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
