Wk4- Fm Case "3" Insomnia

Front 1

This was a case about depression.

Back 1

Many things can mimic depression so lab orders are important to r/o other causes

Front 2

She talks about anhedonia, insomnia, and stress

Back 2

grief about the loss of her husband a yr ago

also looked at common cuses of insomnia in the elderly

Front 3

What are 3 diseases that could mimic depression?

Back 3

hypothyroidism
Parkinson's
dementia

So think of dementia and TSH

Front 4

So how do you tx a depressed patient with elevated TSH ?

Back 4

you treat with levothyroxine (Synthroid) and normalize their T4 levels. The depression should subside

Front 5

Why can Parkinson's mimic depression?

Back 5

because apparently, PArkinson's shows depression symptoms BEFORE the motor sx's in some patients

Front 6

Why would you confuse dementia and depression?

Back 6

Many reasons- many elderly are depressed and/or demented. They both show poor concentration and memory, poor sleep. They both may appear slow, confused or forgetful.

Front 7

What is included in the Mini Cog test for mental status?

Back 7

they have to remember 3 words and then repeat them at a later time. They also have to draw 10:45 on a clock face

This is HIGHLY sensitive 99%

Front 8

Which is preffered, the Mini Cog or the MMSE?

Back 8

the mini cog is generally better

Front 9

What is the basis of dx of depression?

Back 9

depressed mood + 5 of the SIG E CAPS sxs

Front 10

SIG E CAPS

Back 10

sleep
interest (anhedonia)
Guilt
Energy
Concentration
Attention
Psychomotor
Suicidal ideation

Front 11

What is the timeline for major depressive disorder vs. normal grief?

Back 11

MDD lasts more than two months and is also char'd by additional symptoms like guilt about actions not taken, thoughts of death, morbid preoccupation with worthlessness, marked psychomotor retardation, prolonged and marked functional impairment

Front 12

Which ethnic groups show lower dx rates of depression>

Back 12

AAs and hispanics

Front 13

So how do Latinos generally present with depression?

Back 13

with somatic c/o

Front 14

How do we know that this is a purely cultural perception issue?

Back 14

because US born Hispanics have equal rates of depression dx. It's only in immigrants that they are not depressed as much

Front 15

What weird psych effect is more common in Latinos?

Back 15

they have more hallucination-like experiences

Front 16

What are some factors that increase the likelihood of suicide completion?

Back 16

white male
older
previous attempts
plan of action

Front 17

What types of elderly people are most likely to complete suicide?

Back 17

older men who are widowers and living alone
lack social support
experience stress
probably addiction and EtoH as well

Front 18

What is the most common means of suicide in the elderly?

Back 18

drug OD

Front 19

What is concerning for PCPs and suicide?

Back 19

about 3/4 of these patients have SEEN a PCP in the past month

Front 20

Does suicide increase with age?

Back 20

only the COMPLETION of suicide increases

Front 21

What NTs are most affected by antidepressants?

Back 21

5-HT, DA, and NE

Front 22

List of SSRIs

Back 22

citalopram
fluoxetine
fluvoxamine
paroxetine
sertraline
escitalopram

Front 23

SNRIs

Back 23

venlaxafine, desvenlaxafine, duloxetine

Front 24

How does bupropion work?

Back 24

NE and DA reuptake inhibitor

Front 25

What is the best use of mirtazapine?

Back 25

best used antidepressant for sleep

Front 26

3 TCAs

Back 26

amitriptyline, nortriptyline, and doxepin

Front 27

Examples of MAOIs

Back 27

phenelzine, tranylcypromine

Front 28

side effects of SSRIs and SNRIs

Back 28

headaches
sleep disturbance
GI problems like nausea, diarrhea
SIADH can occur apparently
GI bleeds

Front 29

Big side effect of TCAs?

Back 29

tachyarrhythmias

Front 30

Some common causes of insomnia in the elderly

Back 30

environment- noise, uncomfortable bedding

Drugs, alcohol and caffeine

sleep apnea

parasomnias

jet lag, shift work

psych disorders

cardioresp disorders

pain

Front 31

What are parasomnias?

Back 31

they're like RLS or leg jerking etc.

Front 32

Also GERD, hyperthyroidism, pain

Back 32

Sleep apnea causes frequent awakening from breathing obstructions

Front 33

Risk factors for elder abuse

Back 33

dementia
shared living situation of elder and caregiver/abuser
heavy dependence status
social isolation of the elder from others

Front 34

What is used in the elderly as a depression screening?

Back 34

The Geriatric Depression Scale- Short form

Front 35

The GDS-SF is basically a long list of 15 questions about daily life and emotion

Back 35

preferred scale

Front 36

5 lab tests to order as screening for fatigue, insomnia and depression

Back 36

CMP
TSH
CBC
ESR
EKG

Front 37

What is actually a highly evidence based tx for insomnia?

Back 37

sleep restriction therapy

Front 38

What type of CBT do they do for insomina?

Back 38

they teach about sleep hygiene, stimulus control, restriction, and restructuring

Front 39

How does sleep restriction therapy work?

Back 39

the pt restricts their time spent in bed to the amount of time they actually spend asleep per night and then gradually increase this time amount

Front 40

How does sleep compression differ?

Back 40

they are told to gradually reduce their time spent in bed rather than doing it really suddenly

Front 41

What are the safest sleep meds to use at this point?

Back 41

non benzo hypnotics like Ambien and melatonin receptor agonists

Front 42

What do you have to be careful about with giving sleep meds to an older patient?

Back 42

fall risk and sedation

Front 43

Should you use Benadryl to get to sleep in an older patient?

Back 43

no it has a lot of risks

Front 44

Fix a bedtime and an awakening time.
Avoid napping during the day.
Avoid alcohol 4–6 hours before bedtime.
Avoid caffeine 4–6 hours before bedtime.
Avoid heavy, spicy, or sugary foods 4–6 hours before bedtime. Exercise regularly, but not right before bed.
Use comfortable bedding.
Find a comfortable temperature setting for sleeping and keep the room well ventilated.
Block out all distracting noise.
Reserve the bed for sleep and sex.
Try a light snack before bed.
Practice relaxation techniques before bed.
Do not take your worries to bed.
Establish a pre-sleep ritual.
Get into your favorite sleeping position.
No television in the bedroom.
If you wake up in the middle of night and cannot get back to sleep within 15–20 minutes, then get out of bed and do a quiet activity until you can get back to sleep, generally 20 minutes later.

Back 44

tips for better sleep

Front 45

first line tx for depression

Back 45

SSRI or SNRI- but WATCH OUT FOR P450 INTERACTIONS

Front 46

Can you give SSRI to a pregnant lady?

Back 46

you can but there is some animal study evidence of fetal harm

Front 47

What is the downside of Zoloft?

Back 47

tends to have more GI side effects than the others

Front 48

Which antidepressant is most likely to cause a discontinuation syndrome?

Back 48

Paxil (paroxetine) bc of its short half life

Front 49

What is Lexapro?

Back 49

escitalopram- has fewer side effects than Celexa

Front 50

How long does a pt need to take an SSRI to feel the effects?

Back 50

it takes about 4 to 6 weeks

Front 51

how long do you continue the course of the SSRI?

Back 51

9 mos to a year to prevent recurrence

Front 52

CBT has been shown to be about as effective for depression as well.

Back 52

it works by changing dysfunctional thought patterns the pt may harbor that lead to depression sxs

Front 53

Many pts will use herbals for depression but will not report them openly

Back 53

St John's wort is a good example

Front 54

What type of med could contribute to depression?

Back 54

B blocker like propanolol

Front 55

What is the score used to assess suicide risk?

Back 55

SAD PERSONS

Sex male
Age under 19 or over 45
Depression
Previous attempt
EtOH or other substance
Rational thinking impaired
Social support lack
Org'd plan
No significant other
Sickness

Front 56

What score means they need to be hospitalized?

Back 56

7 to 10

4 to 6 suggests outpt mgmt is ok

Front 57

What "contract" is useful in the suicidal patient?

Back 57

a "no harm contract"