Jan 15 2018 – Sleep Disorder Case
Download Document: Recommendations Jan 15 2018
Date: January 15 2018
PLEASE NOTE that Project ECHO® Care of the Elderly case recommendations do not create or otherwise establish a provider-patient relationship between any ECHO Care of the Elderly Hub team member/presenters and any patient whose case is being presented in a Project ECHO® setting.
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The patient is a 75-84 year old male with depression, frailty and sleep issues. The case presenter requested recommendations on medication management and benzodiazepine tapering.
Summary of Recommendations:
- Sleep diary: Consider having the patient complete a sleep diary/journaling- objective findings of actual sleep, identify what activities are being engaged in, then may be able to encourage more of those specific activities such as exercise that may potentially improve sleep (Resource : See attached a sleep diary from the US National Sleep Foundation https://sleepfoundation.org/)
- Cognitive screen: consider in-office cognitive assessment using MOCA (http://www.mocatest.org/) to rule out emerging cognitive disorder that may be perpetuating mood and sleep issues, and/or influence treatment approaches.
- Sleep study: While this was declined by the patient initially, may consider overnight home oximetry assessment especially if history is supportive of possible sleep apnea, REM behaviour disorder, or periodic limb movements.
- CBTi/Sleep Hygiene: sleep restriction, stimulus control, spirituality, mindfulness approach, engaging in routine. Also minimizing caffeine, alcohol, nicotine or other sleep-disrupting substances, especially late in day. (Resource: sleepio.com; www.myshuti.com/)
- Engage pt as a collaborator; educating about the risks, negative and positive outcomes of the medications (improved alertness, cognition Resource: Educational pamphlet)
- Non-pharmacological suggestions: Light therapy including sunlight, meditation/spirituality exploration, Tai-chi/group-based exercise programs, mindfulness approach, acupuncture/pressure and music. Also using a notepad by the bedside to “off-load” anything that is worrying the patient. (Resource: See below referenced articles)
- Medications: Optimize the treatment of the chronic condition, anxiety/mood. Insomnia is a dx of exclusion. Review the previous medications trials: adequate doses? Adequate timeframe? Can consider trial of:
- Switch to another SSRI, or SNRI, or increase mirtazapine (maximum 45mg).
- Consider adding dose of Pregablin- Start 25mg nightly and increase in 25mg increments to a max of 300mg total daily in 1-2 doses. Common side effect include fatigue, dizziness, headaches, dry mouth.
- Buspirone àstart at 5mg po bid, increase to a total dose or 60mg/daily, common side effects include GI upset, restlessness, sleep changes, dizziness.
- Consider adding atypical antipsychotic (either optimizing Abilify or an alternate). Monitor for metabolic, extrapyramidal, CVA risk (established in individuals with dementia), QTc
- Escitalopram 15 mg is above Health Canada recommended dose in adults >65. If continued, the dose should be decreased to 10mg, or get an ECG (to check QTc) and get consent to continue at current dose.
- In combination with the above, continue reduction of lorazepam by 0.25 mg every 2 weeks to <=1 mg and ideally discontinuation, if feasible.
- May consider having a discussion with the patient surrounding setting expectations of chronic condition and tolerance of symptoms
- Consider harm reduction strategies; negotiate an informed and individual safe dose.