3- insomnia Flashcards
Common causes of insomnia in the elderly:
- Environmental problems
- Drugs/alcohol/caffeine
- Sleep apnea
- Parasomnias: restless leg syndrome/periodic leg movements/REM sleep behavior disorder
Disturbances in the sleep-wake cycle
Psychiatric disorders, primarily depression and anxiety
Symptomatic cardiorespiratory disease (asthma/chronic obstructive pulmonary disease/congestive heart failure)
Pain or pruritus
GERD
Hyperthyroidism
Advanced sleep phase syndrome (ASPS)
how many cigarettes does one patch equal
7
Patients should be counseled to avoid caffeine and alcohol for how long before bed
4-6 hrs before bedtime
sleep apnea is common in what percent of elderly
20% to 70%
advanced sleep phase syndrome (ASPS)
excessive circadian rhythm change in elderly
sleepy by 7 pm, wake up at 4 am
alcohol and 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.
exercise and sleep
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.
if you cant sleep for >20 min
get out of bed and go to another room; return to the bedroom when you are tired; repeat as necessary
Cognitive Behavioral Therapy for Insomnia (CBT-I)
sleep hygiene instruction, stimulus control, and sleep restriction with cognitive restructuring– effective!
examples: Sleep restriction therapy and Sleep compression therapy
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.
pharm treatments for elderly insomnia
zolpidem (Ambien)) and melatonin-receptor agonists
Medical Conditions Associated with Depression
Hypothyroidism
Parkinson (60%)
Dementia
risk factors for late-life depression
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
GDS-SF
Geriatric Depression Scale - Short Form
score >5 indicates depression
common SSRI side effects
Headaches
Sleep disturbances (drowsiness and, less frequently, insomnia)
GI -nausea and diarrhea
Sexual dysfunction
serotonin syndrome
lethargy, restlessness, hypertonicity, rhabdomyolysis, renal failure, and possible death
which SSRIs can cause QT interval prolongation at higher doses
Citalopram and Escitalopram
specially in the face of hypokalemia and hypomagnesemia or when combined with other medication
how long should antidepressant be used for first episode
9-12 months
SSRIS are what cateogry in pregnancy
C
paxil is D
fluoxetine’s unique features
long half life: 2-4 days
agitation, motor restlessness, decreased libido in women, and insomnia.
sertraline unique features
used in breastfeeding
approved specifically for OCD, PTSD, panic
More GI side effects
paroxetine unique features
Strong antianxiety effects.
Side effects can include significant weight gain, impotence, sedation, and constipation.
short half life–> discontinuation syndrome
fluvoxamine unique features
particularly useful in OCD
Greater frequency of emesis
citalopram unique features
Most common side effects include nausea, dry mouth, and somnolence.
QT interval over 20 mg/day
what is escitalopram specifically approved for?
Generalized Anxiety Disorder.
Which tests would you order to rule out other causes for symptoms of insomnia, fatigue, and a depressed mood?
CMP: electrolyte, renal, and hepatic problems
TSH : detect hypothyroidism
CBC: anemia and vitamin defici
Depression in Hispanics
detected less
present as somatic
less likely to get adequate therapies
risk factors for elder abuse
- Dementia.
- Shared living situation of elder and abuser (except in financial abuse).
- Caregiver substance abuse or mental illness.
- 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.
- Social isolation of the elder from people other than the abuser.
what can indicate MDD over bereavement
Guilt about things other than actions taken or not taken at the time of death;
Thoughts of death other than feeling that he or she would be better off dead or should have died with the deceased person;
Morbid preoccupation with worthlessness;
Marked psychomotor retardation;
Prolonged and marked functional impairment;
Hallucinatory experiences other than hearing the voice of, or transiently seeing the image of, the deceased person.
lack of attention to hygiene
