13.4 Anxiolytics and Sedative-Hypnotics

Anxiolytics and sedative-hypnotics are crucial medications for managing anxiety disorders and sleep issues. These drugs work by enhancing GABA activity or targeting specific receptors in the brain, helping to calm nerves and promote restful sleep.

Understanding the mechanisms, effects, and considerations of these medications is vital for nurses. From assessing patients to administering drugs and educating about side effects, nurses play a key role in ensuring safe and effective use of anxiolytics and sedative-hypnotics.

Anxiolytics and Sedative-Hypnotics

Features of anxiolytics and sedative-hypnotics

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• Anxiolytics reduce symptoms of anxiety disorders (generalized anxiety disorder, panic disorder, phobias) by decreasing restlessness, nervousness, and excessive worry
  • Common anxiolytics include benzodiazepines (alprazolam, lorazepam) and buspirone
• Sedative-hypnotics treat insomnia and sleep disorders by promoting sleep onset and maintaining sleep duration
  • Examples of sedative-hypnotics include benzodiazepines (temazepam, triazolam), non-benzodiazepine hypnotics (zolpidem, eszopiclone), and melatonin receptor agonists (ramelteon)

Mechanisms vs effects of anxiety medications

• Benzodiazepines enhance the activity of GABA, the primary inhibitory neurotransmitter in the CNS
  • Side effects include drowsiness, dizziness, impaired coordination, memory impairment, and respiratory depression
  • May have additive CNS depression with other CNS depressants (alcohol, opioids) and increase risk of falls and fractures in older adults
• Buspirone acts as a partial agonist at serotonin 5-HT1A receptors, reducing anxiety without causing significant sedation or cognitive impairment
  • Side effects include dizziness, nausea, headache, and nervousness
  • Combining with other serotonergic agents (SSRIs, SNRIs) may increase the risk of serotonin syndrome
• Non-benzodiazepine hypnotics (zolpidem, eszopiclone) bind selectively to the alpha-1 subunit of GABA-A receptors, promoting sleep without causing significant anxiolytic effects
  • Side effects include drowsiness, dizziness, headache, and complex sleep behaviors (sleep-walking, sleep-eating)
  • Additive CNS depression may occur with other CNS depressants
• Melatonin receptor agonists (ramelteon) bind to melatonin receptors (MT1 and MT2) in the suprachiasmatic nucleus, regulating the sleep-wake cycle
  • Side effects include dizziness, fatigue, and headache
  • Minimal drug-drug interactions due to limited metabolism by cytochrome P450 enzymes

Pharmacokinetics and tolerance

• Half-life varies among different anxiolytics and sedative-hypnotics, affecting duration of action and frequency of dosing
• Drug metabolism occurs primarily in the liver, with some medications having active metabolites
• Tolerance may develop with prolonged use, requiring increased doses to achieve the same therapeutic effect
• Cross-tolerance can occur between drugs with similar mechanisms of action, such as benzodiazepines and alcohol

Nursing considerations for sedatives

• Assessment involves evaluating the patient's medical history, including past and current medications, allergies, and comorbidities
  • Assess anxiety level, sleep quality, and duration using validated tools (GAD-7, Insomnia Severity Index)
• Administer medications as prescribed, ensuring correct dose, route, and timing
  • Monitor patient's response to medication, including effectiveness and adverse effects
• Monitor vital signs, level of consciousness, and respiratory status, especially when using benzodiazepines or other CNS depressants
  • Watch for signs of oversedation, respiratory depression, or complex sleep behaviors
• Implement fall prevention strategies, particularly for older adults or patients with impaired mobility
• Educate patients and caregivers about the risks of operating heavy machinery or engaging in activities that require alertness while taking these medications
• Be aware of potential paradoxical reactions, especially in elderly patients or those with certain medical conditions

Patient education for sleep medications

• Explain the purpose, expected benefits, and potential side effects of the prescribed medication
  • Emphasize the importance of taking the medication as directed and not altering the dose without consulting the healthcare provider
• Encourage non-pharmacological interventions, such as relaxation techniques, cognitive-behavioral therapy, and sleep hygiene practices
  • Discuss the benefits of regular exercise, stress management, and a consistent sleep schedule
• Advise patients to avoid alcohol and other CNS depressants while taking anxiolytics or sedative-hypnotics
  • Inform patients about the risks of combining these medications with opioids or other substances that can cause respiratory depression
• Schedule regular follow-up appointments to assess the effectiveness of the medication and monitor for adverse effects
  • Instruct patients to report any concerning symptoms or side effects to their healthcare provider promptly
• Discuss the importance of gradually tapering off the medication under the guidance of a healthcare provider to minimize the risk of withdrawal symptoms
  • Educate patients about the signs and symptoms of withdrawal and when to seek medical attention
• Inform patients about the possibility of rebound insomnia when discontinuing certain sleep medications