DQ 1 WEEK 4 Advance Practice Nurse 2

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%.”

Question

What are common causes of insomnia in the elderly?

SUBMIT

References

Yaremchuk K. Sleep disorders in the elderly. Clin Geriatr Med. 2018 34(2):205-216. doi: 10.1016/j.cger.2018.01.008.

CONTINUE

DIAGNOSES

FINDINGS

NOTES

BOOKMARKS

Common causes of insomnia in the elderly: DQ 1 WEEK 4 Advance Practice Nurse 2

1. Environmental problems

2. Drugs/alcohol/caffeine

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)

10. Hyperthyroidism

11. Advanced sleep phase syndrome (ASPS)

TEACHING POINT

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.

SLEEP HYGIENE

TEACHING

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.” DQ 1 WEEK 4 Advance Practice Nurse 2

You review the handout.

TEACHING POINT

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

EACHING POINT

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. DQ 1 WEEK 4 Advance Practice Nurse 2

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.

Pharmacological Therapy

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.

Preferred agents:

Class

Agents

Comments

Benzodiazepine Receptor Agonists

zolpidem (Ambien)

eszopiclone (Lunesta)

Improved sleep onset latency, total sleep time, and wake after sleep onset

Tricyclic Antidepressants

doxepin 3-6 mg

Doxepin only suggested agent in this class

Orexin Receptor Antagonist

suvorexant (Belsomra)

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.

References

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

CONTINUE

DIAGNOSES

FINDINGS

NOTES

BOOKMARKS

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?” DQ 1 WEEK 4 Advance Practice Nurse 2

“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.”