clozaril and tardive dyskinesia

[inthesky]

I had a patient today who developed these involuntary tongue, jaw clenching, and mouth movements (TD i assume) after just day 4 on clozaril 200mg at bedtime. Poor woman is drooling up a storm and spent the entire day clenching her jaw, really sedated, being unable to control her mouth, and feeling an "inner uneasiness". She did not have any body stiffness. Her voices are gone, but I'm sure she would prefer them to this. She was pounded with benadryl and cogentin and fortunately had relief by the end of the day. So well, the doc INCREASED her clozaril dose. It was somewhat uncomfortable as a new nurse, but I actively convinced the on-call doctor to hold her evening dose and decrease the dosages for tomorrow. He was really flustered and mumbled that this is really rare with clozaril and 200mg is a small dose. but well... treat the patient, not the statistics.

Did I do the right thing? I don't know a whole lot about clozaril or even the clinical pathology of EPS, but this seemed like common sense.

and a curiosity: why do anticholinergic meds like benadryl and cogentin work for the side effects/adverse reactions of other meds which are known to have anticholinergic properties as well? This question has stumped me for a little while. I'm sure it has something to do with the dopamine/acetylcholine balance.

and what are the consequences of giving patients too much benadryl or cogentin? very dry mouths..constipation? =P too much benadryl makes me restless and anxious while a small dose will put me to sleep.

thank you =)

[medsurgrnco, BSN, RN]

I'm impressed that as a new psych nurse you advocated for the patient and addressed the issue with on the on-call doc. Whether this was a low dose or not, and whether these symptoms were rare with this med or not, the patient did develop a number of symptoms that required extra meds so maybe the patient needs to be on a different med.

[inthesky]

The RN before me had even given this patient IM benadryl. She had about a daily total of 100mg benadryl and 3mg cogentin. When I get in report that things have deteriorated to the point of IM necessity, I pay very close attention (although I do have a feeling that this particular nurse uses IMs a bit too liberally. I tend to wait for the pill, unless a) i feel impending disaster/medical emergency b) the patient reports that they feel they need the injection (upon doc/RN discretion of course))

I've been reading some information about possible EPS/TD rebound if med is withdrawn too quickly, but I'm sure that is mostly with long-term usage.

I'm trying to learn to listen to my gut reactions. I felt scared and uncomfortable to give this med. The patient was relieved as well when I told her the doc decided to hold the dose and decrease the med. I woke her up for her other night meds.. and she was lethargic, with a huge string of drool hanging from her mouth.. and happy that i brought ibuprofen for her sore jaw >_<.>

[medsurgrnco, BSN, RN]

Patients can always refuse meds as well, as long as they are not court-ordered... We had a situation at our hospital where a patient was lethargic and a med dose was increased. Night nurse gave it tho commented about the med dose increase which nurse felt was questionable, and a couple of hours later the patient complained of dizziness and then fell (caught by a MHW). Patient then was awake but would not respond to staff, and had to be carried to bed. Doc seemed pretty concerned when called, and nurse pointed out the med dose increase, but pt was okay and just monitored frequently for the rest of the night. Listen to your gut!

[SuesquatchRN, BSN, RN]

Good for you for advocating for her.

I think, though, that you might be wrong that she would prefer the voices. Having lived with a schizophrenic sister, I can tell you that the voices are extremely frightening and cruel.

[inthesky]

very good point suesquatch! That definitely pertains to this patient and my heart goes out to your sister and family. She was ready to accept the drooling and sedation, but the mouth movements and jaw clenching was too much!

[elkpark]

Good for you for advocating for her.

I think, though, that you might be wrong that she would prefer the voices. Having lived with a schizophrenic sister, I can tell you that the voices are extremely frightening and cruel.

(Even in the case of schizophrenia, every person's experience is personal and unique -- not all people experience "voices" that are negative or frightening, and plenty of people consider the "cure" worse than the sxs of the disease.)

[SuesquatchRN, BSN, RN]

(Even in the case of schizophrenia, every person's experience is personal and unique -- not all people experience "voices" that are negative or frightening, and plenty of people consider the "cure" worse than the sxs of the disease.)

Uh huh.

At the point at which someone has to be hospitalized the symptoms are, indeed, worse than the cure. And, as the OP stated, this particular woman was willing to accept the side effects of medication to get rid of what was obviously, to her, extremely upsetting ideation.

And that's why having an intelligent, advocating, vigilant, knowledgeable person such as the OP caring for these folks is vital.

Do the current meds for psychosis bite? Yes indeedy. Does psychosis bite worse? Often.

[inthesky]

well.. what makes psych interesting is that every patient is different and has their own unique story =). One of my favorite patients (69 year old man) believed that we were all controlled by aliens. The aliens would speak to him and were his friends. With medication, he missed his friends, but he was happy to be able to concentrate and read books again. He had some pretty pronounced TD, but it didn't bother him.. as long as he could still manage to smoke two cigarettes at once, all was good.

The patient I'm posting about proclaims herself an expert at discerning voices from reality. We chart her thought processes as 'clear'. She says that she has heard voices since she was a child, but she only goes to the hospital when it becomes more than she can handle, the voices become significantly ridiculing, or if she is having suicidal depression. She appears to be med compliant. I'll be at work tomorrow and hope to find her doing a bit better.

[elkpark]

Uh huh.

At the point at which someone has to be hospitalized the symptoms are, indeed, worse than the cure. And, as the OP stated, this particular woman was willing to accept the side effects of medication to get rid of what was obviously, to her, extremely upsetting ideation.

And that's why having an intelligent, advocating, vigilant, knowledgeable person such as the OP caring for these folks is vital.

Do the current meds for psychosis bite? Yes indeedy. Does psychosis bite worse? Often.

I assume your "uh huh" is intended as sarcasm, but I can't imagine why. I was not trying to be argumentative or suggest that your statement was wrong, only attempting to point out that what you identified as your personal experience with your sister is not representative of the very wide range of possibilities within the world of schizophrenia. Plenty of people are hospitalized because it was someone's opinion that "the symptoms were worse than the cure," but that doesn't mean, necessarily, that the client feels that way.

[SuesquatchRN, BSN, RN]

I never claimed that it was representative of everyone. I said "you MIGHT be wrong" about....

:)