Case 3

65-year-old female with insomnia - Mrs. Gomez

Author: William Hay M.D., University of Nebraska

Learning Objectives:

1. Learn common causes of insomnia in the elderly.

2. Learn the diagnostic criteria for Major Depressive Disorder (MDD).
3. Learn how to use history, physical, and tests to rule out medical causes of
depressive symptoms.
4. Understand the effects of depression on the patient's family.
5. Learn the common therapeutic options for Major Depressive Disorder and
their side effects.
6. Learn the risk factors for elder abuse.
7. Understand the importance of inquiring about the use of complimentary and
alternative therapies use.
8. Understand how culture can affect the evaluation and treatment of
conditions.

Summary of Clinical Scenario: Mrs. Gomez is a 65-year-old Latina woman with

a past medical history significant for type 2 diabetes, hypertension, and
hypercholesterolemia. She presents today with six months of insomnia despite
self-medication with acetaminophen, diphenhydramine, and zapote blanco (a
Mexican herbal remedy). She also notes a lack of interest, inability to focus, and
decreased energy – but she denies suicidal ideation. She has been living with her
daughter and son-in-law since her husband died last year. Physical exam is
unremarkable with the exception of a ten-pound weight gain over the past year.
Diagnostic testing to exclude other medical conditions that could mimic depression
is ordered, and Mrs. Gomez is given citralopram.

At a return visit two months later, Mrs. Gomez admits that she never started her
citralopram as she was worried that people would think she's crazy. She also
expresses concern that care-giving has become too stressful for her daughter.
These issues are addressed. At a final return visit another two months later, Mrs.
Gomez reports she is sleeping better and taking an interest in things again.

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 Can only sleep for a couple of hours at the
Key Findings beginning of the night. Tired. Daughter reports,
from History “moping around the house…in slow motion most of
the time,” doesn’t participate in previous interests.
Key Findings
from Physical Weight 186 pounds (up 10 pounds since last year)
Exam
Differential
Diagnostic testing to rule out depression mimics.
Diagnosis
Key Findings
Not applicable
from Testing
Final Diagnosis Depression

Case Highlights: This case reviews the common causes of insomnia in the
elderly, provides simple tips for correcting sleep hygiene, educates students about
alternative therapies, demonstrates a focused history to elicit signs and symptoms
of depression, guides students how to ask about suicidal ideation, discusses elder-
abuse, and explores the patient-centered approach including the effects of cultural
perspective on treatment plans.

Key Teaching Points

Knowledge:
Depression
Medical conditions associated with depression

Hypothyroidism:
5% of the US population.
Check thyroid-stimulating hormone (TSH).
Treat with thyroid-replacement medications such as triiodothyronine
(T3) and/or thyroxine (T4).
Once TSH levels are returned to the normal range, the symptoms of
depression often subside.
Parkinson’s:
Up to 60% of patients with Parkinson’s experience mild or moderate
depressive symptoms.
Depressive symptoms can be an early feature of Parkinson's disease,
preceding the characteristic movement problems.
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.
Screening for dementia:

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 Mini-Mental State Examination
Mini-cog
(MMSE)
1. Instruct the patient to repeat
the following:
APPLE WATCH PENNY
2. Administer the Clock Drawing
Test: Inside the circle draw the Examines orientation, memory,
hours of a clock as if a child and attention, as well as the
would draw them. Place the ability to name objects, follow
hands of the clock to represent verbal and written commands,
the time "forty five minutes past write a sentence spontaneously,
ten o'clock" and copy a complex shape.
3. Ask the patient to repeat the
three words given previously
If three items correctly recalled,
negative screen.
Sensitivity: 99% Sensitivity: 91%
Specificity: 93% Specificity: 92%

Diagnostic criteria for depression: Depressed mood or anhedonia, and at

least five of the eight criteria must have been present for two weeks or longer.

SIG E CAPS

Sleep: Insomnia or hypersomnia nearly every day.

Interest (loss of): Anhedonia (loss of interest or enjoyment) in usual
activities.
Guilt: Feelings of worthlessness or excessive or inappropriate guilt (which
may be delusional) nearly every day (not merely self-reproach or guilt about
being sick).
Energy (decreased): Fatigue or loss of energy nearly every day.
Concentration (decreased): Diminished ability to think or concentrate, or
indecisiveness, nearly every day (either by subjective account or as
observed by others).
Appetite (increased or decreased)
Psychomotor retardation/Pleasure: Psychomotor agitation or retardation
nearly every day (observable by others, not merely subjective feelings of
restlessness or being slowed down).
Suicidal ideation: Recurrent thoughts of death (not just fear of dying),
recurrent suicidal ideation without a specific plan, or a suicide attempt or a
specific plan for committing suicide.

Major Depressive Disorder vs. Bereavement

The diagnosis of Major Depressive Disorder (MDD) is not given unless the
symptoms of depression are still present two months after the loss. However, the

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 following symptoms may indicate the patient has MDD as they are not ‘normal’ in
the grieving process:

Guilt about things other than actions taken or not taken at the time of the
death
Thoughts of death other than feeling that he or she would be better off dead
or should have died with the deceased person
Morbid preoccupation with worthlessness
Marked psychomotor retardation
Prolonged and marked functional impairment
Hallucinatory experiences other than hearing the voice of, or transiently
seeing the image of, the deceased person.

Effects of ethnicity in depression:

Due to factors such as economics, culture, and differences in presentation,

Hispanics have their depression identified less frequently non-Hispanic
whites. This holds true in some other ethnic groups as well, such as
African-Americans.
Hispanic patients will more frequently present to a doctor for somatic
complaints such as myalgias or fatigue, rather then with stated mood
related complaints.
US born Hispanics experience depression at similar rates to other ethnic
groups. Interestingly, rates of depression in immigrant Hispanics are up to
50% lower than US-born Hispanics.
Psychosis is no more common in Hispanics then other groups, but symptoms
of perceptual distortion such as hearing noises or seeing shadows (known
as celajes) are more common and must be differentiated from psychotic
hallucinations.
Hispanics and other ethnic and economic minorities are less likely to receive
adequate therapies.

Suicide
Factors that increase a patient’s risk to attempt suicide

White male
Previous attempted suicide

Suicide in the elderly

More likely to attempt suicide if they are: widow(er), live alone, perceived
poor health status, have reduced sleep quality, lack a confidant, and
experience stressful life events.
Suicidal behaviors do not increase with age, but rates of completed suicide
do.
Approximately 75% of the elderly who commit suicide had visited a primary
care physician within the preceding month, but their symptoms went
unrecognized.
Drug overdose is the most common means of suicide on the elderly.

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 Depression treatment
Antidepressant mechanisms -- Most antidepressants work on improving the levels
of the neurotransmitters norepinephrine (NE), serotonin (5HT), and dopamine
(DA).

Class of Mechanism of
Examples
Antidepressants Action

citalopram (Celexa); block the reuptake of

Selective
fluoxetine (Prozac); serotonin,
Serotonin
fluvoxamine (Luvox ); potentiating
Reuptake
paroxetine (Paxil); serotonin's effect on
Inhibitors
sertraline (Zoloft); the post-synaptic
(SSRIs):
escitalopram (Lexapro) neuron

Other serotonin and

antidepressants: venlafaxine (Effexor) norepinephrine
reuptake inhibitor
norepinephrine and
bupropion (Wellbutrin) dopamine reuptake
inhibitor
serotonin antagonists
nefazodone (Serzone);
and reuptake
trazodone (Desyrel)
inhibitors
norepinephrine and
mirtazapine (Remeron) serotonin antagonist,
antihistaminic effects
serotonin and
duloxatine (Cymbalta) norepinephrine
reuptake inhibitor
nortriptyline block the reuptake of
(Pamelor); norepinephrine and
Tricyclic amitriptyline serotonin,
antidepressants: clomipramine potentiating their
(Anafranil); doxepin effects on the
(Sinequan) post-synaptic neuron
(rarely used today)
Monoamine phenelzine (Nardil ); block pre-synaptic
oxidase (MOA) tranylcypromine catabolism of
inhibitors: (Parnate) norepinephrine and
serotonin

Side effects of antidepressants

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 SSRI/SNRI side effects:

Headaches
Sleep disturbances (drowsiness and less frequently insomnia)
Gastrointestinal problems (nausea and diarrhea)
Hyponatremia due to the syndrome of inappropriate secretion of antidiuretic
hormone (SIADH)
Serotonin syndrome (lethargy, restlessness, hypertonicity, rhabdomyolysis,
renal failure, and possible death)
Increased risk of gastrointestinal bleeding
Elderly: Increased risk for falls; possible adverse effects on bone density.

TCA side effects:

Arrhythmias
Risk of overdose

Common causes of insomnia in the elderly:

Environmental problems: Noise or uncomfortable bedding.

Drugs/alcohol/caffeine:
Counsel patients to avoid caffeine and alcohol for four to six hours
before bedtime.
Ask about the use of prescription, over-the-counter, alternative, and
recreational drugs that might be affecting sleep.
Sleep apnea:
20-70% of elderly patients.
Obstruction of breathing results in frequent arousal that the patient is
typically not aware of.
Bed partner or family member may report loud snoring or cessation of
breathing during sleep.
Parasomnias:
Restless leg syndrome: irresistible urge to move the legs, often
accompanied by uncomfortable sensations.
Periodic leg movement and REM sleep behavior disorder: 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 sleep-wake cycle: jet lag and shift work.
Psychiatric disorders: depression and anxiety.
Cardiorespiratory disorders:
Asthma, chronic obstructive pulmonary disease, or congestive heart
failure.
Shortness of breath may keep patients awake.
Pain or pruritus may keep patients awake at night.
Gastroesophageal reflux disease (GERD): heartburn, throat pain, or
breathing problems may awaken patients.

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 Hyperthyroidism

Risk factors for elder abuse:

Dementia.
Shared living situation of elder and abuser (except in financial abuse).
Caregiver substance abuse or mental illness.
Heavy dependence of caregiver on elder. Surprisingly, the degree of an
elder's dependency and the resulting stress has not been found to predict
abuse.
Social isolation of the elder from people other then the abuser.

Skills
History:
Screening for depression: The U.S. Preventive Services Task Force (USPSTF)
recommends screening all adults for depression, but especially patients with
chronic diseases like diabetes, as they are at high risk for depression.

Depression screening in the elderly

Zung Depression Scale and the Beck Depression Inventory

'Do you often feel sad or depressed?' is sensitive to screen for, but not to
diagnose, depression.
Geriatric Depression Scale – Short Form (GDS-SF)
Not as sensitive in demented patients.
Score >5 consistent with depression.
Over the past week:
1. Are you basically satisfied with your life?
2. Have you dropped many of your activities and interests?
3. Do you feel that your life is empty?
4. Do you often get bored?
5. Are you in good spirits most of the time?
6. Are you afraid that something bad is going to happen to you?
7. Do you feel happy most of the time?
8. Do you often feel helpless?
9. Do you prefer to stay at home, rather than going out and doing
things?
10. Do you feel that you have more problems with memory than
most?
11. Do you think it is wonderful to be alive now?
12. Do you feel worthless the way you are now?
13. Do you feel full of energy?
14. Do you feel that your situation is hopeless?
15. Do you think that most people are better off than you are?

Differential Diagnosis: Not applicable in this case.

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 Studies:
Screen for common causes of fatigue:

Comprehensive metabolic panel: screen for electrolyte, renal, and hepatic

problems.
TSH: detect hypothyroidism
CBC for anemia and vitamin deficiencies.
Erythrocyte sedimentation rate: test for rheumatologic disease.
EKG: should be done if the patient is using drugs that might alter cardiac
conductivity, such as tricyclic antidepressants.

Management:
Insomnia
Tips for patients to improve sleeping habits:

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.
Don’t 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.

Major Depressive Disorder: Biopsychosocial approach: While either medication

or counseling can be effective when used alone, using the two treatment
modalities concurrently offers the patient the most beneficial and comprehensive
therapy, and is associated with the highest rates of remission.

1. First line pharmaceutical approach: SSRIs.

Each SSRI and SNRI about equally effective in both adult and geriatric
patients.
Match the patient’s symptoms with the drug’s profile, keeping in mind
that each patient's reaction to a medication is different and the final
selection needs to be individualized.

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 Consider cost.
Wide variety of drug-drug interactions, most prominently thru the
P450 system.
All SSRIs are 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.
First SSRI released in the United States. Unusually
long half- life (two to four days), so its effects can
fluoxetine last for weeks after discontinuation. The most
(Prozac) problematic side effects of fluoxetine are agitation,
motor restlessness, decreased libido in women,
and insomnia
Fluoxetine and sertraline are the most studied, and
therefore are the most used SSRIs in pregnancy
and breastfeeding. Sertraline is approved
sertraline
specifically for obsessive-compulsive, panic, and
(Zoloft)
posttraumatic stress disorders. Sertraline has
more gastrointestinal side effects than the other
SSRIs.
Strong anti-anxiety effects. It is the best studied
SSRI in children. Side effects can include
paroxetine significant weight gain, impotence, sedation, and
(Paxil) constipation. Due to its short half-life, paroxetine is
most likely of all the SSRIs to cause antidepressant
discontinuation syndrome.
Particularly useful in obsessive-compulsive
fluvoxamine
disorder. It has a greater frequency of emesis
(Luvox)
compared to other SSRIs.
citalopram Most common side effects include nausea, dry
(Celexa) mouth, and somnolence.
Approved specifically for Generalized Anxiety
escitalopram
Disorder. Overall, has less side effects than
(Lexapro)
citalopram.

Treatment duration:
First episode, take the medication for 9-12 months, as stopping
any sooner runs a high risk for recurrence.
Recurrent episodes of depression are treated for two to three
years.
Multiple recurrences and in the elderly, who experience
increased rates of recurrence, continuous therapy should be
considered.
4-6 weeks before medication is fully effective, but follow-up in 2

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 weeks to monitor side effects.
2. Psychotherapy has been found equally effective as psychotropic
medications.
Cognitive behavior therapy: focuses on changing dysfunctional
thought patterns that perpetuate depression
Interpersonal therapy: focuses on grief, interpersonal disputes, role
transitions and interpersonal deficits
3. Exercise, both aerobic and weight bearing, is equally effective to
antidepressant medication in the treatment of mild to moderate depression,
and may have an additive effect when used in combination simultaneously
with other modalities.
4. Recreational drug and excessive alcohol avoidance.
5. Alternative therapies: Patients frequently will not mention the use of
complementary and alternative medical treatment unless asked. Some
herbs, like saw palmetto for prostatic hypertrophy and St. John's wort for
depression, have shown some effectiveness but most have not been
scientifically studied, so information on them is limited. Herbs and similar
supplements are a particular concern because of their potential to interact
with conventional medications or produce side effects, just like conventional
drugs. Even where they are obtained is also important, as supplements
have repeatedly been found to be contaminated with other herbs, heavy
metals, and even prescription drugs.
6. Consider medication side effects that could contribute to depression such as
propranolol.
7. For patient who is seriously considering suicide, a tool to assess severity of
the situation is the SAD PERSONS scale. This is an acronym for
Sex (male);
Age (<19 or >45);
Depression, diagnosis of;
Previous attempt(s)
Ethanol or other substance abuse
Rational thinking impaired (psychosis, delusions, hallucinations)
Social supports lacking
Organized plan for suicide
No significant other
Sickness (physical illness).
One point is scored for each factor present. A score of 7 to 10
suggests hospitalization is warranted, and a score of 4 to 6 suggests
outpatient treatment is an appropriate clinical action

If hospitalization is unnecessary, a "no-harm contract." should be discussed. This

is an arrangement where the patient agrees to contact their doctor if they are
considering harming themselves. An alternative, such as talking with another
doctor, counselor, suicide hotline or emergency room personnel, should be agreed
upon if the main provider cannot be contacted.

Caregiver Stress: Refer for appropriate resources.

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