment, the nurse finds that the patient presents with hand tremors, drooling, and a mask-like facial expression. What action by the health care provider should the nurse anticipate? Increase in medication dosage Decrease in medication dosage Discontinuation of the medication Discussion of medication compliance

Increase in medication dosage

Rivastigmine Patient Teaching General:

Inform patients that rivastigmine may improve symptoms, but will not stop the disease progression. Ensure patients or care provider are aware of when medication is due and when the dose should be increased. Explain safety techniques (keeping paths clear to avoid injury when a patient may wander). Inform family members that there are support groups available to them, such as the Alzheimer's Disease and Related Disorders Association. Notify family members about specific foods to prepare that may help with consumption and tolerance during this therapy.

Drug Class: Anticholinergics; Antiparkinsonism Mechanism of Action: Examples:

Inhibits or reduces the activity of acetylcholine. Acetylcholine is balanced by dopamine and becomes excessive when dopamine is depleted; this contributes to the motor symptoms seen with parkinsonism. trihexyphenidyl benztropine biperiden

Drug Class: MAO-B Inhibitors Mechanism of Action: Examples:

Inhibits the actions of monoamine oxidase, which is an enzyme that breaks down dopamine. With this enzyme stopped, dopamine is available to be reabsorbed by neurons and saved for later use. selegiline HCl rasagiline

Interactions of Rivastigmine

Interactions Drug: When used with rivastigimine: Effects of theophylline and general anesthetics are increased. TCAs decrease effects of rivastigimine. Cimetidine increases effects of rivastigimine. NSAIDs increase GI effects. Tobacco increases rivastigimine clearance. Lab: May result in higher levels of ALT and AST HERBAL: Cholinergic effects may be increased with gingko biloba.

Interventions for Cabidopa-Levodopa

Interventions Monitor for orthostatic hypotension with initial doses; symptoms include dizziness and fainting upon changing positions. Give with foods that are low in protein because a high-protein diet may inhibit transport of levodopa to the central nervous system (CNS). Screen for signs or symptoms relative to parkinsonism, including stooped forward posture, shuffling gait, masked facies, and resting tremors.

Which statement about rivastigmine is correct? It is metabolized in the kidneys. It is contraindicated in patients with liver disease. It is contraindicated with concurrent use of NSAIDs. It is contraindicated in patients with Alzheimer's disease.

It is contraindicated in patients with liver disease. Rivastigmine is contraindicated in patients with liver disease due to risk of hepatotoxicity.

Pharmacokinetics of Carpidopa-Levodopa

Levodopa is rapidly broken down into dopamine in the intestines and peripheral tissues. Most of it is converted in the intestines and peripheral tissue, leaving only 2% of the levodopa to be transported to the brain for use. This number increases to 10% when carbidopa is administered and prevents decarboxylation of peripheral levodopa. Since a higher percentage is available to the brain, a lower dose is required for therapeutic effect to occur.

Which factor in a patient's health history is most important for the nurse to consider with regard to the patient's treatment plan? Acid reflux Liver disease Prostate cancer Basal cell carcinoma

Liver Disease

A family member states, "My father complains of an upset stomach after taking rivastigmine." Which would be an appropriate response by the nurse? "We may need to decrease his dose." "Make sure he takes the medication with food." "Make sure he takes the medication without food." "We may need to reduce the frequency of his dosing to once daily."

Make sure he takes the medication with food

Which side effects should the nurse teach Mrs. Hill to expect while taking rivastigmine? Select all that apply. Nausea Diarrhea Anorexia Headache Tachycardia Hypertension

Nausea Diarrhea Anorexia Headache

What statement is correct about the pharmacokinetics of topical rivastigmine? Peak action is 4 hours Peak action is 24 hours Onset of action is 2 to 4 hours Onset of action is 0.5 to 1 hour

Onset of action is 0.5 to 1 hour The onset of action for topical rivastigmine is 30 minutes to 1 hour.

Forms of Rivastigmine:

Oral and Transdermal For Oral (special instructions) Administer with food to enhance absorption and reduce GI effects.

Capidopa-Levodopa: Distribution

PB (protein-bound): Carbidopa: 36% Levodopa: Unknown

Capidopa-Levodopa: Peak

PO: 1-3 hours ER: 2-3 hours

Capidopa-Levodopa Duration:

PO: 5 hours ER: 4-5 hours

Rivastigmine Onset:

PO: Unknown Transdermal: 0.5-1 hour

is a progressive neurological disorder that affects movement and is the result of an imbalance of dopamine and acetylcholine.

Parkingson's disease

Pre-Administration Assessment on Patient before giving Rivastigmine:

Patient History Medical history, noting renal or liver disease, peptic ulcer, chronic obstructive pulmonary disease (COPD), asthma, and urinary obstruction History of behavioral changes Assessment Mental and physical abilities; any impairments in self-care or cognition Behavioral disturbances Aphasia Motor function Family's coping ability

Adverse Effects of Rivastigmine

Peripheral cholinergic side effects are more common with rivastigmine than with tacine and donepezil when given orally. The most common cholinergic effects are nausea, vomiting, diarrhea, abdominal pain, and anorexia. COMMON SIDE EFFECTS: dizziness, headache, insomnia, and dyspepsia. OVERDOSE can produce cholinergic crisis, characterized by severe nausea/vomiting, increased salivation, diaphoresis, bradycardia, hypotension, respiratory depression, and seizures. LIFE THREATENING SIDE EFFECTS: Suicidal ideation, hepatotoxicity, Stevens-Johnson syndrome, myocardial infarction (MI), and heart failure.

Which statement correctly explains the action of rivastigmine? Interferes with the breakdown of dopamine Breaks down acetylcholine in the neuron receptors Permits more acetylcholine in the neuron receptors Reverses clinical manifestations of Alzheimer's disease

Permits more acetylcholine in the neuron receptors

Rivastigmine Interventions:

Provide consistent care. Provide ambulation assistance. Assess for side effects common to prolonged use of AchE inhibitors. Check vital signs often for bradycardia or hypotension. Note any changes in behavior, whether better or worse.

Which statement best explains the therapeutic effect of rivastigmine? Improves memory Restores damaged neurons Improve oxygenation in the brain. Increases antioxidants in the brain

Rivastigmine improves memory in patients with mild to moderate Alzheimer's disease.

Rivastigmine General Info

Rivastigmine is available in oral and transdermal doses. When given with food, the absorption of rivastigmine is enhanced. AChE will convert the drug into inactive metabolites, whereas the other cholinesterase inhibitors are converted by enzymes in the liver. The dose is administered 2x a day, due to its short half-life, and the dose is slowly increased. When rivastigmine is administered transdermally, drug levels in the blood are more constant than with an oral administration.

Patient Teaching: Side Effects for Cabidopa-Levodopa

Side Effects Inform patients that discolored urine or dark perspiration may occur. Instruct patients that dyskinesia (involuntary muscle movement) should be reported. Teach patients that side effects may include GI disturbances, orthostatic hypotension, and mental disturbances.

Which is a correct therapeutic goal for treatment of Parkinson's Disease? To cure Parkinson's disease To delay the progression of Parkinson's disease To improve the patient's ability to carry out activities of daily living To return the patient's ability to carry out activities of daily living to baseline

To improve the patient's ability to carry out activities of daily living

Which route of administration for rivastigmine results in a peak concentration between 8 and 16 hours? Oral Intravenous Transdermal Subcutaneous

Transdermal

Parkinsonism results when the brain stops producing the neurotransmitter called dopamine due to the deterioration of neurons in the substantia nigra. The cause of this neuron degeneration is idiopathic (unknown). This disease produces multiple symptoms that include:

Tremor—a shaky limb or constant movement of hands or fingers Bradykinesia—slowed movement Rigid muscles—muscle stiffness, limited range of motion and pain Impaired posture and balance—controlled by the extrapyramidal motor system Loss of automatic movements—unconscious movements, such as blinking and smiling Speech or writing changes—less inflections with speech or difficulty writing

Rivastigmine Excretion:

Urine

Carbidopa enhances the effects of levodopa by preventing levodopa decarboxylation, resulting in an increased availability of levodopa for transport to the brain. This means more levodopa can cross the ______ and be converted into ________

blood brain barrier dopamine

During patient discharge, a family member states to the nurse, "My mother's Alzheimer's disease can be cured." How should the nurse respond? "The disease cannot be slowed." "You are likely to develop this disease." "Everyone over 65 develops some level of this disease." "The symptoms may be treated, but the disease itself cannot be cured."

the symptoms may be treated, but the disease itself cannot be cured.