3: 65-year-old woman with insomnia

Question 1

Sleep apnea is common in the elderly, occurring in 20% to 70% of elderly patients.

Answer 1

Obstruction of breathing results in frequent arousal that the patient is typically not aware of; however, a bed partner or family member may report loud snoring or cessation of breathing during sleep.

Question 2

Common Causes of Insomnia in the Elderly

Answer 2

• Issues that may lead to an environment that is not conducive to sleep .
• Question the use of prescription, over-the-counter, alternative, and recreational drugs that might be affecting sleep.: Patients should be counseled to avoid caffeine and alcohol for four to six hours before bedtime.
• In restless leg syndrome, the patient experiences an irresistible urge to move the legs, often accompanied by uncomfortable sensations.
• In periodic leg movement and REM sleep behavior disorder, the patient experiences involuntary leg movements while falling asleep and during sleep respectively.
• Disturbances in the sleep-wake cycle include jet lag and shift work.
• Patients with depression and anxiety commonly present with insomnia.
• Patients with shortness of breath due to cardiorespiratory disorders often report that these symptoms keep them awake.
• Pain or pruritus may keep patients awake at night.
• Those with GERD may report heartburn, throat pain, or breathing problems.

Question 3

Circadian rhythms change, with older adults tending to get sleepy earlier in the night. In advanced sleep phase syndrome (ASPS)

Answer 3

this has progressed to the point where the patient becomes drowsy at 6 to 7 p.m. If they go to sleep at this hour, they sleep a normal seven to eight hours, waking at 3 or 4 a.m. However, if they try to stay up later, their advanced sleep/wake rhythm still causes them to awaken at 3 or 4 a.m. This can be difficult to distiguish from insomnia.

Question 4

Good Sleep Hygiene: Your Personal Habits

Answer 4

Fix a bedtime and an awakening time. Do not be one of those people who allows bedtime and awakening time to drift. The body “gets used to” falling asleep at a certain time, but only if this is relatively fixed. Even if you are retired or not working, this is an essential component of good sleeping habits.

Avoid napping during the day. If you nap throughout the day, it is no wonder that you will not be able to sleep at night. The late afternoon for most people is a “sleepy time.” Many people will take a nap at that time. This is generally not a bad thing to do, provided you limit the nap to 30 to 45 minutes and can sleep well at night.

Avoid alcohol four to six hours before bedtime. Many people believe that alcohol helps them sleep. While alcohol has an immediate sleep-inducing effect, a few hours later as the alcohol levels in the blood start to fall, there is a stimulant or wake-up effect.

Avoid caffeine four to six hours before bedtime. This includes caffeinated beverages such as coffee, tea and many sodas, as well as chocolate, so be careful.

Avoid heavy, spicy, or sugary foods four to six hours before bedtime. These can affect your ability to stay asleep.

Exercise regularly, but not right before bed. Regular exercise, particularly in the afternoon, can help deepen sleep. Strenuous exercise within the two hours before bedtime, however, can decrease your ability to fall asleep.

Question 5

Your Sleeping Environment

Answer 5

Use comfortable bedding. Uncomfortable bedding can prevent good sleep. Evaluate whether or not this is a source of your problem, and make appropriate changes.

Find a comfortable temperature setting for sleeping and keep the room well ventilated. If your bedroom is too cold or too hot, it can keep you awake. A cool (not cold) bedroom is often the most conducive to sleep.

Block out all distracting noise, and eliminate as much light as possible.

Reserve the bed for sleep and sex. Don’t use the bed as an office, workroom or recreation room. Let your body “know” that the bed is associated with sleeping.

Question 6

Getting Ready For Bed

Answer 6

Try a light snack before bed. Warm milk and foods high in the amino acid tryptophan, such as bananas, may help you to sleep.

Practice relaxation techniques before bed. Relaxation techniques such as yoga, deep breathing and others may help relieve anxiety and reduce muscle tension.

Don’t take your worries to bed. Leave your worries about job, school, daily life, etc., behind when you go to bed. Some people find it useful to assign a “worry period” during the evening or late afternoon to deal with these issues.

Establish a pre-sleep ritual. Pre-sleep rituals, such as a warm bath or a few minutes of reading, can help you sleep.

Get into your favorite sleeping position. If you don’t fall asleep within 15 to 30 minutes, get up, go into another room, and read until sleepy.

Question 7

Risk Factors for Completed Suicide

Answer 7

Sex: The person most likely to succeed in a suicidal attempt is a white male. While females are more likely to attempt suicide; males are more likely to complete one.

Age: Although overall suicidal behaviors do not increase with age, rates of completed suicide do increase with age.

• -Elderly persons attempting suicide are also more likely to be widows/widowers, live alone, perceive their health status to be poor, experience poor sleep quality, lack a confidante, and experience stressful life events.
• -Importantly, approximately 75% of elderly persons who commit suicide had visited a primary care physician within the preceding month, but their symptoms were not recognized or treated, underscoring that physicians must be tuned in to the signs and symptoms of depression and risks for suicide. Drug overdose is the most common means of suicide on the elderly, making the safety of medications chosen to treat the condition important.

Previous attempts: Having previously attempted suicide is a risk factor for attempting suicide again.

Suicide is the eighth leading cause of death among American Indian/Alaskan Natives (AI/AN), and for those ages 15 to
34, occurs 1.5 times the rate of other U.S. ethnicities in that age group.

Poverty by itself is not a risk factor.

Question 8

Major Depression Diagnostic Criteria

Answer 8

For a diagnosis of major depression, the patient must have at least five of the following nine criteria for a minimum of two weeks.
A least one of the symptoms must be either (1) depressed mood or (2) loss of interest or pleasure.

Sleep: Insomnia or hypersomnia nearly every day.

Interest (loss of): Anhedonia (loss of interest or enjoyment) in usual activities.

Guilt: Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).

Energy (decreased): Fatigue or loss of energy nearly every day.

Concentration (decreased, or crying): Diminished ability to think or concentrate, or indecisiveness, nearly every day
(either by subjective account or as observed by others).

Appetite (increased or decreased): or significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month).

Psychomotor retardation: Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down).

Suicidal ideation: Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.

Question 9

Risk factors for late-life depression include:

Answer 9

Female sex
Social isolation
Widowed, divorced, or separated marital status
Lower socioeconomic status
Comorbid general medical conditions, e.g. stroke, heart disease and cancer Uncontrolled pain
Insomnia
Functional impairment
Cognitive impairment

Question 10

Depression is a very serious disease in the elderly:

Answer 10

Depression increases the risk of disabilities in mobility and the activities of daily living by about 70% over the course of six years.

Alcohol and drug abuse are very common comorbidities complicating depression.

Completed suicide is more common in older depressed patients.

Question 11

Assessing Severity of Suicidal Ideation

Answer 11

A tool used to assess whether a patient is seriously contemplating suicide is the SAD PERSONS scale:

Sex (male)
Age (< 19 or > 45)
Depression, diagnosis of
Previous attempt(s)
Ethanol or other substance abuse
Rational thinking impaired (psychosis, delusions, hallucinations) 
Social supports lacking
Organized plan for suicide 
No significant other Sickness (physical illness)

One point is scored for each factor present.

• -A score of 4 to 6 suggests outpatient treatment is an appropriate clinical action
• -A score of 7 to 10 suggests hospitalization is warranted

Question 12

Two dementia screening tools are:

Answer 12

The Mini-Cog exam
The Mini-Mental State Exam (MMSE)

The Mini-Cog exam is faster and more sensitive and specific than the MMSE.

Question 13

Common side effects of SSRI/SNRIs include:

Answer 13

• -Headaches
• -Sleep disturbances (drowsiness and, less frequently, insomnia)
• -Gastrointestinal problems such as nausea and diarrhea
• -Sexual dysfunction

They can also cause:

• -Hyponatremia, due to the syndrome of inappropriate secretion of antidiuretic hormone (SIADH)
• -Serotonin syndrome (lethargy, restlessness, hypertonicity, rhabdomyolysis, renal failure, and possible death)
• -Increased risk of gastrointestinal bleeding

In the elderly you also have to be concerned about an increased risk for falls with these medications, and recent studies show that they might have adverse effects on bone density.

Older antidepressants such as TCAs can cause arrhythmias. Citalopram and Escitalopram can cause QT interval prolongation at higher doses, especially in the face of hypokalemia and hypomagnesemia or when combined with other medication that have this same effect. Reports of symptomatic arrhythmia is uncommon.

Often patients with depression will present with arthralgias and myalgias, but SSRI/SNRIs do not cause arthralgias.

Question 14

Depression in Hispanics

Answer 14

Due to factors such as economics, culture, and differences in presentation, Hispanics have their depression identified less frequently than non-Hispanic whites. This holds true in some other ethnic groups as well, such as African Americans.

Hispanic patients will more frequently present to a doctor for somatic complaints such as myalgias or fatigue, rather than with stated mood-related complaints.

U.S.-born Hispanics experience depression at similar rates to other ethnic groups. Rates of depression in immigrant Hispanics are up to 50% lower than U.S.-born Hispanics.

Psychosis is no more common in Hispanics than other groups, but symptoms of perceptual distortion such as hearing noises or seeing shadows (known as celajes) are more common and must be differentiated from psychotic hallucinations.

Hispanics and other ethnic and economic minorities are less likely to receive adequate therapies.

Question 15

Early research indicates the following risk factors for abuse:

Answer 15

1. Dementia.
2. Shared living situation of elder and abuser (except in financial abuse).
3. Caregiver substance abuse or mental illness.
4. Heavy dependence of caregiver on elder. Surprisingly, the degree of an elder’s dependency and the resulting
   stress has not been found to predict abuse.
5. Social isolation of the elder from people other than the abuser.

Question 16

Assessing Suicidal Ideation

Answer 16

• -Do you want to die? Have you thought about dying? Have you considered hurting yourself?
• -Do you have a plan for hurting or killing yourself? Do you have the means to carry out this plan? If not, how would you obtain the means?
• -Have you taken any medications, alcohol, or drugs today? Have you had problems with alcohol or drugs in the past? Have other people thought so?
• -Have you ever tried to hurt or kill yourself before?
• -Has anyone in your family or any of your friends ever taken their life?
• -Have you lost interest in life? What problems in your life would be solved by killing yourself? Do you feel hopeless about your life? Do you feel hopeless about these problems ever being solved?
• -Have you begun to give away your belongings? Have you made plans for your loved ones?
• -What would happen if you successfully killed yourself? Would anything happen to you after you died? Who would be upset and who would be relieved if you killed yourself?

Question 17

Treatments for Primary Insomnia in the Elderly: Cognitive Behavioral Therapy for Insomnia (CBT-I)

Answer 17

CBT-I (which includes sleep hygiene instruction, stimulus control, and sleep restriction with cognitive restructuring) has been shown to be most effective. CBT-I combines different behavioral treatments, resulting in improvements lasting up to two years. Examples include:

Sleep restriction therapy: The patient is told to reduce his or her sleep/in-bed time to the average number of hours the patient has actually been able to sleep over the last two weeks (as opposed to the number of hours spent in bed (awake plus asleep)). As sleep efficiency increases, time allowed in bed is increased gradually by 15- to 20-minute increments approximately once every five days (if improvement is sustained) until the individual’s optimal sleep time is obtained.

Sleep compression therapy: The patient is counseled to decrease the amount of time spent in bed gradually to match total sleep time rather than making an immediate substantial change.

Question 18

Treatments for Primary Insomnia in the Elderly: Pharmacological Therapy

Answer 18

All drugs for the treatment of insomnia can be associated with side effects - particularly prolonged sedation and dizziness - that can result in the risk of injuries and confusion. Non-benzodiazepines (e.g., zolpidem (Ambien)) and melatonin- receptor agonists are the safest and most efficacious hypnotic drugs currently available.

Benzodiazepines can be effective but have more complications and the additional risk of addiction.

Antihistamines, antidepressants, anticonvulsants, and antipsychotics are associated with more risks than benefits in older adults.

Question 19

Selective serotonin reuptake inhibitors (SSRIs)

Answer 19

Selectively block reuptake of serotonin, potentiating serotonin’s effect on the post-synaptic neuron

Citalopram (Celexa) 
Fluoxetine (Prozac) 
Fluvoxamine (Luvox) 
Paroxetine (Paxil) 
Sertraline (Zoloft) 
Escitalopram (Lexapro)

Question 20

Tricyclic antidepressants (TCAs)

Answer 20

Block reuptake of norepinephrine and serotonin, potentiating their effects on the post-synaptic neuron

Nortriptyline (Pamelor)
Amitriptyline
Clomipramine (Anafranil)
Doxepin (Sinequan)

Question 21

Monoamine oxidase (MAO) inhibitors

Answer 21

Block pre-synaptic catabolism of norepinephrine and serotonin (rarely used today)

Phenelzine (Nardil)
Tranylcypromine (Parnate)

Question 22

Others (Antidepressant meds)

Answer 22

Serotonin and norepinephrine reuptake inhibitors: Venlafaxine (Effexor) and Duloxetine (Cymbalta)

Norepinephrine and dopamine reuptake inhibitors: Bupropion (Wellbutrin)

Serotonin antagonist and reuptake inhibitors: N efazodone (Serzone) and Trazodone (Desyrel)

Norepinephrine and serotonin antagonist, antihistaminic effects: Mirtazapine (Remeron)

Serotonin partial agonist and reuptake inhibitor: VIIBRYD (Vilazodone HCl)

Question 23

Management of Depression

Answer 23

When treating patients with major depression disorder, a biopsychosocial approach should be considered. “Bio” refers to pharmacotherapy; “psycho” refers to psychotherapy; and “social” refers to the identification of life stressors.

While either medication or counseling can be effective when used alone, using the two treatment modalities concurrently offers the patient the most beneficial and comprehensive therapy, and is associated with the highest rates of remission.

Medication:
In a first episode of depression, it’s usually recommended that the patient take the medication for nine to 12 months, as stopping any sooner runs a high risk for recurrence. Recurrent episodes of depression are treated for two to three years. With multiple recurrences and - in the elderly, who experience increased rates of recurrence - continuous therapy should be considered.
SSRIs, such as sertraline, and SNRIs are generally considered safe and effective drugs for depression. They have lower rates of side effects compared to the older tricyclics and, unlike the tricyclics, have little risk in overdose. A tricyclic such as amitriptyline would not be a first-line approach.

Psychotherapy:
Psychotherapy, most notably cognitive behavior therapy and interpersonal therapy, have been found as effective as psychotropic medications. It can be especially useful for patients who want to avoid medication.

Exercise:
Trials of mixed exercise indicated a small but statistically significant positive effect favoring exercise for the treatment of mild to moderate depression and, similarly to combining psychotherapy and medication, may have an additive effect when used in combination simultaneously with other modalities.

Avoidance of other substances:
Additionally, avoidance of recreational drug and excessive alcohol use is a necessary part of any treatment regimen.

ECT:
While ECT is not an appropriate treatment for an initial episode of major depression, it is a safe and effective therapy that can be useful in patients with psychotic depression or severe nonpsychotic depression unresponsive to medications or psychotherapy.

Question 24

Antidepressant Profiles

Answer 24

Effectiveness:
The selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) are all about equally effective in both adult and geriatric patients. While matching the patient’s symptoms with the drug’s profile, keep in mind that each patient’s reaction to a medication is different and the final selection needs to be individualized.

Cost:
Cost is another strong consideration. There are now generic preparations of some of the SSRIs, making them more affordable.

Drug-drug interactions:
Also, antidepressants have a wide variety of drug-drug interactions, most prominently through the P450 system.

Safety during pregnancy:
Most SSRIs are categorized by the U.S. Food and Drug Administration as Pregnancy Category C, but trimester-specific or population-specific risks exist. Paxil is Pregnancy Category D.

Question 25

Pregnancy Category C

Answer 25

Animal reproduction studies have shown an adverse effect on the fetus and there are no adequate and well- controlled studies in humans, but potential benefits may warrant use of the drug in pregnant women despite potential risks.

Question 26

Pregnancy Category D

Answer 26

There is positive evidence of human fetal risk based on adverse reaction data from investigational or marketing experience or studies in humans, but potential benefits may warrant use of the drug in pregnant women despite potential risks.

Question 27

Fluoxetine (Prozac)

Answer 27

Unusually long half life (two to four days), so effects can last for weeks after discontinuation.

Most problematic (but uncommon) side effects include agitation, motor restlessness, decreased libido in women, and insomnia.

Question 28

Sertraline (Zoloft)

Answer 28

In addition to being a frequently used SSRI in pregnancy and breastfeeding, approved specifically for obsessive-compulsive, panic, and posttraumatic stress disorders.

More gastrointestinal side effects than the other SSRIs.

Question 29

Paroxetine (Paxil)

Answer 29

Strong antianxiety effects.

Side effects can include significant weight gain, impotence, sedation, and constipation.

Due to its short half-life, paroxetine is most likely of all the SSRIs to cause antidepressant discontinuation syndrome.

Question 30

Fluvoxamine (Luvox)

Answer 30

Particularly useful in obsessive-compulsive disorder. Greater frequency of emesis compared to other SSRIs.

Question 31

Citalopram (Celexa)

Answer 31

Most common side effects include nausea, dry mouth, and somnolence.

Maximum recommended dose: 20 mg per day for patients 60 years of age due to concerns of QT interval prolongation.

Question 32

Escitalopram (Lexapro)

Answer 32

Approved specifically for Generalized Anxiety Disorder. Overall, fewer side effects than citalopram.

Question 33

Adherence to Antidepressant Medication in the Elderly

Answer 33

Providers note adherence to depression treatment in older adults occurs only about half the time. The reasons are understandable and include:

Inability to afford the medication
Concerns about side effects
Worry about the stigma of the diagnosis
Not understanding how to take the medication properly

The important thing is to not blame the patient, but to educate her/him about the recommendations, allowing the patient to ask questions and fully express any concerns.

Question 34

Evaluation of Fatigue or Depression

Answer 34

A complete metabolic panel screens for electrolyte, renal, and hepatic problems
A TSH can detect hypothyroidism
A CBC will show anemia and vitamin deficiencies

Question 35

Medical Conditions Associated with Depression

Answer 35

Hypothyroidism:
About 5% of the U.S. population has hypothyroidism. Checking the level of thyroid stimulating hormone (TSH) would help make the diagnosis. Hypothyroidism can be treated with thyroid-replacement medications such as triiodothyronine (T3) and/or levothyroxine (T4). Once TSH levels are returned to the normal range, the symptoms of depression often subside.

Parkinson disease:
Up to 60% of people with this disorder experience mild or moderate depressive symptoms. Although several reports have shown a link between depressive symptoms and Parkinson disease, it is unclear whether one causes the other or if both may arise from some common mechanism. A recent study has indicated that depressive symptoms are an early feature of Parkinson disease, preceding the characteristic movement problems seen in Parkinson such as tremor and rigid muscles. Therefore, people with signs of depression who start to develop movement problems should be promptly evaluated to rule out a diagnosis of Parkinson disease.

Dementia:
Dementia and depression may be difficult to differentiate, as people with either disorder are frequently passive or unresponsive, and they may appear slow, confused, or forgetful. The Mini-Mental State Examination (MMSE) is useful to assess cognitive skills in people with suspected dementia. (The MMSE examines orientation, memory, and attention, as well as the ability to name objects, follow verbal and written commands, write a sentence spontaneously, and copy a complex shape.) Early and accurate diagnosis of dementia is important for patients and their families because it allows early treatment of symptoms. For people with other progressive dementia, early diagnosis may allow them to plan for the future while they can still help to make decisions. These people also may benefit from drug treatment.