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

Decline in hours slept by age

0

1

2

3

4

5

6

7

8

30 40 50 60 70 80

Hours Sleep

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

General precautions

Start low, go slow Avoid q hs dosing Use only 2-3 weeks

Questions?