Event 2: Geriatric Insomnia Management

Mrs. Johnson's Sleep

Patient reports that her sleep is not restful causing increased daytime fatigue
- “Deteriorating sleep quality”
Our patient’s insomnia risk factors
- Decreased mobility, age
- Potential contributing medical comorbidities
  - GERD, depression, chronic pain, COPD
- Citalopram use
  - 15% incidence of insomnia
Current medications for sleep
- Diphenhydramine in Tylenol PM® 500mg/25mg; 2 caplets PO QHS prn sleep (using regularly)
- Zolpidem 10mg PO QHS prn sleep (using regularly)
Additional assessment information needed
- Daytime napping
- Nocturia
- Caffeine intake
- Citalopram use
- Sleep apnea
Non-pharmacologic insomnia interventions
- Avoid daytime napping
- Maintain a consistent sleep/wake schedule
- Optimize daytime exercise and light exposure
- Minimize caffeine and alcohol intake
- Restrict time in bed to sleep only
- Establish a consistent routine before going to sleep
- Do not stay in bed if you have not fallen asleep within 30 minutes
Diphenhydramine and chronic zolpidem not recommended in older adults
Diphenhydramine is a highly anticholinergic agent
- Consider stopping since safer insomnia alternatives exist
Increased potential for delirium, fall, and fractures with zolpidem
- Additional insomnia assessment information needed before adjusting therapy
  - Unclear duration of zolpidem use
  - Will require zolpidem tapering to prevent withdrawal
  - Decrease dose by 50% for 2 weeks prior to discontinuation
Patient may experience decreased insomnia by optimizing
- Pain and depression management
Potential improvement in GERD symptoms by discontinuing ibuprofen

Beers Criteria Medications

Beers Criteria medications our patient is receiving:

Ibuprofen 600mg orally TID
Diphenhydramine in Tylenol PM® 500mg/25mg; 2 caplets orally as needed for insomnia (using regularly)
Zolpidem 10mg orally as needed for insomnia (using regularly)
Patient at risk for GI bleeding and worsening CKD from ibuprofen
- Safer analgesic alternatives exists, recommend stopping ibuprofen
Diphenhydramine is highly anticholinergic.
- Use safer sleep aid
Chronic zolpidem not recommended
- Increased potential for delirium, fall, and fractures
- Additional insomnia assessment information needed before adjusting therapy
  - Duration of use unknown
  - Requires tapering to prevent withdrawal
  - Decrease dose by 50% for 2 weeks prior to discontinuation
Patient prescribed Hydrocodone/Acetaminophen 5mg/325mg tablets, 1 tab Q4H prn pain
- Receiving a combination opioid product with 325mg/tablet of acetaminophen
- Potential daily acetaminophen dose 1950mg/day
Patient self-medicating with Acetaminophen/Diphenhydramine (Tylenol PM®) 500mg/25mg caplets, 2 caplets orally as needed for insomnia
- Additional 1000mg/day acetaminophen
- Potential total daily acetaminophen dose 2950mg

New Patient Visit

We are going to try to determine the specific type of pain Mrs. Johnson is experiencing.

Let’s review the history for important clues.

Test Your Knowledge

What type of pain is being described by the patient?

Incorrect

Correct. Mrs. Johnson's complaints of “throbbing and achy” pain in her back suggest a somatic type of nociceptive pain. Her complaints of “burning” and “pins and needles” pain in her legs suggests the presence of neuropathic pain. Nociceptive pain: Pain that arises from actual or threatened damage to non-neural tissue and is due to the activation of nociceptors. Nociceptors are neural structures in peripheral tissue that detect harmful stimuli. These may be classified according to the mode of noxious stimulation; the most common categories being "thermal" (heat or cold), "mechanical" (crushing, tearing, etc.) and "chemical" (iodine in a cut, chili powder in the eyes). Nociceptive pain may also be divided into "visceral," "deep somatic" and "superficial somatic" pain. Visceral structures are highly sensitive to stretch, ischemia and inflammation, but relatively insensitive to other stimuli that normally evoke pain in other structures, such as burning and cutting. Visceral pain is diffuse, difficult to locate and often referred to a distant, usually superficial, structure. It may be accompanied by nausea and vomiting and may be described as sickening, deep, squeezing, and dull. Deep somatic pain is initiated by stimulation of nociceptors in ligaments, tendons, bones, blood vessels, fasciae and muscles, and is dull, aching, poorly localized pain. Examples include sprains and broken bones. Superficial pain is initiated by activation of nociceptors in the skin or other superficial tissue, and is sharp, well-defined and clearly located. Examples of injuries that produce superficial somatic pain include minor wounds and minor (first degree) burns. Neuropathic Pain: Pain arising as direct consequence of a lesion or disease affecting the somatosensory system. This includes a wide variety of potential sites within the nervous system including peripheral nerves, the spinal cord, thalamus and somatosensory cortex. The most striking sign of neuropathic pain (as opposed to nociceptive pain) is the relative lack of tissue pathology. Most patients do not have obvious tissue injury (although they may have had previous injury) yet complain of pain, and their complaints often seem to be out of proportion to the pain that would be expected to accompany the original injury. The cardinal features of neuropathic pain include constant pain, which can be superficial or deep, sharp or aching. Patients with neuropathic pain will often describe their pain as being electric like or “pins and needles”. Some patients experience bouts of lancinating pain (i.e., sudden and sharp, severe bursts of pain), and allodynia (i.e., pain experienced after normally nonpainful stimuli, such as light touch). Patients with allodynia can have difficulty wearing clothing.

Incorrect

Pain Pathways Specific to Mrs. Johnson

Mrs. Johnson's low back pain is a somatic type pain caused by her arthritis. The pain generators are in the lumbar region where the transduction is occurring. The pain signal is transmitted along A-delta and C fibers from her lumbar spine to the CNS where modulation and perception take place.

Mrs. Johnson's leg pain is a neuropathic type pain. The pain generators are in the central spinal canal where her cauda equina is impinged by her central stenosis. This is the site of transduction for her leg pain. Pain impulses are transmitted up the cauda equine and to the CNS where modulation and perception occur.

Past Medical History

Alcohol abuse in her early 20s
Osteoarthritis requiring episodic cortisone injections in her left knee and right shoulder
Diabetes mellitus for nine years
COPD
Osteoporosis
Hypertension
Episodic depression throughout life

Current Prescribed Medications

Lisinopril 10 mg daily
Amlodipine 10mg orally daily
Glipizide XL 10mg daily
Sitagliptin 25mg orally daily
Tiotropium 18mcg Inhale daily
Albuterol 90mcg/puff MDI 1-2 puffs inhale Q4h as needed SOB
Citalopram recently increased to 40mg daily
Ibuprofen 600mg TID
Zolpidem 10mg QHS as needed (using regularly)
Hydrocodone/Acetaminophen 5/325mg as needed pain

Family History

Alcoholism in father and brother
Father disabled at 46 due to low back pain; died of cirrhosis at 52
Mother had diffuse osteoarthritis and died from heart disease at 82
Mother had been treated for depression

Social History

Married twice – divorced her first husband at 30 because of ETOH use. Remarried at 35 to a supportive man who died of cancer a few years ago.
Two adult daughters who live nearby and are supportive
Smokes 5 cigarettes daily
Distant history of ETOH abuse

Gait and Range of Motion

Physical Examination Findings

Blood pressure 140/92. Afebrile. Ht 5’4”. Wt 194 lbs. (BMI* 33)
Antalgic and guarded gait
Decreased range of motion and pain with both lumbar flexion and extension
Motor exam grossly intact but limited by pain
Sensory exam consistent with diabetic peripheral neuropathy
Asymmetric DTR’s
Negative straight leg raise exam

*Body mass index (BMI) is a measure of body fat based on height and weight that applies to adult men and women.

A BMI > 30 is designated as obesity
A BMI ≥ 35 or 40 is severe obesity
A BMI of ≥ 35 or 40–44.9 or 49.9 is morbid obesity
A BMI of ≥ 45 or 50 is super obesity

Chart showing body mass index based on height and weight — Body Mass Index

Motor exam seemed grossly intact, but was limited secondary to her pain.

Sensory exam demonstrated classic “stocking” sensory deficit distribution which is consistent with her history of diabetes

DTR’s were assymetric suggesting the presence of lumbar pathology

Straight leg (SLR) was negative. She complained of low back pain with SLR which is a nonspecific finding, but there was not any reproduction of radicular pain

Test Your Knowledge

The most appropriate next step in the care of this patient would be?

Incorrect

Correct. Referrals to an emergency room or neurosurgeon are not indicated at this time. She has no “red flags” that would suggest the need for urgent medical intervention or surgical evaluation, #3 is ill advised given that therapeutic doses of ibuprofen have not been helpful and the toxicity profile is concerning. #4 is incorrect as it seems far too aggressive and poses unnecessary toxicities. #5 is not mandatory as the patient does not have overt “red flags” to suggest she needs urgent diagnostic studies. #’s 6 and 7 are both reasonable considerations as these interventions are frequently helpful with painful conditions and pose minimal risk The “red flags” were described in the Agency for Health Care Policy and Research guidelines for the management of back pain published in 1994. The “red flags” are signs and symptoms that suggest the patient may have a serious condition causing their low back pain that would mandate urgent imaging studies. Such conditions include tumours, infection, fractures and neurological damage. Red Flags include: Signs or symptoms of Cauda Equina Syndrome: Features of Cauda Equina Syndrome include some or all of: urinary retention, faecal incontinence, widespread neurological symptoms and signs in the lower limb(s), gait abnormality, saddle area numbness and a lax anal sphincter. Acute Cauda Equina Syndrome is a medical emergency and requires urgent hospital referral. significant trauma weight loss history of cancer fever intravenous drug use steroid use over 55 years at age of onset severe, unremitting night-time pain The AHCPR guidelines remain an excellent framework with which to approach patients with low back pain.

Agency for Health Care Policy and Research information on low back pain: http://www.ncbi.nlm.nih.gov/pubmed/7987418

Test Your Knowledge

The patient has requested some additional help with pain while she arranges a visit with the chiropractor, which options below are appropriate treatment considerations?

Incorrect. It is inappropriate since safe treatments exist. It is also inappropriate as it is neither empathetic nor addresses her concern regarding her ongoing pain.

Correct. It is a reasonable alternative.

Correct. It is reasonable given her recent favorable response to this.

Incorrect. It is inappropriate given that better options exist and this would negatively impact her diabetes.

Incorrect. It is inappropriate as this agent is only indicated in patients with well established opioid tolerance. Furthermore, it is our expectation this patient will improve with time, so sustained release opioids are probably not going to be needed.

Test Your Knowledge

What patient education elements and counseling would be appropriate to review at this time?

Correct. #’s 1, 2, 3, and 5 are correct. #4 is incorrect and inconsistent with AHCPR guidelines. #5 is incorrect as exhaustive explanations would likely be too much for the patient to process. See article - Opioid Complications and Side Effects: Pain Physician 2008: Opioid Special Issue: 11:S105-S120 • ISSN 1533-3159 See Guideline Summary NGC-9043: “Low back pain: clinical practice guidelines linked to the International Classification of Functioning, Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association”. Bibliographic Source(s) Delitto A, George SZ, Van Dillen LR, Whitman JM, Sowa G, Shekelle P, Denninger TR. Low back pain. J Orthop Sports Phys Ther 2012 Apr;42(4):A1-A57. [327 references] PubMed Patient Education and Counseling Clinicians should not utilize patient education and counseling strategies that either directly or indirectly increase the perceived threat or fear associated with low back pain, such as education and counseling strategies that (1) promote extended bed-rest or (2) provide in-depth, pathoanatomical explanations for the specific cause of the patient's low back pain. Patient education and counseling strategies for patients with low back pain should emphasize (1) the promotion of the understanding of the anatomical/structural strength inherent in the human spine, (2) the neuroscience that explains pain perception, (3) the overall favorable prognosis of low back pain, (4) the use of active pain coping strategies that decrease fear and catastrophizing, (5) the early resumption of normal or vocational activities, even when still experiencing pain, and (6) the importance of improvement in activity levels, not just pain relief.

Incorrect

Options for Mrs. Johnson

Mrs. Johnson and Hydrocodone

The patient is starting to take hydrocodone.
If sufficient pain relief is obtained, she may stay on a moderate dose of hydrocodone for some time.
If the pain gets worse, consider that she may be developing tolerance to the opioid.
A higher dose of hydrocodone or a more effective opioid will help overcome development of tolerance.
Dependence can only be demonstrated by physiological withdrawal symptoms.
The patient is elderly, so there may be a reduction in drug metabolism of hydrocodone and acetaminophen, which she is taking.
If she is prescribed another medication, care must be taken to determine if a new medication will alter the metabolism of hydrocodone/acetaminophen.
Since she has mentioned depression, she should be asked if she is taking St. John’s Wort because St. John’s Wort will increase the activity of Cytochrome P450 enzymes and will metabolize hydrocodone and hydromorphone faster.
You will not know if the patient is dependent on an opioid unless you stop giving the patient an opioid or administer an antagonist, such as naloxone. The severity of withdrawal symptoms is indicative of the level of dependence.

Drug Metabolism

Prescription/OTC medications and herbs (e.g., St. John’s Wort) can alter drug metabolism.
- Relevant to Mrs. Johsnon
  - ethanol induces CYP2E1, an enzyme that metabolizes certain medications more rapidly if the patient has been drinking alcohol
  - smoking will induce CYP1A2, so medications metabolized using this enzyme will be less effective

ALWAYS ASK WHAT MEDICATIONS OR HERBS THE PATIENT IS TAKING

How Aging Affects Drug Metabolism

Aging is associated with a ~40% reduction of blood flow to the liver and a similar reduction in liver mass. There is a greater chance of adverse drug reactions in the elderly.
- Mrs. Johnson, at age 80, will metabolize many drugs more slowly than a younger patient.

Nurse Manager

Some symptoms that Mrs. Johnson has reported may be contributing to, or be the result of, her pain.

The nurse manager, as a resource about overall healthy behaviors meets with Mrs. Johnson after she finishes her visit with Dr. Kent.

How Do Nurses Help Patients/Families with their Struggles?

We see it all… the front row seat to suffering:
- physical, emotional, spiritual
The primary intervention we can do is to be.
To be present with the patient /family
To listen and facilitate

Sleep Hygeine

Urinary Incontinence

Defined as involuntary urinary leakage
Can occur due to:
- Functional abnormalities of the lower urinary tract
- Infection or other associated illnesses

Health Benefits of Weight Loss

Goals of Weight Management Treatment

Assist patient in preventing further weight gain (as minimum goal) with healthy food choices.
Reduce body weight slowly with healthy changes and increased physical activity.
Maintain a lower body weight over the long term.

The nurse has provided a lot of information about better health behaviors. How ready is the patient to act on this advice?

Next: Event 3: Mrs. Johnson's Chiropractic Visit