3- insomnia

Question 1

Common causes of insomnia in the elderly:

Answer 1

1. Environmental problems
2. Drugs/alcohol/caffeine
3. Sleep apnea
4. 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)

Question 2

how many cigarettes does one patch equal

Answer 2

7

Question 3

Patients should be counseled to avoid caffeine and alcohol for how long before bed

Answer 3

4-6 hrs before bedtime

Question 4

sleep apnea is common in what percent of elderly

Answer 4

20% to 70%

Question 5

advanced sleep phase syndrome (ASPS)

Answer 5

excessive circadian rhythm change in elderly

sleepy by 7 pm, wake up at 4 am

Question 6

alcohol and sleep

Answer 6

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.

Question 7

exercise and sleep

Answer 7

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 8

if you cant sleep for >20 min

Answer 8

get out of bed and go to another room; return to the bedroom when you are tired; repeat as necessary

Question 9

Cognitive Behavioral Therapy for Insomnia (CBT-I)

Answer 9

sleep hygiene instruction, stimulus control, and sleep restriction with cognitive restructuring– effective!

examples: Sleep restriction therapy and Sleep compression therapy

Question 10

Sleep restriction therapy

Answer 10

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.

Question 11

Sleep compression therapy

Answer 11

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 12

pharm treatments for elderly insomnia

Answer 12

zolpidem (Ambien)) and melatonin-receptor agonists

Question 13

Medical Conditions Associated with Depression

Answer 13

Hypothyroidism
Parkinson (60%)
Dementia

Question 14

risk factors for late-life depression

Answer 14

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 15

GDS-SF

Answer 15

Geriatric Depression Scale - Short Form

score >5 indicates depression

Question 16

common SSRI side effects

Answer 16

Headaches
Sleep disturbances (drowsiness and, less frequently, insomnia)
GI -nausea and diarrhea
Sexual dysfunction

Question 17

serotonin syndrome

Answer 17

lethargy, restlessness, hypertonicity, rhabdomyolysis, renal failure, and possible death

Question 18

which SSRIs can cause QT interval prolongation at higher doses

Answer 18

Citalopram and Escitalopram

specially in the face of hypokalemia and hypomagnesemia or when combined with other medication

Question 19

how long should antidepressant be used for first episode

Answer 19

9-12 months

Question 20

SSRIS are what cateogry in pregnancy

Answer 20

C

paxil is D

Question 21

fluoxetine’s unique features

Answer 21

long half life: 2-4 days

agitation, motor restlessness, decreased libido in women, and insomnia.

Question 22

sertraline unique features

Answer 22

used in breastfeeding

approved specifically for OCD, PTSD, panic

More GI side effects

Question 23

paroxetine unique features

Answer 23

Strong antianxiety effects.

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

short half life–> discontinuation syndrome

Question 24

fluvoxamine unique features

Answer 24

particularly useful in OCD

Greater frequency of emesis

Question 25

citalopram unique features

Answer 25

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

QT interval over 20 mg/day

Question 26

what is escitalopram specifically approved for?

Answer 26

Generalized Anxiety Disorder.

Question 27

Which tests would you order to rule out other causes for symptoms of insomnia, fatigue, and a depressed mood?

Answer 27

CMP: electrolyte, renal, and hepatic problems
TSH : detect hypothyroidism
CBC: anemia and vitamin defici

Question 28

Depression in Hispanics

Answer 28

detected less

present as somatic

less likely to get adequate therapies

Question 29

risk factors for elder abuse

Answer 29

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 30

what can indicate MDD over bereavement

Answer 30

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