This week, complete the Aquifer case titled “Case #3: 65-year-old female with insomnia – Mrs. Gomez”
Apply information from the Aquifer Case Study to answer the following discussion questions:
· Discuss the Mrs. Gomez’s history that would be pertinent to her difficulty sleeping. Include chief complaint, HPI, Social, Family and Past medical history that would be important to know.
· Describe the physical exam and diagnostic tools to be used for Mrs. Gomez. Are there any additional you would have liked to be included that were not?
· Please list 3 differential diagnoses for Mrs. Gomez and explain why you chose them. What was your final diagnosis and how did you make the determination?
· What plan of care will Mrs. Gomez be given at this visit, include drug therapy and treatments; what is the patient education and follow-up?
You are doing an eight-week clerkship in a family medicine practice. Christina, the medical assistant, hands you the progress note for the next patient, which identifies the patient as Mrs. Gomez, “a 65-year-old woman who is here today reporting that she can’t sleep.”
Dr. Lee, your preceptor, fills you in: “Mrs. Gomez has been a patient here for several years. Difficulty sleeping is a new issue for her. Her past medical history is significant for hypertension and diabetes. Generally, she has been doing well, although I notice that her last hemoglobin A1c has climbed to 8.7%.”
What are common causes of insomnia in the elderly?
Yaremchuk K. Sleep disorders in the elderly. Clin Geriatr Med. 2018 34(2):205-216. doi: 10.1016/j.cger.2018.01.008.
Common causes of insomnia in the elderly:
1. Environmental problems
3. Sleep apnea
4. Parasomnias: restless leg syndrome/periodic leg movements/REM sleep behavior disorder
5. Disturbances in the sleep-wake cycle
6. Psychiatric disorders, primarily depression and anxiety
7. Symptomatic cardiorespiratory disease (asthma/chronic obstructive pulmonary disease/congestive heart failure)
8. Pain or pruritus
9. Gastroesophageal reflux disease (GERD)
11. Advanced sleep phase syndrome (ASPS)
Common Causes of Insomnia in the Elderly
Issues that may lead to an environment that is not conducive to sleep.
· Specific examples include: noise or uncomfortable bedding.
· You can teach the patient sleep hygiene techniques that will increase the likelihood of a restful night’s sleep.
Question the use of prescription, over-the-counter, alternative, and recreational drugs that might be affecting sleep.
Patients should be counseled to avoid caffeine and alcohol for four to six hours before bedtime.
Sleep apnea is common in the elderly, occurring 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.
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.
As in sleep apnea, the sleeper is often unaware of these behaviors and a bed partner or family member may need to be asked about these movements.
Disturbances in the sleep-wake cycle include jet lag and shift work.
Patients with depression and anxiety commonly present with insomnia.
Any patient presenting with insomnia should be screened for these disorders.
Patients with shortness of breath due to cardiorespiratory disorders often report that these symptoms keep them awake.
Pain or pruritus may keep patients awake at night.
Those with GERD may report heartburn, throat pain, or breathing problems.
These patients may also have trouble identifying what awakens them.
Detailed questioning may be needed to elicit the symptoms of this disorder.
Elderly patients with hyperthyroidism frequently do not present with typical symptoms such as tachycardia or weight loss, and laboratory studies may be required to detect this problem.
Circadian rhythms change, with older adults tending to get sleepy earlier in the night. In advanced sleep phase syndrome (ASPS), this has progressed to the point where the patient becomes drowsy at 6 to 7 p.m. If they go to sleep at this hour, they sleep a normal seven to eight hours, waking at 3 or 4 a.m. However, if they try to stay up later, their advanced sleep/wake rhythm still causes them to awaken at 3 or 4 a.m. This can be difficult to distiguish from insomnia.
Dr. Lee tells you, “Poor sleeping habits can also cause insomnia. Here is a handout on sleep hygiene. For some patients, simply correcting their sleep habits by following these tips will correct their quality of sleep.”
You review the handout.
Good Sleep Hygiene
Your Personal Habits
· Fix a bedtime and an awakening time. The body “gets used to” falling asleep at a certain time, but only if this is relatively fixed. Even if you are retired or not working, this is an essential component of good sleeping habits.
· Avoid napping during the day. If you nap throughout the day, it is no wonder that you will not be able to sleep at night. The late afternoon for most people is a “sleepy time.” Many people will take a nap at that time. This is generally not a bad thing to do, provided you limit the nap to 30 to 45 minutes and can sleep well at night.
· Avoid alcohol four to six hours before bedtime. Many people believe that alcohol helps them sleep. While alcohol has an immediate sleep-inducing effect, a few hours later as the alcohol levels in the blood start to fall, there is a stimulant or wake-up effect.
· Avoid caffeine four to six hours before bedtime. This includes caffeinated beverages such as coffee, tea and many sodas, as well as chocolate, so be careful.
· Avoid heavy, spicy, or sugary foods four to six hours before bedtime. These can affect your ability to stay asleep.
· Exercise regularly, but not right before bed. Regular exercise, particularly in the afternoon, can help deepen sleep. Strenuous exercise within the two hours before bedtime, however, can decrease your ability to fall asleep.
Your Sleeping Environment
· Use comfortable bedding. Uncomfortable bedding can prevent good sleep. Evaluate whether or not this is a source of your problem, and make appropriate changes.
· Find a comfortable temperature setting for sleeping and keep the room well ventilated. If your bedroom is too cold or too hot, it can keep you awake. A cool (not cold) bedroom is often the most conducive to sleep.
· Block out all distracting noise, and eliminate as much light as possible.
· Reserve the bed for sleep and sex. Don’t use the bed as an office, workroom or recreation room. Let your body “know” that the bed is associated with sleeping.
Getting Ready For Bed
· Try a light snack before bed. Warm milk and foods high in the amino acid tryptophan, such as bananas, may help you to sleep.
· Practice relaxation techniques before bed. Relaxation techniques such as yoga, deep breathing and others may help relieve anxiety and reduce muscle tension.
· Don’t take your worries to bed. Leave your worries about job, school, daily life, etc., behind when you go to bed. Some people find it useful to assign a “worry period” during the evening or late afternoon to deal with these issues.
· Establish a pre-sleep ritual. Pre-sleep rituals, such as a warm bath or a few minutes of reading, can help you sleep.
· Get into your favorite sleeping position. If you don’t fall asleep within 15 to 30 minutes, get up, go into another room, and read until sleepy.
Getting Up in the Middle of the Night
Most people wake up one or two times per night for various reasons. If you find that you get up in the middle of night and cannot get back to sleep within 15 to 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.
A Word About Television
Many people fall asleep with the television on in their room. This is often a bad idea. Television is a very engaging medium that tends to keep people up. We generally recommend that the television not be in the bedroom. At the appropriate bedtime, the TV should be turned off and the patient should go to bed. This also applies to computers, tablets and smart phones. Some people find that the radio helps them go to sleep. Since radio is a less engaging medium than TV, this is probably a good
Treatments for Primary Insomnia in the Elderly
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 is recommended as the first choice for most patients with insomnia. CBT-I combines different behavioral treatments, resulting in improvements lasting up to two years. Recent guidelines recommend CBT-I as the first-line therapy for insomnia in adults. 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.
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.
Benzodiazepine Receptor Agonists
Improved sleep onset latency, total sleep time, and wake after sleep onset
doxepin 3-6 mg
Doxepin only suggested agent in this class
Orexin Receptor Antagonist
Improved sleep-onset and/or sleep-maintenance insomnia.
Benzodiazepines can be effective but have more complications and the additional risk of addiction.
Antihistamines, antidepressants (in the absence of depression), 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.
Qaseem A, Kansagara D, Forciea MA, Cooke M, Denberg TD. Management of Chronic Insomnia Disorder in Adults: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2016;165(2):125-33. DOI: 10.7326/M15-2175
After discussing these potential causes of insomnia with Dr. Lee, you feel prepared to talk with Mrs. Gomez. You knock on the exam room door and enter to find a pleasant-appearing Latina who is accompanied by her daughter, Silvia. You introduce yourself and ask if you may ask her a few questions, to which she agrees.
“What brings you to the clinic today?”
“I’m just so tired lately. I just can’t seem to sleep.”
“Tell me more about this.”
“Well, for the last six months I can’t sleep for more than a couple of hours before I wake up,” Mrs. Gomez tells you.
On further questioning, Mrs. Gomez denies any discomfort such as pain or breathing problems disturbing her sleep. She denies any snoring, apneic spells (a period of time during which breathing stops or is markedly reduced), or physical restlessness during sleep. Her daughter agrees that she has not seen these problems. She rarely consumes alcohol or caffeine.
When you ask if anything like noise or an uncomfortable sleeping environment might be bothering her, she replies that this is not a problem – but her daughter interjects: “Yes, in fact Mom’s waking up the rest of us, walking around and turning on the TV. My husband and I both work. So we all need our rest. Mom came to live with us last year after Dad passed away. We’re her only family around here and we thought we should help her.”
You tell Mrs. Gomez,
“I’m sorry to hear about your husband.”
“Yes, we were married for 30 years. This has been a difficult time for me.”
“Do you find that you feel sad most of the time?”
“Of course I am sad when I think about my husband and how much I miss him. But I wouldn’t say that I’m sad most of the time.”
Silvia states, “But Mom, you spend most of your time just moping around the house.” Turning to you she elaborates, “She seems to be in slow motion most of the time. She doesn’t even go to church anymore. She used to go three to four times a week. She used to read all the time, and she doesn’t do that anymore either.”
Mrs. Gomez explains, “I haven’t been reading as much as I used to because I can’t seem to focus and I end up reading the same page over and over.” She goes on to say, “And I don’t seem to have any energy to do anything. I’m not even able to help out around the house. I feel bad about that; I should be helping out more. I seem to spend a lot of time just watching TV and eating junk food.”
I’m not familiar with that product, but I’ll mention it to Dr. Lee. I’m glad you brought it up. It’s important that your doctors know about everything you are taking, whether it’s prescription medication or not. I’m sorry nothing seems to be helping you sleep. We’ll get to the bottom of this together.”
You turn your attention to taking Mrs. Gomez’s past medical history. You learn:
· Type 2 diabetes
· Hysterectomy (due to fibroids)
· Glyburide (10 mg daily)
· Metformin (1,000 mg bid)
For blood pressure:
· Methyldopa (250 mg bid)
· Lisinopril (10 mg daily)
· Atorvastatin (80 mg daily)
For CHD prophylaxis:
· Aspirin 81 mg daily
For osteoporosis prevention:
· Calcium citrate with vitamin D (600mg/400 IU bid)
Diphenhydramine is her only over-the-counter medication, and she is taking no traditional or herbal medications beyond the zapote tea.
She does not smoke, and drinks only small amounts of alcohol on holidays.
Kemp C, Rasbridge LA. Refugee and Immigrant Health: A Handbook for Health Professionals. Cambridge, UK. Cambridge University Press; 2004.
Given what you have heard from Mrs. Gomez and her daughter, especially
· her inability to focus,
· her lack of energy,
· the sense that she is in slow motion,
· she has stopped doing activities she previously enjoyed,
You are concerned that her insomnia may be due to depression. Depression may stem from environmental stressors such as her husband’s death and her loss of independence along with a primary neurochemical imbalance. Her depression also could be caused by another medical condition.
Medical Conditions Associated with Depression
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:
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.
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 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.
Hypertension (C) and asthma (E) have not been specifically linked to higher rates of depression.
Some other diseases that have been linked to depression include:
· Endocrine disease (Addison disease, diabetes, Cushing syndrome, hypoglycemia, hyperparathyroidism)
· Acquired immunodeficiency syndrome
· Cardiovascular disease (myocardial infarction, angina)
· Cancer (particularly of the pancreas)
· Cerebral arteriosclerosis, cerebral infarction
· Electrolyte and renal abnormalities
· Folate, cobalamin and thiamine deficiencies
· Intracranial tumors
· Multiple sclerosis
· Rheumatologic disease (rheumatoid arthritis, systemic lupus erythematosus, temporal arteritis)
· Temporal lobe epilepsy
· Huntington’s Disease
· Chronic pain
· EVIEW OF SYSTEMS
· Keeping in mind the disorders associated with depression, you elicit a review of systems from Mrs. Gomez to help discover what these indicate regarding her underlying illness.
· Constitutional: Mrs. Gomez has gained about 10 lbs in the last six months. She denies fevers or dizziness. This makes you less concerned about cancer or other systemic illness.
· Respiratory: No shortness of breath, making cardio-respiratory disease less likely.
· Cardiac: No chest pains, palpitations or edema, decreasing the likelihood of cardiovascular disease.
· Gastrointestinal: No nausea, changes in bowel habits, hematochezia or melena. This makes you less concerned about gastrointestinal cancer or occult blood loss leading to anemia.
· Endocrinologic: No polydipsia or polyuria, decreasing the likelihood of poorly controlled diabetes.
· Neurologic: No acute neurologic changes or tremors. Her daughter confirms that patient has been alert, oriented and has had no episodes of confusion. So you are now less concerned about cerebral infarction, intracranial tumors, multiple sclerosis, and Parkinson disease.
· Urologic: Normally urinates one to two times at night.
· Once you have completed your review of systems, you excuse yourself from the room for a moment while Mrs. Gomez changes into a gown.
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