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Anxiety and Sleep Disorders in the Elderly
Thomas Magnuson, M.D.
Assistant Professor
Division of Geriatric Psychiatry
Department of Psychiatry
What is anxiety?
Normal, adaptive emotion Run from a tiger Pass a test
When excessive, it is maladaptive Cannot function at work, in school, in
relationships Paralyzing, embarrassing
Symptoms
Cognitive Worry Fearfulness
Behavioral Phobias, Hyperkinesis
Physiologic Heart palpitations Hyperventilation
Anxiety Disorders
Common source of anxiety is depressive disorders 50% of those with depression have significant anxiety
Ego dystonic Patients usually come to us Uncomfortable
Most common group of mental illnesses 11% of the population Cause a significant amount of suffering and dysfunction May even lead to disability
Epidemiology
6 month and lifetime prevalence Decline from mid-life to old age 19.7% at 6 months 34.1% lifetime
Indicates anxiety disorders are the most prevalent mental health diagnoses in elders as in adults Roughly 10%
Leads to higher medical and psychiatric morbidity in geriatric patients
Anxiety Disorders
Panic disorder With agoraphobia Without agoraphobia
Agoraphobia without panic disorder Social phobia Specific phobia Generalized anxiety disorder
Anxiety disorders
Obsessive-compulsive disorder (OCD) Acute stress disorder Posttraumatic stress disorder (PTSD) Due to general medical condition Substance-induced NOS
Substance-induced Anxiety Disorder
More likely to happen as one ages As one is more likely to be on medication(s)
Anxiety related to the use, abuse or withdrawl from medications or drugs Alcohol, amphetamines, anticholinergics, antidepressants,
anti-TB drugs, anti-HTN, caffeine, cannibus, beta-blockers (w/d), cocaine, digitalis, dopamine, ephedrine, l-dopa, methylphenidate, NSAIDs, pseudoepedrine, asa, sedative-hypnotics (w/d), steroids, theophylline, thyroid
Anxiety Disorder Due To General Medical Condition
Again more likely in the elderly The elderly have more medical problems
This is a partial list of common conditions Cardiovascular-CHF, arrhythmia, MI Endocrine-hypoPTH, thyroid, hyperadrenalism Immunologic- RA, SLE, TA Lung disease-Asthma, COPD, PE GI disease-Crohn’s, UC Neurological illness-CVA, MS, MG, Neurosyphillis,
postconcussive syndrome, seizures, TIAs, vertigo
Prevalence in the Elderly
Prevalent in the elderly Many studies note anxiety symptoms
1-19% in community dwelling elderly GAD 1-14%, Phobic disorders 0.7-7% Panic disorder 0.1-1%
Anxiety leads to impairment in quality of life Related to disability in some cases
Anxiety about existing disability Anxiety can lead to disability
Steeper cognitive declines when anxiety untreated in dementia Anxious people cannot focus or pay attention
Anxiety in the Elderly
Most coupled with depression Schoerers et al., 2005
Those with GAD became depressed over time 40% had anxiety/depression or just depression 36 mos later
Dementia High levels of anxiety exist in demented patients
Great Britain Ballard, et al 1995 22% subjective anxiety 11% autonomic anxiety 38% tension 13% situational anxiety 2% panic attacks
Anxiety in Long Term Care
Multiple studies 1994 Australia
11.2% NH residents had generalized anxiety disorder 58% of those with anxiety were also depressed
2005 Holland 5% had only an anxiety disorder 5% had both an anxiety and mood disorder
2006 Holland 5.7% had a diagnosable anxiety disorder 4.2% had subthreshold anxiety 29% had anxiety symptoms
Not recognized in the Elderly Yet, still not diagnosed readily in the elderly
Not commonly noted in clinics If so, commonly seen as part of a mood problem
There is a strong correlation Various scenarios
Preexisting Mildly present, now with stressors more problematic Completely new onset
Older people don’t meet criteria Current criteria don’t capture the quality of anxiety in
the elderly Anxious mood, tension, vague somatic complaints Elderly do not endorse daily worry
Not recognized in the elderly
Age of onset for anxiety is presumed to be youth
Dementia, depression are “elderly problems” Not PTSD, OCD and phobias Older women are supposed to be anxious
Ageist assumption Most anxiety disorders in the elderly are chronic,
except: Agoraphobia, fear of falling Generalized Anxiety Disorder
Not recognized in the elderly
Less need to leave ones’ social network Agoraphobia, fear of falling are common in geriatric
patients These patients avoid office visits May not be able to travel to appointments readily
Anxiety doesn’t disrupt functional life Though present, there is likely no work or school or
partner to interfere with With move into long term care these anxieties come to
the top
Working up anxiety
Clinical evaluation Laboratory testing
Rule out common conditions that lead to anxiety History and physical
Past medical history Medication use, alcohol use Family and social history Physical exam
Trembling, racing heart, rapid breathing, sweating, dry mouth Mental status exam
Poor attention, distractibility, much motor movement, easily startled, wide-eyed, feeling of dread
Rarely requires special psychological testing
Treatment
Anxiolytics Benzodiazepines
Agents that calm and relieve anxiety across the lifespan So make sure you are treating anxiety Most common agents
Alprazolam (Xanax) Lorazapam (Ativan) Clonazepam (Klonopin)
Adverse events Sedating Potential for gait instability Dependency producing Paradoxical effect more prevalent in the elderly, esp. in dementia
Treatment
Anxiolytics Benzodiazepines
Some agents are longer lasting than others Alprazolam<Lorazepam<Clonzepam
Longer lasting agents may accumulate in the residents system and lead to intoxication or adverse events
Metabolism differences Some agents require less involvement of the liver
Lorazepam (Ativan) Oxazepam (Serax)
Treatment
Anxiolytics Buspirone (BuSpar)
A unique nonbenzodiazepine agent Serotonin 1-A agonist No sedation, cognitive or motor impairment
Takes 4-8 weeks to fully work Time frame is like an antidepressant Not good for panic disorder Good in mixed depression-anxiety states
May not work as well in chronic benzodiazepine users
Treatment Antidepressants
SSRIs used in GAD, panic, OCD, PTSD First line agents in panic disorder and OCD Safe in the elderly Mild GI, headache symptoms Irritability, anxiety and sexual dysfunction
Venlafaxine (Effexor), duloxetine (Cymbalta) SNRIs used commonly for anxiety Heightens blood pressure
Tricyclics Clomipramine (Anafranil) good for OCD, but too anticholinergic for
older patients May employ nortriptyline (Pamelor) if cardiac disease not an issue
Treatment Antidepressants
Bupropion (Wellbutrin) Mechainsm a puzzle Activating Few drug-drug interactions
Mirtazapine (Remeron) Sedating, appetite enhancing at low doses Data exists supporting the medication being used in anxiety
disorders
Treatment
Psychotherapy Helpful if
The patient desires to be a therapy patient If the patient is not motivated it will not work Many elderly see therapy as proof they are now “nuts”
Nontraditional supportive therapists may be more palatable Like ministers, priests, rabbis
The patient can comprehend the therapist’s instructions Cognitive-behavioral therapy Supportive therapy
Make sure the therapist has some experience working with the elderly Child therapy analogy
Interventions for anxious patients Routine
Structure is important since anxiety relates to loss of control Many cognitively impaired residents improve with a higher level of
structure because their anxiety is lessened Exercise
Physical activity burns off anxiety Pacing may be the residents way of lessening anxiety
Rote activity Repetitive actions
From knitting to saying the rosary to rocking in a chair Brief, regular appointments with a trusted staff
For patients who wish to discuss anxiety Reality testing, family phone calls, simulated presence
Sleep Disorders in the Elderly
Brenda K. Keller, MDAssistant Professor
Geriatrics & GerontologyUniversity of Nebraska Medical
Center
Sleep disorders in the elderly person
Epidemiology Review changes in the sleep cycle with aging Non-pharmacological Management of sleep
disorders
Epidemiology
20-40% of older Americans experience insomnia at least a few nights per month
2/3 of elderly in institutions experience problems with sleep
Insomnia may be: Difficulty falling asleep 18.1% Difficulty staying asleep 18.6% Not feeling restored by sleep 30.9%
Rockwood et al J Am Geriatr Soc 2001; 49:639-41
Normal Sleep Pattern
After sleep onset: Sleep usually progresses through NREM
stages 1 to 4 within 45 to 60 min. Slow-wave sleep (NREM stages 3 and 4) predominates in the first third of the night and comprises 15 to 25% of total nocturnal sleep time in young adults.
The first REM sleep episode usually occurs in the second hour of sleep.
Changes in sleep with age Light sleep (Stages 1 and 2) increases with age =More
awakenings Deep sleep (Stages 3 and 4) decreases from ~25%
down to 3% of total sleep time The depth of slow-wave sleep, as measured by the
arousal threshold to auditory stimulation, also decreases with age. In the otherwise healthy older person, slow-wave
sleep may be completely absent, particularly in males. Decreased amount of REM sleep Sleep quality and efficiency is 70-80% of younger
subjects. Changes occur in the day/night cycle.
Circadian Rhythm Changes
6:00p 7:00 8:00 9:00 10:00 11:00 MN 1:00 2:00 3:00 4:00 5:00 6:00a 7:00 8:00 9:00
Sleepy, go to bed wake up
Standard phase
Advanced phaseSleepy go to bed wake up
Changes in sleep in LTC residents with dementia
Increased fragmentation of sleep Leads to problems with daytime fatigue, nighttime
wakefulness Average hours of sleep 6.2 hours But, average sleep episode was 21 minutes, peak
83 minutes Commonly seen in sleep charting
Impact of Disrupted Sleep
Difficulty staying awake during the day
Impaired attention Slowed response time Impaired memory and concentration Decreased performance Mortality due to common causes of death is
2 x higher in older people with sleep disorders than those who sleep well.
Evaluation
Sleep history Timing of insomnia Sleep schedule Sleep environment Sleep habits Daytime effects Symptoms of other
sleep disorders
Medical history- Social History
Stressors ETOH/Caffeine use
Medication review Psychiatric history
Depression Mania Psychosis
Sleep Environment in NH Mixed up stimuli
High levels of night time noise and light Low levels of daytime light “Casino effect”
Care routines do not promote sleep Every two hour toileting Waking patients to change them Vitals being checked
Absence of defined “night time” routine with lowering of hall lights and TV’s. Dark at night and quiet at night
Elementary school stop lights are reminders
Medical History
Common conditions associated with sleep disturbances Arthritis CHF Gastrointestinal disorders Asthma Angina/Arrhythmias Urinary symptoms Neurological symptoms
Effectiveness of Non-pharmacological Treatment of Insomnia Improve symptoms of insomnia in 70-80% of
patients with primary insomnia
Effects last at least 6 months after treatment completed
Non-pharmacological Management
Sleep hygiene Stimulus control Sleep restriction Cognitive therapy Paradoxical intention
Non-pharmacological Management
Sleep hygiene Should be entertained with any sleep problem Education about health and environmental
practices that affect sleep For staff, family and residents
This strategy is used in conjunction with other techniques to improve sleep A common starting point with sleep physicians
Sleep Hygiene
Health Factors Diet Exercise Substance abuse
Environmental Factors Light Noise Room temperature Mattress
Non-pharmacological Management
Stimulus control Reinforces temporal and environmental cues for
sleep onset Go to bed when sleepy Use the bed only for sleep Bedtime routines Regular morning rise time Avoid napping
Or a brief scheduled event
Non-pharmacological Management
Sleep restriction Decrease amount of time in bed to increase sleep
efficiency i.e., you can only be in bed five hours
Sleep efficiency means how much time you are asleep when actually in bed
Only allowed time in bed is usually spent asleep If awake…out of bed!
Increase by 15 minutes per night 5:15, 5:30, 5:45, etc.
Wake time constant, bedtime adjusted Always up at 6 am
Allows short scheduled afternoon nap
Non-pharmacological Management
Cognitive therapy If a resident is not cognitively impaired Involves identifying dysfunctional beliefs and
attitudes about sleep and replaces them with adaptive substitutes.
Helps minimize anticipatory anxiety and arousal
Non-pharmacological Management
Paradoxical intention Based on premise that performance
anxiety inhibits sleep onset Involves persuading a patient to engage in the feared
behavior of staying awake If pt stops trying to fall asleep and genuinely attempts
to stay awake, sleep may come more easily
Pharmacological Treatments
FDA Approved Benzodiazepines Non-Benzo hypnotics-
Type I Gaba receptor agents
Eszopiclone Rozerem
Non-FDA Approved Herbal therapies Hormones/naturopathic Sedating
antidepressants OTC antihistamines
Choose carefully due to risk of side effects