Anxiety and Sleep Disorders in the Elderly

1. Anxiety and Sleep Disorders in the Elderly Thomas Magnuson, M.D. Assistant Professor Division of Geriatric Psychiatry Department of Psychiatry

2. What is anxiety? • Normal, adaptive emotion • Run from a tiger • Pass a test • When excessive, it is maladaptive • Cannot function at work, in school, in relationships • Paralyzing, embarrassing

3. Symptoms • Cognitive • Worry • Fearfulness • Behavioral • Phobias, • Hyperkinesis • Physiologic • Heart palpitations • Hyperventilation

4. Anxiety Disorders • Common source of anxiety is depressive disorders • 50% of those with depression have significant anxiety • Ego dystonic • Patients usually come to us • Uncomfortable • Most common group of mental illnesses • 11% of the population • Cause a significant amount of suffering and dysfunction • May even lead to disability

5. Epidemiology • 6 month and lifetime prevalence • Decline from mid-life to old age • 19.7% at 6 months • 34.1% lifetime • Indicates anxiety disorders are the most prevalent mental health diagnoses in elders as in adults • Roughly 10% • Leads to higher medical and psychiatric morbidity in geriatric patients

6. Anxiety Disorders • Panic disorder • With agoraphobia • Without agoraphobia • Agoraphobia without panic disorder • Social phobia • Specific phobia • Generalized anxiety disorder

7. Anxiety disorders • Obsessive-compulsive disorder (OCD) • Acute stress disorder • Posttraumatic stress disorder (PTSD) • Due to general medical condition • Substance-induced • NOS

8. Substance-induced Anxiety Disorder • More likely to happen as one ages • As one is more likely to be on medication(s) • Anxiety related to the use, abuse or withdrawl from medications or drugs • Alcohol, amphetamines, anticholinergics, antidepressants, anti-TB drugs, anti-HTN, caffeine, cannibus, beta-blockers (w/d), cocaine, digitalis, dopamine, ephedrine, l-dopa, methylphenidate, NSAIDs, pseudoepedrine, asa, sedative-hypnotics (w/d), steroids, theophylline, thyroid

9. Anxiety Disorder Due To General Medical Condition • Again more likely in the elderly • The elderly have more medical problems • This is a partial list of common conditions • Cardiovascular-CHF, arrhythmia, MI • Endocrine-hypoPTH, thyroid, hyperadrenalism • Immunologic- RA, SLE, TA • Lung disease-Asthma, COPD, PE • GI disease-Crohn’s, UC • Neurological illness-CVA, MS, MG, Neurosyphillis, postconcussive syndrome, seizures, TIAs, vertigo

10. Prevalence in the Elderly • Prevalent in the elderly • Many studies note anxiety symptoms • 1-19% in community dwelling elderly • GAD 1-14%, • Phobic disorders 0.7-7% • Panic disorder 0.1-1% • Anxiety leads to impairment in quality of life • Related to disability in some cases • Anxiety about existing disability • Anxiety can lead to disability • Steeper cognitive declines when anxiety untreated in dementia • Anxious people cannot focus or pay attention

11. Anxiety in the Elderly • Most coupled with depression • Schoerers et al., 2005 • Those with GAD became depressed over time • 40% had anxiety/depression or just depression 36 mos later • Dementia • High levels of anxiety exist in demented patients • Great Britain Ballard, et al 1995 • 22% subjective anxiety • 11% autonomic anxiety • 38% tension • 13% situational anxiety • 2% panic attacks

12. Anxiety in Long Term Care • Multiple studies • 1994 Australia • 11.2% NH residents had generalized anxiety disorder • 58% of those with anxiety were also depressed • 2005 Holland • 5% had only an anxiety disorder • 5% had both an anxiety and mood disorder • 2006 Holland • 5.7% had a diagnosable anxiety disorder • 4.2% had subthreshold anxiety • 29% had anxiety symptoms

13. Not recognized in the Elderly • Yet, still not diagnosed readily in the elderly • Not commonly noted in clinics • If so, commonly seen as part of a mood problem • There is a strong correlation • Various scenarios • Preexisting • Mildly present, now with stressors more problematic • Completely new onset • Older people don’t meet criteria • Current criteria don’t capture the quality of anxiety in the elderly • Anxious mood, tension, vague somatic complaints • Elderly do not endorse daily worry

14. Not recognized in the elderly • Age of onset for anxiety is presumed to be youth • Dementia, depression are “elderly problems” • Not PTSD, OCD and phobias • Older women are supposed to be anxious • Ageist assumption • Most anxiety disorders in the elderly are chronic, except: • Agoraphobia, fear of falling • Generalized Anxiety Disorder

15. Not recognized in the elderly • Less need to leave ones’ social network • Agoraphobia, fear of falling are common in geriatric patients • These patients avoid office visits • May not be able to travel to appointments readily • Anxiety doesn’t disrupt functional life • Though present, there is likely no work or school or partner to interfere with • With move into long term care these anxieties come to the top

16. Working up anxiety • Clinical evaluation • Laboratory testing • Rule out common conditions that lead to anxiety • History and physical • Past medical history • Medication use, alcohol use • Family and social history • Physical exam • Trembling, racing heart, rapid breathing, sweating, dry mouth • Mental status exam • Poor attention, distractibility, much motor movement, easily startled, wide-eyed, feeling of dread • Rarely requires special psychological testing

17. Treatment • Anxiolytics • Benzodiazepines • Agents that calm and relieve anxiety across the lifespan • So make sure you are treating anxiety • Most common agents • Alprazolam (Xanax) • Lorazapam (Ativan) • Clonazepam (Klonopin) • Adverse events • Sedating • Potential for gait instability • Dependency producing • Paradoxical effect more prevalent in the elderly, esp. in dementia

18. Treatment • Anxiolytics • Benzodiazepines • Some agents are longer lasting than others • Alprazolam<Lorazepam<Clonzepam • Longer lasting agents may accumulate in the residents system and lead to intoxication or adverse events • Metabolism differences • Some agents require less involvement of the liver • Lorazepam (Ativan) • Oxazepam (Serax)

19. Treatment • Anxiolytics • Buspirone (BuSpar) • A unique nonbenzodiazepine agent • Serotonin 1-A agonist • No sedation, cognitive or motor impairment • Takes 4-8 weeks to fully work • Time frame is like an antidepressant • Not good for panic disorder • Good in mixed depression-anxiety states • May not work as well in chronic benzodiazepine users

20. Treatment • Antidepressants • SSRIs used in GAD, panic, OCD, PTSD • First line agents in panic disorder and OCD • Safe in the elderly • Mild GI, headache symptoms • Irritability, anxiety and sexual dysfunction • Venlafaxine (Effexor), duloxetine (Cymbalta) • SNRIs used commonly for anxiety • Heightens blood pressure • Tricyclics • Clomipramine (Anafranil) good for OCD, but too anticholinergic for older patients • May employ nortriptyline (Pamelor) if cardiac disease not an issue

21. Treatment • Antidepressants • Bupropion (Wellbutrin) • Mechainsm a puzzle • Activating • Few drug-drug interactions • Mirtazapine (Remeron) • Sedating, appetite enhancing at low doses • Data exists supporting the medication being used in anxiety disorders

22. Treatment • Psychotherapy • Helpful if • The patient desires to be a therapy patient • If the patient is not motivated it will not work • Many elderly see therapy as proof they are now “nuts” • Nontraditional supportive therapists may be more palatable • Like ministers, priests, rabbis • The patient can comprehend the therapist’s instructions • Cognitive-behavioral therapy • Supportive therapy • Make sure the therapist has some experience working with the elderly • Child therapy analogy

23. Interventions for anxious patients • Routine • Structure is important since anxiety relates to loss of control • Many cognitively impaired residents improve with a higher level of structure because their anxiety is lessened • Exercise • Physical activity burns off anxiety • Pacing may be the residents way of lessening anxiety • Rote activity • Repetitive actions • From knitting to saying the rosary to rocking in a chair • Brief, regular appointments with a trusted staff • For patients who wish to discuss anxiety • Reality testing, family phone calls, simulated presence

24. Sleep Disorders in the Elderly Brenda K. Keller, MD Assistant Professor Geriatrics & Gerontology University of Nebraska Medical Center

25. Sleep disorders in the elderly person • Epidemiology • Review changes in the sleep cycle with aging • Non-pharmacological Management of sleep disorders

26. Epidemiology • 20-40% of older Americans experience insomnia at least a few nights per month • 2/3 of elderly in institutions experience problems with sleep • Insomnia may be: • Difficulty falling asleep 18.1% • Difficulty staying asleep 18.6% • Not feeling restored by sleep 30.9% Rockwood et al J Am Geriatr Soc 2001; 49:639-41

27. 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.

28. Changes in sleep with age • Light sleep (Stages 1 and 2) increases with age =More awakenings • Deep sleep (Stages 3 and 4) decreases from ~25% down to 3% of total sleep time • The depth of slow-wave sleep, as measured by the arousal threshold to auditory stimulation, also decreases with age. • In the otherwise healthy older person, slow-wave sleep may be completely absent, particularly in males. • Decreased amount of REM sleep • Sleep quality and efficiency is 70-80% of younger subjects. • Changes occur in the day/night cycle.

29. 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 Advanced phase Sleepy go to bed wake up

30. Decline in hours slept by age

31. Changes in sleep in LTC residents with dementia • Increased fragmentation of sleep • Leads to problems with daytime fatigue, nighttime wakefulness • Average hours of sleep 6.2 hours • But, average sleep episode was 21 minutes, peak 83 minutes • Commonly seen in sleep charting

32. Impact of Disrupted Sleep • Difficulty staying awake during the day • Impaired attention • Slowed response time • Impaired memory and concentration • Decreased performance • Mortality due to common causes of death is 2 x higher in older people with sleep disorders than those who sleep well.

33. Sleep history Timing of insomnia Sleep schedule Sleep environment Sleep habits Daytime effects Symptoms of other sleep disorders Medical history- Social History Stressors ETOH/Caffeine use Medication review Psychiatric history Depression Mania Psychosis Evaluation

34. Sleep Environment in NH • Mixed up stimuli • High levels of night time noise and light • Low levels of daytime light • “Casino effect” • Care routines do not promote sleep • Every two hour toileting • Waking patients to change them • Vitals being checked • Absence of defined “night time” routine with lowering of hall lights and TV’s. • Dark at night and quiet at night • Elementary school stop lights are reminders

35. Medical History • Common conditions associated with sleep disturbances • Arthritis • CHF • Gastrointestinal disorders • Asthma • Angina/Arrhythmias • Urinary symptoms • Neurological symptoms

36. Effectiveness of Non-pharmacological Treatment of Insomnia • Improve symptoms of insomnia in 70-80% of patients with primary insomnia • Effects last at least 6 months after treatment completed

37. Non-pharmacological Management • Sleep hygiene • Stimulus control • Sleep restriction • Cognitive therapy • Paradoxical intention

38. Non-pharmacological Management • Sleep hygiene • Should be entertained with any sleep problem • Education about health and environmental practices that affect sleep • For staff, family and residents • This strategy is used in conjunction with other techniques to improve sleep • A common starting point with sleep physicians

39. Health Factors Diet Exercise Substance abuse Environmental Factors Light Noise Room temperature Mattress Sleep Hygiene

40. Non-pharmacological Management • Stimulus control • Reinforces temporal and environmental cues for sleep onset • Go to bed when sleepy • Use the bed only for sleep • Bedtime routines • Regular morning rise time • Avoid napping • Or a brief scheduled event

41. Non-pharmacological Management • Sleep restriction • Decrease amount of time in bed to increase sleep efficiency • i.e., you can only be in bed five hours • Sleep efficiency means how much time you are asleep when actually in bed • Only allowed time in bed is usually spent asleep • If awake…out of bed! • Increase by 15 minutes per night • 5:15, 5:30, 5:45, etc. • Wake time constant, bedtime adjusted • Always up at 6 am • Allows short scheduled afternoon nap

42. Non-pharmacological Management • Cognitive therapy • If a resident is not cognitively impaired • Involves identifying dysfunctional beliefs and attitudes about sleep and replaces them with adaptive substitutes. • Helps minimize anticipatory anxiety and arousal

43. Non-pharmacological Management • Paradoxical intention • Based on premise that performance anxiety inhibits sleep onset • Involves persuading a patient to engage in the feared behavior of staying awake • If pt stops trying to fall asleep and genuinely attempts to stay awake, sleep may come more easily

44. FDA Approved Benzodiazepines Non-Benzo hypnotics- Type I Gaba receptor agents Eszopiclone Rozerem Non-FDA Approved Herbal therapies Hormones/naturopathic Sedating antidepressants OTC antihistamines Pharmacological Treatments Choose carefully due to risk of side effects

45. General precautions • Start low, go slow • Avoid q hs dosing • Use only 2-3 weeks

46. Questions?