• Neuromuscular disorder that fluctuates between muscle weakness and rapid fatigue
• Common symptoms: ptosis, difficulty swallowing, weakness of muscles including respiratory (BULBAR
SYMPTOMS)
Reversible Cholinesterase Inhibitors
• Prototype: Pyridostigmine (Mestinon)
• MOA: prevents the breakdown of acetylcholine
• Adverse effects: excessive muscarinic stimulation (increased salivation, sweating, GI motility, urination, bradycardia, miosis), paralysis of respiratory muscles in toxic doses
• CONTRAINDICATIONS: clients with obstruction of GI or urinary tract
• LIFETIME TREATMENT
• CAUTION: clients with peptic ulcer disease, asthma, coronary insufficiency, or hyperthyroidism
• Drug Interactions: muscarinic antagonists, nondepolarizing & depolarizing neuromuscular blockers (anesthesia)
• Dosage: 60-1500 mg/day Q 3-4 hours
• Start with small doses increasing to optimal dosage…improvements of bulbar symptoms. Patient modification is accepted.
Myasthenic Crisis
• Inadequate medication
• Extreme muscle weakness
• Treat with cholinesterase inhibitor
• NEOSTIGMINE** is a parasympathomimetic, specifically, a reversible cholinesterase inhibitor.
Cholinergic Crisis
• Overdose of a cholinesterase inhibitor
• Extreme muscle weakness or frank paralysis
• Treatment includes respiratory support, withhold cholinesterase, & atropine administration
Myasthenic Crisis Vs Cholinergic Crisis
• Medication history
• Challenge dose of Edrophonium (tensilon)
– If the symptoms get better it is a myasthenic crisis
– If the symptoms worsen it is a cholinergic crisis (NOT GOOD )
• Emergency equipment (atropine and respiratory support)
Nursing Interventions Client Education
>Assess client for s/s of MG.
>Assess for adverse effects of meds.
>Assess respirations & swallowing.
>Administer meds exactly as scheduled.
>Teach client meds are life long
>Teach importance of adhering to med schedule
>Teach to take meds 30-60 mins prior to meals
>Encourage to carry med card at all times.
>Encourage to wear MedAlert braclet/necklace

• Neurodegenerative disorder
• Characterized by 4 involuntary movements:
– Tremor
– Rigidity
– Bradykinesia
– Postural instability
– Dopamine and actecholine**
• Therapeutic Goals
– No Cure
– Improve ability to carry out ADL’s
– Drug selection & dosages determined by the extent PD interferes with client’s life
• Work
• Bathing
• Dressing
• Eating
• Dopaminergic agents
– Most commonly used for PD
• Promote activation of dopamine receptors
• Anticholinergic agents
– Prevent activation of cholinergic receptors
• Less effective than levodopa, better tolerated
• Most appropriate for younger clients with mild symptoms
•
(cross BBB and converts into dopamine)
• Dopamine agonists
• COMT inhibitors
• Dopamine Releaser
• MAO-B Inhibitor
– Dopamine cannot be used as replacement therapy, it does not cross blood brain barrier
• Prototype:
– reduction in symptoms will happen in a short period of time in pt’s with true Parkinson’s
• MOA: Levodopa is converted to dopamine in the CNS.
Carbidopa (not therapeutic effect on its own- use with levodopa) prevents peripheral destruction of
Levodopa.

• Adverse Effects:
– N/V* (administer in sm doses at the start of treatment et w/food)
– dyskinesias**(abnormal movement – often happens because of over medication) (decrease dosage of med, but the decrease may result in resumption of PD symptoms)
– postural hypotension* (monitor BP, instruct about hypotension – dizziness/lightheadedness)
– dysrhythmias** (monitor VS, ECG, notify PCP, use cautiously in clients w/cardiovascular disorders)
– psychosis** (administer antipsychotic med such as clozapine)
– darkened sweat & urine (harmless side effect)
– akinetic spells (immobilized for periods of time – on/off periods)
– Loss of effect (wearing off – at the end of the dose intervals – minimized by shortening dose interval or giving a drug that prolongs Levodopa’s half-life (comtan or mirapax or sinemet CR)
Acute loss of effect can occur at anytime during treatment, can also be referred to as on/off phenomenon – can last from min to hrs – as a patients disease process worsens these will also worsen
(*=early AE **=late AE (2-3 yrs of treatment)
Food retards the absorption, not best teaching – may be done early on, but teach pt AE will subside
• Contraindications: history of melanoma, narrow-angle glaucoma(dopamine drugs increase pressure), vitamin B
6,
MAO inhibitors & antipsychotic drugs
• Dosage: 10/100, 25/100, 25/250, 25/100mg CR, 50/200mg CR
Nursing Interventions
• Assess client’s s/s of PD
• Monitor for adverse effects
• Assess for psychiatric behavior
• Assess client’s skin & teach skin assessment
• Divide protein intake into several times throughout the day – dopamine binds to protein
Client Education
• Avoid driving or operating heavy machinery until drug is working
• Teach about Vitamin B6 - contraindication (Pyridoxine)
• Darkened sweat and urine (harmless)
• Teach about orthostatic hypotension
• Instruct client to NEVER abruptly discontinue medications and always take at the same time
• Inform clients that effects usually increase over a couple of months
• Usually works best within the 1 st 2 years of treatment, it is not uncommon to revert after 5 yr – because of disease progression
• Prototype:
– not as affect but better tolerated
• MOA: blocks muscarinic receptors in the striatum
• Reduces tremor and some rigidity
• Adverse Effects: dry mouth, urinary retention, tachycardia, blurred vision, constipation, photophobia, confusion,
& hallucinations
• Much better for young pt, not good for older pts because of CNS symptoms
• Contraindications: narrow-angle glaucoma & prostatic hypertrophy or urinary retention
• Dosage: 1-2mg 3 times/day

Nursing Interventions
• Assess client’s s/s of PD.
• Monitor urinary output.
• Assess for psychiatric behavior.
• Watch for signs of orthostatic hypotension.
Client Education
• Encourage the use of chewing gum or mouthwash for dry mouth.
• Avoid overheating or hot places.
• Eat high fiber and 8 8 oz servings of H20.
• Teach client to never discontinue meds abruptly.
• Prototype:
– added to sinemet**
• MOA: inhibit breakdown of levodopa in the periphery
– With levodopa it causes blood levels to be smoother and more sustained
• Adverse Effects: dyskinesias, orthostatic hypotension, nausea, hallucinations, & sleep disturbances
• Contraindications: don’t use in combination with methyldopa, dobutamine, or isoproterenol,
• Dosage: 200 mg to be taken with each dose of Sinemet, up to 1600mg per day
• **DO NOT TAKE ALONE
Client Education
• Instruct client to take with levodopa/carbidopa (sinemet).
• Avoid driving or activities that require alertness until response to drug is known.
• Inform client that drug may change urine to a brownish orange color.
• Caution client to change positions slowly.
• Prototype:
– used with sinemet (for wearing off)
• MOA: stimulates dopamine receptors in the striatum of the brain
• Adverse Effects: SLEEP ATTACKS (suddenly w/out warning) when used alone (call doc immediately)
Nausea (take with food) , constipation
Dizziness , weakness
daytime somnolence, insomnia
hallucinations (administer antipsychotic med)
• Elderly do not tolerate well because of AE’s
• When used as monotherapy: orthostatic hypotension & dyskinesias
• When used with Levodopa it has beneficial and harmful interactions. Use with Levodopa can decrease motor control fluctuations and allow for lower dosage of Levodopa. Concurrent use can also increase the risk of orthostatic hypotension and dyskinesias
• Contraindications: Cimetidine – Tagamet
• Dosage: 0.125mg – 1.5mg TID gradually increased over 2 months
• Can be taken alone – often used for restless leg syndrome

Nursing Interventions
>Assess for S/S of PD before & throughout therapy.
>Assess for hallucinations & confusion.
>Assess for drowsiness & sleep attacks.
Client Education
>Take with meals
>Avoid driving/other activities that require alertness
until drug response is known
>Change positions slowly
• Prototype:
• MOA: inhibits breakdown of dopamine
• May delay progression of PD (use 1 st in pt that is newly diagnosed with PD)
• Adverse Effects: insomnia, dry mouth
• Contraindications: can increase the effects of levodopa, don’t use in combination with meperidine or fluoxetine
• Dosage: 5mg with breakfast & lunch
Nursing Interventions
• Assess for S/S of PD prior to and during therapy.
• Assess BP periodically during therapy.
• Administer with breakfast and lunch only.
Client Education
• Take with breakfast & lunch. Taking it late in the day can cause insomnia.
• Do not double dose. Increased doses can cause a hypertensive crisis.**
• Teach S/S of hypertensive crisis.
• Increase fluids or chew gum to avoid dry mouth.
• Alzheimer’s Disease
• Irreversible disease characterized by progressive memory loss, impaired thinking, neuropsychiatric symptoms, & inability to perform ADL’s
• Prototype:
• MOA: prevent the breakdown of ACh by acetycholinesterase & thereby increase the availability of ACh at cholinergic synapses.
• Adverse Effects: GI effects, dizziness, H/A, bronchconstriction, caution in clients with asthma & COPD
• Drug Interactions: (blocks) antihistamines, tricyclic antidepressants, conventional antipsychotics
• Dosage: QHS
• They slow down the progression (by a few month), they do not cure.
• Prototype:
newest on the market
• MOA: modulates the effects of glutamate at NMDA (n-methal d-aspartate)
receptors: believed to play critical role in learning and memory
• Adverse effects: dizziness, H/A, confusion, constipation (very minimal) – much more tolerated than Aricept
• Drug Interactions: NMDA antagonist, sodium bicarbonate (Be CAREFUL w/ Renal Patients)
• Dosage: 5mg/day – 20mg/day (twice/day) – tritated up over a months time

• Vitamin E
• Selegiline
• Estrogen – delays dementia
• Ginkgo Biloba – improves symptom, but has anticoagulant effect
• NSAIDS – long term use
Nursing Responsibilities
• Ensure client has no history of asthma or COPD.
• Monitor for GI symptoms.
• Obtain current medication list.
Client & Family Education
• Follow titration schedule as directed.
• Notify physician if side effects are intolerable.
• Do not abruptly stop treatment.
• Notify physician if any changes or addition of medication is made.
• Multiple Sclerosis
• A chronic, inflammatory, autoimmune disorder that damages the myelin sheath of neurons in the CNS, causing a wide variety of sensory and motor deficits.
Prototype:
• MOA: suppresses autoimmune destruction of myelin
• Adverse Effects: Flu-like symptoms(go away over time – take Tylenol), hepatotoxicity (usually rare but serious – test baseline, then Q3months – if elevated – decrease/stop dose), myelosuppression (supress bone marrow – monitor CBC – baseline 3,6 mos and 1year), injection-site reactions, depression
• Drug Interactions: other drugs that can cause bone marrow suppression or liver injury
• Recommended for relapsing-remitting and secondary-progressive still experiencing acute exacerbation
• Prototype:
(for relapsing-remitting – subQ daily) better tolerated than all other beta
• MOA: protects myelin by inhibiting the immune response to myelin basic protein
• Adverse Effects: injection-site reactions &, self-limited post injection reaction(10% of pt get – last for about 15 min – flushing, palpitations, chest pains, anxiety)
Nursing & Client Education
>Obtain and monitor LFT’s and CBC
>Identify high-risk clients
>Instruct on IM and SQ injections
>Minimize side effects -analgesics/antipyretics
-oral Benadryl, topical hydrocortisone
-apply ice to injection site

• Prototype:
– for MS pts with lots of neuromuscular complications (worsening relapsing-remitting) severe cases
• MOA: suppress production of immune system cells & decreases autoimmune destruction of myelin
• Adverse Effects: myelosuppression, cardiotoxicity, fetal harm, hair loss, GI distress, menstrual irregularities, & blue-green tint to urine, skin, & sclera
• Dosage: IV every 3 months
Nursing Interventions
• Monitor CBC’s at baseline, before each dose, & 10-14 days after each dose.
• Monitor LFT’s at baseline and before each dose.
• Perform a pregnancy test before each dose.
• Perform echocardiogram before each dose & whenever heart failure develops.
Client Education
• Avoid contact with people who have infections & report s/s of infections immediately.
• Avoid becoming pregnant.
• Discuss all other potential side effect with client & family.
• Muscle spasm – involuntary contraction of muscle or muscle group
• Causes
– Epilepsy
– Hypocalcemia
– Acute & chronic pain syndromes
– Trauma
• Mechanism of Action
– Through enhancing presynaptic inhibition of motor neurons in the CNS
• Therapeutic Use
– Relieve localized spasm resulting from muscle injury
– Decrease local pain & tenderness
– Increase range of motion
Therapeutic use is almost always associated with sedation
Adverse Effects
>CNS depression >Hepatic toxicity (Zanaflex, Skelaxin &Paraflex) >Physical Dependence
>Dry mouth, blurred vision, photophobia, urinary retention, constipation (Flexeril & Norflex)
>Interesting……brown, black, or green urine (Zanaflex) Also, ↓bp, hallucinations, & psychotic symptoms

• Spasticity - Movement disorder of CNS origin characterized by heightened muscle tone, spasm, and loss of dexterity
• Causes
– Multiple sclerosis
– Cerebral palsy
– Acts in the CNS
– Decreases spasticity
– Allows increased performance
– Helpful only for spinal cord injury, MS, & CP
– Will also seen it used in CVA patients
– Usually titrated up over time
Adverse Effects of Baclofen
• CNS effects
• GI symptoms (nausea, constipation) (Advise client to increase intake of high fiber foods)
• Urinary retention (Monitor client I&O’s)
• No antidote for overdose** (can cause coma, respiratory distress/failure)
• Withdrawal – does not cause dependence, but if abruptly stopped it can cause high fever, spasticity, muscle breakdown, hallucinations, seizures, etc.
• Avoid alcohol
– Only benzodiazepine labeled for treating spasticity
– Acts in CNS
– Mimicks the actions of GABA at the receptors in spinal cord and brain
– Does not affect skeletal muscle directly
Adverse Effect of Diazepam
– Sedation
– Acts directly on skeletal muscle
– Suppresses the release of calcium from the sarcoplasmic reticulum
– The only peripherally acting muscle relaxant
• Uses
– Spasticity associated with MS, CP, & spinal cord injury
– Malignant hyperthermia**
Adverse Effects
• Hepatic toxicity
• Muscle weakness
• Drowsiness
• Anorexia, N/V, Diarrhea
• Acne-like rash

Nursing Interventions
• Assess for s/s of muscle spasms and spasticity.
• Assess for adverse med effects.
• Monitor liver enzymes.
• Not the best med for patients with active life due to the muscle weakness it causes
Client Education
• Caution client to avoid CNS depressants.
• Teach client to take med as prescribed.
• Warn client against abruptly stopping med.
• Inform of CNS effects & advise to avoid driving & other hazardous activities if impairment occurs.
• Abortive Therapy
– Non-specific analgesics
– Migraine-specific
• Preventative Therapy
– Beta blockers
– Tricyclic antidepressants
– Antiepileptics
Abortive Therapy
• Goal
– Eliminate h/a pain
– Suppress n/v – metoclopramide (Reglan)
• Drug selection (only take 1-2/wk)
– Depends on intensity of attack
• Mild to moderate – aspirin-like drug
• Moderate to severe – migraine-specific drug
• Failed therapy - opioids
• Aspirin + Reglan can be quite effective with fewer side effects
• Do not use acetaminophen alone
• Excedrin Migraine = acetaminophen + aspirin + caffeine
• Midrin = acetaminophen + isometheptene + dichloralphenazone
• Opioids
-
• Prototype: Ergotamine (Cafergot) used for migraines and cluster headaches: should not be used on a daily basis, can cause dependency
• MOA: promotes vasoconstriction & reduces the amplitude of pulsations
• Adverse Effects: N/V, leg weakness, myalgia, parasthesias to fingers & toes, angina-like pain, tachycardia & bradycardia

• Overdose: Ergotism- ischemia secondary to constriction of peripheral arteries: causing cold extremities, paleness, numbness, gangrene
• Contraindications: Triptans, clients with hepatic or renal impairment, sepsis, CAD, PVD, & pregnancy
• Dosage: SL, oral, intranasal, & rectal
• Withdrawl symptoms: headache, N/V, ….continuous cycle
Nursing Responsibilities
• Assess frequency, location, duration, & characteristics of h/a. Assess pain before & after med administration.
• Monitor BP & peripheral pulses periodically during therapy.
• Assess for s/s of ergotism.
• Assess for n/v & administer anti-nausea meds if ordered.
Client Education
• Instruct client to take at first sign of an impending h/a.
• Do not exceed the maximum dose.
• Encourage to rest in a quiet, dark room after taking ergotamine.
• Review s/s of toxicity & instruct to report these immediately.
• Caution client against smoking & exposure to cold.
• Caution client to avoid driving until response to drug is known.
1B/1D
• Prototype:
• MOA: actions of vasoconstriction & suppression of inflammation
• Adverse Effects: vertigo, tingling sensations, chest symptoms, coronary vasospasms (50% complain of Chest
pressure and heavy arms: this is not related to CAD, this med causes pulmonary vasoconstriction)
• Dosage: PO, SubQ, nasal spray
• Contraindications: Ergot alkaloids, other triptans, MAOI’s, hx of CAD, MI, or HTN, smoking, obesity, DM
• Dosage: SQ, NS, & PO
• Do not give to patients with parathesias with migraine because of the increased vasoconstriction
Nursing Responsibilities
• Review client’s health history.
• Assess pain location, intensity, duration, and associated symptoms during migraine attack prior to & after med administration.
• Monitor for s/s of coronary vasospasm.
Client Education
• Inform client that sumatriptan is only to be used for relief of migraine attack & not to prevent attacks.
• Instruct client to take sumatriptan as soon as symptoms of migraine appear.
• Advise client to lie down in a quiet, dark room after taking medication.
• Caution client to avoid during pregnancy or if planning to become pregnant.
• Advise client to notify physician if pain or tightness in chest occurs during use.
• Advise client to avoid driving until response to medication is known.

(two or more attacks a month and do not respond adequately to abortive therapy)
• Beta Blockers – preferred drug
• Tricyclic antidepressants
– benefits equal to propanolol
– anticholinergic effects (dryness)
• Antiepileptics Drugs
–
only extended release approved
• S/E – nausea, wt. gain, tremor, hair loss
– topiramate (Topamax) approved in 2004
• titrate slowly (benefits takes several weeks)
• S/E – parasthesias, fatigue, weight loss, cognitive dysfunction
• Estrogens – used to prevent menstrual migraines (onset is 2 days before cycle begins)
– topical estrogens
– birth control pills
– frovatriptan (Frova)
• Calcium Channel Blockers (varapamil)
• Angiotensin II Receptor Blocker (ARB)
• Supplements
– Ribloflavin
– Coenzyme Q-10
– Feverfew
– Butterbur