Anxiolytics and sedative-hypnotics: Nursing pharmacology

Axiolytics and sedative hypnotics are medications that act as central nervous system depressants that reduce tension and induce calm or sleep and are primarily used to relieve anxiety as well as insomnia.

It's important to note that the preferred medications for the long-term management of anxiety are typically selective serotonin reuptake inhibitors, or SSRIs for short, due to their low abuse potential and dependence.

But medications that can be used for the short-term management include benzodiazepines, barbiturates, and miscellaneous anxiolytics.

First, let's start with benzodiazepines. These medications are usually taken orally, but some of them can also be administered intravenously, intramuscularly, subcutaneously, sublingually, or even rectally.

Now, based on the overall duration of action. Benzodiazepines can be subdivided into three main groups.

The first group includes short-acting benzodiazepines, which typically end in azolam, such as alprazolam and midazolam. The second group covers intermediate acting benzodiazepines that end in azepam, like lorazepam and clonazepam.

And finally, the third group includes long-acting benzodiazepines that also end innazepam, such as diazepam. In addition to treating anxiety and insomnia, benzodiazepines are also indicated for treatment for status epilepticus, where a person has ongoing or multiple seizures for over 5 minutes.

Other important indications include preoperative sedation, induction of general anesthesia sedation for mechanical ventilation, and alcohol withdrawal syndrome.

Now benzodiazepines work by binding to GAA receptors, increasing the frequency at which they open up to let chloride ions into the cell.

The influx of negatively charged chloride ions makes the neurons less responsive to stimuli. Now, benzodiazepines can cause side effects like headaches, sedation, and dizziness, as well as blurred vision and dry mouth.

Also, despite being a central nervous system depressant, benzodiazepines can cause paradoxical stimulation in certain parts of the brain, leading to symptoms such as fast speech, excitement, and restlessness.

In rare cases, clients might experience urinary incontinence, constipation, or even develop leukopenia. Which can lead to fever, malaise, and sore throat.

Finally, if used continuously over long periods of time, benzodiazepines can lead to tolerance, dependency, and abuse. So when medication is discontinued, the client may experience withdrawal symptoms.

Which include anxiety, tremors, tachycardia, hypertension, agitation, delirium, and life-threatening seizures. As far as contraindications go, benzodiazepine should be avoided in individuals with myasthenia gravis, since they can exacerbate myasthenia symptoms.

Other contraindications include severe liver impairment, and acute narrow angle glaucoma, and must not be combined with other CNS depressants such as alcohol.

Finally, benzodiazepine should be avoided during pregnancy, breastfeeding, and in individuals diagnosed with sleep apnea.

Now, let's switch our focus to barbiturates that can be used as anxiolytics or sedative hypnotics, such as butobarbital, pentobarbital, and phenobarbital, which can be administered orally, intravenously or intramuscularly.

Barbiturates also bind gaba A receptors, but in contrast to benzodiazepines, they increase the duration of their opening, therefore increasing the influx of chloride ions.

As a result, the neuron becomes less responsive to stimuli. Besides anxiety, barbiturates can also be used for preoperative sedation, anesthesia induction, convulsions, and to induce coma and life-threatening conditions, such as increased intracranial pressure.

Barbiturates can cause side effects like headache, somnolence, confusion, hallucinations, and vertigo, and CNS depression may even lead to coma or death.

Some clients can experience bradycardia, hypotension, and syncope, while others may experience respiratory depression or even apnea.

Common gastrointestinal problems include nausea, vomiting, and constipation. While important musculoskeletal side effects include asthenia, or lack of energy and physical weakness, and ataxia, which refers to a lack of coordination and muscle control.

Just like benzodiazepines, barbiturates can also cause a paradoxical stimulation. As well as tolerance and dependence, which can be followed by withdrawal symptoms.

Finally, on rare occasions, clients treated with barbiturates can develop a life-threatening rash called Stevens-Johnson syndrome.

Important contraindications include concomitant administration of barbiturates with other CNS depressants, such as alcohol and benzodiazepines, as well as hypotension, laryngospasm, and bronchospasm.

Finally, we have miscellaneous anxiolytics. Which include non-benzodiazepine, sedative hypnotics, and buspirone.

First, let's focus on non-benzodiazepines. Zolpidemdalalo.

And azipicclone, which are often referred to as ZZZ medications. These medications are taken orally, and they are called non-benzodiazepines because they have a different chemical structure to the benzodiazepines, but the same mechanism of action.

The most common side effects associated with non-benzodiazepines include headache, hot flashes, anxiety, nausea and vomiting.

Also, some clients might present with ataxia and erectile dysfunction. Additionally, non-benzodiazepines have a boxed warning.

About abnormal sleep behaviors like sleepwalking or engaging in other activities while not fully awake. And just like benzodiazepines, these medications should not be used for prolonged periods.

Because they can cause tolerance, dependence, and withdrawal symptoms. Finally, non-benzodiazepines should not be combined with alcohol or other CNS depressants like benzodiazepines, antihistamines, antipsychotics.

Or opioids, since the depressive effects are addictive and can get severe to the point of respiratory depression and coma.

On the other hand, buspirone is taken orally and works by binding to and activating serotonin 5H21 receptors, as well as blocking dopamine DA2 receptors.

Clients on buspirone may develop side effects like headaches, dry mouth, and sedation. It may also cause dopamine-related movement disorders.

Such as dystonia Akathisia And pseudo-Parkinsonism. Finally, this medication should be used with caution in those with hepatic or renal impairment, especially elderly clients.

OK, before administering an anxiolytic or sedative hypnotic, be sure to perform a baseline assessment that includes vital signs, weight, level of consciousness, mental and behavioral status, as well as frequency and severity of symptoms.

Obtain your client's laboratory values, including CBC, hepatic function, renal function, and cardiac function. Then teach your client why the medication is prescribed.

And how it can help reduce their symptoms. Be sure to remind them how sedation is a common side effect during therapy.

And advise them to be careful about engaging in any hazardous activities such as driving. During therapy, monitor for development of side effects and assess for the desired therapeutic response.

If a benzodiazepine is prescribed, obtain additional baseline data, such as a history of abuse. If the medication is prescribed for anxiety, assess your client's baseline mental status and presence of restlessness, irritability, and other manifestations of anxiety.

Also, obtain a negative pregnancy test and remind your client that the medication can cause fetal harm, especially during the first trimester.

In addition, if your client is planning on becoming pregnant, prompt them to inform their healthcare provider. Also, let your client know that gastric upset may occur, and that they can minimize this problem by advising them to take their medication with food.

If your client is prescribed midazolam, stress the importance of avoiding grapefruit in any form to decrease the risk of toxicity, and advise your client to avoid alcohol or other CNS depressants during therapy.

Also remind them that they should not suddenly stop taking their medication. As this could lead to potentially life-threatening withdrawal symptoms.

During treatment, continue to monitor your client for side effects, as well as for the desired therapeutic response. And for indications of abuse such as changes in behavior, mental status, or requests for an increased dose.

If you are caring for a client who is prescribed an IV benzodiazepine, be sure to administer an intravenous dose carefully and slowly to avoid side effects, such as hypotension and bradycardia.

Remember, the medication is a vesicant, so take care during injection to avoid extravasation, which can cause harm to your client's veins.

Notify the provider right away if these side effects occur. During therapy, closely monitor your client's IV site, vital signs, level of sedation, and institute fall precautions.

Now, if an IV barbiturate is prescribed, remember to administer the medication slowly and carefully to avoid extravasation.

Keep in mind that the risk for respiratory depression and bradycardia is increased when administering an IV, so keep a close eye on their vital signs.

Also, monitor their level of sedation and institute fall precautions. Also, watch for the development of a rash.

This could indicate the development of Stevens-Johnson syndrome, which requires immediate intervention. OK, if your client is experiencing insomnia and is prescribed one of the ZZZ medications, first inquire about factors that could interfere with their sleep, such as use of caffeine, sleep hygiene practices, or life stressors.

Let your client know that the medication works quickly. So they should take the medication immediately before going to bed.

Caution your client about dangerous sleep behaviors that may occur, such as sleepwalking or even sleep driving. If they or another household member thinks they are experiencing the side effect, prompt them to stop the medication and contact their healthcare provider.

Now, if buspirone is prescribed, be sure to check your client's liver and renal function labs to confirm they do not have severe impairment.

Instruct them to take the medication with or without food at a consistent time of the day, and avoid grapefruit or grapefruit juice.

Which can result in an elevated serum concentration of the medication. Finally, buspirone has been known to cause dopamine-related movement disorders like dystonia or akathisia.

So be sure to periodically monitor your client for these. And instruct a client to contact their healthcare provider if they experience any feeling of restlessness, abnormal movements, twitching, or trouble speaking or swallowing.

All right, as a quick recap. Anxiolytics and sedative hypnotics are medications that depress the central nervous system to relieve anxiety or insomnia.

They are also used to provide sedation or treat status epilepticus. Nursing considerations include assessing baseline data about the client's disorder, the medication is prescribed to treat, providing client education, monitoring during therapy, and promoting the effectiveness of medication therapy.