Fm Cases - Case 3

Front 1

Common causes of insomnia in the elderly

Back 1

1. Bad Sleeping conditions: TV, noise, lights...
2. Drugs/alcohol/caffeine
3. Sleep apnea
4. Parasomnias: restless leg syndrome/periodic leg movements/REM sleep behavior disorder
5. Disturbances in the sleep-wake cycle
6. Depression/Anxiety
7. Cardiorespiratory disease (asthma/chronic obstructive pulmonary disease/congestive heart failure)
8. Pain or pruritus
9. GERD
10. Hyperthyroidism
11. Advanced sleep phase syndrome (ASPS)

Front 2

Good Sleep Hygiene: Personal Habits

Back 2

1) Fixed bedtime/waking time

2) No naps

3) No alcohol or caffeine 4-6 hours before bed

4) No heavy, sugary, spicy, foods before bed

5) Exercise regularly, but not < 2hr before bed

Front 3

Good Sleep Hygiene: Sleeping Environment

Back 3

1. comfortable bedding
2. comfortable temp/good ventilation
3. Block out noise/light
4. bed for sleep and sex only

Front 4

getting ready for bed

Back 4

1) Light snack before bed. (high in tryptophan)

2) Relaxation: Deep breathing->reduced tension

3) No worries to bed

4) Establish pre-sleep ritual

5) favorite sleeping position

Not asleep within 15-30 minutes? Get up, go into another room, and read until sleepy

Front 5

Sleep apnea

Back 5

occurring in 20-70% of elderly patients

Obstruction of breathing results in frequent arousal that the patient is typically not aware of;

loud snoring or cessation of breathing during sleep

Front 6

restless leg syndrome

Back 6

irresistible urge to move the legs/uncomfortable sensations

Front 7

periodic leg movement and REM sleep behavior disorder

Back 7

Involuntary leg movements while falling asleep and during sleep respectively

sleeper often unaware of these behaviors, therefore ASK bed partner

Front 8

Disturbances in the sleep-wake cycle

Back 8

jet lag and shift work

Front 9

Any patient presenting with insomnia should be screened for?

Back 9

depression and anxiety

Front 10

Conditions that keep patients awake

Back 10

Patients with shortness of breath due to cardiorespiratory disorders

Pain or pruritus

GERD (heartburn, throat pain, or breathing problems)

Ask lots of q's b/c patients may have trouble identifying what wakes them

Front 11

How do elderly patients present with Hyperthyroidism?

Back 11

Insominia. Unlike young people, older individuals rarely experience tachycardia/weight loss

Front 12

advanced sleep phase syndrome (ASPS)

Back 12

Circadian rhythms change, with older adults tending to get sleepy earlier in night

Become drowsy at 6 to 7 PM. If they go to sleep at this hour, they sleep a normal 7-8 hours, waking at 3 or 4 am

if they try to stay up later, their advanced sleep/wake rhythm still causes them to awaken at 3 or 4 am

Difficult to distinguish from insomnia

Front 13

Behavioral treatments for primary insomnia proven in the elderly

Back 13

ONLY CBT:

1) sleep restriction/sleep compression therapy

2) multi-component cognitive-behavioral therapy

Front 14

Pharmacological Treatment for insomnia in elderly

Back 14

All drugs for the treatment of insomnia associated with prolonged sedation & dizziness

Non-benzo's like zolpidem [full agonist of GABA A ɣ 1 subunit = Ambien] and melatonin-receptor agonists are the safest/most effictive hypnotic drugs currently available

Front 15

Benzodiazepines for insomnia in elderly?

Back 15

Bad idea.

Benzo's do not bind to GABA receptors directly, just increase Cl- flow through channel by keeping them open longer when GABA already bound. Unlike zolpidem it is not specific to A ɣ 1 subunit, but binds to all GABA A Receptors -> LOT"S of side-effects including anxiolytic, myorelaxant, & anticonvulsant properties in addition to very strong hypnotic properties & additional risk of addiction

Front 16

Antihistamines, antidepressants, anticonvulsants, and antipsychotics for insomnia in elderly?

Back 16

Sleep restriction therapyMore risks than benefits

Front 17

evidence base for exercise as a treatment for insomnia in elderly?

Back 17

Not conclusive, but good for overall health

Front 18

Sleep restriction therapy

Back 18

Reduce sleep/in-bed time to # of hours patient was able to actually sleep/night (if 4 hours in bed asleep and 4 wake, spend only 4 hours in bed)

As sleep efficiency increases, gradually increase time in bed by 15- to 20-minute increments every 5 days

Continue until optimal sleep time attained

Front 19

Sleep compression therapy

Back 19

decrease time spent in bed gradually to match total sleep time rather than making an immediate substantial change

Front 20

Medical conditions is associated with depression

Back 20

Hypothyroidism - check TSH

Parkinson's disease - 60% of Parkinson's patients have mild/moderate depression. Cause/effect not known. Depressive symptoms usually precede motor disturbances

Dementia

Front 21

TSH testing results

Back 21

TSH up/NormalT4 ->>Normal thyroid function

TSH up/LowT4->>Overt hypothyroidism

TSH Nml-Low/LowT4->>Central hypothyroidism

TSH up/Nml T4->> Subclinical hypothyroidism

Front 22

Diseases linked to depression

Back 22

• Endocrine disease (Addison's disease, diabetes, thyroid disease, Cushing's syndrome, hypoglycemia, hyperparathyroidism)
• AIDS
• CVD (MI, angina)
• Cancer (particularly of the pancreas)
• Cerebral arteriosclerosis, cerebral infarction
• •Electrolyte and renal abnormalities
• •Folate, cobalamin and thiamine deficiencies
• •Hepatitis
• Intracranial tumors
• MS
• Parkinson's
• Porphyria
• Autoimmune (rheumatoid arthritis, systemic lupus erythematosus, temporal arteritis)
• Dementia
• Syphilis
• Temporal lobe epilepsy

Front 23

What factors increase a patient's risk for completed suicide?

Back 23

white male (While females = more likely to attempt suicide, males more likely to succeed)

Having previously attempted suicide

Older age

Front 24

Requirements for Dx. of Major Depression

Back 24

At least 5/9 symptoms for a minimum of 2 wks

Must include EITHER

(1) depressed mood

(2) loss of interest or pleasure (Anhedonia)

PAGE DISCS

Psychomotor retardation

Appetite (increased or decreased)

Guilt: Feelings of worthlessness or or guilt

Energy (decreased): Fatigue

Depressed mood

Interest lost: Anhedonia

Sleep: Insomnia/hypersomnia

Concentration (decreased, or crying)

Suicidal ideation

Front 25

Dangers of Depression in the Elderly

Back 25

1. Depression Incr risk of deteriorating mobility/activities of daily living by 70% over 6yrs

2. Alcohol/drug abuse = very common comorbidity

3. Completed suicide more common in older depressed patients

Front 26

Major Depressive Disorder vs. Bereavement

Back 26

Dx. of Major Depressive Disorder not given unless symptoms are still present two months after loss

certain symptoms not characteristic of "normal" grief reaction:

1) Guilt about things other than actions taken at the time of the death of loved one

2) Thoughts of death other than feeling that he/she would be better off dead or should have died with the deceased person

3) Morbid preoccupation with worthlessness

4) Marked psychomotor retardation

5) Prolonged and marked functional impairment

6) Hallucinatory experiences other than transient voice/image of deceased

Front 27

Assessing for Severity of Suicidal Ideation

Back 27

One point is scored for each factor present:

Sex (male);
Age (< 19 or > 45);
Depression, diagnosis of;
Previous attempt
Ethanol/other substance abuse
Rational thinking impaired (psychosis, delusions, hallucinations)
Social supports lacking
Organized plan for suicide
No significant other
Sickness (physical illness)

Score of 4 to 6 -> outpatient treatment

Score of 7 to 10 ->hospitalize

Front 28

No-harm Contract

Back 28

arrangement in which the patient agrees to contact their doctor if they are considering harming themselves

with an ALTERNATIVE if doctor unavailable

Front 29

Patient Health Questionnaire, Two-Item Version (PHQ-2)

Back 29

Over the last 2 weeks, how often have you been bothered by any of the following problems?"

1) "little interest or pleasure in doing things"

2) "feeling down, depressed, or hopeless."

patient can answer:

• "not at all" (0 points)
• "several days" (1 point)
• "more than half the days" (2 points)
• "nearly every day" (3 points)

Front 30

Most antidepressants work on the following neurotransmitters

Back 30

norepinephrine (NE), serotonin (5HT), and dopamine (DA)

Front 31

Common side effects of SSRI/SNRIs include

Back 31

• Headaches

• Sleep disturbances--drowsiness and, less frequently, insomnia

• GI sx. = nausea & diarrhea

• Hyponatremia, due to the syndrome of inappropriate secretion of antidiuretic hormone (SIADH);

• serotonin syndrome

• Increased risk of GI bleeding

Front 32

treatment of choice for depression

Back 32

SSRI/SNRI

CBT/Interersonal therapy

exercise

Front 33

Escitalopram

Back 33

SSRI approved specifically for Generalized Anxiety Disorder

Front 34

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

Back 34

• complete metabolic panel screens for electrolyte/renal/hepatic problems

• TSH detects hypothyroidism

• CBC reveals anemia/vitamin deficiencies

Front 35

risk factors for ELDER abuse:

Back 35

1. Dementia.
2. Shared living situation
3. Caregiver substance abuse/mental illness
4. Heavy dependence of caregiver on elder
5. Social isolation of the elder

Front 36

Types of Elder abuse

Back 36

An estimated 2-10% of the elderly will at some point experience abuse, which can fall into one of five categories:

1. Physical abuse, which includes acts done with the intention of causing physical pain or
   injury.
2. Psychological abuse, defined as acts done with the intention of causing emotional pain or injury.
3. Sexual assault.
4. Material exploitation, involving the appropriation of the older person's money or property.
5. Neglect.

Front 37

Barriers to Adherence to Antidepressant Medication in the Elderly

Back 37

• Inability to afford the medication
• Concerns about side effects
• Worry about the stigma of the diagnosis
• Not understanding how to take the medication properly