A 78-year-old man comes to the office due to disturbed sleep. He describes being unable to sleep well for the past few months and says that it is making him feel "slowed down" and without energy. The patient used to get 7-8 hours of restful sleep each night. Now his sleep is restless: he describes needing 45-60 minutes to fall asleep and frequently awakening during the night. On average, he sleeps a total of 5-6 hours each night. He often gets up at 4:30 AM as he is unable to return to sleep. The patient has a history of hypertension treated with amlodipine. He does not drink caffeinated beverages or smoke cigarettes. He used to drink 2 beers with friends during his weekly golf and card games but has canceled these activities of late as he is too tired and no longer enjoys them. The patient is retired and has lived alone since his wife died a year ago. He admits to mild forgetfulness and says that his appetite and concentration "aren't what they used to be." Height is 180 cm (5 ft 11 in) and weight is 93 kg (205 lb). Physical examination is noncontributory apart from a 5.4-kg (12-lb) weight loss since his last visit 6 months ago. Which of the following is the most likely explanation for this patient's symptoms?

Question

A 78-year-old man comes to the office due to disturbed sleep.  He describes being unable to sleep well for the past few months and says that it is making him feel "slowed down" and without energy.  The patient used to get 7-8 hours of restful sleep each night.  Now his sleep is restless: he describes needing 45-60 minutes to fall asleep and frequently awakening during the night.  On average, he sleeps a total of 5-6 hours each night.  He often gets up at 4:30 AM as he is unable to return to sleep.  The patient has a history of hypertension treated with amlodipine.  He does not drink caffeinated beverages or smoke cigarettes.  He used to drink 2 beers with friends during his weekly golf and card games but has canceled these activities of late as he is too tired and no longer enjoys them.  The patient is retired and has lived alone since his wife died a year ago.  He admits to mild forgetfulness and says that his appetite and concentration "aren't what they used to be."  Height is 180 cm (5 ft 11 in) and weight is 93 kg (205 lb).  Physical examination is noncontributory apart from a 5.4-kg (12-lb) weight loss since his last visit 6 months ago.  Which of the following is the most likely explanation for this patient's symptoms?

Quizplus · Accepted Answer

The majority of older adults with depression initially present to primary care providers and focus more on somatic complaints than on subjective changes in mood and interest. This patient is concerned with his sleep disturbance, but further history indicates associated symptoms of depression that raise concern for a major depressive disorder (MDD). In addition to initial and middle insomnia and early-morning awakening, the patient is experiencing loss of interest in both socializing and previously pleasurable activities (anhedonia), low energy, impaired concentration, and weight loss (ie, he has 5 of 9 symptoms of a major depressive episode, sufficient for diagnosis). His weight loss and increasing social isolation are particularly concerning and should not be dismissed as normal age-related changes. His forgetfulness and impaired concentration are consistent with reversible cognitive impairment commonly seen in elderly depression. Common sleep changes in depression include multiple awakenings and early-morning awakening (as in this patient), as well as decreased REM latency and restorative sleep. This patient would be appropriately treated with antidepressants and/or cognitive-behavioral therapy, not sleep medication. (Choice A) Normal age-related sleep changes include decreased total sleep time, increased nighttime awakenings, and phase advance (becoming sleepy earlier in the evening and awakening earlier), not anhedonia or weight loss, making MDD the more likely diagnosis. (Choice B) Although acute grief often involves symptoms that overlap with depression, it has been a year since the death of the patient's wife, and his depressive symptoms have been present for only a few months. (Choice C) Insomnia disorder involves persistent difficulties initiating or maintaining sleep, resulting in clinically significant distress or impairment. It is diagnosed only when coexisting mental disorders and medical conditions do not adequately explain the predominant symptom of insomnia. (Choice E) Sleep patterns are often disrupted in people with mild neurocognitive impairment. However, this patient's mild forgetfulness and impaired concentration are common symptoms of elderly depression; together with his other depressive symptoms, they suggest a clinical picture of MDD. (Choice F) Depressed patients with insomnia often experience restlessness at night. However, restless leg syndrome involves a specific urge to move the legs in response to uncomfortable sensations. It tends to worsen at night, but it can also occur during the day. Educational objective: Sleep disturbances are commonly seen in depression. New-onset insomnia in elderly patients who have associated symptoms of depression should raise concern for major depressive disorder. References: Differential diagnoses and assessment of depression in elderly patients. (http://www.ncbi.nlm.nih.gov/pubmed/20141704) Sleep related cognitions in individuals with symptoms of insomnia and depression. (http://www.ncbi.nlm.nih.gov/pubmed/25766706) Aging, circadian rhythms and depressive disorders: a review. (http://www.ncbi.nlm.nih.gov/pubmed/24319642)

A 78-Year-Old Man Comes to the Office Due to Disturbed