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13 - Psychiatric Issues |
397
elderly women were found to be less likely to
drink heavily; however, they are more likely than
men to develop late-onset alcohol abuse.
175
Although light to moderate consumption
of alcohol has been shown to decrease risk of
cardiovascular disease, diabetes, and dementia,
heavy alcohol use is associated with increased
morbidity and mortality.
179-182
Morbidities associ-
ated with chronic alcohol use include pancre-
atitis, peptic ulcer disease, cirrhosis, throm-
bocytopenia, cardiomyopathy, hypertension,
respiratory illnesses, and increased trauma from
falls or motor vehicle accidents.
171,183
Chronic
alcohol use results in cognitive impairment, with
cerebral atrophy and cerebellar degeneration.
Cerebrovascular accidents are more common in
alcoholics, which also result in significant cogni-
tive and functional decline.
175
Sleep disturbances
are frequently reported by individuals who drink
heavily, including those who use alcohol to
help initiate sleep. Alcohol has been proven to
decrease sleep maintenance, REM sleep, and
delta sleep. For elderly alcoholics, the negative
effects of alcohol on sleep are in addition to the
reduced REM and deep sleep that accompany
normal aging.
184
Alcoholics are often deficient in several
essential vitamins because of altered absorption
and decreased intake. Vitamin B12 and folate
deficiencies are common and can lead to macro-
cytic and hemolytic anemias, peripheral neurop-
athy, paresthesias, and weakness in the lower
extremities if not supplemented.
176
Thiamine
deficiency results in both Wernicke encephalop-
athy and Korsakoff syndrome. Wernicke enceph-
alopathy presents as acute confusion, ataxia,
and abnormal eye movements, and Korsakoff
syndrome presents as memory impairment.
175
Diagnostic Criteria
According to the DSM-5, one meets criteria for a
substance-use disorder if the use of a substance
leads to significant impairment defined by two
or more of the following and occurs within a
12-month period: (1) the substance is used in
larger amounts or for a longer period of time than
was intended; (2) there are continued efforts or
unsuccessful attempts to decrease use; (3)
a significant amount of time is spent seeking,
using, and recovering from the substance; (4)
one craves the substance; (5) recurrent use
results in inability to meet obligations at work,
home, or school; (6) abuse continues despite
experiencing social and personal problems as a
result; (7) normal social and work-related activi-
ties decrease because of substance use; (8)
abuse occurs in situations that are dangerous
(e.g., driving while intoxicated); (9) substance
use continues despite the patient knowing
concurrent illnesses and psychiatric disorders
are related to the use; (10) tolerance develops;
and (11) withdrawal symptoms occur when not
using the substance.
21
Presentation Specic to Geriatric
Patients
Due to age-related physical changes, older
adults have an increased sensitivity to alcohol
and other mood-altering medications. As people
age, lean body mass and total body water
decreases, which leads to decreased distribu-
tion and higher serum concentrations of these
substances.
171
Impaired hepatic blood flow
and reduced aldehyde-dehydrogenase can
lead to reduced metabolism of alcohol.
185
It and
other abused substances can easily penetrate
the CNS, making older adults more sensitive
to the effects of these substances compared
to younger adults. The interaction between
alcohol and prescription medications, especially
psychotropic medications, is a major concern in
this age group.
175
Because of these age-related factors, the
recommended appropriate intake of alcohol
for older adults is lower than the standards
established for young to middle-age adults.
The National Institute on Alcohol Abuse and
Alcoholism
186
and the Substance Abuse and
Mental Health Services Administration Treatment
Improvement Protocol
170
recommend no more
than one standard drink per day and no more
than two standard drinks on any occasion for
adults older than 65. A standard drink is defined
as 5 ounces of wine, 12 ounces of beer, or a
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| Fundamentals of Geriatric Pharmacotherapy
mixed drink containing 1.5 ounces of hard liquor.
Use beyond these recommendations is consid-
ered hazardous or at-risk drinking.
167
Many geriatric and substance-abuse
specialists agree there are limitations with using
the DSM-5 criteria to diagnose substance-use
disorders in the elderly.
187
Because of these limi-
tations, it is suspected there is low reporting in
older adults. As mentioned, one of the criteria for
substance-use disorder is developing tolerance,
which is usually shown by increased use of the
substance to obtain the same level of effect.
For older adults, substance use may appear
to decrease or stay the same due to increased
sensitivity and higher blood levels at lower
amounts. Lower quantities used may also make
it difficult for older users to meet the criterion of
spending a great deal of time in activities related
to substance use.
187
The criterion of withdrawal
may not be applicable for patients who develop
late-onset substance dependence and have not
yet experienced a period of withdrawal.
175
Finally,
because older adults are often retired or isolated
from social situations, compared to younger
adults, the criterion of failing to meet daily obli-
gations because of substance use is not as likely
to apply to many late-life substance users.
187
KEY POINT:
Limitations exist when
using the DSM-5 criteria for substance-use
disorders to diagnose geriatric patients.
ese limitations result in underdiagnosis
of late-life substance abuse.
Screening for Alcohol Dependence or
Hazardous Drinking
Alcohol abuse/dependence screening should be
part of a patient’s regular physical examination
and done at least yearly.
170
Common screening
tools used in older adults include the Short
Michigan Alcoholism Screening Test–Geriatric
version (SMAST-G), the CAGE questionnaire,
and the Alcohol Use Disorders Identification Test
(AUDIT). Out of the three screening tools, the
SMAST-G was developed specifically for older
adults.
167
The CAGE questionnaire is considered
the easiest to use in a clinic setting and has high
specificity for detecting alcohol abuse. However,
it has low sensitivity for detecting alcohol depen-
dence and at-risk drinking.
171,175
Patient self-
reporting continues to be the primary method
of obtaining history of alcohol use, although any
collateral information from the patient’s spouse
and family is helpful.
171
If a patient states he
or she abstains from alcohol, clinicians should
continue to question the reasons for abstaining.
Some individuals currently abstain from alcohol
because of abuse problems in the past.
171
Common Problems Encountered
When Treating Elderly Patients
Ethanol Withdrawal and Acute
Treatment
Older age has not been shown to increase risk
of drug and alcohol withdrawal. However, older
adults may experience longer duration of with-
drawal symptoms and are more likely to have
complications due to a longer history of alcohol
abuse, medical comorbidities, baseline cogni-
tive impairment, and sensitivity to drug treat-
ments.
171,188
Older age has also been associ-
ated with longer hospital stays for treatment and
greater risk of being discharged to an extended-
care facility.
189
Patients experiencing alcohol withdrawal
typically present with autonomic hyperactivity,
including increased pulse and blood pressure,
increased temperature, restlessness, anxiety,
tremor, and insomnia. These symptoms usually
present within the first 12–48 hours after the last
drink consumed. Severe symptoms, such as
hallucinations, delirium tremens, seizures, and
coma, can develop as late as 2–10 days after
withdrawal. Because alcohol withdrawal can be
severe and fatal, careful evaluation and benzo-
diazepine regimens should be made available
as recommended using the Clinical Institute
Withdrawal Assessment (CIWA) tool (Table
13-3).
175,188,190
Patients who are predicted to have minimal
to moderate withdrawal symptoms, no history of
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399
complicated withdrawal, no significant comor-
bidities, and who have a caregiver available to
monitor closely may complete the detoxifica-
tion process as an outpatient. The patient and
caregiver should be educated on how to use
the CIWA (Table 13-3) to assess the severity of
withdrawal symptoms. If the patient experiences
moderate withdrawal (CIWA score between 8
and 15), then a benzodiazepine can be admin-
istered to help relieve symptoms. The CIWA
should be used every 4 hours, and a clinician
should follow up with the patient daily during the
withdrawal period.
188
Patients should be admitted for inpatient
detoxification if they have a history of withdrawal
delirium or seizures, complex medical or psychi-
atric illnesses, suicidal thoughts, no strong
support system, or a CIWA score >15. Hospi-
talization can also provide further benefits, such
as lack of access to alcohol and a new environ-
ment.
188
For relief and prevention of alcohol with-
drawal symptoms, benzodiazepines are first-line
therapy for all patients, including older adults.
They act on the GABA A–type receptor, similar
to alcohol, and augment the inhibition effect of
GABA. Much data exist showing benzodiaz-
epines reduce the risk of delirium and seizures
during withdrawal.
188
However, the choice of
benzodiazepine (long-acting versus short-
acting) to treat elderly patients is not as clear.
As discussed, long-acting benzodiazepines
with active metabolites may be less tolerated
in the elderly due to age-related pharmaco-
kinetic and pharmacodynamic changes. The
adverse effects of these benzodiazepines may
be one of the reasons more complications and
longer hospital stays have been observed in
Table 13-3. Clinical Institute Withdrawal Assessment for Alcohol
220
Symptom Range of Scores
a
Agitation 0 = normal activity
7 = constantly moving
Anxiety 0 = calm, at ease
7 = acute panic symptoms
Auditory hallucinations 0 = no hallucinations
7 = continuous hallucinations
Disorientation 0 = oriented, no cognitive impairment
4 = disoriented to time, place, and person
Headache 0 = no pain
7 = extremely severe
Nausea/vomiting 0 = no GI symptoms
7 = constant nausea/vomiting/dry heaves
Sweating 0 = no sweating
7 = drenching sweats
Tactile hallucinations 0 = no hallucinations
7 = continuous hallucinations
Tremor 0 = no tremor present
7 = severe tremor
Visual hallucinations 0 = no hallucinations
7 = continuous hallucinations
a
Maximum score is 67. Minimal/mild withdrawal symptoms score <8, moderate withdrawal symptoms score
8–15, severe withdrawal symptoms score >15.
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| Fundamentals of Geriatric Pharmacotherapy
elderly patients undergoing detoxification versus
younger adults.
189,191,192
Based on the possible risk of adverse
effects with long-acting benzodiazepines, clini-
cians may wish to use short-acting agents,
such as lorazepam or oxazepam, for with-
drawal treatment in the elderly. However, one
should also keep in mind the risk: it is possible
a patient may not be provided adequate
coverage of withdrawal symptoms with short-
acting agents.
188
A recommended practice is to
start with diazepam, using the CIWA protocol.
The patient should be monitored closely for
adverse effects of the medication. If they occur,
then therapy can be switched to a shorter-
acting benzodiazepine if withdrawal coverage
is still needed.
Unless an older patient has a seizure
disorder, history of alcohol withdrawal seizures,
or history of delirium tremens scheduled benzo-
diazepine regimens are not recommended.
For most cases of detoxification, a symptom-
triggered approach, such as a CIWA protocol,
should be used to prevent unneeded benzodi-
azepine use.
188
In addition to treating withdrawal symptoms,
electrolytes and vitamins should be supple-
mented, if needed. Thiamine supplementation
(100 mg daily) should be provided in all cases
of alcoholism. Vitamin B12 and folate are also
recommended if serum levels are low or macro-
cytic anemia is present. Electrolytes, especially
magnesium, should be checked and corrected
if abnormal.
175
KEY POINT:
Although short-acting
benzodiazepines are usually recommended
over long-acting agents for elderly
patients, short-term use of long-acting
benzodiazepines is more likely to ensure
adequate coverage during withdrawal without
increasing risk of seizures. Careful dosing
and diligent monitoring are required.
Long-Term Treatment for Alcohol
Dependence
Treatment research for late-life substance-use
disorders is lacking, but published data have
slowly emerged over the last two decades,
especially for alcohol treatment. Studies have
shown psychosocial and pharmacological treat-
ments to be effective for older adults and result in
increased quality of life.
171
Community programs
for elders assisting with alcohol abstinence
have shown to be just as or more beneficial in
improving quality of life compared to middle-
aged adults.
192-194
Brief advice during clinic visits has been
shown to significantly decrease drinking in the
elderly. Several studies have demonstrated that
10–15 minutes of counseling regarding alcohol
use can significantly reduce drinking compared
to usual-care patients.
194-196
In addition, two
large trials were performed to investigate the
effectiveness and feasibility of implementing
brief advice in primary care and within commu-
nity screening programs.
197,198
Psychosocial
intervention is considered the cornerstone of
therapy when treating substance-use disor-
ders and maintaining sobriety. It has also been
beneficial for older adults and, interestingly, the
best results are observed when older patients
are involved in age-specific programs versus
mixed-age groups. Studies have shown older
adults to have higher program completion rates,
higher group attendance, and higher abstinence
rates at 6 months and 1 year after completing
a program when placed in age-specific versus
mixed-age programs.
199-201
They should include
the following: (1) group therapy with other older
adults that is supportive and helps build self-
esteem; (2) a focus on coping with common
psychosocial issues in the elderly such as
depression, loneliness, and loss of spouse; (3)
a focus on increasing social support for the
patient; (4) clinicians who are experienced in
working with the elderly; and (5) an ability to refer
patients to a case manager and other outside
services.
169,187
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401
KEY POINT:
Psychosocial intervention
is considered the cornerstone of therapy
when treating substance-use disorders and
maintaining sobriety. Age-specic programs
have been shown to work best for older adults.
Three agents (disulfiram, naltrexone, and
acamprosate) are currently FDA approved to
help maintain abstinence from alcohol. All have
been shown to be most efficacious when used
along with psychosocial therapy. Patients should
understand that pharmacotherapy is prescribed
as an adjunct and not as a replacement for indi-
vidual or group therapy.
Disulfiram is the oldest agent available for
treatment of alcohol dependence. It is used as
a deterrent from drinking in order to avoid the
symptoms associated with the alcohol-disulfiram
interaction and is not recommended for elderly
patients because of the adverse effects of acet-
aldehyde and the risk of exacerbating concur-
rent illnesses.
170
Naltrexone is an opioid antagonist with a
recommended dosing of 50 mg daily orally or
380 mg monthly if given intramuscularly. The
most common adverse effects reported are GI
symptoms (nausea, stomach pain, anorexia)
and injection site reactions with the parenteral
product. Elevation in liver transaminases and
hepatotoxicity are reported for both the oral and
injectable drug. Therefore, baseline liver function
tests should be obtained and monitored peri-
odically with therapy. Naltrexone should not be
used in patients with history of liver impairment
or those taking opioid therapy.
202
There are data supporting the efficacy
and safety of naltrexone in older adults. Oslin
and colleagues led a double-blind, random-
ized placebo-controlled study in 50–70-year-old
veterans. The treatment group was assigned
naltrexone 50 mg daily. It did not significantly
improve complete abstinence, but those taking
naltrexone were less likely to relapse to heavy
drinking.
203
Another study comparing compli-
ance among older and younger patients found
adherence to naltrexone and psychosocial
therapy was better among older adults.
204
In
this study, a higher naltrexone dose of 100 mg
daily was used, and there was no difference in
tolerability of the medication in the older versus
younger group.
Acamprosate is the newest agent approved
for maintenance of alcohol abstinence. It is
recommended that acamprosate be initiated
after detoxification and sobriety of at least 7
days. A dose of 666 mg three times a day is
normally prescribed. Although food has no
significant effect on absorption of acampro-
sate, patients may be encouraged to take it with
meals to increase compliance. The medication
is renally cleared; therefore, dose adjustments
should be made for decreased renal function.
Patients with a creatinine clearance between 30
and 50 mL/min should start with 333 mg three
times daily, and it should not be used in patients
with creatinine clearance of <30 mL/min. Acam-
prosate is usually well tolerated, and diarrhea
is the most common adverse effect.
205
To date,
there have been no trials published addressing
the efficacy of acamprosate in the elderly. It is
suspected the medication should be well toler-
ated in older adults without exacerbating any
chronic diseases. However, many elderly should
be dosed the lower dose (333 mg three times
daily) because of age-related renal impairment.
Nonmedical Prescription Drug Use
The prevalence of nonmedical prescription drug
use is noted to range from 0.14% to 1.4% in
patients age 50 and older.
206
Prescription drug
abuse appears to be uncommon among elderly,
especially if they do not have a history of other
types of substance abuse. Risk factors include
female gender, depression, social isolation, and
history of alcohol and other substance abuse.
207,208
Late-life abusers usually do not have to use illegal
methods to obtain controlled substances. Unsafe
amounts of medications are often obtained by
using multiple physicians, borrowing medica-
tion from family and friends, or by keeping and
collecting prescriptions over time.
209
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Benzodiazepines may be of concern for
abuse due to their addiction potential, and they
continue to be one of the most prescribed medi-
cations in the elderly.
104,169
Benzodiazepines are
used for many psychiatric symptoms, such as
agitation, anxiety, and insomnia. As discussed,
chronic use should be avoided in the elderly
if possible because of the high risk of adverse
effects in this population. If the use of benzodiaz-
epines outweighs the risks, then shorter-acting
agents such as lorazepam and oxazepam are
recommended, and use should be limited to no
more than 4 months.
170
For patients who are at
risk for abuse, highly lipophilic agents such as
diazepam and alprazolam should be avoided.
169
Benzodiazepine withdrawal symptoms are
more likely to present as confusion and disori-
entation in older adults rather than increased
anxiety and insomnia, often witnessed in younger
adults.
175
Treatment of benzodiazepine abuse
is gradual tapering of the medication. Patients
addicted to short-acting benzodiazepines such
as alprazolam should be switched to a longer-
acting agent first (clonazepam is a popular
choice). The longer-acting benzodiazepine can
then be slowly tapered.
175
Opioid prescribing has increased signifi-
cantly over the last 15 years for all age groups
to meet national standards for adequate pain
control.
210
Since the start of the “right to pain relief”
movement in the late 1990s, it has increased
by 149%.
211
Consequently, both rates of opioid
abuse and overdose have increased as well.
212
In the elderly population, recent studies have
also shown an increased risk of falls, fractures,
and myocardial infarctions with the chronic use
of opioids.
213-215
To provide adequate pain control
for patients but minimize the risks associated with
opioid overprescribing, national programs and
policies have recently been implemented.
216,217
The FDA now requires a Risk Evaluation and
Mitigation Strategy (REMS) from manufacturers
of long-acting opioid products. Requirements of
the REMS may include specialty certification from
prescribers and registry of patients for national
monitoring.
216
In addition to the REMS program,
several state medical boards have adopted the
Federation of State Medical Boards Model Policy
for the Use of Controlled Substances for the
Treatment of Pain.
217
Physicians in these states
are required to provide a thorough evaluation of
patients who complain of pain, which includes
assessing substance abuse history. A detailed
treatment plan is developed, documented, and
signed by the physician and patient. These
documents along with the records of ongoing
care of the patient are saved and archived.
Clinicians should be aware that drug-
seeking behavior can also be the result of inad-
equate pain control. Chronic opioid users will
develop physical dependence and can experi-
ence uncomfortable withdrawal symptoms such
as hyperalgesia, diarrhea, nausea, rhinorrhea,
shivering, anxiety, and agitation if therapy is
discontinued abruptly. Physical dependence can
occur, even if addiction is not present. Whether
abuse is suspected or the patient simply wishes
to discontinue therapy, opioids should be gradu-
ally tapered to prevent withdrawal.
209
This is true
for opioids of lower abuse potential also, such
as tramadol. Tapering the daily dose by 10% per
week is recommended. A more rapid taper of
25% to 50% every few days is appropriate for
those abusing opioids.
218
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C 1: M D D, M
S
Subjective:
TM is a 72-year-old male patient who presents to his primary care provider for the first time in
5 years with complaints of stomach and joint pain, trouble sleeping, increased anxiety, impaired
concentration and short-term memory, and lack of energy. TM is worried he has something
seriously wrong with him such as cancer.
After interviewing the patient, it is also discovered TM is no longer exercising or visiting the
community senior center as he did in the past. He mentions that he is getting old and his joint
pain has worsened over the last year to a point where he has trouble walking. TM states, “I’m
not sure why I’m still alive. I wish I would just pass in my sleep.” TM becomes tearful when he
talks about his deceased wife.
Medications:
No prescription medications, has been using OTC omeprazole 20 mg daily for stomach pain
and uses occasional acetaminophen for joint pain.
Past Medical History:
Obstructive sleep apnea (uses CPAP as prescribed), osteoarthritis.
Allergies:
NKDA.
Family History:
Both parents are dead, but neither parent had a history of mental illness.
Social History:
TM’s wife died unexpectedly a year ago while hospitalized for pneumonia. He has three
children and six grandchildren, but they all live out of state. He denies alcohol, tobacco, or illicit
drug use.
Objective:
Ht 70˝, Wt 265 lb, BP 138/89 mmHg, P 65 BPM, pain = 7/10.
Labs:
Basic metabolic panel and complete blood count are normal, TSH 3.5 milli-International
Units/L; vitamin B12 450 mg/mL.
Assessment:
TM meets the diagnostic criteria for major depressive disorder, moderate to severe. He
has decreased interest in his daily activities, trouble sleeping, decreased energy, memory
complaints, and passive suicidal ideation. In addition, he has symptoms of generalized
anxiety, with trouble sleeping, decreased energy, impaired concentration, and anxiety. He also
complains of joint and stomach pain, which may be associated with his depression.
Plan:
1.
Sertraline 25 mg can be offered to the patient as a first-line agent. Begin 25 mg daily ×1
week then titrate to 50 mg daily.
2. Refer patient to the neuropsychologist for psychotherapy, if patient agrees.
3. Begin scheduled acetaminophen 1,000 mg every 8 hours for joint pain.
4. Return to clinic in 1 week.
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Rationale:
1.
Psychotherapy and medication therapy should be offered to the patient for optimal
treatment. Sertraline, citalopram, or escitalopram are appropriate choices for a first-line
SSRI as they have a favorable pharmacokinetic profile for older adults and are available as
generic medications.
2.
Because TM has several risk factors for suicide (age, white male, chronic pain, immobility,
isolation), he should be followed frequently in the beginning of therapy (every week or
every other week). Further work-up for stomach and joint complaints may be required,
but symptoms may improve as depression is treated. This can be addressed at his return
appointment.
Case Summary:
TM is a 72-year-old man who suffered the loss of his wife 1 year ago and now presents with
late-onset depression and anxiety. He also has somatic complaints of stomach and joint pains.
Some thoughts of death are evident, which increase concern that he may consider suicide. He
is not on medications associated with depression. The stomach and joint pain may be separate
diagnoses or may be associated with his depression. Treatment with an SSRI is appropriate to
begin, as is more effective management of his pain symptoms with acetaminophen.
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C 2: I
Subjective:
SB is an 81-year-old male who presents to his primary care physician for routine physical
exam. On questioning, SB states that he is concerned he is not getting a full 8 hours of sleep
at night. He complains of having difficulties falling asleep and waking up several times during
the night, sometimes with shortness of breath. He denies fevers, chills, nocturia, dysuria, or
dyspnea. SB wakes up well-rested and is able to perform his usual activities of daily living and
instrumental activities of daily living without drowsiness.
Social History:
Negative for tobacco use, occasional alcohol use during special occasions. SB recently started
drinking 1–2 beers to help him feel sleepy before bedtime.
Objective:
PMH: BPH, HTN, CHF; BP 152/78, P 76 BPM (sitting), BP 148/78 P 78 BPM (standing).
Medications:
Terazosin 1 mg at bedtime, finasteride 5 mg daily, furosemide 20 mg twice daily, lisinopril
20 mg every morning, aspirin 81 mg daily. OTC/herbals: none.
Physical Examination:
Within normal limits except trace pitting edema in ankles bilaterally and a slightly enlarged
prostate.
Labs:
Urinalysis negative.
Assessment:
SB is an 81-year-old man who presents with concerns about his total sleep time, sleep latency,
and frequent nocturnal awakenings. He has several modifiable factors that can exacerbate
insomnia to be addressed before hypnotic therapy is considered. He may be experiencing
adverse outcomes associated with his current drug regimen that are exacerbating insomnia,
either via adverse effects or poor disease state control.
Plan:
1.
Educate patient on the normal changes in the elderly that may be affecting his sleep
pattern and in daily routines that affect sleep hygiene. Educate patient on proper sleep
hygiene and offer cognitive behavioral therapy.
2. Discontinue alcohol consumption before bedtime. Caution patient on self-treating with
OTC sleep aids. These interventions may worsen his sleep complaints and his comorbid
conditions.
3. Recommend reevaluation of his heart failure regimen with other members of the
care team. Specifically, evaluate the administration times of furosemide and consider
adjustment of the dose to avoid a diuretic effect at night. Evaluate whether optimizing
his heart failure regimen may improve heart failure symptoms in general, and sleep
symptoms specifically.
Rationale:
Because SB wakes up well-rested without daytime drowsiness, pharmacologic treatment with
a hypnotic medication is not necessary at this time. However, interventions can be made to
reduce the contribution that alcohol or evening doses of furosemide may contribute to poor
sleep patterns. In addition, education about daily routines and sleep hygiene can assist with
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| Fundamentals of Geriatric Pharmacotherapy
the promotion of healthy sleep patterns. At this visit, there are not enough data to critically and
completely evaluate his heart failure therapy, but SB’s current symptoms warrant a review of
disease state control and drug therapy.
Case Summary:
SB’s case illustrates examples of both nonpharmacological and nonhypnotic pharmacological
approaches that can be considered for a patient presenting with complaints about insomnia.
The addition of a hypnotic at this time might provide some immediate relief, but it is possible
that any benefit would be limited if underlying problems are not corrected. Due to the chronic
nature of the comorbidities in this case, the use of hypnotic medication to mask ongoing
symptoms has the potential to become a nightly, long-term routine.
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