Case 3: Elderly with Insomnia Flashcards Preview

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Flashcards in Case 3: Elderly with Insomnia Deck (64):
1

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

2

Avoid caffeine ___ to ___ hrs before bedtime

4 to 6

3

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

4

Restless leg syndrome

Irresistible urge to move legs + uncomfortable sensations

5

Periodic leg movement

Involuntary leg movements while falling asleep
- unaware of actions, partner notices

6

REM sleep behavior disorder

Involuntary leg movements throughout sleep
- unaware of actions, partner notices

7

GERD preventing sleep due to

Heartburn
Throat pain
Breathing problems

8

Hyperthyroidism in the elderly

Does not present with classic signs (tachycardia, weight loss) - need lab studies to detect problem

9

Do not confuse insominia in elderly with...

advanced sleep phase syndrome

10

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

11

Sleep Hygiene involves attention to (5):

1. personal habits
2. sleep environment
3. getting ready for bed
4. getting up in middle of night
5. television

12

Personal habits (4)

1. Fix a bedtime and awakening time (stick to schedule)
2. Avoid napping during the day (if you do, nap for 30 minutes in late afternoon)
3. Avoid caffeine, alcohol, sugary/spicy/heavy foods 4-6 hours before bedtime
4. Exercise regularly but not right before bed

13

Sleep environment (4)

1. Use comfortable bedding
2. Set comfortable temperature
3. Block noise and light
4. Reserve bed for sleep and sex only

14

Getting ready for bed (5)

1. Try light snack (warm milk, banana- high in tryptophan)
2. Relaxation techniques prior to bed
3. Don't take worries to bed
4. Establish pre-sleep ritual
5. Get into favorite sleeping position (if you don't fall asleep in 15 minutes, go into another room and read until sleepy)

15

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.

16

Person most likely to complete suicidal attempt

White male

17

Person most likely to attempt suicide

White female

18

RFs for completed suicide

- male
- age (elderly - most often due to drug overdose)
- previous attempts

19

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

20

MDD vs Bereavement

The diagnosis of Major Depressive Disorder is generally not given unless the symptoms are still present two months after the loss

21

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

22

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

23

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)

24

4 to 6 SAD PERSONS

Outpatient treatment

25

7 to 10 SAD PERSONS

Hospitalization

26

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)

27

Screening for dementia is important in geriatric patients with depression becaue

Geriatric Depression Scale is less sensitive in demented patients

28

Two ways to screen for dementia

Mini-cog (faster, more sensitive and specific)
MMSE

29

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**

30

Serotonin syndrome

lethargy
restlessness
hypertonicity
rhabdomyolysis
renal failure
possible death

31

TCA side effects

arrhythmias

32

Citalopram
Escitalopram

Side effects

QT interval prolongation at higher intervals (especially if combined with hypoK or hypo Mg)

33

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

34

Celajes

Hispanics who hear noises or see shadows - must be differentiated from psychotic hallucinations

35

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

36

Do not agree to ______ ________ if patient is truly suicidal

withhold information

37

St Johns Wort

effective for short term treatment of mild to moderate depression

38

Always ask about herbs and similar supplements because of

a) potential interaction w conventional mediations
b) production of side effects

39

Medical conditions associated with depression (3)

- hypothyroidism
- Parkinson's disease
- dementia

40

People with signs of depression who then start to develop movement problems should be evaluated for

Parkinsons disease

41

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

42

Evaluation of fatigue and depression

1. CMP (renal fxn, electrolytes, liver fxn)
2. TSH (detect hypothyroidism)
3. CBC (detect anemia, vitamin deficiencies

43

Treatments for primary insomnia in elderly

1. CBT for insomnia
a) sleep restriction therapy
b) sleep compression therapy

2. Pharmacological therapy
a) non benzos (safer, more effective)
b) melatonin receptor agonists (safer, more effective)
c) benzos

44

Side effects of pharm treatment for insomnia

Prolonged sedation and dizziness that can result in risk of injuries and confusiono

45

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

46

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)

47

Fluoxetine

Prozac
- long half life (2 to 4 days): effects last post dc
- SE: agitation, motor restlessness, decreased libido, insomnia

48

Sertraline

Zoloft
- more common SSRI used in pregnancy, breastfeeding
- approved for OCD, panic, and PTSD
- more GI side effects than other SSRIs

49

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

50

Fluvoxamine

Luvox
- OCD
- greater frequency of emesis than other SSRIs

51

Citalopram

Celexa
- prolongs QT - max is 20 mg/day for pts > 60
- SE: nausea, dry mouth, solmonolence

52

Escitalopram

Lexapro
- approved for GAD
- prolongs QT
- less side effects than Celexa

53

TCAs mechanism of action and examples

- block reuptake of norepinephrine and serotonin - potentiating their effects at post synaptic neuron
- Nortriptyline
- Amtriptyline
- Clomipramine
- Doxepin

54

MAO inhibitors mechanism of action and examples

Block pre synaptic catabolism of norepi and sertonin
- Phenelzine
- Tanylcypromine

55

SNRIs

Venlafaxine (effexor)
Duloxetine (cymbalta)

56

NDRIs

Buproprion (Wellbutrin)

57

Management of depression: biopsychosocial approach

Bio: pharmacotherapy
Psycho: psychotherapy
Social: identify life stressors

Use medication + counseling

58

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

59

Safest and most effective drugs for depression (and cheapest)

SSRIs and SNRIs
(TCAs have higher risk of overdose, not first line)

60

Psychotherapy: especially useful in pts who want to avoid medication

- CBT
- interpersonal therapy

61

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

62

Safety of SSRIs during pregnancy

Most Pregnancy Category C
Paxil is Pregnancy Category D

63

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

64

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.