Transcript Anxiety Disorders in the Elderly

Anxiety and Sleep
Disorders in the Elderly
Thomas Magnuson, M.D.
Assistant Professor
Division of Geriatric Psychiatry
Department of Psychiatry
What is anxiety?
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Normal, adaptive emotion
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Run from a tiger
Pass a test
When excessive, it is maladaptive
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Cannot function at work, in school, in relationships
Paralyzing, embarrassing
Symptoms
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Cognitive
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Behavioral
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Worry
Fearfulness
Phobias,
Hyperkinesis
Physiologic
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Heart palpitations
Hyperventilation
Anxiety Disorders
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Common source of anxiety is depressive disorders
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Ego dystonic
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50% of those with depression have significant anxiety
Patients usually come to us
Uncomfortable
Most common group of mental illnesses
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11% of the population
Cause a significant amount of suffering and dysfunction
May even lead to disability
Epidemiology
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6 month and lifetime prevalence
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Indicates anxiety disorders are the most prevalent
mental health diagnoses in elders as in adults
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Decline from mid-life to old age
19.7% at 6 months
34.1% lifetime
Roughly 10%
Leads to higher medical and psychiatric morbidity in
geriatric patients
Anxiety Disorders
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Panic disorder
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With agoraphobia
Without agoraphobia
Agoraphobia without panic disorder
Social phobia
Specific phobia
Generalized anxiety disorder
Anxiety disorders
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Obsessive-compulsive disorder (OCD)
Acute stress disorder
Posttraumatic stress disorder (PTSD)
Due to general medical condition
Substance-induced
NOS
Substance-induced Anxiety
Disorder
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More likely to happen as one ages
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As one is more likely to be on medication(s)
Anxiety related to the use, abuse or withdrawl from
medications or drugs
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Alcohol, amphetamines, anticholinergics, antidepressants,
anti-TB drugs, anti-HTN, caffeine, cannibus, beta-blockers
(w/d), cocaine, digitalis, dopamine, ephedrine, l-dopa,
methylphenidate, NSAIDs, pseudoepedrine, asa, sedativehypnotics (w/d), steroids, theophylline, thyroid
Anxiety Disorder Due To
General Medical Condition
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Again more likely in the elderly
 The elderly have more medical problems
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This is a partial list of common conditions
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Cardiovascular-CHF, arrhythmia, MI
Endocrine-hypoPTH, thyroid, hyperadrenalism
Immunologic- RA, SLE, TA
Lung disease-Asthma, COPD, PE
GI disease-Crohn’s, UC
Neurological illness-CVA, MS, MG, Neurosyphillis,
postconcussive syndrome, seizures, TIAs, vertigo
Prevalence in the Elderly
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Prevalent in the elderly
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Many studies note anxiety symptoms
 1-19% in community dwelling elderly
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GAD 1-14%,
Phobic disorders 0.7-7%
Panic disorder 0.1-1%
Anxiety leads to impairment in quality of life
 Related to disability in some cases
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Anxiety about existing disability
Anxiety can lead to disability
Steeper cognitive declines when anxiety untreated in
dementia
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Anxious people cannot focus or pay attention
Anxiety in the Elderly
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Most coupled with depression
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Schoerers et al., 2005
 Those with GAD became depressed over time
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40% had anxiety/depression or just depression 36 mos later
Dementia
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High levels of anxiety exist in demented patients
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Great Britain Ballard, et al 1995
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22% subjective anxiety
11% autonomic anxiety
38% tension
13% situational anxiety
2% panic attacks
Anxiety in Long Term Care
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Multiple studies
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1994 Australia
 11.2% NH residents had generalized anxiety disorder
 58% of those with anxiety were also depressed
2005 Holland
 5% had only an anxiety disorder
 5% had both an anxiety and mood disorder
2006 Holland
 5.7% had a diagnosable anxiety disorder
 4.2% had subthreshold anxiety
 29% had anxiety symptoms
Not recognized in the Elderly
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Yet, still not diagnosed readily in the elderly
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Not commonly noted in clinics
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If so, commonly seen as part of a mood problem
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Various scenarios
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There is a strong correlation
Preexisting
Mildly present, now with stressors more problematic
Completely new onset
Older people don’t meet criteria
 Current criteria don’t capture the quality of anxiety in
the elderly
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Anxious mood, tension, vague somatic complaints
Elderly do not endorse daily worry
Not recognized in the elderly
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Age of onset for anxiety is presumed to be
youth
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Dementia, depression are “elderly problems”
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Not PTSD, OCD and phobias
Older women are supposed to be anxious
 Ageist assumption
Most anxiety disorders in the elderly are chronic,
except:
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Agoraphobia, fear of falling
Generalized Anxiety Disorder
Not recognized in the elderly
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Less need to leave ones’ social network
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Agoraphobia, fear of falling are common in geriatric
patients
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These patients avoid office visits
May not be able to travel to appointments readily
Anxiety doesn’t disrupt functional life
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Though present, there is likely no work or school or
partner to interfere with
With move into long term care these anxieties come to
the top
Working up anxiety
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Clinical evaluation
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Laboratory testing
 Rule out common conditions that lead to anxiety
History and physical
 Past medical history
 Medication use, alcohol use
 Family and social history
 Physical exam
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Trembling, racing heart, rapid breathing, sweating, dry mouth
Mental status exam
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Poor attention, distractibility, much motor movement, easily
startled, wide-eyed, feeling of dread
Rarely requires special psychological testing
Treatment
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Anxiolytics
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Benzodiazepines
 Agents that calm and relieve anxiety across the lifespan
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So make sure you are treating anxiety
Most common agents
 Alprazolam (Xanax)
 Lorazapam (Ativan)
 Clonazepam (Klonopin)
Adverse events
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Sedating
Potential for gait instability
Dependency producing
Paradoxical effect more prevalent in the elderly, esp. in dementia
Treatment
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Anxiolytics
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Benzodiazepines
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Some agents are longer lasting than others
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Alprazolam<Lorazepam<Clonzepam
Longer lasting agents may accumulate in the residents
system and lead to intoxication or adverse events
Metabolism differences
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Some agents require less involvement of the liver
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Lorazepam (Ativan)
Oxazepam (Serax)
Treatment
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Anxiolytics
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Buspirone (BuSpar)
 A unique nonbenzodiazepine agent
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Takes 4-8 weeks to fully work
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Serotonin 1-A agonist
No sedation, cognitive or motor impairment
Time frame is like an antidepressant
Not good for panic disorder
Good in mixed depression-anxiety states
May not work as well in chronic benzodiazepine users
Treatment
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Antidepressants
 SSRIs used in GAD, panic, OCD, PTSD
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Venlafaxine (Effexor), duloxetine (Cymbalta)
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First line agents in panic disorder and OCD
Safe in the elderly
Mild GI, headache symptoms
Irritability, anxiety and sexual dysfunction
SNRIs used commonly for anxiety
Heightens blood pressure
Tricyclics
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Clomipramine (Anafranil) good for OCD, but too anticholinergic for
older patients
May employ nortriptyline (Pamelor) if cardiac disease not an issue
Treatment
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Antidepressants
 Bupropion (Wellbutrin)
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Mechainsm a puzzle
Activating
Few drug-drug interactions
Mirtazapine (Remeron)
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Sedating, appetite enhancing at low doses
Data exists supporting the medication being used in anxiety
disorders
Treatment
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Psychotherapy
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Helpful if
 The patient desires to be a therapy patient
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The patient can comprehend the therapist’s instructions
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If the patient is not motivated it will not work
Many elderly see therapy as proof they are now “nuts”
 Nontraditional supportive therapists may be more palatable
 Like ministers, priests, rabbis
Cognitive-behavioral therapy
Supportive therapy
Make sure the therapist has some experience working with
the elderly
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Child therapy analogy
Interventions for anxious
patients
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Routine
 Structure is important since anxiety relates to loss of control
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Exercise
 Physical activity burns off anxiety
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Pacing may be the residents way of lessening anxiety
Rote activity
 Repetitive actions
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Many cognitively impaired residents improve with a higher level of
structure because their anxiety is lessened
From knitting to saying the rosary to rocking in a chair
Brief, regular appointments with a trusted staff
 For patients who wish to discuss anxiety
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Reality testing, family phone calls, simulated presence
Sleep Disorders in the Elderly
Brenda K. Keller, MD
Assistant Professor
Geriatrics & Gerontology
University of Nebraska Medical
Center
Sleep disorders in the elderly person
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Epidemiology
Review changes in the sleep cycle with aging
Non-pharmacological Management of sleep
disorders
Epidemiology
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20-40% of older Americans experience
insomnia at least a few nights per month
2/3 of elderly in institutions experience
problems with sleep
Insomnia may be:
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Difficulty falling asleep 18.1%
Difficulty staying asleep 18.6%
Not feeling restored by sleep 30.9%
Rockwood et al J Am Geriatr Soc 2001; 49:639-41
Normal Sleep Pattern
After sleep onset:
 Sleep usually progresses through NREM
stages 1 to 4 within 45 to 60 min. Slow-wave
sleep (NREM stages 3 and 4) predominates
in the first third of the night and comprises 15
to 25% of total nocturnal sleep time in young
adults.
 The first REM sleep episode usually occurs in
the second hour of sleep.
Changes in sleep with age
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Light sleep (Stages 1 and 2) increases with age =More
awakenings
Deep sleep (Stages 3 and 4) decreases from ~25%
down to 3% of total sleep time
The depth of slow-wave sleep, as measured by the
arousal threshold to auditory stimulation, also decreases
with age.
 In the otherwise healthy older person, slow-wave
sleep may be completely absent, particularly in males.
Decreased amount of REM sleep
Sleep quality and efficiency is 70-80% of younger
subjects.
Changes occur in the day/night cycle.
Circadian Rhythm Changes
Sleepy, go to bed
wake up
Standard phase
6:00p 7:00 8:00 9:00 10:00 11:00 MN 1:00 2:00 3:00 4:00 5:00 6:00a 7:00 8:00 9:00
Sleepy
Advanced phase
go to bed
wake up
Decline in hours slept by age
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7
6
5
4
Hours Sleep
3
2
1
0
30
40
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60
70
80
Changes in sleep in LTC
residents with dementia
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Increased fragmentation of sleep
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Leads to problems with daytime fatigue, nighttime
wakefulness
Average hours of sleep 6.2 hours
But, average sleep episode was 21 minutes, peak
83 minutes
Commonly seen in sleep charting
Impact of Disrupted Sleep
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Difficulty staying awake during the
day
Impaired attention
Slowed response time
Impaired memory and concentration
Decreased performance
Mortality due to common causes of death is
2 x higher in older people with sleep
disorders than those who sleep well.
Evaluation
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Sleep history
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Timing of insomnia
Sleep schedule
Sleep environment
Sleep habits
Daytime effects
Symptoms of other
sleep disorders
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Medical history
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Social History
 Stressors
 ETOH/Caffeine use
Medication review
Psychiatric history
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Depression
Mania
Psychosis
Sleep Environment in NH
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Mixed up stimuli
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Care routines do not promote sleep
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High levels of night time noise and light
Low levels of daytime light
“Casino effect”
Every two hour toileting
Waking patients to change them
Vitals being checked
Absence of defined “night time” routine with lowering
of hall lights and TV’s.
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Dark at night and quiet at night
 Elementary school stop lights are reminders
Medical History
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Common conditions associated with sleep
disturbances
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Arthritis
CHF
Gastrointestinal disorders
Asthma
Angina/Arrhythmias
Urinary symptoms
Neurological symptoms
Effectiveness of Nonpharmacological Treatment of
Insomnia
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Improve symptoms of insomnia in 70-80% of
patients with primary insomnia
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Effects last at least 6 months after treatment
completed
Non-pharmacological Management
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Sleep hygiene
Stimulus control
Sleep restriction
Cognitive therapy
Paradoxical intention
Non-pharmacological Management
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Sleep hygiene
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Should be entertained with any sleep problem
Education about health and environmental
practices that affect sleep
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For staff, family and residents
This strategy is used in conjunction with other
techniques to improve sleep
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A common starting point with sleep physicians
Sleep Hygiene
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Health Factors
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Diet
Exercise
Substance abuse
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Environmental Factors
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Light
Noise
Room temperature
Mattress
Non-pharmacological Management
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Stimulus control
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Reinforces temporal and environmental cues for
sleep onset
Go to bed when sleepy
Use the bed only for sleep
Bedtime routines
Regular morning rise time
Avoid napping
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Or a brief scheduled event
Non-pharmacological Management
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Sleep restriction
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Decrease amount of time in bed to increase sleep
efficiency
 i.e., you can only be in bed five hours
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Sleep efficiency means how much time you are asleep when
actually in bed
Only allowed time in bed is usually spent asleep
 If awake…out of bed!
Increase by 15 minutes per night
 5:15, 5:30, 5:45, etc.
Wake time constant, bedtime adjusted
 Always up at 6 am
Allows short scheduled afternoon nap
Non-pharmacological Management
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Cognitive therapy
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If a resident is not cognitively impaired
Involves identifying dysfunctional beliefs and
attitudes about sleep and replaces them with
adaptive substitutes.
Helps minimize anticipatory anxiety and arousal
Non-pharmacological Management
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Paradoxical intention
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Based on premise that performance
anxiety inhibits sleep onset
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Involves persuading a patient to engage in the feared
behavior of staying awake
If pt stops trying to fall asleep and genuinely attempts
to stay awake, sleep may come more easily
Pharmacological Treatments
Choose carefully due to risk of side effects
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FDA Approved
Benzodiazepines
Non-Benzo hypnotics-
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Type I Gaba receptor
agents
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Eszopiclone
Rozerem
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Non-FDA Approved
Herbal therapies
Hormones/naturopathic
Sedating
antidepressants
OTC antihistamines
General precautions
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Start low, go slow
Avoid q hs dosing
Use only 2-3 weeks
Questions?