Case 3: Elderly with Insomnia Flashcards
Causes of insomnia in elderly (12)
- Uncomfortable sleep environment (noise, bad bedding)
- Caffeine or alcohol within 6 hours of bedtime
- Sleep apnea
- Restless legs syndrome
- Periodic leg movement
- REM sleep behavior disturbances
- Disturbance of sleep-wake cycle (jet lag, shift work)
- Depression, anxiety
- Cardiorespiratory disorders (SOB during sleep)
- Pain or pruritis
- GERD
- hyperthyroidism
Avoid caffeine ___ to ___ hrs before bedtime
4 to 6
Sleep apnea
Obstruction of breathing that results in frequent arousal that the patient is not typically aware of, but bed partner notices loud snoring or cessation of sleep
Restless leg syndrome
Irresistible urge to move legs + uncomfortable sensations
Periodic leg movement
Involuntary leg movements while falling asleep
- unaware of actions, partner notices
REM sleep behavior disorder
Involuntary leg movements throughout sleep
- unaware of actions, partner notices
GERD preventing sleep due to
Heartburn
Throat pain
Breathing problems
Hyperthyroidism in the elderly
Does not present with classic signs (tachycardia, weight loss) - need lab studies to detect problem
Do not confuse insominia in elderly with…
advanced sleep phase syndrome
Advanced sleep phase syndrome
Circadian rhythms change as people age - elderly sleep earlier at night (6 to 7 pm) and wake earlier (3 to 4 am)
- if they try to stay up later, their advanced circadian rhythm can still cause them to waken at 3 or 4 am
Sleep Hygiene involves attention to (5):
- personal habits
- sleep environment
- getting ready for bed
- getting up in middle of night
- television
Personal habits (4)
- Fix a bedtime and awakening time (stick to schedule)
- Avoid napping during the day (if you do, nap for 30 minutes in late afternoon)
- Avoid caffeine, alcohol, sugary/spicy/heavy foods 4-6 hours before bedtime
- Exercise regularly but not right before bed
Sleep environment (4)
- Use comfortable bedding
- Set comfortable temperature
- Block noise and light
- Reserve bed for sleep and sex only
Getting ready for bed (5)
- Try light snack (warm milk, banana- high in tryptophan)
- Relaxation techniques prior to bed
- Don’t take worries to bed
- Establish pre-sleep ritual
- Get into favorite sleeping position (if you don’t fall asleep in 15 minutes, go into another room and read until sleepy)
Getting up in the middle of the night
If you find that you get up in the middle of night and cannot get back to sleep within 15-20 minutes, then do not remain in the bed “trying hard” to sleep. Get out of bed. Leave the bedroom. Read, have a light snack, do some quiet activity, or take a bath. You will generally find that you can get back to sleep 20 minutes or so later. Do not perform challenging or engaging activity such as office work, housework, etc. Do not watch television.
Person most likely to complete suicidal attempt
White male
Person most likely to attempt suicide
White female
RFs for completed suicide
- male
- age (elderly - most often due to drug overdose)
- previous attempts
Major Depression Dx Criteria
Requires 5/9 criteria for 2 week minimum
- at least one symptom must be a) depressed mood or b) loss of interest or pleasure
- Sleep: insomnia or hypersomnia every day
- Interest: loss of (anhedonia)
- Guilt: feelings of worthlessness, guilt
- Energy is decreased
- Concentration is decreased
- Appetite: either increased or decreased (change of more than 5% of body weight in a month)
- Psychomotor retardation or agitation observed by others: slowed down or restlessness
- Suicidal ideation: recurrent thoughts of death +/- plan
MDD vs Bereavement
The diagnosis of Major Depressive Disorder is generally not given unless the symptoms are still present two months after the loss
Features more characteristic of MDD (and not bereavement)
- guilt about things other than actions taken or not taken by survivor at time of death
- thoughts of death - feeling better off if died w person
- morbid preoccupation w worthlessness
- marked psychomotor retardation
- prolonged functional impairment
- hallucinations: hearing or seeing deceased person
RFs for late life depression (9)
- Female
- social isolation
- widowed, divorced, separate marital status
- lower SES
- comorbid general med conditions
- uncontrolled pain
- insomnia
- functional impairment
- cognitive impairment
SAD PERSONS scale to assess severity of suicidal ideation
Sex (male)
Age (<19, >45)
Depression diagnosis
Previous attempts Ethanol or other substance use Rational thinking impaired (psychosis, hallucinations) Social supports lacking Organized plan No significant other Sickness (physical illness)
4 to 6 SAD PERSONS
Outpatient treatment
7 to 10 SAD PERSONS
Hospitalization
If hospitalization for suicidal risk is not felt to be necessary, create this –>
no harm contract: patient agrees to contact doctor if they are considering harming themselves (or an alternative)
Screening for dementia is important in geriatric patients with depression becaue
Geriatric Depression Scale is less sensitive in demented patients
Two ways to screen for dementia
Mini-cog (faster, more sensitive and specific)
MMSE
SSRIs/SNRIs side effects
- headaches
- sleep disturbances: drowsiness or insomnia
- GI problems: nausea, diarrhea
- increased risk of GI bleeding
- hyponatremia (SIADH)
- Serotonin syndrome
- adverse effects on bone density
do not cause arthralgias
Serotonin syndrome
lethargy restlessness hypertonicity rhabdomyolysis renal failure possible death
TCA side effects
arrhythmias
Citalopram
Escitalopram
Side effects
QT interval prolongation at higher intervals (especially if combined with hypoK or hypo Mg)
Depression in Hispanics
- identified less frequently than non Hispanic whites
- present with somatic complaints: fatigue, myalgias rather than mood complaints
- US born hispanics have 2x as much depression than immigrant Hispanics
- Hispanics and other minorities: less likely to receive adequate therapy
Celajes
Hispanics who hear noises or see shadows - must be differentiated from psychotic hallucinations
Elder abuse risk factors
- dementia
- shared living situation of elder + abuser
- caregiver substance abuse
- caregiver mental illness
- heavy dependence of CAREGIVER on ELDER (not other way around!)
- social isolation of elder from people other than abuser
Do not agree to ______ ________ if patient is truly suicidal
withhold information
St Johns Wort
effective for short term treatment of mild to moderate depression
Always ask about herbs and similar supplements because of
a) potential interaction w conventional mediations
b) production of side effects
Medical conditions associated with depression (3)
- hypothyroidism
- Parkinson’s disease
- dementia
People with signs of depression who then start to develop movement problems should be evaluated for
Parkinsons disease
MMSE (mini mental state exam)
tool to assess cognitive skills in people w suspected dementia - examines
- orientation
- memory
- attention
- ability to name objects
- follow verbal and written commands
- write a sentence spontaneously
- copy complex shape
Evaluation of fatigue and depression
- CMP (renal fxn, electrolytes, liver fxn)
- TSH (detect hypothyroidism)
- CBC (detect anemia, vitamin deficiencies
Treatments for primary insomnia in elderly
- CBT for insomnia
a) sleep restriction therapy
b) sleep compression therapy - Pharmacological therapy
a) non benzos (safer, more effective)
b) melatonin receptor agonists (safer, more effective)
c) benzos
Side effects of pharm treatment for insomnia
Prolonged sedation and dizziness that can result in risk of injuries and confusiono
Most efficacious drugs for insomnia (and safest)
Non-benzos: zolpidem (Ambien)
Melatonin receptor agonists
**Benzos work but are associated w more complications and addiction
Don’t use antihistamines, antidepressants, anticonvulsants, and antipsychotics to treat insomnia in elderly
SSRIs mechanism of action and examples
Selectively block reuptake of serotonin (potentiate effect on post synaptic neuron)
- Fluoxetine (Prozac)
- Fluvoxamine (Luvox)
- Paroxetine (Paxil)
- Sertraline (Zoloft)
- Citalopram (Celexa)
- Escitalopram (Lexapro)
Fluoxetine
Prozac
- long half life (2 to 4 days): effects last post dc
- SE: agitation, motor restlessness, decreased libido, insomnia
Sertraline
Zoloft
- more common SSRI used in pregnancy, breastfeeding
- approved for OCD, panic, and PTSD
- more GI side effects than other SSRIs
Paroxetine
Paxil
- Pregnancy Category D
- strong anti anxiety effects
- best in kids
- SE: weight gain, impotence, sedation, constipation
- shortest half life: most likely SSRI to cause antidepressant discontinuation syndrome
Fluvoxamine
Luvox
- OCD
- greater frequency of emesis than other SSRIs
Citalopram
Celexa
- prolongs QT - max is 20 mg/day for pts > 60
- SE: nausea, dry mouth, solmonolence
Escitalopram
Lexapro
- approved for GAD
- prolongs QT
- less side effects than Celexa
TCAs mechanism of action and examples
- block reuptake of norepinephrine and serotonin - potentiating their effects at post synaptic neuron
- Nortriptyline
- Amtriptyline
- Clomipramine
- Doxepin
MAO inhibitors mechanism of action and examples
Block pre synaptic catabolism of norepi and sertonin
- Phenelzine
- Tanylcypromine
SNRIs
Venlafaxine (effexor)
Duloxetine (cymbalta)
NDRIs
Buproprion (Wellbutrin)
Management of depression: biopsychosocial approach
Bio: pharmacotherapy
Psycho: psychotherapy
Social: identify life stressors
Use medication + counseling
Medication for depression depends on what time and past history
First episode: 9-12 months of med
Recurrent episode: 2-3 years of med
Multiple recurrences in elderly: lifelong use of med
Safest and most effective drugs for depression (and cheapest)
SSRIs and SNRIs
TCAs have higher risk of overdose, not first line
Psychotherapy: especially useful in pts who want to avoid medication
- CBT
- interpersonal therapy
Electroconvulsive therapy for depression
- not appropriate for initial episode of MDD
- safe and effective in pts with psychotic depression
- safe and effective in pts w nonpsychotic depression refractory to medication or psychotherapy
Safety of SSRIs during pregnancy
Most Pregnancy Category C
Paxil is Pregnancy Category D
Pregnancy Category C
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
Pregnancy Category D
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.
