Anxiety, Headaches, Insomnia, Restless Legs, and Hypertension: Multiple Disorders or One Problem?
Mrs. W is a 65-year-old retired school teacher. Her husband died two years ago in a car accident. Mrs. W’s two daughters are both school teachers who live nearby. She has five grandchildren and often cares for them when her daughters need help. Mrs. W went through a period of grief and mourning following the sudden loss of her husband but continued to teach until 6 months ago after reaching her 65th birthday. She decided to retire and traveled to Europe with some friends. While traveling, Mrs. W started drinking coffee each morning with her friends, and often drank several cups during the day while touring. She began to have difficulty sleeping, which she blamed on the traveling. After returning home, she continued to meet her friends at a local coffee shop almost every morning. She frequently drank several cups of coffee to help her “get going,” and started bringing a cup with her when she ran errands. On weekends or days when she did not meet her friends, Mrs. W began having headaches. She started taking an over-the-counter analgesic that contained aspirin, acetaminophen, and caffeine. This was helpful, but Mrs. W started feeling nervous at night, with difficulty falling asleep. She has developed a sensation of restlessness in her legs, and finds that she needs to get up and walk around her house to relieve it. Mrs. W wakes up several times each night to use the bathroom and has a great deal of difficulty falling back to sleep. She sees a neurologist about her headaches and restlessness and is asked about any prescription drugs that she takes, but not about over-the-counter medications. She reports taking alendronate 70 mg once weekly for osteoporosis. Her blood pressure is noted to be slightly elevated at 145/90 mm Hg. She describes feeling anxious and restless at night. Her neurological examination does not reveal any focal findings. Mrs. W is given a diagnosis of tension headaches, anxiety disorder, and restless legs syndrome. She is given a prescription for levodopa-carbidopa 25/100 mg at bedtime, gabapentin 100 mg 3 times per day, and paroxetine 20 mg once daily. She feels somewhat drowsy after taking the gabapentin, and increases her coffee consumption throughout the day. She is still sleeping poorly, wakes up often, and is very irritable and anxious. Her daughters are concerned about her frequent complaints of restlessness, ongoing headaches, a racing feeling in her chest, and her irritability. They convince her to see a primary care physician, Dr. D, affiliated with her health plan who specializes in cardiology.
Dr. D finds Mrs. W to be a nervous-appearing woman, with an elevated blood pressure of 150/ 95 mm Hg and a heart rate of nearly 100 bpm. Her electrocardiogram reveals sinus tachycardia, and the remainder of her physical examination in essentially normal. Dr. D asks many more questions about her use of caffeine, alcohol, smoking, and over-the-counter medications. He finds that Mrs. W is drinking at least 8-10 large cups (12-16 oz) of coffee per day and takes the over-the-counter analgesic containing 65 mg of caffeine per tablet. She drank 2 large cups of coffee and took 2 tablets of headache medication prior to her appointment. Dr. D feels that Mrs. W does not suffer from restless legs syndrome, tension headaches, or an anxiety disorder. He discusses her coffee and other caffeine consumption and points out that her symptoms seem all related to the more than 500-600 mg per day of caffeine that she has been ingesting. He strongly advises her to stop all of her caffeine use. He also recommends that she stop the paroxetine and levodopa-carbidopa. Mrs. W is very skeptical, as she feels coffee has been a main part of her socializing, has helped her feel more alert when she watches her grandchildren, and is a beverage she has become accustomed to drinking throughout her 35-year teaching career. She stops the medications without any problems. She follows Dr. D’s advice about eliminating caffeine for 2 days, but develops a severe headache and feels like she has no energy. Her friends invite out for coffee and suggest that she seek another opinion.
Caffeine is the most commonly used substance in the United States.1 Eighty-five percent of adults consume caffeine on a daily basis, with an average intake of 200 mg per day (Table).2-4 Coffee remains the most popular caffeinated beverage, with 65% of Americans drinking it daily. More males than females tend to drink large amounts of caffeine, while women consume more over-the-counter medications that contain caffeine, such as headache and pain remedies.2,3 Caffeinated soda is consumed daily by 50% of adults, and 25% drink caffeinated tea. While caffeine is present in chocolate and energy and sports drinks, consumption of these products by older adults is limited. Older adults often have routines that developed around coffee breaks and other forms of socialization, and have developed habits that include daily use of coffee or tea. They are also more sensitive to the effects of caffeine.3
In the body, caffeine is very rapidly and almost completely absorbed. Its behavioral effects include feelings of increased energy, alertness, concentration, and a reduction in fatigue and sleepiness. The mild stimulant effect of caffeine and its ability to increase alertness and performance on basic tasks account for a great deal of its popularity. Caffeine does not improve performance on complex tasks, or those that require fine motor coordination.1,3 Peak blood levels of caffeine occur about 1 hour following consumption, and the behavioral effects appear to correlate with peak levels. The half-life of caffeine is 5-6 hours in young adults.4 Among adults, the half-life increases with age, and may be up to 12 hours in the very old, in patients taking several concurrent medications, and in elderly persons with multiple chronic medical conditions.
The mechanism of action of caffeine is due to its ability to block the release of adenosine, an inhibitory neurotransmitter. Caffeine causes an increase in the release of norepinephrine, epinephrine, dopamine, and serotonin. Other effects of caffeine include cerebral vasoconstriction, a diuretic effect, increase in gastric acid secretion, enhanced physical exercise performance, and mild relaxation of bronchial muscles.3,5 It belongs to the methylxanthine class of compounds that also includes theophylline.
The adverse effects of caffeine may be significant and debilitating, particularly in vulnerable populations such as the elderly and those with psychiatric disorders that include anxiety syndromes, anorexia nervosa, and bipolar disorder. Ingestion of more than 250 mg of caffeine over a short period of time has been associated with an intoxication syndrome that includes symptoms of restlessness, nervousness, anxiety, insomnia, diuresis, facial flushing, muscle twitching, tachycardia, agitation, excess energy, and gastrointestinal upset.1,6-8 Patients who present acutely symptomatic may require evaluation in the emergency department.
Caffeine-induced disorders are included in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision.1 At present, caffeine intoxication is the primary recognized disorder; syndromes of chronic caffeine use are noted to include an anxiety disorder and sleep disorder. The medical complications of chronic caffeine use may include hypertension, cardiac arrhythmias, fibrocystic breast disease, restless legs syndrome, and accelerated bone loss.2,6-8 The diuretic effects of caffeine may contribute to dehydration and is associated with worsening of urinary incontinence among women who are predisposed to this condition.
Caffeine is associated with clinical withdrawal symptoms that include headache, fatigue, and excessive sleepiness. Symptoms often begin 12-24 hours after caffeine intake is stopped, and may last as long as 2-5 days. Many patients will increase their caffeine intake to counteract these symptoms, creating an increased risk for adverse reactions.7 The American Dietetic Association provides information on the caffeine content of common beverages and foods, as well as patient information that may be downloaded from its website (www.eatright.org).
Outcome of the Case Patient
Mrs. W consults with a dietician recommended by one of her friends and completes a food diary for a 1-week period. The dietician finds that on a typical day, Mrs. W consumes 120 ounces of brewed coffee. She calculates her caffeine intake to be 2025 mg per day, in addition to the 65 mg per tablet in the headache pills that she takes 2-3 times per day. The dietician explains that this amount is quite high and may cause insomnia, irritability, anxiety, increased urination, increased heart rate, and increased blood pressure. She also points out that amounts over 1000 mg per day are considered medically problematic and not recommended. While Mrs. W is taking alendronate for osteoporosis, her high caffeine intake may significantly increase her risk of bone loss. When presented with this information, Mrs. W realizes how her problems seem to be significantly related to her coffee intake. The dietician gives her a list of caffeine-free products and points out how easy it is to drink decaffeinated beverages without affecting her ability to socialize; she suggests drinking herbal tea at night. The dietician refers Mrs. W back to her internist to monitor her blood pressure and re-evaluate the need for other medications. Mrs. W is counseled to expect feelings of tiredness, decreased energy, and headaches in the first few days after stopping her use of caffeine, but realizes that following this she will return to a far more stable state.
Mrs. W switches to decaffeinated coffee and tea. She stops taking her over-the-counter headache medication and uses a relaxation tape to help with the headaches that occur frequently during the first week. Her daughters visit daily and provide encouragement. She returns to Dr. D after 6 weeks without caffeine use. Mrs. W’s sleep has improved, she is no longer anxious, and she feels more energetic again. Her blood pressure is 115/74 mm Hg, and her pulse is 72 bpm. She has occasional headaches once or twice per week, but feels she can manage using a warm cloth applied to her forehead while listening to relaxation tapes. She has stopped taking all medications except alendronate. Dr. D congratulates Mrs. W on making these positive changes. He suggests that she have repeat bone density testing to monitor her osteoporosis. He feels she is a healthy woman who has adopted beneficial lifestyle habits. Dr. D also realizes that he needs to start taking a more detailed history of caffeine intake when he evaluates patients.
Dr. Lantz is Chief of Geriatric Psychiatry, Beth Israel Medical Center, First Avenue @ 16th Street 2B49, New York, NY 10003; (212) 420-2457; fax: (212) 420-3936; e-mail: email@example.com.
1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC: American Psychiatric Association, 2000: 232-234.
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3. Rapuri PB, Gallagher JC, Kinyamu HK, Ryschon KL. Caffeine intake increases the rate of bone loss in elderly women and interacts with vitamin D receptor genotypes. Am J Clin Nutr 2001;74(6):694-700.
4. Shuh KJ, Griffiths RR. Caffeine reinforcement: The role of withdrawal. Psychopharmacology 1997;130(4):320-326.
5. Norager CB, Jensen MB, Madsen MR, Laurberg S. Caffeine improves endurance in 75-yr-ol citizens: A randomized, double-blind, placebocontrolled, crossover study. J Appl Physiol 2005;99(6):2302-2306.
6. Dodick DW. Chronic daily headache. N Engl J Med 2006;354(2):158-165.
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