3. 65-year-old female with insomnia - Mrs.

Gomez

November 12, 2017 11:34:18 PM EST

Learning objectives

The student should be able to...

describe the common causes of insomnia in the elderly

describe the common therapeutic options for major depressive disorder and their side effects

perform history, physical, and tests to rule out medical causes of depressive symptoms

describe the diagnostic criteria for major depressive disorder

recognize the importance of inquiring about the use of complementary and alternative therapies.

perform history, physical, and tests to rule out medical causes of depressive symptoms

recognize how culture can affect the evaluation and treatment of conditions.

describe the risk factors for elder abuse

appreciate the effects of depression on the patient's family.

Knowledge

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 (http://ummidtown.org/programs/sleep/patients/sleep-hygiene) 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 20-70% 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.

Scherer Lindsey - lscherer@bryant.edu 1/16

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 night. In advanced sleep phase syndrome
(ASPS), this has progressed to the point where the patient becomes drowsy at 6 to 7 PM. If they go to sleep at this hour, they
sleep a normal 7-8 hours, waking at 3 or 4 am. However, if they try to stay up later, their advanced sleep/wake rhythm still
causes them to awaken at 3 or 4 am. This can be difficult to distiguish from insomnia.

Good Sleep Hygiene

Your Personal Habits

Your Sleeping Environment

Getting Ready For Bed

Getting Up in the Middle of the Night

A Word About Television

Hyperlink "Your Personal Habits"

Your Personal Habits

Fix a bedtime and an awakening time . Do not be one of those people who allow bedtime and awakening time to drift. 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-
45 minutes and can sleep well at night.

Avoid alcohol 4-6 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 your blood start to fall, there is a stimulant or wake-up effect.

2/16
 Avoid caffeine 4-6 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 4-6 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 2 hours before bedtime, however, can decrease your ability to fall asleep.

Hyperlink "Your Sleeping Environment"

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.

Hyperlink "Getting Ready For Bed"

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 15-30 minutes, get up, go into another room,
and read until sleepy.

Hyperlink "Getting Up in the Middle of the Night"

Getting Up in the Middle of the Night

Most people wake up one or two times a night for various reasons. If you find that you get up in the middle of night and cannot
get back to sleep within 15-20 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.

3/16
Hyperlink "A Word About Television"

A Word About Television

Many people fall asleep with the television on in their room. Watching television before bedtime 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. 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 idea.

Risk Factors for Completed Suicide

Sex: The person most likely to succeed in a suicidal attempt is a white male. While females are more likely to attempt
suicide, males are more likely to complete one.

Age: Although overall suicidal behaviors do not increase with age, rates of completed suicide do increase with age.

Elderly persons attempting suicide are also more likely to be widows/widowers, live alone, perceive their health status
to be poor, experience poor sleep quality, lack a confidante, and experience stressful life events.

Importantly, approximately 75 percent of elderly persons who commit suicide had visited a primary care physician
within the preceding month, but their symptoms were not recognized or treated, underscoring that physicians must be
tuned into the signs and symptoms of depression and risks for suicide. Drug overdose is the most common means of
suicide on the elderly, making the safety of medications chosen to treat the condition important.

Previous attempts: Having previously attempted suicide is a risk factor for attempting suicide again.

Suicide is the 8th leading cause of death among American Indian/Alaskan Natives (AI/AN), and for those aged 15-34, occurs
1.5 times the rate of other U.S. ethnicities in that age group.

Poverty by itself is not a risk factor.

Major Depression Diagnostic Criteria

For a diagnosis of major depression, the patient must have at least five of the following nine criteria for a minimum of
two weeks.
A least one of the symptoms must be either (1) depressed mood or (2) loss of interest or pleasure.

Depressed Mood

(The eight remaining criteria can be remembered using the mnemonic SIG E CAPS):

S leep: Insomnia or hypersomnia nearly every day.

I nterest (loss of): Anhedonia (loss of interest or enjoyment) in usual activities.

G uilt: Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely
self-reproach or guilt about being sick).

E nergy (decreased): Fatigue or loss of energy nearly every day.

C oncentration (decreased, or crying): Diminished ability to think or concentrate, or indecisiveness, nearly every day (either
by subjective account or as observed by others).

4/16
A ppetite (increased or decreased): or significant weight loss when not dieting or weight gain (e.g., a change of more than 5%
of body weight in a month).

P sychomotor retardation: Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective
feelings of restlessness or being slowed down).

S uicidal 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 is generally not given unless the symptoms are still present two months after the
loss. However, the presence of certain symptoms that are not characteristic of a "normal" grief reaction may be helpful in
differentiating bereavement from a Major Depressive Episode. These include:

Guilt about things other than actions taken or not taken by the survivor at the time of the death;
Thoughts of death other than the survivor 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; and
Hallucinatory experiences other than thinking that he or she hears the voice of, or transiently sees the image of, the
deceased person.

Risk factors for Late-life depression

Risk factors for late-life depression include:

Female sex
Social isolation
Widowed, divorced, or separated marital status
Lower socioeconomic status
Comorbid general medical conditions, e.g. stroke, heart disease & cancer.
Uncontrolled pain
Insomnia
Functional impairment
Cognitive impairment

Depression in the Elderly

Depression is a very serious disease in the elderly:

Depression increases the risk of disabilities in mobility and the activities of daily living by about 70% over the course of
6 years.
Alcohol and drug abuse are very common comorbidities complicating depression.
Completed suicide is more common in older depressed patients.

Assessing Severity of Suicidal Ideation

A tool used to assess whether a patient is seriously contemplating suicide is the SAD PERSONS scale:

Sex (male)

5/16
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 4 to 6 suggests outpatient treatment is an appropriate clinical action

A score of 7 to 10 suggests hospitalization is warranted

Screening for Depression

The U.S. Preventive Services Task Force (USPSTF) recommends screening all adults for depression
(https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/depression-in-adults-screening1?
ds=1&s=Depression%20in%20Adults:%20Screening) , but especially patients with chronic diseases like diabetes, as they are at high
risk for depression. Several screening tools are available, including:

Geriatric Depression Scale - Short Form (http://consultgeri.org/try-this/general-assessment/issue-4.pdf) (GDS-SF)

Zung Depression Scale
Beck Depression Inventory

Even the simple question, "Do you often feel sad or depressed?" seems to be sensitive to screen for, but not to diagnose,
depression. If this question is positive, further testing would need to be done to make the diagnosis.

Hyperlink "The Mini-cog exam "

This Multimedia material is not included in this Summary, please open Case to review.

Screening for Dementia in Geriatric Patients with Depression

Screening for dementia is important in geriatric patients with depression because the Geriatric Depression Scale is less
sensitive in demented patients.

Two dementia screening tools are:

The Mini-cog exam

The Mini-mental state exam (MMSE)

The mini-cog exam is faster and more sensitive and specific than the MMSE.

Sensitivity Specificity
Mini-cog 99% 93%
MMSE 91% 92%

6/16
Hyperlink "The Mini-cog exam "

This Multimedia material is not included in this Summary, please open Case to review.

Side Effects of SSRI/SNRIs

Common side effects of SSRI/SNRIs include:

Headaches
Sleep disturbances--drowsiness and, less frequently, insomnia
Gastrointestinal problems such as nausea and diarrhea
Sexual dysfunction

They can also cause:

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

In the elderly you also have to be concerned about an increased risk for falls with these medications, and recent studies
show that they might have adverse effects on bone density.

Older antidepressants such as TCAs can cause arrhythmias. Citalopram and Escitalopram can cause QT interval
prolongation at higher doses, especially in the face of hypokalemia and hypomagnesemia or when combined with other
medication that have this same effect. Reports of symptomatc arrythmia is uncommon.

Often patients with depression will present with arthralgias and myalgias, but SSRI/SNRIs do not cause arthralgias.

Depression in Hispanics

Due to factors such as economics, culture, and differences in presentation, Hispanics have their depression identified less
frequently than 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 than with
stated mood related complaints.

U.S.-born Hispanics experience depression at similar rates to other ethnic groups. Rates of depression in immigrant
Hispanics are up to 50% lower than U.S.-born Hispanics.

Psychosis is no more common in Hispanics than 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.

Elder Abuse

Early research indicates the following risk factors for 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

7/16
 has not been found to predict abuse.
Social isolation of the elder from people other than the abuser.

Clinical Skills

Assessing Suicidal Ideation

Do you want to die? Have you thought about dying? Have you considered hurting yourself?
Do you have a plan for hurting or killing yourself? Do you have the means to carry out this plan? If not, how would you
obtain the means?
Have you taken any medications, alcohol, or drugs today? Have you had problems with alcohol or drugs in the past?
Have other people thought so?
Have you ever tried to hurt or kill yourself before?
Has anyone in your family or any of your friends ever taken their life?
Have you lost interest in life? What problems in your life would be solved by killing yourself? Do you feel hopeless
about your life? Do you feel hopeless about these problems ever being solved?
Have you begun to give away your belongings? Have you made plans for your loved ones?
What would happen if you successfully killed yourself? Would anything happen to you after you died? Who would be
upset and who would be relieved if you killed yourself?

It can also be helpful to talk with the patient's friends and family, maintaining appropriate confidentiality, although the
professional should not agree to withhold information if a patient is truly suicidal.

Complementary and Alternative Therapies

When obtaining a medication history, health care providers should ask routinely about herbal and other supplements--as well
as over-the-counter medications and nutritional supplements. Patients frequently will not mention the use of complementary
and alternative medical treatment unless they are asked about them. Be respectful when patients discuss alternative
therapies, even if you are unfamiliar or skeptical about a particular treatment.

Herbs and similar supplements are a concern because of their potential to interact with conventional medications or produce
side effects, just like conventional drugs. Even where they were obtained is important, as supplements have repeatedly
been found to be contaminated with other herbs, heavy metals, and even prescription drugs. Only a few herbs have been
scientifically studied, so information on their effectiveness is limited. St. John's Wort has been shown to be effective for short
term treatment of mild to moderate depression.

Clinical Reasoning

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:

H ypothyroidism: About five percent 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.

8/16
Parkinson's disease: Up to 60 percent of people with this disorder experience mild or moderate depressive symptoms.
Although several reports have shown a link between depressive symptoms and Parkinson's 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's disease, preceding the characteristic movement problems seen in Parkinson's
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's 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.

Studies

Evaluation of Fatigue or Depression

A complete metabolic panel screens for electrolyte, renal, and hepatic problems
A TSH can detect hypothyroidism
A CBC will show anemia and vitamin deficiencies

Management

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 (which includes sleep hygiene instruction, stimulus control, and sleep restriction with cognitive restructuring) has been
shown to be most effective. CBT-I combines different behavioral treatments, resulting in improvements lasting up to two
years. 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 2 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 5 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. Non-benzodiazepines (e.g., zolpidem [Ambien]) and melatonin-receptor
agonists are the safest and most efficacious hypnotic drugs currently available.

Benzodiazepines can be effective but have more complications and the additional risk of addiction.

Antihistamines, antidepressants, anticonvulsants, and antipsychotics are associated with more risks than benefits in older
adults.

9/16
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.

Antidepressant Medications

Most antidepressants work by improving the levels of the neurotransmitters norepinephrine (NE), serotonin (5HT), and
dopamine (DA). There are four major classes of antidepressants:

>Others
Class Mechanism Examples

Selective serotonin reuptake
inhibitors (SSRIs)
Citalopram (Celexa)
Fluoxetine (Prozac)
Selectively block reuptake of serotonin, potentiating Fluvoxamine (Luvox)
serotonin's effect on the post-synaptic neuron Paroxetine (Paxil)
Sertraline (Zoloft)
Escitalopram (Lexapro)

Nortriptyline (Pamelor)
Block reuptake of norepinephrine and serotonin, Amitriptyline
Tricyclic antidepressants (TCAs)
potentiating their effects on the post-synaptic neuron Clomipramine (Anafranil)
Doxepin (Sinequan)

Monoamine oxidase (MAO) Block pre-synaptic catabolism of norepinephrine and Phenelzine (Nardil)
inhibitors serotonin (rarely used today) Tranylcypromine (Parnate)

Venlafaxine (Effexor) and

Others Serotonin and norepinephrine reuptake inhibitors
Duloxetine (Cymbalta)

Norepinephrine and dopamine

Bupropion (Wellbutrin)
reuptake inhibitors
Serotonin antagonist and reuptake
N efazodone (Serzone) and Trazodone (Desyrel)
inhibitors
Norepinephrine and serotonin
Mirtazapine (Remeron)
antagonist, antihistaminic effects
Serotonin partial agonist and
VIIBRYD (Vilazodone HCl)
reuptake inhibitor

Management of Depression

When treating patients with major depression disorder, a biopsychosocial approach should be considered. "Bio" refers to
pharmacotherapy; "psycho" refers to psychotherapy; and "social" refers to the identification of life stressors.

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.

Medication:
In a first episode of depression, it's usually recommended that the patient 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. With multiple
recurrences and, in the elderly, who experience increased rates of recurrence, continuous therapy should be considered.

10/16
SSRIs, such as sertraline, and SNRIs are generally considered safe and effective drugs for depression. They have lower
rates of side effects compared to the older tricyclics and, unlike the tricyclics, have little risk in overdose. A tricyclic such as
amitriptyline would not be a first-line approach.

Psychotherapy:
Psychotherapy, most notably cognitive behavior therapy and interpersonal therapy, have been found as effective as
psychotropic medications. It can be especially useful for patients who want to avoid medication.

Exercise:
Trials of mixed exercise indicated a small but statistically significant positive effect favoring exercise for the treatment of mild
to moderate depression and, similarly to combining psychotherapy and medication, may have an additive effect when used in
combination simultaneously with other modalities.

Avoidance of other substances:

Additionally, avoidance of recreational drug and excessive alcohol use is a necessary part of any treatment regimen.

ECT:
While ECT is not an appropriate treatment for an initial episode of major depression, it is a safe and effective therapy that can
be useful in patients with psychotic depression or severe nonpsychotic depression unresponsive to medications or
psychotherapy.

Antidepressant Profiles

Effectiveness
The selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) are all about
equally effective in both adult and geriatric patients. While matching the patient's symptoms with the drug's profile, keep in
mind that each patient's reaction to a medication is different and the final selection needs to be individualized.

Cost
Cost is another strong consideration. There are now generic preparations of some of the SSRIs, making them more
affordable.

Drug-drug interactions
Also, antidepressants have a wide variety of drug-drug interactions, most prominently through the P450 system.

Safety during pregnancy

Most SSRIs are categorized by the U.S. Food and Drug Administration as Pregnancy Category C, but trimester-specific or
population-specific risks exist. Paxil is Pregnancy Category D.

Pregnancy Animal reproduction studies have shown an adverse effect on the fetus and there are no adequate and well-
Category controlled studies in humans, but potential benefits may warrant use of the drug in pregnant women despite
C potential risks.
Pregnancy There is positive evidence of human fetal risk based on adverse reaction data from investigational or marketing
Category experience or studies in humans, but potential benefits may warrant use of the drug in pregnant women
D despite potential risks.

Profiles

Drug Comments

Unusually long half life (two to four days), so effects can last for weeks after discontinuation.
Fluoxetine
Most problematic (but uncommon) side effects include agitation, motor restlessness, decreased libido
(Prozac)
in women, and insomnia.

11/16
Sertraline In addition to being a frequently used SSRI in pregnancy and breastfeeding, approved specifically for
(Zoloft) obsessive-compulsive, panic, and posttraumatic stress disorders.
More gastrointestinal side effects than the other SSRIs.

Strong antianxiety effects.

Paroxetine Side effects can include significant weight gain, impotence, sedation, and constipation.
(Paxil) Due to its short half-life, paroxetine is most likely of all the SSRIs to cause antidepressant
discontinuation syndrome.

Fluvoxamine Particularly useful in obsessive-compulsive disorder.

(Luvox) Greater frequency of emesis compared to other SSRIs.

Most common side effects include nausea, dry mouth, and somnolence.
Citalopram
maximum recommended dose: 20 mg per day for patients 60 years of age due to concerns of QT
(Celexa)
interval prolongation.

Escitalopram Approved specifically for Generalized Anxiety Disorder.

(Lexapro) Overall, fewer side effects than citalopram.

Adherence to Antidepressant Medication in the Elderly

Providers note adherence to depression treatment in older adults occurs only about half the time. The reasons are
understandable and include:

Inability to afford the medication

Concerns about side effects
Worry about the stigma of the diagnosis
Not understanding how to take the medication properly

The important thing is to not blame the patient, but to educate her/him about the recommendations, allowing the patient to ask
questions and fully express any concerns.

References

Shochat T, Ancoli-Israel S. Assessment and treatment of seep disturbances in older adults. Clin Psychol Rev
2000;20;783"805

Adapted from the University of Maryland Medical Center website. Page title: Insomnia.
(http://umm.edu/health/medical/reports/articles/insomnia).

Hyperlink "Your Personal Habits"

Your Personal Habits

12/16
 Fix a bedtime and an awakening time . Do not be one of those people who allow bedtime and awakening time to drift. 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-
45 minutes and can sleep well at night.

Avoid alcohol 4-6 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 your blood start to fall, there is a stimulant or wake-up effect.

Avoid caffeine 4-6 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 4-6 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 2 hours before bedtime, however, can decrease your ability to fall asleep.

Hyperlink "Your Sleeping Environment"

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.

Hyperlink "Getting Ready For Bed"

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 15-30 minutes, get up, go into another room,
and read until sleepy.

13/16
Hyperlink "Getting Up in the Middle of the Night"

Getting Up in the Middle of the Night

Most people wake up one or two times a night for various reasons. If you find that you get up in the middle of night and cannot
get back to sleep within 15-20 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.

Hyperlink "A Word About Television"

A Word About Television

Many people fall asleep with the television on in their room. Watching television before bedtime 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. 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 idea.

Bloom HG, et al. Evidence-Based Recommendations for the Assessment and Management of Sleep Disorders in Older
Persons, J Amer Geriatric Soc. 2009;57:761-789.

Kemp C, Rasbridge LA. Refugee and Immigrant Health: A Handbook for Health Professionals. Cambridge, UK: Cambridge
University Press; 2004.

Alonso et al., Journal of Neurology, Neurosurgery, and Psychiatry, June 2009.

Tunzi M, Saba G. The Suicidal Patient in Family Medicine: Principle and Practice - 6th Ed. New York, NY: Springer-Verlag
New York, Inc.; 2003.

Suidide Data Prevention Sheet. Centers for Disease Control and Prevention, National Center for Injury Prevention and
Control, Division of Violence Prevention. http://www.cdc.gov/ViolencePrevention/pdf/Suicide-DataSheet-a.pdf Accessed
January 5, 2017.

American Psychiatric Association. Task Force on DSM-V. Diagnostic and Statistical Manual of Mental Disorders: DSM-V, 5th
ed. Washington, D.C.: American Psychiatric Association; 2013.

American Psychiatric Association. Task Force on DSM-V. Diagnostic and Statistical Manual of Mental Disorders: DSM-V, 5th
ed. Washington, D.C.: American Psychiatric Association; 2013.

Blazer D. Depression in late life. Journal Gerontol. 2003;58A;3:249-265

Cole MG, Dendukuri N. Risk factors for depression among elderly community subjects: a systematic review and meta-
analysis. Am J Psychiatry 2003; 160:1147.

Patterson WM, Dohn HH, Bird J, Patterson GA. The evaluation of suicidal patients: the Sad Persons

14/16
scale. Psychosomatics. 1983;24:343-9.

Borson S, Scanlan J, Brush M, Vitaliano P, Dokmak A. The mini-cog: a cognitive vital signs measure for dementia screening
in multilingual elderly. Int j Geriatr Psychiatry . 2000 Nov;15(11):1021-7.

Mahoney J, et al. Screening for depression: single question versus GDS. J Am Geriatr Soc. 1994;42:1006-8.

Sharp L, Lipsky M. Screening for Depression Across the Lifespan. Am Fam Physician. 2002;66:1001-8,1045-6,1048,1051-2.

Yesavage JA, Brink TL, Rose TL, Lum O, Huang V, Adey MB, et al. Development and validation of a geriatric depression
screening scale: a preliminary report. J Psychiatr Res. 1982-83;17:37-49.

Blazer D. Depression in Late Life. Journal Gerontol 2003;58A;3:249-265

Lisanby SH. Electroconvulsive Therapy for Depression. N Engle J Med.The Medical Letter. SSRIs and Osteoporosis. The
Medical Letter. Nov 19, 2007:V49n1274:95-6

Med Lett Drugs Ther. 2013 Jul 22;55(1421):59

Blazer D. Depression in Late Life. Journal Gerontol 2003;58A;3:249-265

Birrer R, Veruri S. Depression in Later Life, Am Fam Physician 2004;69:2375-82

Bridle c, Spanjers k, Patel S, et al.Effect of exercise on depression severity in older people:systematic review and meta-
analysis of randomised controlled trials. BJP 2012;201;180-185.

Keller MB, McCullough JP, Klein DN, et al. A comparison of nefazodone, the cognitive behavioral-analysis system of
psychotherapy, and their combination for the treatment of chronic depression. N Engl J Med. 2000;342:1462-1470.

Lisanby SH. Electroconvulsive therapy for depression. N Engl J Med. 2007;357:1939-1944.

Thompson L, Coon D, Gallagher-Thompson D. Comparison of desipramine and cognitive/behavioral therapy in the treatment
of elderly outpatients with mild-to-moderate depression. Am J Geriatr Psychiatr. 2001;9:225-240.

Gartlehner G, et al, Comparative Benefits and Harms of Second-Generation Antidepressants, Ann Intern Med. 2008;149:734-
750.

Warner CH, Bobo W, Warner C, Reid S, Rachal J. Antidepressant discontinuation syndrome. Am Fam Physician . 2006 Aug
1;74(3):449-56.

Med Lett Drugs Ther. 2013 Jul 22;55(1421):59

Tainted Weight Loss Product, U.S. Food and Drug Administation website.
http://www.fda.gov/Drugs/ResourcesForYou/Consumers/BuyingUsingMedicineSafely/MedicationHealthFraud/ucm234592.htm.
Accessed June 16, 2015.

Carpenter D. St. John's wort and S-adenosyl methionine as natural alternatives to conventional antidepressants in the era of
the suicidality boxed warning. Altern Med Rev. 2011;16(1):17-39.

Hu Z et al. "Herb-drug interactions: a literature review." Drugs. 2005;65(9):1239-1282.

Kemp C, Rasbridge LA. Refugee and Immigrant Health: A Handbook for Health Professionals. Cambridge, UK: Cambridge
University Press; 2004

15/16
Ortiz B, et al, Complementary and Alternative Medicine Use Among Hispanics in the United States. Ann Pharmacother.
2007;41(6):994-100.

Saper RB et al. Lead, mercury, and arsenic in US- and Indian-manufactured Ayurvedic medicines sold via the
Internet. JAMA. 2008, 300;8: 915-923.

Surfman N. Contamination of Botanical Dietary Suppelements by Digitalis Lanata. NEJM. 998, 339; 12: 806-811.

Birrer R, Veruri S. Depression in later life, Am Fam Physician. 2004;69:2375-82

Ayalon L, Aren P, Alvidrez J. Adherence to Antidepressant Medications in Black and Latino Elderly Patients. Am J Geriatr
Psychiatry. 2005;13;7:572-580

Betancourt J, Carrillo JE, Green AR. Hypertension in multicultural and minority populations: linking communication to
compliance. Curr Hypertens Rep. 1999;1:482- 8.

Lewis-Fernndez R, Das A, Alfonso C, Weissman M, Olfson M. Depression in US Hispanics: diagnostic and management
considerations in family practice. J Am Board Fam Pract. 2005;18;4:282-96.

Tripp-Reimer, T., Brink, P.J., & Saunders, J.M. (1984). Cultural asessment: Content and process. Nursing Outlook.
1984;32;2:78-82.

Lachs MS, Pillemer K. Elder abuse. Lancet. Oct 2 2004;364(9441):1263-1272.

Zivin K, Kales H. Adherence to depression treatment in older adults. Drugs Aging. 2008:25(7);559-571.

16/16