Published by National Institute of Mental Health http://www.nimh.nih.gov/suicideprevention/suifact.cfm
The notion that aging is a multifactorial process is commonly accepted. Many of the age-related changes that occur in a senior’s nervous system have an impact on the function of sleep. In the elderly, sleeping difficulties often occur in conjunction with depression. Because depression raises the risk of suicide in this population, it is important for pharmacists to question their elderly patients about sleeping difficulties.
Sleep Difficulties Increase With Aging
Complaints of sleep difficulty increase with age, tend to be more common in women than in men, and occur in about 50% of community-dwelling elderly people.1 The loss of sleep associated with sleep disturbances directly affects quality of life and often contributes to increased risk of chronic fatigue, falls, and accidents.2,3 Insomnia, a complaint of poor quality of sleep, results in a sense of nonrestorative sleep.1 Through both objective and subjective reporting, it has been shown that elderly adults, as compared to younger adults, have longer sleep latency (time to fall asleep), lower sleep efficiency (amount of sleep given the length of time in bed), a higher number of nighttime awakenings, awaken earlier in the morning than they would like, and need more daytime naps.1,4 In fact, the sleep pattern is altered in elderly individuals, with a significant decrease in delta sleep, REM sleep, and total sleep time.4,5
Because of frequent nocturnal awakenings involving wandering and confusion, sleep in institutionalized elderly people living in nursing homes is extremely disturbed.1 The fragmented sleep seen in these elderly people may be such that in a 24-hour period, not a single hour may be spent fully awake or fully asleep.1
Providing both emotional and physical restoration, sleep is essential to life.6 There is a wide interindividual variability in the amount of sleep required per night, ranging from three to 10 hours.7
Insomnia and Depression
It is well documented that insomnia is frequently comorbid with various psychiatric disorders, and researchers have indicated that sleep disturbances may be an early sign or the cause of some psychiatric disorders.8,9 While chronic insomnia may trigger depression, the converse has also been shown; that is, depression is a common, prominent cause of insomnia. Depressive and anxiety disorders are among some of the most common causes for sleep disturbances in an elderly individual.10-13 The actual relationship between insomnia and depression has been studied in older adults. One British study looked at whether sleep disturbances predict depression in seniors 65 and older. Livingston et al reported that a current sleep disturbance was the strongest predictor of future depression in nondepressed older adults.14 In another study, Roberts and colleagues looked prospectively at Californians 50 and older and found a variety of factors associated with developing depression one year later: sleep problems, psychomotor agitation, mood disturbance, low self-esteem, and loss of feeling and pleasure.15 Even though the etiology of sleep disturbances in the development of depression is unclear and sleep problems in older adults may not always be related to depression or result in a future depressive episode, it is important to emphasize that further assessment should be done to rule out all medical, psychiatric, or iatrogenic causes of insomnia. Health care professions should suspect that insomnia lasting more than three weeks may be a symptom of a medical or psychiatric disorder.6
While reviewing epidemiologic studies, Ford and Cooper-Patrick found that people in the general population may find it easier and less stigmatizing to report symptoms of insomnia more accurately than symptoms of depression such as poor concentration, fatigue, and depressed mood.16 Additionally, Ohayon and colleagues reported that a large proportion of individuals with concomitant insomnia and depressive symptoms may seek treatment only for insomnia.17
Depression, Morbidity, and Suicide Risk
Why is it so important to assess the risk for depression in a senior with insomnia who may not feel comfortable with the subject or who feels stigmatized by self-reporting a depressed mood? As mentioned earlier, a depressive disorder is among the most common causes for sleep disturbances in the elderly. Furthermore, depression is one of the most common psychiatric disorders among the elderly, with clinically significant depressive symptoms appearing in 30% of institutionalized seniors and in 8% to 15% of community-dwelling elderly.18 It has been shown that patients with any medical diagnosis were twice as likely to develop depression than were patients without a medical diagnosis. Depression increases mortality in hospitalized patients, increases medical morbidity, worsens the outcomes of medical disorders, increases the perception of poor health and the use of medical services, and increases the economic burden on the health care system.19
It must not be overlooked that depression is the psychiatric disorder most likely to raise the risk of successful suicide in the elderly. Statistics reveal that suicide rates in the United States are highest in people 70 and older. Suicide in white men is 45% more common in those ages 65 to 69 than in those ages 15 to 19.18 It is about 85% more common in those ages 70 to 74 and greater than three and one half times more common in men older than 85 than in men in the 15-to-19 age group.18 While suicide attempts are rarer in older people than in younger people, they are more lethal as a result of more careful planning, more lethal self-destructive acts, and fewer indications of the intent.19 Younger patients are more likely to seek or respond to suicide interventions than are the elderly.18 Although mood disorders are more prevalent in women than men across the spectrum of age, successful suicide is disproportionately higher in males, especially in elderly men.19
Diagnostic Questioning and the Geriatric Depression Scale (GDS)
Unless specific questions are asked, depression may go unrecognized, as it is well known that as many as 70% of seniors who commit suicide were seen by their primary care physicians within the last few weeks of their lives.4,18 Presentation of depression in the elderly varies as compared with that in the younger population. Rather than psychological complaints, somatic complaints often predominate in the clinical scenario. Although older patients often do not report a dysphoric mood, apathy and withdrawal are common. Loss of self-esteem is prominent, and guilt is less common. The inability to concentrate, with a resultant impairment of memory and other cognitive functions, is commonly seen. In addition to a review of systems, health care practitioners can question elderly patients regarding: sleep disturbance, appetite changes, trouble concentrating, lack of energy, and loss of interest. Whenever possible, in addition to ongoing primary care, referral for consultation with an experienced geriatric psychiatrist and/or psychologist is helpful in diagnosing and managing depressive disorders.
Senior care pharmacists may find the Geriatric Depression Scale (GDS; see RESOURCES) helpful in identifying depressed geriatric patients for referral for a full evaluation. The GDS may also be used subsequently by the pharmacist as an outcomes measure of antidepressant therapy in the management of depression.
General Principles of Pharmacologic Intervention
A thorough history, physical examination, and basic laboratory studies are important to fully evaluate the patient and rule out medical and medication-related causes of insomnia and depression. Additionally, the selection of the appropriate antidepressant medication (selective serotonin reuptake inhibitors, tricyclic antidepressants [TCAs], monoamine oxidase inhibitors, or atypical antidepressants), adequate dosages, and a sufficient trial period are imperative in the treatment of depression in the elderly. In seniors, an adequate antidepressant trial is longer than that for younger adults, with a complete response often seen after six to 12 weeks.19 Nuances related to medication therapy in the geriatric population should be clearly expressed by pharmacists in recommendations and educational communications. The impact of aging and medical conditions associated with aging on the pharmacokinetic profile of a medication and the increased risk of associated side effects must be understood with regard to geriatric dosage guidelines, disease-drug contraindications (eg, TCAs and cardiac conduction defects), and drug interactions (eg, CYP450 inhibition and possible toxicities).
When sleep medication is deemed the best course of treatment after careful consideration of nonpharmacologic interventions (eg, sleep hygiene, stimulus-control therapy, and sleep-restriction therapy) in the elderly, short-acting nonbenzodiazepine hypnotics (zolpidem or zaleplon) are recommended.1 These medications reduce both sleep latency, due to their quick absorption and onset, and the risk of daytime sleepiness the following day, due to their short half-life. Caution should be exercised when a longer-acting hypnotic is prescribed in a geriatric patient since associated side effects may be particularly pronounced in seniors.1 Longer-acting hypnotic agents may be associated with changes in sleep architecture such as a reduction in delta or deep sleep, morning hangover with excessive daytime sleepiness, impaired motor coordination, and visuospatial problems that may contribute to an increased risk of injury. In an attempt to prevent rebound insomnia, a very gradual taper is recommended when termination of treatment is warranted.
Conclusion
When caring for older patients, it is important to make the distinction between pathological changes and normal aging. Remaining cognizant of this helps to avoid not only dismissing a treatable pathology as merely an accompaniment to old age but also treating a natural aging process as a disease while overlooking the possibility of iatrogenic effects.
Insomnia may be a symptom of medical and psychiatric conditions, changes in lifestyle, or medications, among other precipitating factors. When an elderly patient presents with complaints of insomnia, the clinician should assess for possible depression since many seniors do not seek help for or verbally express symptoms of this condition, which is common among them and is associated with morbidity and mortality. By raising awareness that insomnia, a symptom of depression for many people, may be reported more readily than depressive symptoms, pharmacists may become involved in identifying those at risk for depression and in facilitating the appropriate evaluation, intervention, and education of patients and their families and caregivers.
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