Steven R. Barczi, M.D.Madison V.A. GRECC

Section of Geriatrics/Gerontology

University of Wisconsin School of Medicine and Public

Health

Sleep Sleep Disorders in Disorders in

Older PersonsOlder Persons

Cathy A. Alessi, MDVA Greater Los Angeles GRECC

– Sepulveda CampusUCLA Multicampus Program in

Geriatric Medicine and Gerontology

2

Part One: Part One:

Age-Related Changes in Age-Related Changes in Sleep and Conditions that Sleep and Conditions that Impair Sleep in Older Impair Sleep in Older PeoplePeople

3

Karacan et al, 1976; Vitiello et al, 2004

Sleep Complaints as We Sleep Complaints as We AgeAge

AgeAge

50

40

30

20

10

0

Per

cen

tP

erce

nt

10-19 20-29 30-39 40-49 50-59 60-69 70+

4

2003 Sleep in America Poll2003 Sleep in America PollNational Sleep Foundation survey; US adults aged 55 – 84 (N = National Sleep Foundation survey; US adults aged 55 – 84 (N =

1506)1506)

Age 55 – Age 55 – 6464

Age 75 - 84Age 75 - 84

Naps 4 – 7 times per Naps 4 – 7 times per weekweek

10%10% 24%24%

Difficulty falling asleepDifficulty falling asleep 19%19% 16%16%

Awake a lot during the Awake a lot during the nightnight

33%33% 35%35%

Daytime sleepiness Daytime sleepiness interferes with daily interferes with daily activitiesactivities

28%28% 28%28%

www.sleepfoundation.org

5

The Consequences of Poor The Consequences of Poor Sleep/ Daytime SleepinessSleep/ Daytime Sleepiness

• Decrements in attention, vigilance and Decrements in attention, vigilance and memory memory Dinges DF, ‘97Dinges DF, ‘97

• Increased depression Increased depression Ford DE, 1989Ford DE, 1989 • Increased problems with balance and Increased problems with balance and

falls when using sedatives falls when using sedatives Schorr RI, ‘94; Tinetti Schorr RI, ‘94; Tinetti MM

• Increased MVAs Increased MVAs Lyznicki JM 1998Lyznicki JM 1998

• Increased HTN, CVD morbidity and Increased HTN, CVD morbidity and mortality in those with OSA mortality in those with OSA Newman AB 2000Newman AB 2000

6

The Basic Principles of The Basic Principles of SleepSleep

• Non-REM sleepNon-REM sleep– stage 1- transitionalstage 1- transitional– stage 2- majority of sleep timestage 2- majority of sleep time– stages 3 & 4 - slow wave sleep; stages 3 & 4 - slow wave sleep; restorativerestorative

• REM sleepREM sleep– active EEG, dreams, rapid eye movements, active EEG, dreams, rapid eye movements,

skeletal muscle paralysis, autonomic skeletal muscle paralysis, autonomic activation, respiratory instabilityactivation, respiratory instability

– related to memoryrelated to memory

7

Changes in Sleep with AgingChanges in Sleep with Aging

The ability to The ability to stay asleep stay asleep changeschanges most most markedly with markedly with agingaging

Sleep is Sleep is cyclicalcyclical

8Modified from: Carskadon MA et al. J Geriatr Psychiatry. 1980;13:135-151; Reprinted from: Ancoli-Israel S. All I Want Is a Good Night’s Sleep. Mosby; 1996

Ave

rag

e T

ime

to

Fal

l A

slee

p (

Min

ute

s)

Time of Day

1000 1200 1400 1600 1800

20

15

10

5

0

Adolescents

Younger Adults

Older Adults

Sleep Apnea

Narcolepsy

Sleepiness Across Sleepiness Across LifespanLifespan

9

Medical Illness &

Medications

Psychiatric & Neurologic

Primary Sleep

Disorders

Circadian Changes

Poor Sleep Behaviors

Causes of Disturbed Sleep in Causes of Disturbed Sleep in

AgingAging Poor Sleep Behaviors

Circadian Changes

Sleep Problem

10

Selected Medical Selected Medical Conditions that Disrupt Conditions that Disrupt

SleepSleep

Selected Medical Selected Medical Conditions that Disrupt Conditions that Disrupt

SleepSleepPain:Pain: arthritis, cancer, neuropathy arthritis, cancer, neuropathy

Cardiac and Vascular:Cardiac and Vascular: angina, CHF, PVD angina, CHF, PVD

Pulmonary:Pulmonary: COPD, secretions, bronchospasm, COPD, secretions, bronchospasm,

Gastrointestinal:Gastrointestinal: GE reflux, ulcer pain, hunger GE reflux, ulcer pain, hunger

Endocrine:Endocrine: hypo/hyperthyroidism, diabetes hypo/hyperthyroidism, diabetes

Genitourinary:Genitourinary: BPH and nocturia, incontinance BPH and nocturia, incontinance

11

Medications that Influence Medications that Influence Sleep & WakefulnessSleep & Wakefulness

Agents that affect sleep Agents that affect sleep charactercharacter

• OTC decongestantsOTC decongestants

• Beta agonist MDI’sBeta agonist MDI’s

• Caffeine containing OTCsCaffeine containing OTCs

• TheophyllineTheophylline

• Activating antidepressantsActivating antidepressants

• Selegeline Selegeline

• CorticosteroidsCorticosteroids

• Beta blockersBeta blockers

• Acetylcholinesterase Acetylcholinesterase InhibitorsInhibitors

• Certain antiarrhythmicsCertain antiarrhythmics

Agents that cause sleepinessAgents that cause sleepiness

• Analgesics (e.g., narcotics)Analgesics (e.g., narcotics)

• Antidepressants (e.g., Antidepressants (e.g., imipramine, trazodone)imipramine, trazodone)

• Antihypertensives (e.g., Antihypertensives (e.g., clonidine)clonidine)

• AntihistaminesAntihistamines

• Antimuscarinics (e.g. Antimuscarinics (e.g. Ditropan)Ditropan)

• Dopamine AgonistsDopamine Agonists

• Antiepileptics (e.g. Antiepileptics (e.g. Neurontin)Neurontin)

Almost one-third of all prescription medications in PDR list insomnia as a possible side effect

12

Psychiatric/ Neurological Psychiatric/ Neurological Causes of InsomniaCauses of Insomnia

Psychiatric/ Neurological Psychiatric/ Neurological Causes of InsomniaCauses of Insomnia

•DepressionDepression (sleep maintenance, early (sleep maintenance, early am awakenings, short REM latency)am awakenings, short REM latency)

•Anxiety/ PTSDAnxiety/ PTSD (sleep initiation, sleep (sleep initiation, sleep awakenings, parasomnias) awakenings, parasomnias)

•DementiaDementia ((sleep wake dysregulationsleep wake dysregulation, , sleep maintenance, nocturnal wandering)sleep maintenance, nocturnal wandering)

•ParkinsonismParkinsonism (sleep maintenance, (sleep maintenance, restless legs, periodic limb movements, restless legs, periodic limb movements, REM sleep behavior disorder)REM sleep behavior disorder)

13

Prevalence of Primary Prevalence of Primary Sleep DisordersSleep Disorders

ConditionCondition All AdultsAll Adults ElderlyElderly

Sleep ApneaSleep Apnea 1%-10% 24%-40%

Periodic Limb Movements Periodic Limb Movements 5% 30%-45%

Restless Leg Syndrome Restless Leg Syndrome 2%-15% 12%-30%

REM Sleep BehaviorREM Sleep Behavior D/OD/O 0.5% 0.5%-2%

Young T, et al., Ancoli-Israel S, et al., Sleep 2001; Mant E, et al., Age Young T, et al., Ancoli-Israel S, et al., Sleep 2001; Mant E, et al., Age and Ageing 1992; Ancoli-Israel S, et al. Sleep 1993; Phillips BA, et al., and Ageing 1992; Ancoli-Israel S, et al. Sleep 1993; Phillips BA, et al., Sleep 1994; Hoch CC, et al., Sleep 1994; O’Keefe ST, et al., Age and Sleep 1994; Hoch CC, et al., Sleep 1994; O’Keefe ST, et al., Age and Ageing 1994; Phillips B, et al., Arch Int Med 2000; Allen R, et al. Arch Ageing 1994; Phillips B, et al., Arch Int Med 2000; Allen R, et al. Arch Int Med 2005Int Med 2005

14

Part Two: Part Two:

Clinical approaches to sleep Clinical approaches to sleep problems including non-problems including non-pharmacological and pharmacological and pharmacological pharmacological interventionsinterventions

15

Obstructive Sleep ApneaObstructive Sleep Apnea

• ““typical patient” = obese, sleepy, snorer with typical patient” = obese, sleepy, snorer with hypertensionhypertension

• exam: obesity, large neck, crowded exam: obesity, large neck, crowded oropharynx oropharynx

• common symptoms:common symptoms:– poor sleep restoration, excessive daytime poor sleep restoration, excessive daytime

sleepiness, sleepiness, – loud crescendo snoringloud crescendo snoring, cessation of breathing, , cessation of breathing,

choking sounds during sleepchoking sounds during sleep– nocturia, nighttime confusion, morning headache, nocturia, nighttime confusion, morning headache, – poor memory, irritability, personality changespoor memory, irritability, personality changes– hypertension, right heart failure, arrhythmiashypertension, right heart failure, arrhythmias

16

High Risk for Sleep ApneaHigh Risk for Sleep Apnea(2 of 3 categories required)(2 of 3 categories required)

• SleepinessSleepiness– 3-4x/week or3-4x/week or– asleep while drivingasleep while driving

• Associated Associated conditionsconditions– hypertension orhypertension or– Obesity w BMI >30 Obesity w BMI >30

kg/mkg/m22

• SnoringSnoring– louder than louder than

speech orspeech or– 3-4x/week or3-4x/week or– bothered others orbothered others or– observed observed

breathing pauses breathing pauses 3-4x/week3-4x/week

Berlin (Cleveland) Sleep Questionnaire- Netzer N, Ann Int Berlin (Cleveland) Sleep Questionnaire- Netzer N, Ann Int Med 1999Med 1999

17

Sleep Apnea ConsequencesSleep Apnea Consequences

•Increased car Increased car accidentsaccidents•Impaired memoryImpaired memory•High blood pressureHigh blood pressure•Increased stroke riskIncreased stroke risk•Increased heart Increased heart rhythm disturbancesrhythm disturbances•Worsened heart Worsened heart failurefailure•Increased mortality in Increased mortality in heart failureheart failure

Ancoli-Israel, et al. Sleep, 1996 Days

Cu

mu

lati

ve P

rop

ort

ion

S

urv

ivin

g

Peppard PE, et al. NEJM 2000; Newman AB, et al. Am J Epidemiol 2001; Lanfranchi PA, et al. Circulation 1999; Mallon L, et al. J Intern Med 2002; Yaggi H et al, NEJM; 2005.

May 3, 2002

When to Treat Sleep When to Treat Sleep Apnea Apnea

in the Elderly?in the Elderly?• Symptomatic from sleepinessSymptomatic from sleepiness• When co-morbid conditions may When co-morbid conditions may

benefit from treatmentbenefit from treatment– Cognitive dysfunctionCognitive dysfunction– Congestive Heart FailureCongestive Heart Failure– HypertensionHypertension– NocturiaNocturia

• When AHI or desaturations are When AHI or desaturations are severesevere

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Treatment of Sleep Treatment of Sleep ApneaApnea

• Continuous positive Continuous positive airway pressure (nasal airway pressure (nasal CPAP, BiPAP, Auto-CPAP, BiPAP, Auto-CPAP, VPAP)CPAP, VPAP)

• Oral appliances Oral appliances • SurgerySurgery

– UPPP or LAUPUPPP or LAUP– Mandibular advancementMandibular advancement

• Other Other (wt loss, tobacco (wt loss, tobacco cessation, supine cessation, supine preclusion, modafinil)preclusion, modafinil)

Less favorable Less favorable outcomes over outcomes over age 50age 50

Improve QOL, Improve QOL, sleepiness and sleepiness and cognitioncognition

www.sleepapnea.orgwww.sleepapnea.org

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Periodic Limb Movements Periodic Limb Movements of Sleep (PLMS) of Sleep (PLMS)

Periodic Limb Movements Periodic Limb Movements of Sleep (PLMS) of Sleep (PLMS)

• Periodic episodes of Periodic episodes of repetitiverepetitive (q 20-40 (q 20-40 sec), sec), stereotypedstereotyped limb movements limb movements during sleep (extend big toe, dorsiflex during sleep (extend big toe, dorsiflex ankle, flex knee) ankle, flex knee)

• Limb movements Limb movements maymay result in arousals, result in arousals, sleep fragmentation and sleep fragmentation and daytime daytime sleepinesssleepiness

21

PLMS in AgingPLMS in Aging

• in Parkinsonism, renal disease, in Parkinsonism, renal disease, diabetes and spinal disease diabetes and spinal disease

• Prevalence is higher but severity Prevalence is higher but severity does not worsen with increasing does not worsen with increasing age age Gehrman 2002Gehrman 2002

• Medications can exacerbate Medications can exacerbate problem: problem: TCAs & SSRIs antidepressants, TCAs & SSRIs antidepressants, anti-psychoticsanti-psychotics, Lithium, ETOH , Lithium, ETOH

22

PLMS ManagementPLMS ManagementPLMS ManagementPLMS Management

• Modify medications (if possible)Modify medications (if possible)

• Encourage modest PM exerciseEncourage modest PM exercise

• Dopamine agonists or L-DopaDopamine agonists or L-Dopa

• GabapentinGabapentin

• BenzodiazepinesBenzodiazepines

• OpioidsOpioids

Second line agents Second line agents due to adverse due to adverse effect profileseffect profiles

Not FDA approved Not FDA approved for this conditionfor this condition

23

Features of Restless Legs Features of Restless Legs Syndrome (RLS)Syndrome (RLS)

Features of Restless Legs Features of Restless Legs Syndrome (RLS)Syndrome (RLS)

• Urge to moveUrge to move extremities associated extremities associated with paresthesias/ with paresthesias/ dysesthesiasdysesthesias

• Worsening of symptoms at rest with Worsening of symptoms at rest with temporary relief with movementtemporary relief with movement

• Worsening of symptoms in evening/ Worsening of symptoms in evening/ at bedtimeat bedtime (circadian component) (circadian component)

www.rls.orgwww.rls.org

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RLS: Risks and RLS: Risks and Associated Associated ConditionsConditions

• Family historyFamily history• Medical conditions: Fe deficiency Medical conditions: Fe deficiency

anemia, Renal Insufficiency, anemia, Renal Insufficiency, Neuropathy (DM, RA)Neuropathy (DM, RA)

• Periodic limb movementsPeriodic limb movements• Medications can exacerbate: Medications can exacerbate:

Caffeine, antihistamines, TCAs, SSRIs, Caffeine, antihistamines, TCAs, SSRIs, antipsychotics, metoclopramideantipsychotics, metoclopramide

NIH Publication #00-3788, 2000NIH Publication #00-3788, 2000

25

RLS ManagementRLS ManagementRLS ManagementRLS Management

• Dopamine agonists> Sinemet Dopamine agonists> Sinemet • Opioids Opioids • Gabapentin/ CarbamazapineGabapentin/ Carbamazapine • Iron replacement Iron replacement

(if ferritin <50mcg))(if ferritin <50mcg)) • ? Clonidine? Clonidine• ? Magnesium? Magnesium• ? Clonazepam/ BZDs (No RCT supports efficacy)? Clonazepam/ BZDs (No RCT supports efficacy) Allen 2001Allen 2001

Efficacy Efficacy supported supported by RCTs by RCTs (OFF LABEL (OFF LABEL USE USE except except

RopiniroleRopinirole))

26

REM Sleep Behavior REM Sleep Behavior DisorderDisorder

• major features:major features:– vigorous motor behaviors and vivid dreamsvigorous motor behaviors and vivid dreams– lack of muscle atonia during REM sleep= lack of muscle atonia during REM sleep= “acting out dreams”“acting out dreams”– may result in injury; > 85% of cases are menmay result in injury; > 85% of cases are men

• etiology etiology (males>> females)(males>> females) – acuteacute: drug-induced (e.g., SSRIs, TCAs) and drug withdrawal: drug-induced (e.g., SSRIs, TCAs) and drug withdrawal– chronicchronic: idiopathic, synucleinopathies (e.g., Parkinson’s : idiopathic, synucleinopathies (e.g., Parkinson’s

disease, Lewy body dementia, multi-system atrophy), disease, Lewy body dementia, multi-system atrophy), psychiatric illnesspsychiatric illness

• diagnosis: polysomnographydiagnosis: polysomnography • treatmenttreatment

– environmental safetyenvironmental safety– Melatonin or donepazilMelatonin or donepazil if cognitive impairment, if cognitive impairment,

neurodegenerativeneurodegenerative– alternatives: clonazepam or temazepamalternatives: clonazepam or temazepam

27

Insomnia is aInsomnia is a symptomsymptom as as much as a diagnosismuch as a diagnosis

(one needs to seek out the cause)(one needs to seek out the cause)

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Evaluation of Sleep Evaluation of Sleep ProblemsProblems

• InterviewInterview• Sleep log, sleep questionnairesSleep log, sleep questionnaires• Focused physical exam & laboratory Focused physical exam & laboratory

testingtesting• Indications for polysomnography*:Indications for polysomnography*:

– When sleep-related breathing disorder or periodic When sleep-related breathing disorder or periodic limb movement disorder is suspectedlimb movement disorder is suspected

– When initial diagnosis is uncertain, treatment fails When initial diagnosis is uncertain, treatment fails (behavioral or pharmacologic), or precipitous arousals (behavioral or pharmacologic), or precipitous arousals occur with violent or injurious behavioroccur with violent or injurious behavior

•Littner et al. American Academy of Sleep Medicine. Standards of Practice Committee. Sleep 26(6):754-760, 2003.

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The Sleep InterviewThe Sleep Interview

Is there a complaint of poor sleep or Is there a complaint of poor sleep or unsatisfactory sleep? unsatisfactory sleep? (daytime consequences?)(daytime consequences?)

Is there a complaint of excessive daytime Is there a complaint of excessive daytime sleepiness?sleepiness?

Sleep Schedule and NappingSleep Schedule and NappingSnoring, apneas, abnormal movementsSnoring, apneas, abnormal movementsAlcohol / caffeine useAlcohol / caffeine useAmount and timing of daily light exposureAmount and timing of daily light exposureDaily exercise Daily exercise

Sateai et al. Evaluation of Chronic Insomnia. SLEEP. 23(2):243-308, 2000.

30

Treatment Options for Treatment Options for Later Life InsomniaLater Life Insomnia

• Behavioral Approaches (CBT)Behavioral Approaches (CBT)– Stimulus control, sleep restriction, Stimulus control, sleep restriction,

relaxation, cognitive restructuringrelaxation, cognitive restructuring

• Bright Light TherapyBright Light Therapy

• Sedative-HypnoticsSedative-Hypnotics

• Sedating AntidepressantsSedating Antidepressants

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Cognitive-Behavioral Cognitive-Behavioral TherapyTherapy

• Nine randomized controlled trials Nine randomized controlled trials support efficacy of cognitive-behavioral support efficacy of cognitive-behavioral therapy (CBT) for improved sleep therapy (CBT) for improved sleep maintenance in older adultsmaintenance in older adults

• 2 RCTs support that patients with 2 RCTs support that patients with chronic insomnia have more sustained chronic insomnia have more sustained improvement when receiving CBT improvement when receiving CBT (compared to drug tx) (compared to drug tx) Morin 1999, Sivertsen Morin 1999, Sivertsen 20062006

32

Common non-pharmacological Common non-pharmacological measures to improve sleepmeasures to improve sleep

• regular bedtime/ rising timeregular bedtime/ rising time• go to bed only when sleepygo to bed only when sleepy• get out of bed if unable to fall asleepget out of bed if unable to fall asleep• decrease/eliminate daytime napsdecrease/eliminate daytime naps• exercise (am, afternoon)exercise (am, afternoon)• use bed only for sleepinguse bed only for sleeping• eliminate alcohol/ tobacco before bedtimeeliminate alcohol/ tobacco before bedtime• wind down, relaxwind down, relax• control environment, follow bedtime ritualcontrol environment, follow bedtime ritual

33

RCT: CBT vs. RCT: CBT vs. Pharmacotherapy for Pharmacotherapy for

Insomnia in Older AdultsInsomnia in Older Adults

1012141618202224

Assessment

To

tal

Sco

re Placebo

PCT

Combined

CBT

Morin C et al. JAMA 1999; 281:11

PCT was Temazepam

34

Hypnotic Use in Older Hypnotic Use in Older AdultsAdults

• 32% of adults 65 32% of adults 65 yrs and older have yrs and older have taken medications taken medications to aid sleep in to aid sleep in past yrpast yr NSF 2000NSF 2000

• Adults over age 65 Adults over age 65 comprise 13% of comprise 13% of the population but the population but use 40% of all use 40% of all sedative-hypnotics sedative-hypnotics prescribed.prescribed. Mellinger Mellinger 19851985

National Sleep Foundation Poll 2003National Sleep Foundation Poll 2003Roehrs 1989Roehrs 1989Beers 1988Beers 1988

05

101520253035404550

Prev

alenc

e

Selected Elderly Populations

Community (daily)

Community (episodic)

Hospitalized

Nursing Home

35

Psychotropic Use: Hip Fracture Psychotropic Use: Hip Fracture Cases vs. Age and Gender-Cases vs. Age and Gender-

Matched ControlsMatched Controls

0

0.5

1

1.5

2od

ds

rati

o

Glynn, 2001Glynn, 2001

36

Medications Approved by the Medications Approved by the FDA for InsomniaFDA for Insomnia

Medication Medication Duration of Action Duration of Action ½ life½ life Dose DoseBenzodiazepinesBenzodiazepinesTriazolam (Halcion) Short 2-5 hrs 0.125-0.25mgTriazolam (Halcion) Short 2-5 hrs 0.125-0.25mgTemazepam (Restoril) Intermediate 8-15 hrs 7.5-30mgTemazepam (Restoril) Intermediate 8-15 hrs 7.5-30mgEstazolam (ProSom) Intermediate 10-24 hrs 0.5-2 mgEstazolam (ProSom) Intermediate 10-24 hrs 0.5-2 mg

BZD Receptor AgonistsBZD Receptor AgonistsZaleplon (Sonata)Zaleplon (Sonata) Ultra-short 1 hr Ultra-short 1 hr 5-20 mg 5-20 mgZolpidem (Ambien Short 1.5-4.5 hrs 5-10 mgZolpidem (Ambien Short 1.5-4.5 hrs 5-10 mgZolpidem CR (Ambien CR) Short-Intermed 1.5-4.5 hrs 6.25-12.5 mgZolpidem CR (Ambien CR) Short-Intermed 1.5-4.5 hrs 6.25-12.5 mgEszopiclone (Lunesta) Intermediate 6-9 hrs 1-3 mgEszopiclone (Lunesta) Intermediate 6-9 hrs 1-3 mg

Melatonin Receptor Melatonin Receptor AgonistAgonistRamelteon (Rozerem) Short 2-5 hrs 8mgRamelteon (Rozerem) Short 2-5 hrs 8mg

37

Hypnotics Trials in the Hypnotics Trials in the ElderlyElderly

StudyStudy DrugDrug Type/ Type/ DurationDuration

EfficacyEfficacy Geriatric Geriatric OutcomesOutcomes

Nakra ’92 N=45Nakra ’92 N=45 TemazepamTemazepam

TriazolamTriazolam

DB /single DB /single dose dose

Subjective; + Subjective; + sleep latencysleep latency

Neuro-psych: dec Neuro-psych: dec learninglearning

Shaw ’92 N=119Shaw ’92 N=119 ZolpidemZolpidem DB placebo DB placebo cont/ 21 dayscont/ 21 days

Subjective; inc Subjective; inc TSTTST

None measuredNone measured

Roger ’93 N=221Roger ’93 N=221 TriazolamTriazolam

ZolpidemZolpidem

DB placebo DB placebo cont/ 21 dayscont/ 21 days

Subjective;Subjective; inc inc sleep qualitysleep quality

Dec memory Dec memory triazolam> zolptriazolam> zolp

Vgontzas ’94 N=8Vgontzas ’94 N=8 TemazepamTemazepam DB placebo DB placebo cont/ 7 dayscont/ 7 days

Subj; inc sleep Subj; inc sleep timetime

““no memory no memory changes”changes”

Hedner ’00Hedner ’00 ZaleplonZaleplon RCT/ 14 daysRCT/ 14 days Subj + sleep Subj + sleep latency, + TSTlatency, + TST

NC – cognitionNC – cognition

No falls dataNo falls data

Unpublished ’03 Unpublished ’03 N=292, N=231N=292, N=231

EszopicloneEszopiclone RCT/ 2 wks; 2 RCT/ 2 wks; 2 wkswks

Subj + sleep Subj + sleep quality, +TSTquality, +TST

NC- cognition, NC- cognition, no fallsno falls

DB= double blind, RCT= randomized controlled trial, TST= total sleep timeDB= double blind, RCT= randomized controlled trial, TST= total sleep time

38

Pharmacologic Pharmacologic Approaches – Agents to Approaches – Agents to

AvoidAvoid

Pharmacologic Pharmacologic Approaches – Agents to Approaches – Agents to

AvoidAvoidBased upon Geriatrics Based upon Geriatrics

Literature, Literature, side effect profiles side effect profiles exceed benefit with:exceed benefit with:– AntihistaminesAntihistamines– BarbituratesBarbiturates– Long half-life benzodiazepinesLong half-life benzodiazepines– High-anticholinergic tricyclic High-anticholinergic tricyclic

antidepressantsantidepressants

39

Pharmacologic Pharmacologic Approaches - Approaches -

AntidepressantsAntidepressants

Pharmacologic Pharmacologic Approaches - Approaches -

AntidepressantsAntidepressants• The role for these agents in non-depressed The role for these agents in non-depressed

agents is actively debated (This is agents is actively debated (This is OFF OFF LABEL USELABEL USE))

• Trazodone- most widely prescribed hypnotic Trazodone- most widely prescribed hypnotic (used for dementia) but limited efficacy (used for dementia) but limited efficacy data, orthostasis & rebound insomnia data, orthostasis & rebound insomnia

• Mirtazapine is sedating but data regarding Mirtazapine is sedating but data regarding long term adverse effects and efficacy is long term adverse effects and efficacy is absentabsent

40

Part Three: Part Three:

Sleep in Institutional Sleep in Institutional Settings: the Hospital and Settings: the Hospital and the Nursing Homethe Nursing Home

41

Insomnia in Hospitalized Insomnia in Hospitalized PatientsPatients

Very little literature focuses on management Very little literature focuses on management of insomnia in hospitalized adults…of insomnia in hospitalized adults…

Factors associated with sleep changes Factors associated with sleep changes include:include:– Acute physical symptoms (e.g. pain, dypnea)Acute physical symptoms (e.g. pain, dypnea)– Psychological response (anxiety, depression)Psychological response (anxiety, depression)– Shift in sleep-wake cycle due to environmentShift in sleep-wake cycle due to environment– Sustained bed rest/ daytime nappingSustained bed rest/ daytime napping– DeliriumDelirium

42

In Hospital Causes for In Hospital Causes for AwakeningsAwakenings

(N=52, 24 women, mean age= 57.4)(N=52, 24 women, mean age= 57.4)

• Nocturia Nocturia 73%73%

• Noise Noise 48% 48%

(RN-RN and RN-patient conversations, machinery)(RN-RN and RN-patient conversations, machinery)

• RN checks/ observationRN checks/ observation 40%40%

• Medication passesMedication passes 40%40%

• Pain or discomfort Pain or discomfort 30%30%

• Lights Lights 27%27%(RN station, corridors, flashlights)(RN station, corridors, flashlights)

Jarman et al., Int J Nursing Prac 8:75-80, 2002Jarman et al., Int J Nursing Prac 8:75-80, 2002

43

Noise in HospitalNoise in Hospital

Cmiel et al., Am J Nursing 2004 104:40-48Cmiel et al., Am J Nursing 2004 104:40-48

Hospital SoundsHospital Sounds Comparable SoundsComparable Sounds

Loudest transient at change of Loudest transient at change of shift – 113 dBshift – 113 dB

Jackhammer – 111 dBJackhammer – 111 dB

Portable X-ray machine – 98 dBPortable X-ray machine – 98 dB Motorcycle – 95 dBMotorcycle – 95 dB

Bedside monitor alarms – 75 dBBedside monitor alarms – 75 dB Heavy truck traffic – 81 dBHeavy truck traffic – 81 dB

Empty semiprivate room – 53 dBEmpty semiprivate room – 53 dB Conversational speech – 60 dBConversational speech – 60 dB

EPA-recommended average noise level for hospital in daytime = EPA-recommended average noise level for hospital in daytime = 45 dB; nighttime average = 35dB45 dB; nighttime average = 35dB

44

RN Sleep Promotion Team- RN Sleep Promotion Team- Noise ReductionNoise Reduction

Cmiel et al., Am J Nursing 2004 104:40-48Cmiel et al., Am J Nursing 2004 104:40-48

Pre-interventionPre-intervention Post-interventionPost-intervention

Shift change peak 113 dBShift change peak 113 dB Shift change peak 86 dBShift change peak 86 dB

Staff Interventions- Staff Interventions- report in designated rooms, report in designated rooms, close patient doors, cover IV pump speakers, close patient doors, cover IV pump speakers, change time of supply staff deliveries, avoid change time of supply staff deliveries, avoid housekeeping staff shortcuts, eliminate unit housekeeping staff shortcuts, eliminate unit overhead pages between 9pm-7am; reschedule overhead pages between 9pm-7am; reschedule non-urgent X-ray and lab timesnon-urgent X-ray and lab times

Equipment interventions- Equipment interventions- adjust cardiac monitor adjust cardiac monitor alarm volumes, padded pneumatic tube alarm volumes, padded pneumatic tube receptacles, alter paper towel dispensersreceptacles, alter paper towel dispensers

45

A Non-pharmacologic Sleep A Non-pharmacologic Sleep Protocol in an Acute Hospital Protocol in an Acute Hospital

SettingSetting ((McDowell et al., JAGS McDowell et al., JAGS 1998, 46(6):700-705)1998, 46(6):700-705)

Prospective CohortProspective Cohort of 111 patients, mean age 79.3 (± 6.4), of 111 patients, mean age 79.3 (± 6.4), 68% women68% women

Intervention:Intervention: warm drink, relaxation tapes and back massage warm drink, relaxation tapes and back massage at HS; at HS; option for hypnotic therapy (HT) if ineffectiveoption for hypnotic therapy (HT) if ineffective

Outcomes:Outcomes: • Absolute reduction of 23% for HT use from pre- to post Absolute reduction of 23% for HT use from pre- to post

interventionintervention• Overall adherence rate was 400/539 (74%) patient-daysOverall adherence rate was 400/539 (74%) patient-days• The sleep protocol had a stronger association with quality The sleep protocol had a stronger association with quality

of sleep (rho = .75, of sleep (rho = .75, PP = .001) than did HT (rho = .07, = .001) than did HT (rho = .07, PP = .45)= .45)

46

Many factors contribute to Many factors contribute to sleep problems in NH sleep problems in NH

residentsresidents

• Age-related changes in sleepAge-related changes in sleep

• Dementia, depressionDementia, depression

• Other illnesses Other illnesses

• Medications (including sedatives)Medications (including sedatives)

• Increased prevalence of sleep disorders Increased prevalence of sleep disorders (e.g., sleep apnea)(e.g., sleep apnea)

• Poor sleep hygiene, lack of bright light Poor sleep hygiene, lack of bright light exposureexposure

• Sleep-disruptive NH environment and Sleep-disruptive NH environment and routinesroutines

47

Benzodiazepines increase the risk of Benzodiazepines increase the risk of falls in NH residents falls in NH residents ((Ray et al. JAGS 48:682-685, Ray et al. JAGS 48:682-685,

2000)2000) (N = 2510 residents in 53 Tennessee NHs)(N = 2510 residents in 53 Tennessee NHs)

Daytime fallsDaytime falls(7 am – 8 pm)(7 am – 8 pm)

Nighttime falls Nighttime falls (8 pm – 7 am)(8 pm – 7 am)

Any Any benzodiazepinebenzodiazepine

1.38 (1.25-1.51)1.38 (1.25-1.51) 1.83 (1.55-2.15)1.83 (1.55-2.15)

Short-acting*Short-acting*(half-life< 12 hours)(half-life< 12 hours)

NSNS 2.19 (1.59-3.03)2.19 (1.59-3.03)

Intermediate-Intermediate-actingacting(half-life 12-23 hrs)(half-life 12-23 hrs)

1.43 (1.29-1.59)1.43 (1.29-1.59) 1.68 (1.39-2.02)1.68 (1.39-2.02)

Long-actingLong-acting(half-life (half-life >> 24 hrs) 24 hrs)

1.77 (1.38-2.26)1.77 (1.38-2.26) 1.80 (1.14-2.83)1.80 (1.14-2.83)

*Includes temazepam, oxazepam, zolpidem, triazolam

Rate ratios (95% confidence intervals); adjusted for age, gender, race, time since admission to facility and since zero time, BMI, ambulatory status, ADL dependency, incontinence, cognitive impairment, physical restraint use, past falls, and use of anticonvulsants, antiparkinsonian drugs, antidepressants, antipsychotics, and other sedatives. Reference group is non-users, no benzos in preceding 7 days.

48

Effects of light treatment on sleep and Effects of light treatment on sleep and circadian rhythms in demented NH circadian rhythms in demented NH

residentsresidents(Ancoli-Israel et al. JAGS 50:282-289, 2002)(Ancoli-Israel et al. JAGS 50:282-289, 2002)

• RCT, N = 77 demented residents in 2 NHsRCT, N = 77 demented residents in 2 NHs• Treatment groupsTreatment groups (10 day treatment)(10 day treatment)::

– Evening bright lightEvening bright light (2500 lux 5:30 pm – 7:30 pm)(2500 lux 5:30 pm – 7:30 pm)

– Morning bright lightMorning bright light (2500 lux 9:30 am – 11:30 am)(2500 lux 9:30 am – 11:30 am)

– Daytime sleep restrictionDaytime sleep restriction (attended to 6 hrs each day by research staff to (attended to 6 hrs each day by research staff to restrict daytime sleeping)restrict daytime sleeping)

– Evening dim red lightEvening dim red light (<50 lux 5:30 pm – 7:30 pm)(<50 lux 5:30 pm – 7:30 pm)

• Wrist actigraphy outcomes:Wrist actigraphy outcomes:– No effects on nighttime sleep or daytime alertness.No effects on nighttime sleep or daytime alertness.– Significant effects on circadian rhythms of activitySignificant effects on circadian rhythms of activity

49

Daily social and physical activity Daily social and physical activity intervention: effects on sleep and intervention: effects on sleep and

memorymemory(Naylor et al. Sleep 23:87-95, 2000)(Naylor et al. Sleep 23:87-95, 2000)

• Controlled trial, N = 23 residents in a Controlled trial, N = 23 residents in a continued care retirement facilitycontinued care retirement facility

• Intervention:Intervention:– Enforced schedule of structured social and Enforced schedule of structured social and

physical activity (9 – 10:30 am, 7 pm – 8:30 pm; physical activity (9 – 10:30 am, 7 pm – 8:30 pm; daily for two weeks)daily for two weeks)

• Results:Results:– Increased slow wave sleep Increased slow wave sleep (by polysomnography)(by polysomnography)

– Improvement in memory-oriented tasks Improvement in memory-oriented tasks (by (by neuropsychological testing)neuropsychological testing)

50

RCT of a nonpharmacological RCT of a nonpharmacological intervention to improve sleep in NH intervention to improve sleep in NH

residentsresidents(N=118 residents from 4 NHs) (N=118 residents from 4 NHs) Alessi et al, JAGS 53:803-810, 2005Alessi et al, JAGS 53:803-810, 2005

• Intervention combined efforts toIntervention combined efforts to::– ↓ ↓ daytime daytime in-bed timein-bed time– ↑ ↑ daytime daytime sunlight exposuresunlight exposure– ↑↑ daytime physical activitydaytime physical activity– ↓↓ nighttime noise and lightnighttime noise and light– provide bedtime routineprovide bedtime routine

• ResultsResults::– Modest decrease in duration of nighttime awakeningsModest decrease in duration of nighttime awakenings– Nearly 50% decrease in daytime sleeping Nearly 50% decrease in daytime sleeping – Increased participation in social and physical activities Increased participation in social and physical activities

and social conversationand social conversation

51

Summary: Sleep Summary: Sleep Changes in Older Changes in Older

AdultsAdults• Complex interplay of Complex interplay of multiple multiple

factorsfactors (rarely does one factor (rarely does one factor cause changes)cause changes)

• MedicalMedical and psychological and psychological factors play increasing role in factors play increasing role in later life later life

• Primary sleep disordersPrimary sleep disorders are are more prevalent in older personsmore prevalent in older persons

• Improving sleep behavioral Improving sleep behavioral factors and treating illness is factors and treating illness is first stepfirst step

• Risks for hypnotic use increase Risks for hypnotic use increase with agewith age

Poor Sleep

Behavior

Medical Illness &

Medications

Psychiatric and

Neurologic

Primary Sleep

Disorders

Circadian Changes

Sleep Problem