This week, complete the Aquifer case titled “Case #3: 65-year-old female with insomnia - Mrs. Gomez”
Apply information from the Aquifer Case Study to answer the following discussion questions:
· Discuss the Mrs. Gomez’s history that would be pertinent to her difficulty sleeping. Include chief complaint, HPI, Social, Family and Past medical history that would be important to know.
· Describe the physical exam and diagnostic tools to be used for Mrs. Gomez. Are there any additional you would have liked to be included that were not?
· Please list 3 differential diagnoses for Mrs. Gomez and explain why you chose them. What was your final diagnosis and how did you make the determination?
· What plan of care will Mrs. Gomez be given at this visit, include drug therapy and treatments; what is the patient education and follow-up?
You are doing an eight-week clerkship in a family medicine practice. Christina, the medical assistant, hands you the progress note for the next patient, which identifies the patient as Mrs. Gomez, "a 65-year-old woman who is here today reporting that she can't sleep."
Dr. Lee, your preceptor, fills you in: "Mrs. Gomez has been a patient here for several years. Difficulty sleeping is a new issue for her. Her past medical history is significant for hypertension and diabetes. Generally, she has been doing well, although I notice that her last hemoglobin A1c has climbed to 8.7%."
What are common causes of insomnia in the elderly?
Common causes of insomnia in the elderly:
1. Environmental problems
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)
11. Advanced sleep phase syndrome (ASPS)
Common Causes of Insomnia in the Elderly
Issues that may lead to an environment that is not conducive to sleep.
· Specific examples include: noise or uncomfortable bedding.
· You can teach the patient sleep hygiene techniques that will increase the likelihood of a restful night's sleep.
Question the use of prescription, over-the-counter, alternative, and recreational drugs that might be affecting sleep.
- Patients should be counseled to avoid caffeine and alcohol for four to six hours before bedtime.
Sleep apnea is common in the elderly, occurring in 20% to 70% of elderly patients.
- Obstruction of breathing results in frequent arousal that the patient is typically not aware of; however, a bed partner or family member may report loud snoring or cessation of breathing during sleep.
In restless leg syndrome, the patient experiences an irresistible urge to move the legs, often accompanied by uncomfortable sensations.
In periodic leg movement and REM sleep behavior disorder, the patient experiences involuntary leg movements while falling asleep and during sleep respectively.
- As in sleep apnea, the sleeper is often unaware of these behaviors and a bed partner or family member may need to be asked about these movements.
Disturbances in the sleep-wake cycle include jet lag and shift work.
Patients with depression and anxiety commonly present with insomnia.
- Any patient presenting with insomnia should be screened for these disorders.
Patients with shortness of breath due to cardiorespiratory disorders often report that these symptoms keep them awake.
Pain or pruritus may keep patients awake at night.
Those with GERD may report heartburn, throat pain, or breathing problems.
- These patients may also have trouble identifying what awakens them.
- Detailed questioning may be needed to elicit the symptoms of this disorder.
Elderly patients with hyperthyroidism frequently do not present with typical symptoms such as tachycardia or weight loss, and laboratory studies may be required to detect this problem.
Circadian rhythms change, with older adults tending to get sleepy earlier in the night. In advanced sleep phase syndrome (ASPS), this has progressed to the point where the patient becomes drowsy at 6 to 7 p.m. If they go to sleep at this hour, they sleep a normal seven to eight hours, waking at 3 or 4 a.m. However, if they try to stay up later, their advanced sleep/wake rhythm still causes them to awaken at 3 or 4 a.m. This can be difficult to distiguish from insomnia.
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.
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.