Insomnia in the Elderly: Evaluation and Management

@#Sleep disturbance is common in the elderly and is frequently undiagnosed. It has been estimated that 75% of adults >65 years of age has sleep disturbance and 30% of them has insomnia. The classification of insomnia has less significance in the older adults as the subtypes demonstrate significant overlap and usually treatment of the underlying disorder does not solve the problem or cure it. The elderly has multiple comorbidities and polypharmacy with a myriad of cause for insomnia. A comprehensive medical and psychiatric history together with a complete physical examination and mental state examination should be done in the evaluation of the older patient. Behavioural therapy with sleep hygiene education should be the initial treatment together with the treatment of the contributing physical and psychiatric conditions. Referral to an expert for cognitive behavioural therapy or multicomponent therapy may be necessary if the initial therapy failed to produce any improvement. If medications are needed it can be combined with behavioural therapy. Medication used should be the lowest effective dose and prescribed for short-term use of not more than 4 weeks. Medications used need to be discontinued gradually and one needs to be mindful of rebound insomnia upon withdrawal. Wherever possible, it will be ideal to avoid benzodiazepines and other sedative hypnotics as first choice for insomnia. Over the counter sleep aids which usually contain antihistamines may not be good choices as they carry significant risk of adverse events and drug interactions. Currently the safest medications for use in the elderly includes the Z-drugs (zolpidem, zopiclone), melatonin and low dose tricyclic antidepressant Doxepin.

INSOMNIA IN THE ELDERLY: EVALUATION AND MANAGEMENT

@#Sleep disturbance is common in the elderly and is frequently undiagnosed. It has been estimated that 75 percent of adults >65 years of age has sleep disturbance and 30 percent of themhas insomnia. The classification of insomnia has less significance in the older adults as the subtypes demonstrate significantoverlap and usually treatment of the underlying disorder doesnot solve the problem or cure it. The elderly has multiplecomorbidities and poly pharmacy with a myriad of cause forinsomnia. A comprehensive medical and psychiatric historytogether with a complete physical examination and mentalstate examination should be done in the evaluation of the older patient. Behavioural therapy with sleep hygiene educationshould be the initial treatment together with the treatmentof the contributing physical and psychiatric conditions.Referral to an expert for cognitive behavioural therapy ormulticomponent therapy may be necessary if the initial therapy failed to produce any improvement. If medications are neededit can be combined with behavioural therapy. Medication usedshould be the lowest effective dose and prescribed for short-term use of not more than four weeks. Medications used needto be discontinued gradually and one needs to be mindfulof rebound insomnia upon withdrawal. Whenever possible,it will be ideal to avoid benzodiazepines and other sedativehypnotics as first choice for insomnia. Over the counter sleepaids which usually contain antihistamines may not be goodchoices as they carry significant risk of adverse events and druginteractions. Currently the safest medications for use in theelderly includes the Z-drugs (zolpidem, zopiclone), melatoninand low dose tricyclic antidepressant Doxepin.

Thyroid Autoimmune Antibodies and Major Depressive Disorder in Women

<p><b>INTRODUCTION</b>Anti-thyroid antibodies are associated with extra-thyroid diseases such as Graves' ophthalmopathy and Hashimoto's encephalopathy. Some evidence suggests that anti-thyroid antibodies are also associated with depression. Interleukin (IL)-17 appears to play an important role in autoimmune thyroid disease. This study investigated whether specific thyroid autoantibodies and IL-17 distinguished persons with depression from non-depressed controls.</p><p><b>MATERIALS AND METHODS</b>Forty-seven adult females with non-psychotic, current major depressive disorder and 80 healthy female controls participated in this study. Thyroid peroxidase antibodies, thyroglobulin antibodies, thyroid-stimulating hormone (TSH) receptor antibodies, free T3 and T4, TSH and IL-17 were measured from the serum. Measurements were repeated to assess test-retest reliability. Receiver operating characteristic (ROC) curves were used to estimate discriminatory values of the measurements. Differences between groups and associations between the clinical and biochemical assessments were analysed.</p><p><b>RESULTS</b>Median TSH receptor antibody concentration was significantly higher in the depressed than control group (P <0.001). Area under the ROC curve was 0.80 (95% CI, 0.73 to 0.88). Higher TSH receptor antibody titres were associated with greater depression severity scores (r = 0.33, P <0.05). IL-17 levels were not associated with TSH receptor antibody levels or depression severity scores. Thyroid function and other thyroid autoantibodies were not associated with depression severity.</p><p><b>CONCLUSION</b>TSH receptor antibodies might be a biomarker of immune dysfunction in depression.</p>

Review of sleep studies of patients with chronic insomnia at a sleep disorder unit

<p><b>INTRODUCTION</b>Chronic insomnia is associated with many physical and psychiatric illnesses, and its underlying aetiology needs to be identified in order to achieve safe and effective treatment. Obstructive sleep apnoea (OSA) and periodic limb movement disorder (PLMD) are common primary sleep disorders that can lead to chronic insomnia. Patients with these conditions are evaluated using polysomnography (PSG).</p><p><b>METHODS</b>The PSG records of 106 patients with chronic insomnia who presented to a multidisciplinary sleep clinic in Singapore over a five-year period were reviewed. To examine the utility of PSG in the evaluation of chronic insomnia, the clinical diagnoses of the patients before and after the sleep studies were compared.</p><p><b>RESULTS</b>Among the 106 patients, 69 (65.4%) were suspected to have primary sleep disorders based on clinical history and examination alone. Following PSG evaluation, 42.5% and 4.7% of the study population were diagnosed with OSA and PLMD, respectively. OSA was found in 35.9% of the 39 patients who had underlying psychiatric conditions.</p><p><b>CONCLUSION</b>This study illustrates that many patients with chronic insomnia have underlying primary sleep disorders. It also highlights the danger of attributing chronic insomnia in psychiatric patients to their illness, without giving due consideration to other possible aetiologies. Clinicians should maintain a high index of suspicion for the presence of other aetiologies, and make timely and targeted referrals for sleep studies where appropriate.</p>

Comprehensive psychological intervention to improve outcome in functional gastrointestinal disorder: a cohort study

<p><b>INTRODUCTION</b>Patients with functional gastrointestinal disorders (FGIDs) have a decreased quality of life (QoL). Psychological illnesses are strongly associated with FGIDs. This study examined the effect of a comprehensive psychological intervention programme designed for refractory FGID patients.</p><p><b>METHODS</b>Refractory FGID patients at a tertiary gastroenterology unit were encouraged to participate in a psychological intervention programme, which included screening for anxiety and depression in patients, educating patients and physicians on FGIDs, and providing early access to psychiatric consultation for patients with significant psychological illnesses. The duration of follow-up was six months. Outcomes were measured using the Irritable Bowel Syndrome-QoL (IBS-QoL) instrument and the EuroQol five dimensions (EQ-5D) questionnaire.</p><p><b>RESULTS</b>A total of 1,189 patients (68% female, 80% Chinese, mean age 48.6 years) participated in the programme. Among these participants, 51% had a significant psychological disorder (Hospital Anxiety and Depression Scale [HADS] anxiety or depression score > 7). These participants had a significantly poorer QoL (IBS-QoL and EQ-5D, both p < 0.0001), and were more likely to be single or English-speaking, as compared to the participants without psychological disorders. Participants who completed ≥ 3 months of follow-up (n = 906) showed significant and durable improvement. High baseline HADS anxiety score predicted improvement (p < 0.001), with participant IBS-QoL and EQ-5D scores decreasing over time.</p><p><b>CONCLUSION</b>The intervention programme was associated with a clinically meaningful improvement in the QoL of patients with refractory FGIDs. High baseline anxiety was predictive of improvement.</p>

Hoarding in Singapore

Hoarding refers to an excessive acquisition of objects and inability to part with apparently valueless possessions. While it can lead to excessive clutter, distress and disability, it is important to note that not all cases of hoarding are pathological. This article aims to suggest how one can make recommendations to patients and families when they encounter someone exhibiting hoarding behaviour. It also introduces the Hoarding Task Force and relevant legislation in Singapore to address the issue of hoarding in the community.

Evidence-based guidelines on the use of opioids in chronic non-cancer pain--a consensus statement by the Pain Association of Singapore Task Force

<p><b>INTRODUCTION</b>While opioids are effective in carefully selected patients with chronic non-cancer pain (CNCP), they are associated with potential risks. Therefore, treatment recommendations for the safe and effective use of opioids in this patient population are needed.</p><p><b>MATERIALS AND METHODS</b>A multidisciplinary expert panel was convened by the Pain Association of Singapore to develop practical evidence-based recommendations on the use of opioids in the management of CNCP in the local population. This article discusses specific recommendations for various common CNCP conditions.</p><p><b>RESULTS</b>Available data demonstrate weak evidence for the long-term use of opioids. There is moderate evidence for the short-term benefit of opioids in certain CNCP conditions. Patients should be carefully screened and assessed prior to starting opioids. An opioid treatment agreement must be established, and urine drug testing may form part of this agreement. A trial duration of up to 2 months is necessary to determine efficacy, not only in terms of pain relief, but also to document improvement in function and quality of life. Regular reviews are essential with appropriate dose adjustments, if necessary, and routine assessment of analgesic efficacy, aberrant behaviour and adverse effects. The reasons for discontinuation of opioid therapy include side effects, lack of efficacy and aberrant drug behaviour.</p><p><b>CONCLUSION</b>Due to insufficient evidence, the task force does not recommend the use of opioids as first-line treatment for various CNCP. They can be used as secondor third-line treatment, preferably as part of a multimodal approach. Additional studies conducted over extended periods are required.</p>

Schizoaffective disorder-an issue of diagnosis

To highlight the diagnostic challenges in diagnosing a patient with schizoaffective disorder under DSM-IV-TR and to evaluate the effectiveness of changes in DSM-V in addressing these issues. Methods: We present the evolution of the diagnosis from its inception, outline its complex nosology, review the diagnostic difficulties under DSM-IV-TR and critique the proposed changes made in DSM-V. Results: A complex nosology, varied thresholds of diagnosis under DSM-IV-TR, and the inherent difficulty in obtaining a detailed longitudinal history from a patient contribute to the challenge of diagnosing a patient with schizoaffective disorder. Changes in DSM-V attempt to increase the reliability of the diagnosis by specifying and raising temporal thresholds, moving the time of disease observation away from a single episode but towards the lifetime of illness. Conclusion: Changes made in DSM-V only address a small part of the difficulties raised and clinicians will continue to face challenges in diagnosing schizoaffective disorder under DSM-V. However, there might still be value in the proposed changes under DSM-V

Case Of Significant Weight Loss And Dysphagia " Due To A Curse"

Objective: This case illustrates how a patient with medically unexplained symptoms was “cured” using symbolic healing rituals of Christianity and traditional Malay black magic. Method: We report a case of a 49-year-old lady who presented with unexplainable weight loss and dysphagia despite extensive outpatient and inpatient medical investigations. She later attributed these symptoms to a “curse” by a Boyanese man with whom she had disagreements. After catharsis with a Roman Catholic priest and cleansing with a Bomoh (Malay witch doctor), the patient’s health improved. Results: We believe this patient had a conversion disorder due to recent multiple stressors in her life and she attributed her symptoms to the “curse” inflicted to her. The symbolic healing rituals by the Catholic priest and Bomoh “cured” her of her illness which concurred with the patient’s own beliefs for her illness. Conclusion: This article illustrates the importance of the physician being familiar with various local traditional beliefs, and how the interplay between various different religions and customs can come together to treat medically unexplained symptoms in a country like Singapore.

Efficacy of cognitive behavioural therapy for patients with chronic pain in Singapore

<p><b>BACKGROUND</b>The use of Cognitive Behavioural Therapy (CBT) techniques to manage chronic pain is relatively new and understudied in Singapore. Using data collected from group CBT programmes carried out at the Singapore General Hospital (SGH), we seek to explore the efficacy of the programme on pain intensity, self-efficacy, attitudes towards pain, and emotional factors. We also examined the efficacy of the longer 6- to 9-day group programme versus an abridged 2-day version called the Pacing Programme covering only some aspects of the full group programme.</p><p><b>MATERIALS AND METHODS</b>Twenty-nine adult patients underwent the intensive 6- to 9-day group programme while another 10 patients underwent the abridged 2-day group programme. The more extensive group programme encompassed teaching patients cognitive-behavioural methods of coping with pain, such as setting goals, pacing, cognitive restructuring by thinking in more positively, distraction, problem solving, sleep hygiene, communication skills, ability to cope with changes, and relaxation techniques. The abridged programme focused mainly on developing pacing skills. Patients were required to fill out questionnaires at the beginning of the programme, end of the programme, and at the 1-month and 6-month follow-ups to monitor progress.</p><p><b>RESULTS</b>Preliminary results for the intensive 6- to 9-day group programme indicate decrease in pain and pain distress levels, improvements in management of pain, increased confidence to carry out activities despite pain, increased positive self-statements and decreased negative self-statements, decrease in fear of harm and pathophysiological beliefs, as well as decreases in the levels of depression, anxiety, and stress. The abridged 2-day programme yielded little change in pain and pain distress levels, but a slight increase in confidence to carry out activities despite pain.</p><p><b>CONCLUSION</b>These preliminary results provide some evidence supporting the efficacy of CBT techniques in chronic pain management and contribute to the growing body of evidence for the effectiveness of psychological and behavioural techniques in the management of chronic pain.</p>

Clinical aspects and management of fibromyalgia syndrome

Fibromyalgia syndrome (FMS) is a chronic and debilitating musculoskeletal pain disorder of unknown aetiology with usual accompanying features of fatigue, sleep disturbances and stiffness. Its place in medical textbooks was controversial with rheumatologists holding the helm of its management for many years. Over the last decade, abnormalities have been identified at multiple levels in the peripheral, central, and sympathetic nervous systems as well as the hypothalomo-pituitary-adrenal axis stress response system. With the elucidation of these pathways of pain, FMS is known more as a central sensitivity syndrome. This led to tremendous increment in interest in both pharmacological and non-pharmacological treatment of FMS. The United States Food and Drug Administration (FDA) has also successively approved 3 drugs for the management of fibromyalgia--pregabalin, duloxetine and milnacipran. Non-pharmacological modalities showed aerobic exercise, patient education and cognitive behavioural therapy to be most effective. Overall, management of FMS requires a multi-disciplinary approach.

Use of antidepressants in the treatment of chronic pain

There is a high prevalence of chronic pain disorders in the population and the individual and societal costs are large. Antidepressants have been used in the treatment of chronic pain and the pain-relieving effects are independent of the mood-elevating properties. We reviewed randomised-controlled trials, systematic reviews and meta-analyses of antidepressants in the treatment of chronic pain disorders which were identified through searches of MEDLINE and EMBASE. Antidepressants have proved to be effective in the treatment of fibromyalgia, chronic low back pain, diabetic neuropathy, postherpetic neuralgia and chronic headache, in particular tricyclic antidepressants (TCAs). There is emerging evidence that newer dual-action antidepressants are equally efficacious. Antidepressants provide a viable option in the management of chronic pain disorders. Further research into novel antidepressants will aid the pain clinician in optimising treatment for patients.

The media and suicide

Suicide is a common and preventable event that is often reported by the media when there are sensationalistic elements or if the suicide involves a celebrity. Media reports of suicide can induce a copycat or "Werther effect". There is increasing evidence that sensationalistic reporting of suicides has a direct effect on increasing suicide rates. Responsible reporting guidelines drawn up in consultation with media professionals have been shown to improve reporting of suicides. Local reporting on suicides tends to be sensationalistic but also has a strong educational slant. The media should educate both the public and the medical professional about their role in suicide prevention.

Neuropsychiatry--an emerging field

Neuropsychiatry is an emerging field at the intersection of neurology and psychiatry, driven by the unprecedented advances in neuroscience. The arbitrary demarcation between neurology and psychiatry, which largely existed only in the last century and a half, has become less tenable. We discuss the definition and scope of this emerging field. We also review the development of clinical neuropsychiatry in Singapore in the context of historical developments and recent changes in the field from other countries. At a more practical level, we discuss a few of the clinical settings in which neuropsychiatry operates, in particular, the stigma associated with psychiatric disorders locally, and the significant number of patients with psychiatric or psychosomatic symptoms presenting to neurology and general practice clinics. The stigma may be ameliorated by better understanding of the neurobiological basis of psychiatry. We see the future of neuropsychiatry in Singapore, as in other developed countries, as one approach to understand and manage complex brain disorders. We advocate training for both psychiatry and neurology residents in their counterpart fields, which will lead to greater understanding of both fields, and enhance collaboration in clinical care and research.

Hypnotherapy for sleep disorders

Hypnosis can be defined as a procedure during which changes in sensations, perceptions, thoughts, feelings or behaviour are suggested. Hypnosis can be used to amplify whatever it is about therapy that makes it therapeutic. It permits a wide range of choices regarding where and how to intervene in the patient's problems. In this paper, we set out to examine the rationale of using hypnotherapy to manage various types of sleep disorders, and to explore the techniques, strategies and hypnotic scripts employed by various hypnotherapists. We also examine the research data available on the efficacy of hypnosis in the treatment of sleep disorders. Acute and chronic insomnia often respond to relaxation and hypnotherapy approaches, along with sleep hygiene instructions. Hypnotherapy has also helped with nightmares and sleep terrors. There are several reports of successful use of hypnotherapy for parasomnias, specifically for head and body rocking, bedwetting and sleepwalking. Hypnosis is a specialised technique, not a therapy itself, and should be used as an adjunctive intervention within a complete psychological and medical treatment package. Most of the literature is limited to case reports or studies with such a small sample that at times it is very difficult to interpret the results. There is a major placebo effect, so uncontrolled trials are of limited value. It is hard to perform a randomised, double-blind, controlled trial to evaluate hypnotherapy given that cooperation and rapport between patient and therapist is needed to achieve a receptive trance state.