Discussion Question 1
Based on your performance and the expert feedback in your HISTORY collection, describe two missed questions and your understanding of why they were important to collect for this case history. Use specific references from your text to explain.
Discussion Question 2
Based on your performance and the expert feedback in your PHYSICAL EXAM collection, describe two errors in your exam performance or documentation. Use specific references from your text to explain the importance of these findings in correct assessment of this client.
Discussion Question 3
Based on your performance on the PHYSICAL EXAM collection, describe one key finding that you included in your list and describe a specific physical exam that you can perform at the point-of-care to further evaluate the finding. Use specific references from your text.
Discussion Question 4
Based on your performance and the expert feedback in your ASSESSMENT identification of problem categories, choose one missed/incorrect category and use specific references from your text to explain the importance of this category in arriving at correct differential diagnoses for this client.
Discussion Question 5
Based on your performance and the expert feedback in your ASSESSMENT of differential diagnoses, describe one incorrect/missed differential diagnosis and use specific references from your text to support the inclusion of the diagnosis for this client.
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 female 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?
The suggested answer is shown below.
Letter Count: 81/1000
SUBMIT
Answer Comment
Common causes of insomnia in the elderly:
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
1. 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.
2. The use of prescription, over-the-counter, alternative, and recreational drugs might affect sleep.
· Patients should be counseled to avoid caffeine and alcohol for four to six hours before bedtime.
3. 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.
4. In restless leg syndrome, the patient experiences an irresistible urge to move the legs, often accompanied by uncomfortable sensations.
5. In periodic leg movement and REM sleep behavior disorder, the patient experiences involuntary leg movements while falling asleep and during sleep respectively.
· As for 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.
6. Disturbances in the sleep-wake cycle include jet lag and shift work.
7. Patients with depression and anxiety commonly present with insomnia.
· Any patient presenting with insomnia should be screened for these disorders.
8. Patients with shortness of breath due to cardiorespiratory disorders often report that these symptoms keep them awake.
9. Pain or pruritus may keep patients awake at night.
10. 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.
11. 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.
12. 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 distinguish from insomnia.
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.”
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 idea.
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 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.
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 Mrs. Gomez, 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?”
“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 reports no discomfort such as pain or breathing problems disturbing her sleep. She reports no 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.”
ou tell Mrs. Gomez,
“I’m sorry to hear about your husband.”
“Yes, we were married for 30 years. This has been a difficult time for me.”
“Do you find that you feel sad most of the time?”
“Of course I am sad when I think about my husband and how much I miss him. But I wouldn’t say that I’m sad most of the time.”
Silvia states, “But Mom, you spend most of your time just moping around the house.” Turning to you she elaborates, “She seems to be in slow motion most of the time. She doesn’t even go to church anymore. She used to go three to four times a week. She used to read all the time, and she doesn’t do that anymore either.”
Mrs. Gomez explains, “I haven’t been reading as much as I used to because I can’t seem to focus and I end up reading the same page over and over.” She goes on to say, “And I don’t seem to have any energy to do anything. I’m not even able to help out around the house. I feel bad about that; I should be helping out more. I seem to spend a lot of time just watching TV and eating junk food.”
You ask,
“Have you tried anything to help you sleep?”
“I’m not familiar with that product, but I’ll mention it to Dr. Lee. I’m glad you brought it up. It’s important that your doctors know about everything you are taking, whether it’s prescription medication or not. I’m sorry nothing seems to be helping you sleep. We’ll get to the bottom of this together.”
You turn your attention to taking Mrs. Gomez’s past medical history. You learn:
Problem list:
· Hypercholesterolemia
· Type 2 diabetes
· Hypertension
Surgical history:
· Cholecystectomy
· Hysterectomy (due to fibroids)
Medications:
For diabetes:
· Glyburide (10 mg daily)
· Metformin (1,000 mg bid)
For blood pressure:
· Methyldopa (250 mg bid)
· Lisinopril (10 mg daily)
For cholesterol:
· Atorvastatin (80 mg daily)
For CHD prophylaxis:
· Aspirin (81 mg daily)
For osteoporosis prevention:
· Calcium citrate with vitamin D (600mg/400 IU bid)
Diphenhydramine is her only over-the-counter medication, and she is taking no traditional or herbal medications beyond the zapote tea.
Social History
She does not smoke, and drinks only small amounts of alcohol on holidays.
Given what you have heard from Mrs. Gomez and her daughter, especially
· Her inability to focus
· Her lack of energy
· The sense that she is in slow motion
· She has stopped doing activities she previously enjoyed
You are concerned that her insomnia may be due to depression. Depression may stem from environmental stressors such as her husband’s death and her loss of independence along with a primary neurochemical imbalance. Her depression also could be caused by another medical condition.
Question
Which of the following medical conditions is associated with depression? Select all that apply.
The best options are indicated below. Your selections are indicated by the shaded boxes.
· A. Asthma
· B. Dementia
· C. Hypertension
· D. Hypothyroidism
· E. Parkinson disease
SUBMIT
Answer Comment
The correct answers are B, D, E.
TEACHING POINT
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:
Hypothyroidism:
About 5% 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.
Parkinson disease:
Up to 60% of people with this disorder experience mild or moderate depressive symptoms. Although several reports have shown a link between depressive symptoms and Parkinson 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 disease, preceding the characteristic movement problems seen in Parkinson 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 disease.
Dementia:
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.
Hypertension (C) and asthma (A) have not been specifically linked to higher rates of depression.
Some other diseases that have been linked to depression include:
· Endocrine disease (Addison disease, diabetes, Cushing syndrome, hypoglycemia, hyperparathyroidism)
· Acquired immunodeficiency syndrome
· Cardiovascular disease (myocardial infarction, angina)
· Cancer (particularly of the pancreas)
· Cerebral arteriosclerosis, cerebral infarction
· Electrolyte and renal abnormalities
· Folate, cobalamin and thiamine deficiencies
· Hepatitis
· Intracranial tumors
· Multiple sclerosis
· Porphyria
· Rheumatologic disease (rheumatoid arthritis, systemic lupus erythematosus, temporal arteritis)
· Syphilis
· Temporal lobe epilepsy
· Huntington disease
· Chronic pain
· Keeping in mind the disorders associated with depression, you elicit a review of systems from Mrs. Gomez to help discover what these indicate regarding her underlying illness.
· Constitutional: Mrs. Gomez has gained about 10 lbs in the last six months. She reports no fevers or dizziness. This makes you less concerned about cancer or other systemic illness.
· Respiratory: No shortness of breath, making cardio-respiratory disease less likely.
· Cardiac: No chest pains, palpitations or edema, decreasing the likelihood of cardiovascular disease.
· Gastrointestinal: No nausea, changes in bowel habits, hematochezia or melena. This makes you less concerned about gastrointestinal cancer or occult blood loss leading to anemia.
· Endocrinologic: No polydipsia or polyuria, decreasing the likelihood of poorly controlled diabetes.
· Neurologic: No acute neurologic changes or tremors. Her daughter confirms that patient has been alert, oriented and has had no episodes of confusion. So you are now less concerned about cerebral infarction, intracranial tumors, multiple sclerosis, and Parkinson disease.
· Urologic: Normally urinates one to two times at night.
· Once you have completed your review of systems, you excuse yourself from the room for a moment while Mrs. Gomez changes into a gown.
When you return to the exam room, after washing your hands, you perform a physical exam on Mrs. Gomez.
Vital signs:
· Pulse is 60 beats/minute and regular
· Respiratory rate is 16 breaths/minute
· Blood pressure is 128/78 mm Hg
· Weight is 84 kg (186 lbs (up 10 lbs since last year))
· Height is 163 cm (64 in)
Head, eyes, ears, nose and throat (HEENT): No thyromegaly, adenopathy, or masses.
Cardiac: Regular rate and rhythm, no murmur or gallops. No edema.
Respiratory: Clear to auscultation.
Abdominal: Soft, nontender, without organomegaly or masses.
Neurologic: Cranial nerves 3-12 intact. Normal strength and light touch sensation in extremities. No tremors. Normal gait.
You are afraid your next question may upset Mrs. Gomez, but you know it is important to ask: “Mrs. Gomez, I have one more question: When people are down, sometimes they wish they would fall asleep and never wake up.
“Have you had any thoughts of dying or causing harm to yourself?”
“Okay, thank you for your openness with me,” you tell Mrs. Gomez. “I would like to bring in Dr. Lee so she can also perform a physical exam before you get dressed. We’ll be back in just a minute. Do you have any questions for me before I go?”
Mrs. Gomez indicates she doesn’t have any concerns, so you exit the room.
Question
What factors increase a patient’s risk for completed suicide? Select all that apply.
The best options are indicated below. Your selections are indicated by the shaded boxes.
· A. Having a previous suicide attempt.
· B. Having served in the military.
· C. Living in poverty.
· D. Male sex.
· E. Older age.
SUBMIT
Answer Comment
The correct answers are A, B, D, E.
TEACHING POINT
Risk Factors for Completed Suicide
Sex: The person most likely to succeed in a suicidal attempt is an adult male (D). 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 (E).
· 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% 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 in to the signs and symptoms of depression and risks for suicide. Drug overdose is the most common means of suicide in the elderly, making the safety of medications chosen to treat the condition important.
Previous attempts (A): Having previously attempted suicide is a risk factor for completed suicide.
Military Service (B): The suicide rate of military veterans in the United States is higher than that of the general population.
Poverty by itself has not been found to be a risk factor for completed suicide, though it can contribute to psychosocial stress and the development of depressive symptoms.
You locate Dr. Lee and present the case to her, expressing your concern that Mrs. Gomez is depressed. She suggests discussing the evidence you found that Mrs. Gomez may have depression.
You tell Dr. Lee, “Mrs. Gomez has depressed mood and seven of the nine criteria.”
TEACHING POINT
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):
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, or crying): Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).
Appetite (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).
Psychomotor retardation: 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.
TEACHING
“You seem to have established that Mrs. Gomez meets the criteria for a major clinical depression,” says Dr. Lee, and goes on to explain:
TEACHING POINT
Major Depressive Disorder versus Bereavement
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. The table below adapted from the DSM V discusses some potential differences:
Major Depressive Episode
Bereavement (Grief)
Persistent depressed mood and inability to anticipate happiness or pleasure
Feelings of emptiness and loss
Depression persistent, not tied to specific thoughts or preoccupations
Depressed feelings often decrease in intensity over days to weeks and occur in waves, associated with thoughts of the deceased
Pervasive unhappiness and misery
Grief may be accompanied by positive emotions and humor
Self-critical or pessimistic ruminations
Preoccupation with thoughts and memories of the deceased
Feelings of worthlessness and self-loathing
Self-esteem is generally preserved. May be self-deprecating—feeling they should have done more or told the deceased how much he or she was loved
Suicidal ideation because of feeling worthless, undeserving of life, or unable to cope with the pain of depression
Individual thinks about death and dying, generally focused on the deceased and possibly about joining the deceased
TEACHING POINT
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 and cancer
· Uncontrolled pain
· Insomnia
· Functional impairment
· Cognitive impairment
TEACHING POINT
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 six years.
· Alcohol and drug abuse are very common comorbidities complicating depression.
· Completed suicide is more common in older depressed patients.
You express to Dr. Lee your concern that by asking about suicide you may have made the situation worse.
Dr. Lee reassures you: “Many people worry that bringing up the subject of suicide will cause the patient to commit suicide. On the contrary, talking about it allows the opportunity to intervene and prevent a completed suicide.”
TEACHING POINT
Suicide Assessment Five-step Evaluation and Triage (SAFE-T)
SAFE-T (Suicide Assessment Five-Step Evaluation and Triage) Copyright 2009 by Education Development Center, Inc. and Screening for Mental Health, Inc.
1. RISK FACTORS
a. Suicidal behavior: history of prior suicide attempts, aborted suicide attempts, or self-injurious behavior
b. Current/past psychiatric disorders: especially mood disorders, psychotic disorders, alcohol/substance abuse, ADHD, TBI, PTSD, Cluster B personality disorders, conduct disorders (antisocial behavior, aggression, impulsivity) Co-morbidity and recent onset of illness increase risk
c. Key symptoms: anhedonia, impulsivity, hopelessness, anxiety/panic, global insomnia, and command hallucinations
d. Family history: of suicide, attempts, or psychiatric disorders requiring hospitalization
e. Precipitants/stressors/Interpersonal: triggering events leading to humiliation, shame, or despair (e.g, loss of relationship, financial or health status—real or anticipated). Ongoing medical illness (esp. CNS disorders, pain). Intoxication. Family turmoil/chaos. History of physical or sexual abuse. Social isolation
f. Change in treatment: discharge from psychiatric hospital, provider or treatment change
g. Access to firearms
2. PROTECTIVE FACTORS Protective factors, even if present, may not counteract significant acute risk
a. Internal: ability to cope with stress, religious beliefs, and frustration tolerance
b. External: responsibility to children or beloved pets, positive therapeutic relationships, and social supports
3. SUICIDE INQUIRY Specific questioning about thoughts, plans, behaviors, and intent
a. Ideation: frequency, intensity, duration—in last 48 hours, past month, and worst ever
b. Plan: timing, location, lethality, availability, and preparatory acts
c. Behaviors: past attempts, aborted attempts, rehearsals (tying noose, loading gun) versus non-suicidal self injurious actions
d. Intent: extent to which the patient (1) expects to carry out the plan and (2) believes the plan/act to be lethal versus self-injurious.
e. Explore ambivalence: reasons to die versus reasons to live
›For Youths: ask parent/guardian about evidence of suicidal thoughts, plans, or behaviors, and changes in mood, behaviors, or disposition
›Homicide Inquiry: when indicated, esp. in character disordered or paranoid males dealing with loss or humiliation. Inquire in four areas listed above
4. RISK LEVEL/INTERVENTION
a. Assessment of risk level is based on clinical judgment, after completing steps 1–3
b. Reassess as patient or environmental circumstances change
5. DOCUMENT Risk level and rationale; treatment plan to address/reduce current risk (e.g., medication, setting, psychotherapy, E.C.T., contact with significant others, consultation); firearms instructions, if relevant; follow-up plan. For youths, treatment plans should include roles for parent/guardian.
Entering the room with you, Dr. Lee greets Mrs. Gomez and her daughter, and thanks them for allowing you to interview them.
She tells Mrs. Gomez, “I understand that you’ve been having trouble sleeping – not unusual given your recent stresses. These can also lead to feelings of depression. I’d like to look into this by going over a short questionnaire with you.”
Dr. Lee goes over the questions on the Geriatric Depression Scale – Short Form (GDS-SF) with Mrs. Gomez. Her score equals 9. This confirms depression, as a score of > 5 is consistent with the diagnosis of depression.
Dr. Lee then performs a Mini-Cog exam to screen for dementia, explaining to Mrs. Gomez that in cases like this, checking out the patient’s memory and concentration can help to rule out other disorders and can assist in planning treatment. She scores in the normal range.
TEACHING POINT
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.
The PHQ-2 is a simple screen that is 97% sensitive and 59% specific as a depression screen:
“Over the past two weeks, have you often been bothered by either of the following problems?”
1. Little interest or pleasure in doing things.
2. Feeling down, depressed, or hopeless.
If positive, it should be followed up by a diagnostic instrument such as:
· PHQ-9
· Geriatric Depression Scale – Short Form (GDS-SF) (.pdf)
TEACHING POINT
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%
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)
Selectively block reuptake of serotonin, potentiating serotonin’s effect on the post-synaptic neuron
Citalopram (Celexa)
Fluoxetine (Prozac)
Fluvoxamine (Luvox)
Paroxetine (Paxil)
Sertraline (Zoloft)
Escitalopram (Lexapro)
Tricyclic antidepressants (TCAs)
Block reuptake of norepinephrine and serotonin, potentiating their effects on the post-synaptic neuron
Nortriptyline (Pamelor)
Amitriptyline
Clomipramine (Anafranil)
Doxepin (Sinequan)
Monoamine oxidase (MAO) inhibitors
Block pre-synaptic catabolism of norepinephrine and serotonin(rarely used today)
Phenelzine (Nardil)
Tranylcypromine (Parnate)
Serotonin and norepinephrine reuptake inhibitors
Block reuptake of norepinephrine and serotonin, increasing their concentration/availability
Venlafaxine (Effexor) and Duloxetine (Cymbalta)
Others
Norepinephrine and dopamine reuptake inhibitors
Bupropion (Wellbutrin)
Serotonin antagonist and reuptake inhibitors
Nefazodone (Serzone) and Trazodone (Desyrel)
Norepinephrine and serotonin antagonist, antihistaminic effects
Mirtazapine (Remeron)
Serotonin partial agonist and reuptake inhibitor
Vilazodone (Viibryd)
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 medications that have this same effect. Reports of symptomatic arrhythmia are uncommon.
Often patients with depression will present with arthralgias and myalgias, but SSRI/SNRIs do not cause arthralgias.
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 nine to 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.
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 of 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 drugs 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 many antidepressants, making them more affordable.
Drug-drug interactions:
Also, antidepressants have a wide variety of drug-drug interactions, most prominently through the P450 system.
Side effects
While antidepressants are relatively safe, there are potential side effects that vary in frequency and intensity between medications and the individual patient.
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.
Profiles
Drug
Comments
Fluoxetine (Prozac)
· Unusually long half life (two to four days), so effects can last for weeks after discontinuation.
· Most problematic (but uncommon) side effects include agitation, motor restlessness, decreased libido in women, and insomnia.
Sertraline (Zoloft)
· In addition to being a frequently used SSRI in pregnancy and breastfeeding, approved specifically for obsessive-compulsive, panic, and posttraumatic stress disorders.
· More gastrointestinal side effects than the other SSRIs.
Paroxetine (Paxil)
· Side effects can include significant weight gain, impotence, sedation, and constipation.
· Due to its short half-life, paroxetine is most likely of all the SSRIs to cause antidepressant discontinuation syndrome.
· Paxil is Pregnancy Category D
Fluvoxamine (Luvox)
· Particularly useful in obsessive-compulsive disorder.
· Greater frequency of emesis compared to other SSRIs.
Citalopram (Celexa)
· Most common side effects include nausea, dry mouth, and somnolence.
· Maximum recommended dose: 20 mg per day for patients 60 years of age due to concerns of QT interval prolongation.
Escitalopram (Lexapro)
· Approved specifically for Generalized Anxiety Disorder.
· Overall, fewer side effects than citalopram.
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.
Evaluation of Fatigue or Depression
· A complete metabolic panel (D) screens for electrolyte, renal, and hepatic problems
· A TSH (E) can detect hypothyroidism
· A CBC (B) will show anemia and vitamin deficiencies
· A urinalysis (F) is unlikely to be useful unless the depression or fatigue is of recent onset and there is suspicion of infection.
· A brain CT scan (A) is unlikely to yield results in the absence of obvious neurologic changes.
· A chest x-ray (C) is unlikely to add anything in the absence of specific symptoms such as cough or shortness of breath.
· When you re-enter the exam room, Dr. Lee sits down to talk with Mrs. Gomez, “I would like to do a few tests to rule out any medical problem that might be causing your symptoms. But it looks as though you may be suffering from depression, which is completely understandable given the recent changes in your life.
· “This may also explain the increase in your blood sugar: Depression takes away your energy and motivation, so it’s hard to summon the effort to stick to a diet or even remember to take your medication regularly.”
· After discussing the options for treatment and the various SSRIs, Mrs. Gomez agrees to try sertraline (Zoloft). Dr. Lee writes a prescription for sertraline 25 mg daily, which is well tolerated and available in a generic form. She tells Mrs. Gomez, “Possible side effects include headache, nausea, diarrhea, sleepiness, and (infrequently) insomnia. Because of your age and other medical problems, I’m starting with a moderate dose, but we may increase it later if you don’t have an adequate response.”
· Dr. Lee is also worried that Mrs. Gomez’s methyldopa may be aggravating her depression, so she substitutes amlodipine 5 mg daily. This would also be in line with current blood pressure research.
Next, she suggests,
“Mrs. Gomez, another treatment that is very effective for depression is talking with a therapist.”
You recommend Mrs. Gomez try to get some exercise, possibly walking at the local mall. She agrees to try this. And you give Mrs. Gomez and her daughter a handout about the diagnosis of depression and a list of community resources for people struggling with depression.
Dr. Lee reviews the plan with Mrs. Gomez and her daughter: “We will order the blood tests to make sure there are no other medical conditions causing your symptoms. I will order a hemoglobin A1c to see how your diabetes is doing. We may need to adjust your diabetes medicine.”
“Do you have any other questions?” Dr. Lee asks Mrs. Gomez and her daughter. They shake their heads no.
Dr. Lee then concludes the visit: “It will probably take four to six weeks before the medication is fully effective, but it is best if I see you before then – let’s say in two weeks – to monitor your progress and discuss any problems or side effects; we will also review your tests and see if anything else needs to be done. Please feel free to call or come in sooner than that if you have concerns, feel worse, or experience side effects that prevent you from continuing to take your medication.”
At a return visit to Dr. Lee’s office two months later, you see Mrs. Gomez is on the schedule. It is her first visit to the clinic since your previous encounter. Her daughter is in the waiting room.
When you ask how she’s been doing, she says, “Just terrible. I still can’t sleep, and now I find that I’m crying all the time.” She admits that she never started her sertraline and didn’t get the lab tests. She was worried that people would think she’s crazy. She also felt that she should be able to handle her feelings without using drugs.
You ask her what she thinks is wrong with her. She replies she simply thinks she is grieving the loss of her husband. She’s been trying to use prayer to overcome it, but this hasn’t worked so far.
Depression in minority populations
U.S.-born Hispanics experience depression at similar rates to other ethnic groups. Rates of depression in immigrant Hispanics are up to 50 percent lower than U.S.-born Hispanics.
Due to factors such as economics, culture, and language barriers, Hispanics have their depression identified less frequently than non-Hispanic whites. (B) This holds true in some other ethnic groups as well, such as African Americans.
Psychotic features in depression are no more common in minority populations than non-Hispanic whites.
Research shows that Asian Americans, Blacks, and Hispanics with depression are less likely than whites to perceive a need for mental health treatment. (A) This was particularly true for Hispanics interviewed in Spanish (as opposed to those interviewed in English), suggesting acculturation may play a role in this disparity.
Hispanics and other ethnic and economic minorities are less likely to receive adequate therapies. It is important for clinicians to recognize that there are disparities in outcomes for minority patients with depression and to take steps to mitigate them. Such steps could include patient-centered communication, addressing social determinants of health, and reflection about implicit biases.
“I worry about my daughter,” Mrs. Gomez says tearfully through the interpreter. “She’s just so angry all the time.” At this point, Mrs. Gomez starts to cry. You attempt to comfort her for a moment, and then retrieve Dr. Lee for assistance.
Dr. Lee offers Mrs. Gomez a tissue and holds her hand. After a moment, she asks,
“Mrs. Gomez, can you tell me why you are worried about your daughter?”
She replies, “It’s just that Silvia is so short tempered and she cries a lot. I feel bad because I know I’m a terrible burden on the family and it’s causing Silvia a lot of stress.”
Dr. Lee responds,
“I have to ask, has your daughter ever hurt you or threatened you?”
Mrs. Gomez reports no.
A quick exam finds no bruises or other signs of abuse.
Dr. Lee explains to Mrs. Gomez that you and she are going to talk with Silvia and will be back in a moment.
You and Dr. Lee interview Sylvia alone. She admits finding the demands of caring for her mother increasingly draining.
Assuring her that it is common for adult children to find themselves caring for both their parents and their own children (a situation sometimes referred to as the “Sandwich Generation”), Dr. Lee directs Silvia to a website (http://www.familyaware.org/) for families dealing with depression. The website includes:
· Lay-oriented educational materials on depression
· Resources on how to deal with their own emotional reactions to the illness
· Lists of support groups
When you have answered all of her questions, you excuse yourselves from the room.
Dr. Lee states that she doesn’t feel that there is much risk for abuse in this case, although it’s something a provider should keep an eye open for in such taxing situations.
Elder Abuse
Early research indicates the following risk factors for abuse:
1. Dementia.
2. Shared living situation of elder and abuser (except in financial abuse).
3. Caregiver substance abuse or mental illness.
4. 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.
5. Social isolation of the elder from people other than the abuser.
6. You and Dr. Lee return to speak with Mrs. Gomez about her depression.
7. “I can appreciate your concern about the diagnosis of depression,” says Dr. Lee. “I hope it will help to know that these feelings you are having are very common: More than 14 million Americans experience depression in any given year. I see lots of people who are depressed in this clinic, and they are not ‘crazy.’ Depression is not a weakness of character that you should try to deal with on your own. It’s a medical condition just like your diabetes. And just like you take medication to help control your diabetes, we have medication to help with depression. This can be a severe problem, and is unlikely to clear up anytime soon without appropriate help.”
8. “But I am afraid I won’t have the same feelings if I take medication,” Mrs. Gomez interjects, “I don’t want to change who I am.”
9. Dr. Lee explains, “I am glad you shared your concern with me. I want to assure you that the medication won’t change who you are; in fact, I believe that this medication will be helpful in allowing you to be more like you normally are. I also know you are concerned about Silvia and how she’s dealing with her own stress. This is the best thing you can do, not only for yourself, but also for your family.”
10. Mrs. Gomez replies, “Well, I suppose it can’t hurt to give the medicine a try. I don’t seem to be getting better on my own.”
11. Dr. Lee then replies, “Great. I know this is hard for you to do, but I think you will find it helpful. Once you start taking the medication, you may start feeling better as quickly as within a week. But you probably won’t feel the full effects for about two months. Try not to get discouraged. Depression can be very frustrating. It will take time for your depression to go away.”
12. Dr. Lee re-prescribes the sertraline and Mrs. Gomez gives her assurance that she will try it this time. Dr. Lee also reorders the lab tests and refers Mrs. Gomez to the local government Department of Aging to see if there are any support services they might provide.
Adherence to Antidepressant Medication in the Elderly
Providers note that 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 not to blame the patient, but to educate them about the recommendations, allowing the patient to ask questions and fully express any concerns.
You see Mrs. Gomez and her daughter again about two months later when you return to Dr. Lee’s clinic.
“So nice to see you, Mrs. Gomez!”
“How are you feeling?”
“It’s good to see you also. I’m feeling so much better. I sleep all night, I have more energy, and my mood is lighter. The medicine Dr. Lee gave me made me a little nauseous at first, but when I talked with her about it, she told me it was normal and would subside. So, I continued the sertraline and after a couple of weeks, the nausea did go away. I tried to exercise like you suggested, but my arthritis just bothered me too much.”
Today her score on the Geriatric Depression Scale is 4, which is in the normal range.
Silvia adds, “Mom has made new friends at church and has become involved with a group of women there that she spends time with several days a week. It’s nice to see her taking an interest in things again. It actually takes a huge weight off my shoulders, as well. Thank you for all of your help.”
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