64. JUST BREATHE: RECOGNITION AND TREATMENT OF SOMATIC SYMPTOM DISORDER IN OLDER ADULTS

Abstract

Introduction

Somatic symptom disorder is characterized by one or more severe physical symptoms resulting in suffering or significant disruption of daily life, whether or not the etiology is medically explained. Increased prevalence of medical comorbidities in older adults can make it difficult to distinguish somatic manifestations of psychiatric disorders from medical ailments. There is a lack of clear guidelines for treatment of somatic symptom disorder in geriatric patients, particularly in patients with co-occurring mood instability that precludes use of SSRIs and SNRIs in treatment of anxiety leading to somatic manifestations. The purpose of this poster is to provide a review of evidence-based treatments for this condition and highlight the need for specific recommendations for treatment of this condition in older adults.

Methods

A literature review and a case description are utilized to explore evidence-based options for treatment of somatic symptom disorder in older adults.

A literature search was performed on PubMed using the key terms “somatic symptom disorder,” “geriatric,” and “treatment.” Additionally, we look at this case through the lens of a specific patient. Jane is an 86-year-old female with bipolar II disorder and major neurocognitive disorder. Her somatic symptom disorder (with predominant symptoms of intermittent gasping and dizziness) and co-occurring anxiety disorder were previously treated with antidepressants such as mirtazapine and sertraline. However, due to a subsequent mixed mood episode, alternative treatments needed to be considered.

Results

In initial review of the literature, effective strategies for treatment of somatic symptom disorder in elderly patients include cognitive behavioral therapy (CBT) (Verdurmen et al., 2017), antidepressants, consultation with the patient’s primary care provider (Kroenke, 2007), and relaxation techniques (Gould et al., 2019). However, many of these studies and reviews did not specifically focus on older adults in making these recommendations. Additionally, a study exploring the effectiveness of the addition of physical exercise to pharmacologic treatment for late-life depression found that physical exercise improves affective but not somatic manifestations of late-life depression; however, we cannot extrapolate this finding to somatic symptom disorder (Murri et al., 2018).

Ultimately, Jane’s symptoms and mood were stabilized with a combination of olanzapine and pregabalin. There is, however, limited evidence to support use of second-generation antipsychotics and pregabalin in treatment of somatic symptom disorder. While we provided psychoeducation on the somatic symptom disorder and recommended CBT, Jane was not open to pursuing therapy. Additionally, the patient’s cognitive decline is likely exacerbating symptoms and may limit her ability to meaningfully participate in psychotherapy. Psychotherapy may have been more impactful in the early stages of her mood, anxiety, and somatic symptoms prior to her cognitive decline.

Hence, during medication management sessions, we recommend focusing on relaxation, meditation, and distraction techniques. Additionally, despite lack of evidence for physical exercise as an adjunct to pharmacologic treatment of late-life somatic symptom disorder, we have recommended Jane begin routine physical activity with a trainer and physical therapist. We schedule regular followup appointments every 3 months. We also spent a significant amount of time counseling the family and recommended her son to come to all future appointments to continue the conversation regarding our concerns. Finally, we continue to communicate with her primary care physician regarding her physical health and previous workup to avoid unnecessary testing, procedures, medications, and cost to the patient.

Conclusions

There is a lack of clear guidelines for treatment of somatic symptom disorder in older adults, and effective treatment often requires a multidisciplinary collaborative care model, including cooperation between psychology/therapy, physical therapy, primary care, and psychiatry. Educating the patient and family on somatic symptom disorder and effective treatments is paramount to effective reduction in symptoms and to reduce healthcare overutilization that may ultimately result in unnecessary testing or procedures that could increase risk of harm to the patient. CBT has the best evidence for treatment in this population.