Lithium: Treatment and Toxicity

Antimania: Lithium

• Alters sodium transport in nerve and muscle cells.
• Disrupts intraneuronal metabolism of catecholamines.
• Specific biochemical mechanism in mania is unknown.
• Used in treatment of manic episodes and maintenance of bipolar disorder.
• Monitor for signs of lithium toxicity, serum lithium, and sodium levels.
• Contraindicated in renal/cardiovascular disease, severe dehydration, or sodium depletion, and with diuretics.
• May cause fetal harm in pregnant women, avoid in children under 12.
• May take 1-3 weeks for symptom normalization in manic episodes.
• Common side effects include fine hand tremor, polyuria, and mild thirst.
• Can cause abnormal ECG findings and sudden death.
• Lithium toxicity symptoms: diarrhea, vomiting, drowsiness, muscular weakness, lack of coordination.
• High lithium levels cause giddiness, ataxia, blurred vision, tinnitus, large output of dilute urine.
• Take as directed; may increase dizziness/drowsiness, weight gain; low sodium can predispose to toxicity.

Antipsychotics

• Primarily used to manage psychosis, including delusions, hallucinations, paranoia, or disordered thought
• Commonly prescribed for schizophrenia, bipolar disorder, and psychotic depression.
• First-generation (conventional) examples include haloperidol and have more potential side effects.
• Second-generation (atypical) examples include risperidone and have fewer adverse effects.
• Block dopamine receptors in the brain.
• First-generation block dopamine receptors in certain areas of the CNS.
• Second-generation block specific dopamine 2 and serotonin 2 receptors.
• Used for drug-induced psychosis, schizophrenia, extreme mania, resistant depression, and other CNS conditions.
• Elderly with dementia-related psychosis have increased risk of death due to cardiovascular or infection causes.
• First-generation drugs can cause hyperglycemia, hyperlipidemia, and weight gain.
• Monitor elderly with dementia-related psychosis for cardiovascular events or infections.
• Haloperidol is contraindicated in Parkinson's disease or dementia.
• Monitor for neurotoxicity when antipsychotics are combined with lithium (weakness, lethargy, fever, confusion).
• Haloperidol is primarily indicated for schizophrenia and Tourette’s disorder.
• Risperidone is primarily indicated for schizophrenia, acute manic episodes, and irritability caused by autism.
• Atypical antipsychotics also treat depression or nausea.
• Typical antipsychotics such as haloperidol, fluphenazine, trifluoperazine, chlorpromazine, and thioridazine have a higher chance of causing extrapyramidal effects.
• Atypical antipsychotics often cause metabolic changes: hyperglycemia, hyperlipidemia, and weight gain.
• Antipsychotics can be administered via oral, intramuscular (IM), or intravenous (IV) routes.
• Long-acting injectable (LAI) antipsychotics help to improve adherence in patients with difficulty taking daily oral medications.

Nursing Assessments

• Baseline assessments are essential before initiating antipsychotic therapy.
• Mental status examination (MSE) should be performed including appearance, behavior, speech, mood, affect, thought process, thought content, cognition, and insight.
• Assess vital signs to establish baselines (including temperature, pulse, respiration and blood pressure), especially important due to potential side effects like hypotension.
• Check medical history for pre-existing conditions (cardiovascular, neurological, hepatic, or renal impairments) that may contraindicate or require dose adjustments.
• Review current medications, including prescription, over-the-counter, and herbal supplements, to identify potential drug interactions.
• Assess for allergies or previous adverse reactions to medications.
• Evaluate lifestyle factors (diet, exercise, smoking, alcohol, substance use) that may affect treatment adherence or outcomes.
• Functional status assessment including the patient’s ability to perform activities of daily living (ADLs) to gauge the impact of the illness and medications on their independence.
• Nutritional status should be determined as antipsychotics can affect appetite and metabolism.

Medication Management

• Administer medications as prescribed, adhering to proper techniques for oral, IM, or IV routes.
• Nurses have a role in improving adherence to medication regimens by providing education, addressing concerns, and involving patients in treatment decisions
• Therapeutic effects should be monitored, such as reduction in psychotic symptoms, improved mood, and enhanced social functioning.
• Accurately document medication administration, including dose, route, time, and patient response regularly.

Side Effects Monitoring

• Extrapyramidal symptoms (EPS) which include acute dystonia (muscle spasms), akathisia (restlessness), parkinsonism (rigidity, tremor, bradykinesia), and tardive dyskinesia (TD) should be carefully monitored.
• Use standardized scales such as the Abnormal Involuntary Movement Scale (AIMS) for patients with EPS symptoms as directed.
• Metabolic syndrome is another serious side effect that develops with medications, including weight gain, hyperglycemia, dyslipidemia, and hypertension.
• Regularly monitor weight, waist circumference, blood glucose, and lipid panel.
• Cardiovascular effects such as orthostatic hypotension, prolonged QTc interval, and arrhythmias are possible.
• Regularly monitor blood pressure (lying, sitting, standing) and ECG intervals.
• Neuroleptic malignant syndrome (NMS) is a rare but life-threatening reaction characterized by fever, rigidity, altered mental status, and autonomic dysfunction should be looked out for.
• Monitor temperature, muscle rigidity, mental status, and vital signs.
• Anticholinergic effects include dry mouth, blurred vision, constipation, and urinary retention, managed with hydration, fiber intake, and stool softeners.
• Monitor CBC for leukopenia or agranulocytosis, especially with clozapine.
• Check liver function tests for hepatotoxicity.
• Assess for rash, itching, or signs of allergic reactions.
• Monitor for sedation and cognitive impairment, especially during initial treatment.
• Assess for falls risk and implement safety precautions.

Adverse Effects

• Tardive dyskinesia: Involuntary contraction of oral and facial muscles (e.g., tongue thrusting).
• Neuroleptic Malignant Syndrome (NMS): Life-threatening; high fever, unstable blood pressure, myoglobinemia.
• Extrapyramidal Symptoms: Involuntary motor symptoms similar to Parkinson's; treated with anticholinergics like benztropine and trihexyphenidyl.

Client Education

• Medication education includes the name, dose, frequency, and purpose of the medication
• Take medication as directed and evenly spaced.
• Therapeutic effects may take weeks.
• Understand extrapyramidal symptoms; taper dose to discontinue.
• Avoid alcohol or other CNS depressants.
• Use caution when performing complex or high-risk tasks.
• Patients should be instructed to take medications as prescribed and not to discontinue abruptly without consulting their healthcare provider.
• Explain common and serious side effects, including how to manage or report them.
• Provide guidance on lifestyle modifications (diet, exercise, sleep hygiene) to enhance treatment outcomes.
• Share strategies for managing side effects, such as staying hydrated to prevent constipation.
• Educate about potential drug and food interactions.
• Emphasize the importance of regular follow-up appointments and lab monitoring.
• For long-acting injectables, explain the administration schedule, benefits, and potential injection site reactions.

Therapeutic Communication

• Establish a trusting and empathetic relationship with patients.
• Use active listening skills to understand patient concerns, fears, and experiences.
• Encourage patients to express their feelings and thoughts openly.
• Provide reassurance and support, especially during times of distress or exacerbation of symptoms.
• Motivational interviewing techniques can be used to address ambivalence about medication adherence and promote engagement in treatment.
• Communicate effectively with the interdisciplinary team (psychiatrists, psychologists, social workers) to coordinate care and optimize treatment outcomes.
• Demonstrate cultural sensitivity and awareness, and adapt communication style to meet the patient's cultural background, language proficiency, and individual needs.
• Provide education and support to family members or caregivers, involving them in treatment planning and decision-making.
• Regularly assess the patient’s understanding of their illness, medications, and treatment plan, and provide ongoing education and reinforcement as needed.

Stimulants

• Increase CNS activity and dopamine levels.
• Treat ADHD, narcolepsy, and other sleep disorders.
• Examples of Stimulants: methylphenidate (immediate and extended release), dextroamphetamine (Dexedrine), lisdexamfetamine dimesylate (Vyvanse), amphetamine and dextroamphetamine (Adderall).

Short Term Effects

• Increased alertness.
• Narrowed blood vessels.
• Increased body temperature and breathing rate.
• Decreased sleep and appetite.
• Sweating, dilated pupils, restlessness, aggressive behavior, dizziness, tremors, increased concentration, paranoia, hallucinations.

Long Term Effects

• Hostility and paranoia.
• Serious cardiovascular complications.
• Tolerance development.