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158 Cards in this Set

  • Front
  • Back
Psychotropic medications affect what three domains of human funcitoning?
Perception, behaviour and mood.
Antidepressants are all __________ _______.
Antidepressants are all EQUALLY EFFECTIVE (50-60%
improvement as compared to 30-40% on placebo) and have similar drop-out rates.

As a result, drug choice should be tailored to the individual patient, based on patient choice, side effect profile, previous response, co-morbidity, suicide risk and cost.
Patients seem to have better outcomes if given _______ __________ about anti-depressants.
Patients seem to have better outcomes if given clear
information about anti-depressants.
Important determinants of efficacy: read
 Prior treatment history in patient/family members
 Patient preferences
 Expertise of prescribing provider
 Side effect profile (sedating or activating)
 Safety in overdose (8-10 days of a TCA can be a lethal overdose)
 Drug-drug interactions
Important determinants of efficacy
 Prior treatment history in patient/family members
 Patient preferences
 Expertise of prescribing provider
 Side effect profile (sedating or activating)
 Safety in overdose (8-10 days of a TCA can be a lethal
overdose)
 Drug-drug interactions
There are at least _______ separate pharmacological
actions of antidepressants.
There are at least EIGHT separate pharmacological
actions of antidepressants
Most antidepressants block ______________ reuptake (i.e. E, NE, 5HT and DA)
Most antidepressants block MONOAMINE reuptake (i.e. E, NE, 5HT and DA)
Some antidepressants act by blocking the enzyme _________ __________.
Others act by blocking the enzyme MONOAMINE OXIDASE.
Some have their action on only one __________ _________ ____________, and some on more than one.
Some have their action on only one monoamine
neurotransmitter system, and some on more than
one.
Fewer than __% of all patients with
depression show full remission with
optimised treatment, including trials on
numerous medications with and without
concurrent psychotherapy
Fewer than 50% of all patients with
depression show full remission with
optimised treatment, including trials on
numerous medications with and without
concurrent psychotherapy
Antidepressants ___ ____elevate mood in
healthy humans.
Antidepressants do not elevate mood in
healthy humans.
WHAT % of patients will have treatment failure with their first tried antidepressant?
40%
What are the 3 “generations” of drugs to treat
depression and related affective disorders
(anti-depressants)?
 1st generation: monoamine oxidase inhibitors
(MAOI’s) and tricyclic anti-depressants

2nd generation: selective serotonin reuptake
inhibitors (SSRI’s)

 3rd generation: tricyclic anti-depressants with a
twist
Tricyclic antidepressants (TCAs):

Main mode of action?

How many other mechanisms of action do they have?
Block the re-uptake of both norepinephrine and
serotonin and thus elevate neurotransmitter levels
in the synapse

Have at least THREE other mechanisms of action.
What gives rise to the side effects in TCAs
Blockade of OTHER receptors gives rise to the
side-effect profile seen with the TCAs
In TCAs

Blocking of muscarinic cholinergic receptors will produce what side effects?
Dry mouth
Blurred vision
Urinary retention
Constipation,
Confusion,
Memory problems
In TCAs

Histamine side effects:
Adrenergic Side effects:
HISTAMINE: Sedation and weight gain
ADRENERGIC:Postural hypotension and dizziness
Other side effects of TCAs (3)
1. Increased frequency of epileptic seizures
2. SEDATION!
3. Cardiotoxicity ( irregularity of heart rate may be a factor in sudden death in elderly patients with heart disease dangerous in over-dosage;
How much medication is required for a lethal TCA overdose?
A 8-10 day supply can be a lethal dose; hence shift to SSRIs
Mania; convulsions; movement disorders: tremor, akathisia, dystonia or dyskinesia  ECG, BP or heart rate changes (arrhythmias)

Common, uncommon, or rare side effects of SSRis?
Rare
Sedation; dry mouth; sweating; sexual dysfunction including decreased libido, anorgasmia, delayed ejaculation  syndrome of inappropriate antidiuretic hormone hypersecretion (SIADH); low sodium, leading to confusion and delirium

Common, uncommon, or rare side effects of SSRis?
Uncommon
Stimulant effects such as ‘nervousness’, insomnia
Other CNS effects: dizziness, headache, tremor
GI effects: nausea, vomiting, diarrhoea, abdominal discomfort. Weight loss/gain

Common, uncommon, or rare side effects of SSRis?
Common
Venlafaxine =

What generation anti-depressant is it?

It is classified as what type of drug?
Effexor

3rd

Both a TCA and an SSRI therefore both the
effects and the attenuated side effects of both
What are the three advantages of venlafaxine? (3)
1 Clinically meaningful more rapid onset of action (within 1 week)
2 Safety in over dosage is high
3 Probably less interactions with other drugs
What are the disadvantages of venlafaxine relative to SSRIs?
1. Potential for blood pressure elevation at higher doses - requires BP to be monitored closely during first 2 months of being stabilised on any dose above 225 mg/day
2.  Original need for twice a day dosing schedule now overcome with extended release formulation
3. Dose needs to be titrated
Four most common side effects of Effexor (venlafaxine)?
1. slightly anticholinergic
2. nausea
3. dizziness
4. sedation
Two uncommon side effects of Effexor?
1. SIADH (Syndrome of Inappropriate Antidiuretic Hormone Secretion)
2. Serotonin syndrome
In effexor:

At higher doses (i.e. TCA), dose-dependent
increases in what three things?
1. blood pressure (rarely observed below 225 mg/day)
2. sweating
3. tremors
What are some of the common side effects of NDRI's(bupropion).
Dry mouth, tremors, anxiety, loss of appetite,
agitation, dizziness, headache, excessive sweating,
increased risk of seizure, and insomnia. Bupropion
causes less insomnia if it is taken just before going to bed.
Bupropion and sexual side effects relative to other SSRI's?
Sexual side effects normally accompanying SSRI's do not accompany bupropion. Interestingly, patients commonly report increased libido, perhaps evidence of its dopaminergic properties.
What are some of the contraindications of Bupropion ? (5)
1.  Seizure disorder
2. current use of other form;
3. bulimia/anorexia;
4. MAOI in last 14 days;
5. heavy alcohol use
Bupropion is what class of antidepressant ?
Norepinephrine-dopamine reuptake inhibitor
which is the most studied drug with regard to antidepressant action and cognitive effect?
Amitriptyline
Which antidepressant has the greatest sedative and anticholinergic property?
Amitriptyline (TCA)
Performance impairment is always significant with regard to which antidepressant?
Amitriptyline
Describe the effect of a single dose of Amitriptyline?
The effect starts 30 minutes following a single
administration and is maximal by 2 to 4 hours
Middle and long-term administration with
healthy volunteers.

Describe the normalization of cognitive function over time.
Normalisation on cognitive tests occurred between
days seven and 14 for most sedative compounds but
from day 14 to day 21 for amitriptyline
Which drug should be carefully applied in individuals with recent memory problems or in Alzheimer’s disease?
Amitriptyline
A combination of alcohol plus amitriptyline in normal participants caused more cognitive impairment than alcohol with desipramine or zimeldine (Linnoila et al., 1983). What does this indicate?
Alcohol potentiates the negative effects of sedative antidepressants
Patients with depression are subject to neuropsychological deficits in (5)
1. memory
2. attention
3. psychomotor speed
4. processing speed
5. executive function.
When depressed patients are treated, what happens to their cognitive function relative to controls?
They perform better, but they do not perform as well as normal controls.

As such, they improve, at least to a degree, but do not “normalize.”
In depressed patients, Neurocognitive testing may be a function of the ______________ with which they are treated.
Neurocognitive testing may be a function of the
ANTIDEPRESSANT with which they are treated.
How well will depressed patients on bupropion perform on a battery of cognitive tests relative to controls?
Depressed patients on bupropion perform AS WELL as
normals do on a battery of neurocognitive tests.
How well will depressed patients on venlafaxine and SSRIs perform on a battery of cognitive tests relative to controls?
They will not perform as well.
The cognitive benefit of some antidepressants may occur relative to an antidepressant's _________________ activity.

A lack of benefit may relate to its ___________ activity.
The cognitive benefit of some antidepressants may occur relative to an antidepressant's norepinephrine activity.

A lack of benefit may relate to its serontenergic activity.
In single-dose studies, the main impairment in
cognitive function occurs in the agents with strong
____________ or ____________ effects.
In single-dose studies, the main impairment in
cognitive function occurs in the agents with strong
anticholinergic or sedative effects
In single-dose studies, the main impairment in
cognitive function occurs in the agents with strong
anticholinergic or sedative effects
Sedative qualities of the TCAs have their
greatest effect of ________________ functioning while
both the sedative and the anticholinergic effect
contribute to _____________compromise.
Sedative qualities of the TCAs have their
greatest effect of PSYCHO-MOTOR functioning while
both the sedative and the anticholinergic effect
contribute to MEMORY compromise
Normalisation of cognitive function in clinical
groups parallels ______ ____________.
Normalisation of cognitive function in clinical
groups parallels mood improvement
Agents with ______________ or ________________properties
should be carefully prescribed in the elderly
Agents with sedative or anticholinergic properties
should be carefully prescribed in the elderly.
What potentiates the effect of the sedative
antidepressants?
alcohol
Three types of phobia?
Agoraphobia
Social phobia
Specific phobia
Three types of anxiety states
Panic disorder
Generalized anxiety disorder
Obsessive compulsive disorder
Three types of trauma-related anxiety?
Post-traumatic stress disorder
Anxiety from medical condition
Substance induced anxiety
1st line treatments for all Anxiety Disorders?
SSRIs
What are the four uses of BZD
1 Generalised anxiety disorder - short term
2 Sleep disturbance - short term
3 Acute alcohol withdrawal
4 Adjunctive treatment in schizophre
Medical indications of BZD
Anxiolytic –
chronic/phobic anxiety and panic attacks
Medical indications of BZD
Sedative and hypnotic -
sleep disturbance and anaesthesia/premedication
Medical indications for BZD use
Anticonvulsant -
status epilepticus,
myoclonic and photic epilepsy
Medical indications for BZD use
Muscle relaxant
muscle
spasm/spasticity
Medical indications for BZD use
Alcohol withdrawal
Fives uses for BZD?
Anxiolytic
Sedative and hypnotic
Anticonvulsant
Muscle relaxant
Alcohol withdrawal
Risks of BZD (8)
1. Cognitive impairment, decreased motor skills,
2. daytime sedation; often used as “date rape” drugs
3. Additive CNS depression (ethanol,antihistamines,
opioids)
4. Dependence
5. Behavioural disinhibition (paradoxical)
6. Anterograde amnesia
7. Abrupt withdrawal can result in panic attacks,
8. rebound anxiety
 Risk of foetal deformation (1st trimester)
 “Doctor shopping
What are the predictors of BZD use? (4)
1. being female
2. being elderly
3. being an established patient
4. attending a busy doctor, or a doctor in inner urban area
Long term benzodiazepine users are significantly impaired in comparison to controls in which areas of cognition?
Moderate to large effect sizes were found for all cognitive domains, indicating that long term benzodiazepine users were significantly impaired in comparison to controls in all the areas assessed.
This indicates that the effects of BZD are _______ and not specific to any ____________ _________.
This indicates that the effects are global and not specific to any cognitive domain,

but some domains (e.g. sensory
processing, psychomotor speed, non-verbal memory and
visuospatial processing) seem to be more severely affected
than are the others
In BZD use, which cognitive domains seem to be more severely affected than are others?
1. Sensory processing
2. Psychomotor speed
3. non-verbal memory
4. Visuospatial processing
When compared to their initial assessment, previous longterm benzodiazepine users improved across which cognitive domains examined at the follow-up assessment?
ALL.

When compared to their initial assessment, previous longterm benzodiazepine users improved across all of the cognitive domains examined at the follow-up assessment.
Does the cognitive function of long-term benzodiazepine users improve following withdrawal?

Visuospatial, attention/concentration, general
intelligence, psychomotor speed and non-verbal memory) indicating that these categories of cognitive functioning ___________ __________for the benzodiazepine users when they discontinued.
Visuospatial, attention/concentration, general
intelligence, psychomotor speed and non-verbal memory) indicating that these categories of cognitive functioning SIGNIFICANTLY IMPROVED for the benzodiazepine users when they discontinued.
Are previous long-term benzodiazepine users still impaired at follow-up compared to controls or
normative data?

When compared to controls or norms, previous long-term benzodiazepine users performed more poorly on which cognitive domains when examined at follow-up.
All domains except sensory processing.

When compared to controls or norms, previous long-term benzodiazepine users performed more poorly across all cognitive categories, except sensory processing, when examined at follow-up assessment.
The results of Crowe's meta-analysis indicate that, compared to controls or norms, previous long-term benzodiazepine users performed more poorly across all cognitive categories, except ________ _______when examined at follow-up assessment.
The results of Crowe's meta-analysis indicate that, compared to controls or norms, previous long-term benzodiazepine users performed more poorly across all cognitive categories, except sensory processing, when examined at follow-up assessment.
The results of the three meta-analyses support __________ __________in the use of long-term benzodiazepine therapy.
The results of the three meta-analyses support EXTRENE CAUTION in the use of long-term benzodiazepine therapy.
However, the data do not support a full recovery, at least in the first three months following cessation and suggest that there may be some __________ __________ or deficits that take periods longer than three months to recover.
However, the data do not support a full recovery, at least in the first three months following cessation and suggest that there may be some PERMANENT DEFICITS or deficits that take periods longer than three months to recover.
Previous long term benzodiazepine users assessed after at least 6 months of abstinence ___________ ___ ________ __________ ______ in a number of areas as compared to matched normal and anxious
controls.
Previous long term benzodiazepine users assessed after at least 6 months of abstinence continue to display cognitive deficits in a number of areas as compared to matched normal and anxious controls.
Previous long term benzodiazepine users assessed after at least 6 months of abstinence:

Significant moderate to large effects sizes were noted for which three cognitive domains?
 1. Verbal memory
 2. Motor control/performance
 3. Non-verbal memory

No effect for visuospatial skill, but strong trends
_______ and ___________ differences exist between the
performance of long-term benzodiazepine users and those who do not use the drugs independent of their status with regard to anxiety.
CLEAR and CONSISTENT differences exist between the
performance of long-term benzodiazepine users and those who do not use the drugs independent of their status with regard to anxiety
In Crowe's series of studies on BZD use, two largest effects noted in each of these studies were in which domains?
1. Verbal memory
2. Motor control/performance
In Crowe's series of studies on BZD use, two largest effects noted in each of these studies were in verbal memory and motor control/performance.

Which two areas of the brain sub-serve these cognitive functions?
These functions are largely subserved by the hippocampal formation and the reticular formation amongst other regions.
The effect of long term benzodiazepine use is comparable to the deficits noted in what?
The effect of long term benzodiazepine use is comparable to the levels of deficits noted with moderate to severe closed head injury.
Is there a justifiable clinical application for the
benzodiazepines for any presentation on a long-term basis?
No.
Where do z-class drugs bind?
Bind to a subset of GABAA receptors with alpha 1
subunits
What effects do z-class drugs have?
They produce pure sedation (without anxiolytic,
anticonvulsant or muscle relaxing effects)
What is the effect of Z-class drugs on REM sleep?
Minimal.
What is the indication of Z-class drugs?
Insomnia
What is the main advantage of z-class drugs relative to BZD and barbituates?
Less daytime impairment compared to the benzodiazepines and the barbiturates.
The low risk of residual effect, in addition to the _____________ may explain the limited negative influences of these agents on daytime performance.
Short half-life
What appears to be better preserved in people by non-benzodiazepine agents than by benzodiazepines.
Psychomotor tasks and memory capacities
With Z class drugs, impairment can emerge in the first hours after drug administration, whereas psychomotor and memory tests carried out 7-8 hours later (i.e. in the morning) generally show __ ________ __________.
In particular, impairment can emerge in the first hours after drug administration, whereas psychomotor and memory tests carried out 7-8 hours later (i.e. in the morning) generally show no relevant alterations.
On-the-road studies involving benzodiazepine hypnotics reveal what?
On-the-road studies revealed that benzodiazepine hypnotics significantly impaired driving ability the morning following bedtime administration.
On-the-road studies involving benzodiazepine hypnotics reveal what regarding afternoon performance the following day?
Impairment was sometimes also significant in the afternoon (16–17 h after administration).
Benzodiazepines and longterm use: 6 negative consequences?
1 altered use patterns (from night time to
daytime use)
2. excessive sedation
3. cognitive impairment
4. increased risk of accidents
5. Adverse sleep effects
6. Dependence and withdrawal (even at
therapeutic doses)
BZDs have an additive effect with alcohol/other
CNS depressants, increasing ______ ______ _______ _____.
BZDs have an additive effect with alcohol/other
CNS depressants, increasing the risk of harm
Long-term efficacy of BZD use?
limited.
Which benzodiazepines exhibit negative effects on psychomotor and memory function
All.
While the __________ effects resolve with tolerance to
sedation, however, the ___________ effects mostly persist.
While the psychomotor effects resolve with tolerance to sedation, the amnesic effects mostly persist.
Ruled out explanations for the impairment in vigilance in BZD use?
Impairment of vigilance does not appear to be explained by sedation and repeated dosing does not substantially diminish the effect.
In terms of recent BZD use, the neuropsychologist should be aware of.....
Thus the neuropsychologist should be aware of all
benzodiazepine use in the last month but particularly
within the last week.
BZD:

It is clear that the long-term residual effects persist
for at least ___ ________ post cessation.
Also it is clear that the long-term residual effects persist for at least 6 mths post cessation.
In terms of neuropsychological assessment, Z drugs only really a problem in ____ _____ _____after use.
Z drugs only really a problem in first few hours after use
There are 3 “generations” of drugs which are used to treat schizophrenia and related psychotic disorders (anti-psychotics).

What are they?
 1st generation: neuroleptics or typical antipsychotics
 2nd generation: atypical anti-psychotics
 3rd generation: Aripiprazole (Abilify)
Each generation of antipsychotics differs in pharmacology: resulting in different (3)?

Different neurotransmitter systems
 Different effects on symptoms
 Different side-effects
Typical anti-psychotics are _______ _____ ______ antagonists.
Typical anti-psychotics are dopamine D2
receptor antagonists
The ___________ of a typical anti-psychotic for the
D2 receptor is positively associated with
treatment outcome
The affinity of a typical anti-psychotic for the D2 receptor is positively associated with treatment outcome (higher affinity better treatment outcome.

Higher affinity better treatment outcome.
1st generation anti-psychotics are effective at treatment what symptoms?
Only effective at treating positive symptoms
What are the side effects of 1st generation anti-psychotics and what?
Parkinson-like syndrome (because you’re blocking dopamine in the basal ganglia too)
What is tardive dyskinesia and why does it occur?
Abnormal facial and limb movements due to sensitization of D2 receptors.
Most anti-psychotics affect other
neurotransmitter systems including (4)

What does this explain?
1. Histamine,
2. Acetylcholine,
3. Adrenaline
4. Serotonin

Additional side effects
Why were atypical anti-psychotics developed?
Atypical anti-psychotics have been developed because of their more selective action on the dopamine system and/or action on other neurotransmitter systems.
What do all effective antipsychotic drugs block?
D2 receptors.
Side effects of anti-psychotic medication:

Dopaminergic effects on the striatum (EPSE)? (4)
Dystonia/oculogyric crisis
 Parkinsonism
 Akathisia
 Tardive dyskinesia and BLMs
Side effects of anti-psychotic medication:

Anti-cholinergic (muscarinic)? (3)
Dry mouth
 Blurred vision
 Constipation and difficulty in passing urine
Side effects of anti-psychotic medication:

Anti-adrenergic (adrenaline): (5)
1. Drop in blood pressure on standing (postural hypertension)
2. Sedation
3. Failure of ejaculation (especially Thioridazine)
4. Skin rashes, e.g., photosensitivity
5. Weight gain (possibly due to blockade of H1 and 5HT2
Side effects of anti-psychotic medication:

Anti-histaminergic: (1)
sedation
Effects on normals; typicals

Drugs with significant anti-cholinergic
properties e.g., TDZ or CPZ in higher
doses impair performance on a variety of
________ and __________ tasks.
Effects on normals; typicals
 Drugs with significant anti-cholinergic
properties e.g., TDZ or CPZ in higher
doses impair performance on a variety of
MOTOR and COGNITIVE tasks.
Phenothiazenes and halperidol, which
have little anticholinergic activity, do not
seem to impair __________ ________.
Phenothiazenes and halperidol, which
have little anticholinergic activity, do not
seem to impair MOTOR SPEED.
However, Phenothiazenes and halperido are more likely to produce _______ and may thereby cause
decreases in motor speed and coordination.
However, these agents are more likely to
produce extrapyramidal symptoms (EPS) and may thereby cause decreases in motor speed and
coordination.
Effects on patients; typicals

Patients with schizophrenia improved
significantly on _________ ___________, indicating
that modest improvement in neuropsychological
functioning can be observed in treated patients
with schizophrenia (Daston, 1959).
Patients with schizophrenia improved
significantly on associative learning, indicating
that modest improvement in neuropsychological
functioning can be observed in treated patients
with schizophrenia (Daston, 1959).
Continuing administration of antipsychotics to
patients with schizophrenia results in few
significant changes in neuropsychological test
performance, with the possible exception of the
tendency to see improvement in _____________ and
_______________ after medication.
Continuing administration of antipsychotics to
patients with schizophrenia results in few
significant changes in neuropsychological test
performance, with the possible exception of the
tendency to see improvement in ATTENTION and
CONCENTRATION after medication.
Change in cognition with treatment
in schizophrenia:

Participants with schizophrenia showed a significant improvement in ________ ________ _________
Participants with schizophrenia showed a significant improvement in most cognitive tasks.
In assessing the effects of treatment on cog functioning in schizophrenia.

Which tests may be the best candidate for a cognitive endophenotype?
Semantic verbal fluency
The cognitive improvements observed in the
schizophrenia treatment trial were consistent with what?
Practice effects.
Carbamazepine Side Effects (6)
1. Weight gain
2. Neurotoxicity ( Diplopia, drowsiness, blurred vision, vertigo which are transient and reversible with dose reduction)
3. Mild elevation of liver enzymes
4. Hypersensitivity rash (uncommon)
5. Hematologic effects ( Rare: agranulocytosis, blood dyscrasia)

-Discontinue when fever, sore throat, rash, mouth ulcers, bruising or bleeding

6. Syndrome of inappropriate antidiuretic hormine (SIADH) - Cardiac conduction abnormalities (sometimes arrhythmia)
Valproate Side Effects (7)
1. GI: anorexia, indigestion, nausea, vomiting, heartburn, diarrhoea (decrease dose, antacid or H2-antagonist)
2. Irreversible but rare hepatotoxicity
3. Weight gain, increased appetite (Decrease dose, monitor weight)
4. Neutropenia and thrombocytopenia
5. Sedation, tremor (decrease dose
 Beta blocker for tremor)
6. Menstrual disturbances and polycystic ovaries is
possible
7. Transient alopecia
In terms of anti-epileptic drugs, ___________produced the worst performance in terms of cognitive function.
In terms of anti-epileptic drugs, phenobarbital produced the worst performance in terms of cognitive function.
The cognitive effects of antiepileptic agents:

Seizure patients administered antiepileptics
appear to _____________ from seizure control, but
______________ typically overcomes any potential
benefit with heavy sedation and negative
effects on a wide range of functioning.
Seizure patients administered antiepileptics
appear to BENEFIT from seizure control, but
PHENOBARBITAL typically overcomes any potential
benefit with heavy sedation and negative
effects on a wide range of functioning.
Phenytoin specifically effects _______ _________ speed and ________.
Phenytoin specifically effects motor speed and
accuracy.
Carbamazepine’s effects may be more in slowing ___________ _____________.
Carbamazepine’s effects may be more in slowing verbal responses.
Phenobarbital:

Impaired cognition in which four domains (4) >
1. intelligence
2. vigilance
3. memory
4. psychomotor functioning.


Nonepileptic individuals experience greater adverse effects than do epileptic patients
Phenytoin:

Impaired cognition in which domains?
1. vigilance
2. psychomotor functioning
3. memory
4. general intelligence
5. school and work performance in a dose dependent fashion.

This may be due to the effect on motor speed and accuracy
Carbamazepine and valproate are both agents are considered to be ____ __________ and therefore less neuropsychologically _____ ;

Nonetheless while relatively safe, carbamazepine can adversely affect cognition most notably psychomotor speed
Carbamazepine and valproate are both agents are considered to be LESS SEDATING sedating and
therefore less neuropsychologically TOXIC ;

Nonetheless while relatively safe, carbamazepine can adversely affect cognition most notably psychomotor speed
Which AED productes the greatest negative neuropsychological effects?
Phenobarbital.
In terms of AEDs

Phenytoin has a __________ _________ but has a significant sedative effect and dose dependently compromises motor speed and accuracy as well and memory.
Phenytoin has a SMALLER EFFECT but has a significant
sedative effect and dose dependently compromises
motor speed and accuracy as well and memory.
Carbamazepine and valproate have lesser __________
properties but are worse in high-dose or with
______________.
Carbamazepine and valproate have lesser sedative
properties but are worse in high-dose or with
polypharmacy.
Mechanism of action in lithium?
Mechanism of action not fully understood.
Mood-stabilizing effect has been postulated to be due to reduction of ________________ neurotransmitter concentration
Mood-stabilizing effect has been postulated to
be due to reduction of CATECHOLAMINE
neurotransmitter concentration.
Early dose related adverse effects of lithium?
1. GI distress
2. Sedation, weight gain
3. Muscle weakness
4. Polyuria, polydipsia
5. Impaired cognitive function
6. Tremor

Tolerance may develop
Strategies to manage dose-related adverse effects of lithium? (2)
1. Take with meal
2. Beta blocker for tremor
Late Adverse effects of lithium? (5)
1. Psoriasis / acne exacerbation
2. Diabetes insipidus
3. Hypothyroidism
4. Cardiac issues
5. Leukocytosis (increased white blood cell count)
Adverse effects of L Dopa? (4)
1. Cardiac arrhythmia from stimulation of adrenergic
receptors in heart. Dose needs to be adjusted for
people with cardiac problems

2. Abnormal involuntary movements (50%) - i.e.. grimacing of face and tongue movements; slow writhing type of movements (not jerky movements) in arm and face)
Why does peak dose chorea occur?

How is it managed?
1. This is due to high dose of L Dopa and occurs early
in therapy at 2 to 4 weeks i.e. “peak dose chorea”

2.Best way to handle is by reducing dose
Long Term
What occurs in 20 - 25% of the population on L Dopa?
Behavioral disturbances.
Another consequence of L Dopa treatment is trouble in _________
Trouble in thinking (cognitive effects).
L Dopa can induce: (5)
 Psychosis
 Confusion
 Hallucination
 Anxiety
 Delusion
Some individuals develop ___________ which can
include inappropriate sexual behavior; "dirty old
man", "flashers"
Some individuals develop HYPOMANIA which can
include inappropriate sexual behavior; "dirty old
man", "flashers".
Dopaminergic and anticholinergic treatments both led to improvement in __________ __________ but their effects upon cognitive performance dissociated.
Dopaminergic and anticholinergic treatments both led to improvement in MOTOR CONTROL but their effects upon cognitive performance dissociated.
Anticholinergic drugs produced impairment in processes underlying the immediate _____________ of ______________.
Anticholinergic drugs produced impairment in processes underlying the immediate registration of information
Dopaminergic therapy produces improvement on a tasks dependent on working memory and _________ __________.
Dopaminergic therapy produces improvement on a task dependent on working memory and cognitive sequencing.
Cognitive impairment in Parkinson's disease is
____________ in origin:
Cognitive impairment in Parkinson's disease is
multifactorial in origin:

short-term memory processes are served by both dopaminergic and cholinergic subcorticofrontal
systems but much of the cognitive impairment of
Parkinson's disease is independent of this subcortical neurochemical pathology and may be due to early neuronal dysfunction within the cerebral cortex.
Short-term memory processes are served by both __________________ and ________________ ___________________systems.
Short-term memory processes are served by both dopaminergic and cholinergic subcorticofrontal
systems.
Much of the cognitive impairment of Parkinson's disease is independent of subcortical
neurochemical pathology and may be due to early ___________ ___________ within the __________ cortex.
Much of the cognitive impairment of
Parkinson's disease is independent of this subcortical
neurochemical pathology and may be due to early neuronal dysfunction within the cerebral cortex.
What are the 7 red flags in clinical situations?
1. Recent change in medical condition that has not been assessed by their Primary Care Physician (PCP)
2. Symptoms of withdrawal from drugs or alcohol
(sweating, shaking, pale pasty skin, lethargy)
3. Acute change in mental status
4. Evidence of inability to care for self (malnourished, dehydrated, dirty, malodorous, risk of exposure to elements)
5. Evidence of recent sexual or physical abuse that has not been evaluated
6. Suggestions of serious side effects to medications
7. Acknowledged or observed suggestions of suicidality or homicidality factors.
What are the five Factors that should be integrated more fully into the typical neuropsychological
assessment of patients taking psychotropic medications?
1. chronicity of drug administration
2. metabolic capacity
3. the positive neuropsychological effects of
disease management
4. a direct comparison of speeded versus nonspeeded tasks within cognitive domains
5. the temporal onset of patient/significant other cognitive complaints with respect to drug initiation/cessation and
increase/reduction
Summary and conclusions (1)

Within the antidepressant class, which drug is the most concern and for what three reasons?

Acute (2) effects

and persisting impairment in (1) due to....
TCAs are of most concern (particularly
amitriptyline) within the antidepressant class
with acute psychomotor and concentration
effects and persisting anti-cholinergic associated
memory impairment.
Which two classes of antidepressant drugs are in need of more definitive study but are largely safe?
SSRIs and MAOIs.
Among the anxiolytics, benzodiazepines all
produce compromise in which four cognitive domains?

How long do these impairments persist for?
1. Sedative
2. Psychomotor
3. Concentration
4. memory compromise
Atypical vs typical antipsychotics: Which is better in terms of cognitive benefit?
Now seems clear that there is no substantive
cognitive benefit of atypical versus typical
antipsychotics
Seizure patients administered antiepileptics
appear to benefit from seizure control, but
__________________ typically overcomes any potential
benefit due to _________ __________ and negative
effects on a wide range of functioning.
Seizure patients administered antiepileptics
appear to benefit from seizure control, but
phenobarbital typically overcomes any potential
benefit with HEAVY SEDATION and negative
effects on a wide range of functioning.
Which AEDS produce mild effects on cognition?
Carbamazepine, valproic acid and, to a lesser
extent, phenytoin, produce more mild effects.
What does long term treatment with L Dopa produce?
Denervation supersensitivity
Generally you are unlikely to make a false
positive diagnosis with the principal exception of
the effects of which two psychotropic classes?
Benzodiazepines and the sedating and anticholinergic TCAs