Pain Management

Adverse effects: darifenacin, oxybutin, solifenacin

mydriasis, blurred vision, dry eyes, dry mouth, urinary retention, constipation

Mitoxantrone (immunosuppressant) adverse effects

myelosuppression, cardiotoxicity, fetal harm

Antipsychotics: black box warning

Increases risk of death in the elderly when used to treat dementia-related psychosis Death is mostly contributed by CV (heart failure, sudden death) and infection (pneumonia) factors

A client, residing in an assisted living facility, is diagnosed with Parkinson disease and the health care provider prescribes selegiline (Eldepryl). What precaution should the nurse teach the client? Change positions slowly. Take the medication between meals. Perform self-blood glucose monitoring. Withhold the next dose if nausea occurs.

Change positions slowly.

A client newly diagnosed with myasthenia gravis is to begin taking pyridostigmine (Mestinon), a cholinesterase inhibitor. Two days later the client develops loose stools and increased salivation. The nurse concludes that these signs are: Indicative of a myasthenic crisis Cholinergic effects A temporary response Toxic effects of the medication

Cholinergic effects

SSRI Drugs

Citalopram (Celexa) Escitalopram (Lexapro) Fluoxetine (Prozac) Fluvoxamine (Luvox) Paroxetine (Paxil) Sertraline (Zoloft)

Adverse effects of SGAs

Common: sedation, weight gain, ortho hypoTN, dry mouth, blurred vision, urinary retention, constipation, tachycardia Rare: neuroendocrine effects, EPS and TD

A client with schizophrenia who is receiving an antipsychotic medication begins to exhibit a shuffling gait and tremors. The practitioner prescribes the anticholinergic medication benztropine (Cogentin) 2 mg daily. What should the nurse assess the client for daily when administering these medications together? Constipation Hypertension Increased salivation Excessive perspiration

Constipation

Monoamine Oxidase A

Inactivates NE and S-HT Inhibitors: antidepressants: PANAMA PAmate NArdil MArplan

A nurse is educating a client who is taking clozapine (Clozaril) for paranoid schizophrenia. What should the nurse emphasize about the side effects of clozapine? Risk for falls Inability to sit still Increase in temperature Dizziness upon standing

Increase in temperature

Adverse effects of MAO B inhibitors

Insomnia, Ortho hypoTN, HTN crisis (due to high doses, tyramine, sympathomimetic drugs)

Levadopa

Most effective in PD when combined with carbidopa Dopamine restoration (increases dopamine levels in the brain that are depleted in Parkinson disease)

The nurse explains to the family of a client suspected of having myasthenia gravis that edrophonium (Enlon) is used to establish the diagnosis. An increase in which factor will confirm the diagnosis? Symptoms Consciousness Blood pressure Muscle strength

Muscle strength

A client is receiving doxepin (Sinequan). For which most dangerous side effect of tricyclic antidepressants should a nurse monitor the client? Mydriasis Dry mouth Constipation Urine retention

Mydriasis

Antidepressants

SSRIs, SNRIs, TCAs, MAOIs, Atypical antidepressants, St. John's Wort 1-3 wks initial response; max response takes up to 12 wks (NOT PRN) first line: SSRIs, SNRIs, bupropion, mirtazapine second line: MAOIs and TCAs (old drugs)

SGAs (Atypicals)

Safer than FGAs less EPS and TD effects Serious metabolic effects: weight gain, diabetes, dyslipidemia Other adverse effects: sedation ortho hypoTN, increased risk of death in elderly -zapine, -ridone, Quetapine, Aripiprazole, Ziprasidone

What should the nurse include when teaching a client with severe Parkinson disease about carbidopa-levodopa (Sinemet)? Multivitamins should be taken daily Alcohol consumption should be in moderation The medication should be taken with meals A high-protein diet should be followed

The medication should be taken with meals (reduces nausea and vomiting)

Antipsychotics

Therapeutic effects takes MONTHS FGAs - Nuroleptics - causes high rates of extrapyramidal side effects (EPS) and tardive dyskenesia SGAs - Atypical - Lesser daverse effects than FGAs, serious metabolic effects

serotonin syndrome

overstimulation of peripheral serotonin receptors begins 2 - 72 hours after onset of treatment

Positive symptoms

overt symptoms that should not be present: hallucinations, delusions, disorganized thought

More adverse effects of Levodopa

postural hypoTN (increase Na and water, alpha agonist) Dysrhythmias visual hallucinations, nightmaires, paranoid ideation (FGAs decrease psychotic symptoms but increase PD, SGAs are preferred --> clozapine and quetapine) Dark sweat and urine color

An antidepressant is prescribed for a depressed older client. After 1 week the client's son expresses concern that there does not seem to be much improvement. How should the nurse respond? "Antidepressant therapy requires several weeks before it becomes effective." "Antidepressant therapy will be more effective as the physical condition improves." "Additional medications may be required before behavioral changes will be observed." "Additional time is needed for the medication to become effective because of the prolonged depression."

"Antidepressant therapy requires several weeks before it becomes effective."

Therapeutic uses of SGAs

Schizophrenia (last resort since it causes fatal agranulocytosis) Levodopa-induced psychosis

A nurse is interviewing a client in the mental health clinic. Which statement by the client indicates an irreversible adverse response to long-term therapy with an antipsychotic medication? "My mouth is always dry." "I can't seem to sleep at night." "I don't have much of an appetite." "My tongue seems to move by itself."

"My tongue seems to move by itself."

FGAs

Blocks dopamine (causes EPS and prolactin release), histamine (weight gain, sedation), cholinergic receptors (dry mouth, blurred vision, urinary retention, constipation), and alpha1 receptors (otho hypoTN, reflex tachycardia)

SNRIs

Blocks reuptake of serotonin and NE Venlafaxine (Effexor) Desvenlafaxine (Pristiq) Duloxetine (Cymbalta)

Drugs for neuropathic pain in MS

AEDs (carbamezepine (Tegretol), gavapentin (neurontin), oxcarazepin (Trileptal) TCAs (amitriptyline (Elavil), nortriptyline (Pamelor)

Treatment for EPS

Acute Dystonia: antiCHOLinergic drugs (eg, benztropine) IM or IV Parkinsonism: antiCHOLinergic drugs (eg, benztropine, diphenhydramine), amantadine, or both Akathisia: Benzodiazepine, beta blockers, antiCHOLinergic Tardive Dyskinesia (TD): No reliable treatment

More adverse effects of FGAs

Anticholinergic effects, orthostatic hypoTN, sedation, neuroendocrine effects (increase levels of prolactin which leas to gynecomastia and galactorrhea), seizures Sexual dysfunction, agranulocytosis (check and monitor WBCs), severe dysrhythmias

Drugs for OAB

Anticholinergics: Darifenacin, Oxybutin, Solifenacin, Festerodine, Tolterodine, Trospium

FGA drug interactions

Anticholinergics: antihistamines, OTC sleep aids CNS Depressants: antihistamines, BZDs, barbiturates Levodopa and direct DA receptor agonists (most Parkinson medications) - counteract antipsychotic effects

A practitioner prescribes an antidepressant for a hospitalized client who has been severely depressed. Eight days later the nurse notes that the client is neatly dressed and well groomed. The client smiles at the nurse and says, "Things sure look better today." What nursing response is appropriate in light of the client's statement? Complimenting the client's appearance Starting preparations for the client's discharge Arranging for constant supervision of the client Adding privileges to the client's plan of care as a reward

Arranging for constant supervision of the client

Non-motor PD symptoms

Autonomic: constipation (fluid, fiber, stool softener, laxative), urinary incontinence (oxybutynin, anticholinergic), ortho HTN (Na and fluids, steroids), erectile dysfunction (PDE5 inhibitor - sildenafil) Insomnia (levodopa/carbidopa) Excessive daytime sleepiness (modafinil) Depression, dementia, psychosis

Drugs for BPH alpha1 blockers Selective: Silodosin, Tamsulosin Nonselective: Alfuzosin, Doxazosin, Terazosin

Block alpha1 receptor reducing BPH symptoms RAPIDLY but does not delay progression Adverse effects include abnormal ejaculation (volume, failure, retrograde), risk of floppy iris syndrome during cataract surgery hypoTN, fainting, dizziness, nasal congestion

Parkinson's Disease

Chemical imbalance (low dopamine and high acetylcholine)

Drug therapy for MS

DZ modifiers: immunomodulators and immunosupresants Tx of acute relapse: high dose IV glucocorticoids and IV gamma globulin Symptom management: bladder dysfunction, bowel dysfunction, fatiqgue, depression, sexual dysfunction, neuropathic pain

Depression

Decreased norepinephrine, dopamin, and serotonin

TCAs (block NE)

Desipramine (Norpramin) Maprotiline Nortriptyline (Pamelor) Protriptyline (Vivacti

Drugs for bladder dysfunction in MS

Detrusor hyperreflexia (overactiv bladder): tolterodine, oxybutynin, darifenacin, solifenacin Flaccid bladder (urinary retention): bethanechol (urecholine)

Treatment managements of antidepressants

Dose should be low Drugs should be continued for 4-8 wks to assess efficacy Tx should continue at least 4 - 9 months to prevent relapse ADHERENCE IS CRITICAL discontinuation done SLOWLY

Adverse effects of FGAs (EPS)

EPS -> movement disorders -> too little DA and too much ACh Early reactions (hrs to days) - acute dystonia (abnormal muscle tone), parkinsonism, akathisia (restlessness) Late reaction (months to yrs) - tardive dyskinesia

Carbidopa

Enhances Levodopa Prevents decarboxylation of levodopa in the intestine and peripheral tissues --> increasing levodopa availability most effective PD therapy: levodopa + carbidopa = Sinemet or Parcopa

MAO B

Inactivates DA Inhibitors: anti-Parkinson (giline) Selegiline Rasagiline

COMT inhibitors

Inhibit metabolism of Ldopa in the periphery --> increases Ldopa half life in the BBB Entacapone Tolcapone

Drug-drug interaction of Levodopa

Levodopa + MAOI = HTN crisis

Drugs for sexual dysfunction in MS

Lubricants (vaginal dryness) PDE-5 inhibitors (Sildenafil (Viagra), vardenafil (Levitra) for erectile dysfunction

Neostigmine (Prostigmin) therapeutic uses

MG Reversal of Neuromuscular blockade

Food-drug interactions of Levodopa

Meals high in protein interfere with absorption from the intestine and across the BBB

Managing adverse effects of Levodopa

Presence of dyskinesia will need a decrease in L dopa, give amentadine, or surgery and electrical stimulation

AntiCHOLinergic Parkinson Drugs

Reduce tremor and possibly rigidity Benztropine Trihexyphenidyl (Artane)

The health care provider prescribes neostigmine (Prostigmin) for a client with myasthenia gravis. The nurse evaluates that the client understands the teaching about this drug when the client says, "I should: Keep the drug in a container in the refrigerator." Take the drug at the exact time that is listed on the prescription." Plan to take the drug between meals to promote absorption." Expect that the onset of the action of the drug will occur several hours after I take it."

Take the drug at the exact time that is listed on the prescription."

A 62-year-old patient who has Parkinson's disease is taking bromocriptine (Parlodel). Which information obtained by the nurse may indicate a need for a decrease in the dose? The patient has a chronic dry cough. The patient has four loose stools in a day. The patient develops a deep vein thrombosis. The patient's blood pressure is 92/52 mm Hg.

The patient's blood pressure is 92/52 mm Hg.

CHOLinesterase Inhibitors

prevents breakdown of ACh by inhibiting AChE Cannot cure or stop the progression of Alzheimer's DZ For mild-moderate symptoms Therapeutic affect is mild and short-lasting (exception of donepezil) Rivastagmine Galantamine Donepezil

Natalizumab

progressive multifocal leukoencephalopathy, liver injury

Adverse effects of SGAs (Agranulocytosis)

Agranulocytosis: causes gram negative septicemia (monitor WBC and neutrophil q2 weeks for 6 months, then monthly stop clozapine if WBC < 3000; ANC < 1500 Teach patient to monitor s/s of infection

TCAs (block NE and S-Ht)

Amitriptyline (Elavil) Clomipramine (Anafranil) Doxepin (Silenor) Imipramine (Tofranil) Trimipramine (Surmontil)

A health care provider prescribes tolterodine (Detrol) for a client with an overactive bladder. What is most important for the nurse to teach the client to do? Maintain a strict record of fluid intake and urinary output. Chew the extended release capsule thoroughly before swallowing. Report episodes of diarrhea or any increase in respiratory secretions. Avoid activities requiring alertness until the response to medication is known.

Avoid activities requiring alertness until the response to medication is known. Because tolterodine an antispasmatic may cause dizziness and blurred vision which increases risk for injury

Drugs for bowel dysfunction

Bulk-forming laxative: psyllium Enema Stool softeners (docusate sodium) Fatigue (Amantatide, modafinil)

N-methyl-D-aspartate receptor antagonist (NMDA)

Blocks calcium influx by modulating glutamate Well tolerated memantine (moderate-severe)

A client with myasthenia gravis has been receiving neostigmine (Prostigmin) and asks about its action. What information about its action should the nurse consider when formulating a response? Stimulates the cerebral cortex Blocks the action of cholinesterase Replaces deficient neurotransmitters Accelerates transmission along neural sheaths

Blocks the action of cholinesterase

Fingolimod

Bradycardia, infection, liver injury Macular edema

Neostigmine (Prostigmin) pharmacologic effects

CNS - Therapeutic dose causes mild stimulation Toxic dose depresses the CNS (including respiratory)

Entacapone

COMT-I combined with levodopa to enhance effects by inhibiting metabolization of levodopa and increasing availability

Anti-Parkinson Drugs

Cannot reverse neuronal damage. Only treats symptoms 2 broad classes of drugs: Dopaminergic agents and anticholinergic agents (anticholinergic = antimuscarinic = parasympathetic)

A client is to receive donepezil (Aricept) for treatment of dementia of the Alzheimer type. The nurse sits down with the primary caregiver and the client and reviews the purpose of the drug, its dosage, and the usual side effects. What side effect identified by the caregiver leads the nurse to conclude that further teaching is needed? Nausea Dizziness Headache Constipation

Constipation

Neuroleptic malignant syndrome is a potentially fatal reaction to antipsychotic therapy. What signs and symptoms of this syndrome should the nurse identify? Select all that apply. Jaundice Diaphoresis Hyperrigidity Hyperthermia Photosensitivity

Diaphoresis Hyperrigidity Hyperthermia

A client who is taking clozapine (Clozaril) calls the nurse in the psychiatric clinic to report the sudden development of a sore throat and a high fever. What should the nurse instruct the client to do? Stay in bed, drink fluids, take a dose of aspirin, and ask the health care provider to reduce the dosage of clozapine. Discontinue the medication immediately and see the health care provider as soon as an appointment becomes available. Continue the medication, drink fluids, take aspirin, and see the health care provider in a few days if the symptoms do not improve. Discontinue the medication and, if the health care provider is unavailable today, go to the emergency department for evaluation.

Discontinue the medication and, if the health care provider is unavailable today, go to the emergency department for evaluation.

AntiCHOLinergic Parkinson Drugs adverse effects

Dry mouth, blurred vision, constipation, urinary retention, tachycardia

Adverse effects of neostigmine

Excessive muscarinic stimulation neuromuscular blockade (paralysis of respiratory muscle can be fatal)

Drug therapy for Schizophrenia

FGAs and SGAs are equally effective (except clozapine is the most effective of all) FGAs = increased risk of EPS SGAs = greater risk of metabolic effects FGAs are cheaper Routes: oral (preferred) or IM (for severe, acute schizo and long term therapy) 12 months maintenance therapy; 102 days symptoms resolve (full response takes several wks to months) TAPER to discontinue

CHOLinesterase Inhibitors drug interactions

First gen antihistamines, TCA, conventional antipsychotics

MAO B Inhibitors

First line (modest result) Reduces "wear off" effect of Ldopa Increases DA by inhibiting MAO-B enzymes Selegiline Rasagiline

DA Agonists

First line for PD Pramipexole (Mirapex) Ropinirole (Requip) Bromocriptine (Parlodel)

Adverse affects of DA agonists

Nausea, postural hypoTN (dizziness), hallucinations, daytime sleepiness, "sleep attack", fetal injury, impulse control disorders

Adverse effects of Levodopa

Nausea, vomiting Dyskinesia (paradoxical effect) - head bobbing, tics, grimace, chorea movement

CHOLinesterase Inhibitors adverse effects

Nausea, vomiting, diarrhea dyspepsia, dizziness, headache Bronchoconstriction (caution in Asthma and COPD) Bradycardia, hypoTN, syncope (fall risk)

Cholinesterase inhibitors for MG

Neostigmine, pyridostigmine, endrophonium

Implementation: administration

Oral route Assist with administration if needed Involve family in medicating outpatients Inform patients that levodopa ma be taken with food to reduce n/jv but high-protein should be avoided Inform patients that benefits of levodopa may be delayed for weeks to months

Pramipexole

Oral, nonergot DA agonist First line for PD motor symptoms used alone in early PD and combined with levodopa in advanced PD Relieves motor PD symptoms by direct DA receptor in the striatum

Neostigmine (Prostigmin) Precaution

Prevention of Aspiration: teach patient to take meds on time especially BEFORE meals to prevent aspiration

Neostigmine (Prostigmin)

Prevents the breakdown of ACh by AChE

Selegiline (Eldepryl) is prescribed for a client with Parkinson disease who is having an inadequate response to dopar (Levodopa) therapy. When teaching the client about the addition of this drug to the regimen, the nurse should explain that the: Primary health care provider should be contacted immediately if a severe headache occurs. Therapeutic blood level of the drug should be monitored each month. Dosage of the drug can be adjusted daily depending on the client's response that day. Side effects of dopar will decrease when the Eldepryl and dopar are taken concurrently

Primary health care provider should be contacted immediately if a severe headache occurs.

S/S of Myasthenia Gravis

Ptosis Difficulty swallowing Weakness of skeletal muscle (including respiratory muscles)

A client with a tentative diagnosis of myasthenia gravis is scheduled to receive edrophonium (Enlon) to confirm the diagnosis. What response should the nurse anticipate will confirm myasthenia gravis? Brief exaggeration of symptoms Improvement in ptosis of the eyelids Prolonged symptomatic improvement Rapid but brief symptomatic improvement

Rapid but brief symptomatic improvement

Drugs for BPH: PDE-5 Inhibitors Tadalafil

Relaxes smooth muscle in the bladder, prostate, and urethra Adverse effects include HypoTN and priapism (persistent and painful erection)

A nurse is caring for a group of clients on the psychiatric unit. What clinical findings should alert the nurse that serotonin syndrome has developed in one of the clients? Continuous involuntary movement of the tongue and jaw Extremely high blood pressure with headache and flushing Blurred vision, urine retention, dry mouth, and constipation Restlessness, tachycardia, fever, diarrhea, and altered mental status

Restlessness, tachycardia, fever, diarrhea, and altered mental status

Antipsychotic drugs can cause extrapyramidal side effects. Which responses should the nurse document as indicating pseudoparkinsonism? Select all that apply. Rigidity Tremors Mydriasis Photophobia Bradykinesia

Rigidity Tremors Bradykinesia

A health care provider prescribes antipsychotic medication, and the nurse teaches the client about the possible side effects of the drug. The nurse concludes that the client needs further teaching about these side effects when he states that he should call the clinic if he experiences: Tremors Constipation Blurred vision Ringing in the ears

Ringing in the ears

Drugs for Depression in MS

SSRIs (fluoxetine (Prozac), sertraline (Zoloft0, Buproprion (Wellbutrin), TCAs (treat pain, insomnia, incontinence) -->amitriptyline (Elavil), Nortripyline (Pamelor)

The nurse is caring for a client with myasthenia gravis. The nurse expects which test to be ordered to differentiate a myasthenic crisis from a cholinergic crisis? CBC Tensilon Lumbar puncture Magnetic resonance imaging (MRI)

Tensilon

A client is to take an antipsychotic drug twice a day. Two thirds of the daily dose is given in the evening and one third in the morning. What should the nurse tell the client is the rationale for this schedule? To facilitate dreaming To maintain the daily sleep rhythm To reduce sedation during the daytime To decrease assaultiveness in the evening

To reduce sedation during the daytime

A nurse is caring for several clients who have severe psychiatric disorders. What is the major reason that a health care provider prescribes an antipsychotic medication for these clients? To improve judgment To promote social skills To diminish neurotic behavior To reduce the positive symptoms of psychosis

To reduce the positive symptoms of psychosis

A 76-year-old patient is being treated with carbidopa/levodopa (Sinemet) for Parkinson's disease. Which information is most important for the nurse to report to the health care provider? Shuffling gait Tremor at rest Cogwheel rigidity of limbs Uncontrolled head movement

Uncontrolled head movement

Carbidopa-levodopa (Sinemet) is prescribed for a client with Parkinson's disease. The nurse monitors the client for which side effects of the medication? Select all that apply. Vomiting Anorexia Slow heart rate Changes in mood Peripheral edema

Vomiting Anorexia Changes in mood

Metabolic adverse effects of SGAs

Weight gain (monitor every 4 wks until wk 12 then every 3 months) New onset of DM (check fasting blood glucose before therapy, 12 wks later, then yearly Dyslipidemia - increased total LDL and TG but decreased HDL (monitor fasting lipid before therapy, 12 wks later, then every 5 years)

s/s of serotonin syndrome

altered mental status (agitation, confusion, disorientation, anxiety, hallucinations, poor concentration), incoordination, myoclonus, hyper-reflexia, excessive sweating, tremor, fever

Psychotherapeutic drugs

antipsychotics, antidepressants, mood stabilizers, sedative hypnotics, anti anxiety

Multiple sclerosis

autoimmune, usually women are affected, hereditary S/S: nystigmus, tinnitus, diplopia, blurred vision, dysarthria, dysphagia, urinary retention, spastic bladder, constipation, weakness may progress to paralysis, ataxia, vertigo Onset in the 20s-40s

TCAs

block reuptake of NE, S-HT; also block cholinergic, alpha1, histamine and pain long 1/2 life Therapeutic uses: major depression, bipolar, fibromyalgia, neuropathic pain

Neostigmine (Prostigmin) muscarinic effects

bradycardia, bronchoconstriction, urinary urgency, increased GI motility, miosis (excessive constriction of the pupil)

Overactive bladder

detrusor muscle contracts before the bladder is full. do not confuse with incontinence

Symptoms of cholinergic crisis (DUMB BELS)

diarrea urination miosis bronchorrea bradycardia emesis lacrimation salivation/sweating

Cognitive deficits

difficulties with following aspects of cognition can make it heard to live a normal life or earn a living memory attention planning decision making

Memantine interactions

do not combine with other NMDAs (amantadine, ketamine)

Interferon beta adverse effects

flu-like symptoms, liver injury, myelosuppression

Dyskenesia

impaired movement

Pre-administration assessment

increase ability to perform ADLs Assess motor symptoms Skin assessment (levodopa + MAOi --> malignant melanoma) Special consideration to patients with cardiac dz, psychiatric disorders, and patients taking MAOIs

Immunomodulators

interferon beta natalizumab (also used in Chron's dz) Fingolimod

negative symptoms

lack of characteristics that should be present: reduced speech, even when encouraged to interact Lack of emotional and facial expression (affective flattening) Diminished ability to begin and sustain activities (avolition) decreased ability to find pleasure in everyday (anhedonia) Social withdrawal (asociality)

Neostigmine Drug-drug interactions

muscarinic antagonists: atropine --> antidote for neostigmine OD; reverses excessive muscarinic stimulation caused by neostigmine neuromuscular blockade (pancuronium) --> reverses muscle relaxation induced by pancuronium

Adverse effects of FGAs Neuroleptic Malignant Syndrome

muscle rigidity, sudden high fever, sweating dysrhythmia and fluctuations in BP Seizure, coma, respiratory failure TX: Dantrolene (direct-acting muscle relaxant), bromocriptine (relieves CNS toxicity)

Myasthenia Gravis

neuromuscular disorder (PNS) characterized by fluctuating muscle weakness and rapid fatique

TCAs adverse effects

ortho hypoTN, anticholinergic effect, diaphoresis, sedation, cardiotoxicity, seizures, CNS toxicity, hypomania, suicide risk

Drugs for BPH (S alpha reductase inhibitors) dutasteride finasteride

reduce dihydrotestosterone (DHT) production delaying BPH progression (takes months to develop) Adverse Effects include decreased ejaculation, bolume and libido teratogenic to male fetus

Benign prostatic hyperplasia

restricted urine flow due to enlarged prostate

FGAs therapeutic uses

schizophrenia, bipolar disorder, Tourette's syndrome, prevention of emesis

SSRIs adverse effects

sexual dysfunction, insomnia/agitation, GI toxicity, risk for upper GI bleed, nausea, weight gain, ortho hypoTN, serotonin syndrome, withdrawal syndrome (sysphoria, dizziness, GI distress, fatigue, chills, myalgia), suicide risk

Minimizing "wear off" of levadopa

shorten dose interval give a drug that prolongs levadopa's half life (COMT-1) give a direct dopamine agonist

Symptoms of Parkinson's Disease

slow slurred monotonous speech, blank face, rigidity and tremor of extremities and head forward tilt to posture, reduced arm swinging, short shuffling gait

adverse effects: festerodine, toterodine

somnolence, vertigo, dizziness, dry mouth tachycardia mydriasis, blurred vision, dry eyes, dry mouth, urinary retention, constipation

Neostigmine (Prostigmin) neuromuscular effects

therapeutic dose increases the force of contraction Toxic dose decreases the force of contraction

Edrophonium

ultra short-acting cholinergic causes symptom alleviation in Myasthenic crisis causes worsened symptom in cholinergic crisis

Reducing affects of anticholinergic drugs

use long acting formulations (extended release capsule or transdermal patch) Use drugs that don't cross the BB Use drugs that are selective for muscarinic receptors in the bladder