Fm 3 Flashcards
Treatments for Primary Insomnia in the Elderly 2
Of the behavioral treatments, many of which may be of some assistance in the elderly, only sleep restriction/sleep compression therapy and multi-component cognitive-behavioral therapy have met evidence-based criteria for efficacy.
Cognitive Behavioral Therapy for Insomnia (CBT-I)
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.
Pharmacological Therapy
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.
Combining CBT-I and pharmacological therapy can be helpful in some patients.
The evidence base for exercise as a treatment for insomnia is less extensive. Despite this, there are many other reasons to encourage regular physical activity in the elderly, assuming there are no other contraindications to such activity.
Medical Conditions Associated with Depression 3
A number of diseases either cause depressive symptoms or have depression as a comorbidity at higher rates than would be normally expected.
In looking for the causes and associations of depression, first consider the common conditions. Then think about the very serious diseases that you don’t want to miss. Beyond that, there’s a very wide range of diagnoses that can look like depression:
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.
Risk Factors for Completed Suicide 4
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.
Being a member of an ethnic minority: 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.
MDD criteria
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.
Depressed Mood
(The eight remaining criteria can be remembered using the mnemonic SIG E CAPS):
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.
Bereavement (grief) 3 differences from mdd
Usually last less than 6 months
no severe functional impairment or Suicidality
Self-esteem is generally preserved (no guilt or worthlessness). May be self-deprecating—feeling they should have done more or told the deceased how much he or she was loved
Assessing Severity of Suicidal Ideation - sad persons
What tx based on scores
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
Screening for Depression uspstf guidelines and 3 tools to use
The U.S. Preventive Services Task Force (USPSTF) recommends screening all adults for depression, but especially patients with chronic diseases like diabetes, as they are at high risk for depression. Several screening tools are available, including:
Geriatric Depression Scale - Short Form (GDS-SF)
Zung Depression Scale
Beck Depression Inventory
Even the simple question, “Do you often feel sad or depressed?” seems to be sensitive to screen for, but not to diagnose, depression. If this question is positive, further testing would need to be done to make the diagnosis.
Screening for Dementia in Geriatric Patients with Depression 2
Two dementia screening tools are:
The Mini-Cog exam (3 items, draw clock, repeat the 3 items)
The Mini-Mental State Exam (MMSE)
The Mini-Cog exam is faster and more sensitive and specific than the MMSE.
SE of SSRIs/SNRIs (common 4, then 3 others)
Common side effects of SSRI/SNRIs include:
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.
Management of depression 3
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.
Antidepressant Discontinuation Syndrome 6
This phenomenon occurs in approximately 20% of patients after abrupt discontinuation of an antidepressant medication that was taken for at least six weeks. Typical symptoms of this syndrome include: flu-like symptoms, insomnia, nausea, imbalance, sensory disturbances, and hyperarousal. These symptoms usually are mild, last one to two weeks, and are rapidly extinguished with reinstitution of antidepressant medication. Antidepressant discontinuation syndrome is more likely with a longer duration of treatment and a shorter half-life of the treatment drug.
Fluoxetine, sertraline, paroxetine, fluvoxamine, citalopram, escitalopram
Longest half life
More gi issues than the others
Due to its short half-life, paroxetine is most likely of all the SSRIs to cause antidepressant discontinuation syndrome.
Greater frequency of emesis compared to others
concerns of QT interval prolongation
Fewer se than citalopram, used for GAD
Evaluation of Fatigue or Depression 3
A complete metabolic panel screens for electrolyte (cause fatigue), renal, and hepatic problems
A TSH can detect hypothyroidism
A CBC will show anemia and vitamin deficiencies
Common dx of insomnia in elders
Sleep apnea occurs in 20% to 70% of elderly patients. 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.
Some of the other most common causes of insomnia in the elderly are:
Environmental problems such as noise or uncomfortable bedding which are not conducive to sleep.
Drugs, Alcohol, and Caffeine such as over-the-counter, alternative, and certain recreational drugs.
Parasomnias such as restless leg syndrome/periodic leg movements/REM sleep behavior disorder. 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 such as jet lag or shift work.
Psychiatric disorders such as primary depression and anxiety
Symptomatic cardiorespiratory disease (asthma, COPD, heart failure)
Pain or pruritus
Gastroesophageal reflux disease (GERD) due to heartburn, throat pain or breathing problems.
Hyperthyroidism The elderly frequently do not present with typical symptoms such tachycardia or weight loss, and therefore further laboratory studies may be required to detect this problem.
