9 26 09,,,Sleeping Problems 52 Slides

SLEEP PROBLEMS

Slide 2

OBJECTIVES

Know and understand:

• Age-related changes in sleep

• The psychiatric, medical, and neurological causes of sleep problems

• Office-based and objective methods of evaluating sleep

• Appropriate treatment of sleep problems

Slide 3

TOPICS COVERED

• Epidemiology of Sleep Problems

• Changes in Sleep with Aging

• Evaluation of Sleep

• Common Sleep Disorders

• Changes in Sleep with Dementia

• Sleep Disturbances in the Hospital

• Sleep in the Nursing Home

• Management of Sleep Problems

Slide 4

EPIDEMIOLOGY OF SLEEP PROBLEMS IN OLDER PEOPLE (1 of 2)

19%

29%

37%

0%

5%

10%

15%

20%

25%

30%

35%

40%

Difficulty fallingasleep

Nighttimeawakening

Early morningawakening

Slide 5

EPIDEMIOLOGY OF SLEEP PROBLEMS IN OLDER PEOPLE (2 of 2)

• Three large studies show that risk factors account for insomnia in most people studied Chronic illness Mood disturbance Less physical activity Physical disability

• There is little association between sleep complaints and older age

Slide 6

CHANGES IN SLEEP WITH AGING

• Decreased sleep efficiency (time asleep divided by time in bed)

• Stable or decreased total sleep time

• Increased sleep latency (time to fall asleep)

• Earlier bedtime and earlier morning awakening

• More arousals during the night

• More daytime napping

• Decreases in deeper stages of sleep

Slide 7

SCREENING QUESTIONS

• Is the person satisfied with his or her sleep?

• Does sleep or fatigue interfere with daytime activities?

• Does the bed partner or others complain of unusual behavior during sleep, such as snoring, interrupted breathing, or leg movements?

Slide 8

OFFICE EVALUATION OF SLEEP

• Patient sleep log can be helpful

• Supplement with information from bed partner, others, and/or validated sleep questionnaire

• Focused physical exam should be guided by evidence from the history

• Conduct mental status testing

• Findings of the history and physical exam should guide lab testing

Slide 9

OBJECTIVE EVALUATION OF SLEEP

• Polysomnography is indicated if a primary sleep disorder is suspected: Sleep apnea

Periodic limb movement disorder

Violent or other unusual behaviors during sleep

• In-home portable monitoring – screens for sleep apnea

• Wrist-activity monitor – estimates sleep vs. wakefulness

Slide 10

COMMON SLEEP DISORDERS

• Insomnia is usually due to a psychiatric, medical, or neurologic illness

• Excessive daytime sleepiness is usually due to a primary sleep disorder

• Significant overlap among these symptoms

• Don’t exclude a primary sleep disorder in the patient presenting with insomnia

• Don’t refer every patient with daytime sleepiness to a sleep laboratory

Slide 11

PSYCHIATRIC DISORDERS & PSYCHOSOCIAL PROBLEMS

• Depression is a common cause of sleep problems

• Sleep disturbance in older people who are not currently depressed may be an important predictor of future depression

• Treatment of depression may improve the sleep abnormalities

• Bereavement, anxiety, and stress can also be associated with sleep difficulties

Slide 12

DRUG & ALCOHOL DEPENDENCY

• Drug and alcohol use account for 10% to 15% of cases of insomnia

• Chronic use of sedatives may cause light, fragmented sleep

• Chronic use of sleep medications may lead to tolerance

• Alcohol abuse often leads to lighter sleep of shorter duration

• Sedatives and alcohol can worsen sleep apnea

Slide 13

MEDICAL PROBLEMS

• Medical problems can contribute to sleep difficulties: Pain from arthritis, other conditions Paresthesias Cough Dyspnea from cardiac or pulmonary illness Gastroesophageal reflux Nighttime urination

• Sleep can be impaired by diuretics or stimulating agents

• Some antidepressants, antiparkinson agents, and antihypertensives (eg, propranolol) can induce nightmares and impair sleep

Slide 14

SLEEP APNEA (1 of 4)

• Defined as periodic reductions in ventilation during sleep

• Patients report excessive daytime sleepiness – often unaware of frequent arousals at night

• Patients may have morning headache, personality changes, poor memory, confusion, and irritability

• Bed partner may report loud snoring, cessation of breathing, and choking sounds during sleep

Slide 15


• Large body mass – most important predictor

• Other reported predictors:

Falling asleep at inappropriate times or napping

Male gender

Large neck circumference

• Alcoholism is an important risk factor

• Some evidence of an association with dementia

Slide 16


• Validity of home-based diagnostic systems not established, but they may be helpful

• Refer to sleep laboratory for evaluation and, if indicated, a trial of treatment

• Main treatment = nasal CPAP

Evidence conflicts about tolerance in older patients

Comfort-improving devices may improve compliance

Oral appliances may be an option in mild cases

Slide 17

PERIODIC LIMB MOVEMENTS DURING SLEEP (PLMS)

• Debilitating, repetitive, stereotypic leg movements that occur in non-REM sleep

• May present as difficulty maintaining sleep or excessive daytime sleepiness

• Prevalence increases with age

• PLMS associated with sleep complaints not explained by another sleep disorder = periodic limb movement disorder (diagnosis requires polysomnography)

Slide 18

RESTLESS LEGS SYNDROME

• Uncontrollable urge to move legs at night

Symptoms occur while the person is awake

Symptoms can also involve the arms

• Prevalence increases with age

• Polysomnography not required for diagnosis

• Many patients with this condition also have PLMS

Slide 19

TREATMENT OF PLMD AND RESTLESS LEGS SYNDROME

• A dopaminergic agent is the initial agent of choice for older patients

• Evening dose of a dopamine agonist (eg, pramipexole* or ropinirole) commonly used for patients with frequent (eg, nightly) symptoms

• Nighttime dose of carbidopa-levodopa* can be used for patients who need medication infrequently

*Off-label

Slide 20

DISTURBANCES INSLEEP-WAKE CYCLE

• Delayed sleep phase = fall asleep late, awaken late

• Advanced sleep phase = fall asleep early, awaken early – particularly common in older people

• Refer patients with significance disturbance to a sleep laboratory

• Problems related to either condition may respond to appropriately timed bright light

Slide 21

REM SLEEP BEHAVIOR DISORDER

• Excessive motor activities during sleep and a pathologic absence of the normal muscle atonia during REM sleep

• Presenting symptoms are usually vigorous sleep behaviors associated with vivid dreams – may result in injury to the patient or bed partner

• Review patient medications

• Polysomnography is needed to establish the diagnosis

Slide 22

TREATMENT OFREM SLEEP BEHAVIOR DISORDER

• If drug-induced, remove the offending agent

• Clonazepam (off-label) – but adverse effects a concern in older patients

• Melatonin – some evidence for use in patients with coexisting neurodegenerative disorders (eg, Parkinson’s disease)

• Environmental safety interventions are indicated

Slide 23

CHANGES IN SLEEP WITH DEMENTIA

• Older patients with dementia have: More sleep disruption and arousals Lower sleep efficiency Higher percentage of stage 1 sleep and decreases

in stage 3 and 4 sleep

• Disturbances of the sleep-wake cycle are common with dementia Daytime sleep

Nighttime wakefulness

Slide 24

SLEEP DISTURBANCES IN THE HOSPITAL

• Factors contributing to insomnia in the hospital: Illness Medications Change from usual nighttime routines Sleep-disruptive environment

• Nonpharmacologic interventions can help: Daytime bright-light exposure

Change medication times to allow patients to sleep later in morning

Back rub, warm drink, relaxation tape at night

Slide 25

MEDICATIONS FOR SLEEPDISTURBANCES IN THE HOSPITAL

• Benzodiazepine receptor agonists very commonly used

• Sedating antihistamines (eg, diphenhydramine) should not be used

• Keep in mind that sleep-related breathing disorders may be common in hospitalized adults, particularly among those with cardiac illness or stroke

Slide 26

SLEEP PROBLEMS AND INSTITUTIONALIZATION

Up to 70% of caregivers report that nighttime difficulties played a significant role in their decision to institutionalize the older person, often because the sleep of the caregiver was being disrupted

Slide 27

SLEEP IN THE NURSING HOME (1 of 2)

• Causes of sleep difficulties: Multiple physical illnesses Use of psychoactive medications Debility and inactivity Increased prevalence of sleep disorders Environmental factors such as nighttime noise,

light, and disruptive nursing care Lack of exposure to bright light during the day

• One study found average duration of sleep episodes during the night = 20 minutes

Slide 28

SLEEP IN THE NURSING HOME (2 of 2)

• Nonpharmacologic interventions can help:

Morning exposure to bright light

Structured physical and social activities

Nighttime interventions to decrease noise and light disruption

Slide 29

MANAGEMENT OF SLEEP PROBLEMS

• Do not start an older patient with persistent sleep complaints on a sedative hypnotic agent without careful clinical assessment to identify the cause

• If the history and physical exam do not suggest a serious underlying cause, start with a trial of improved sleep hygiene (see next slides)

Slide 30

MEASURES TO IMPROVESLEEP HYGIENE (1 of 2)

• Maintain a regular rising time

• Maintain a regular bedtime, unless not sleepy

• Decrease or eliminate naps, unless necessary

• Exercise daily, but not immediately before bedtime

• Do not use bed for reading or watching television

• Relax mentally before going to sleep

• If hungry, have a light snack (except with symptoms of gastroesophageal reflux or medical contraindications), but avoid heavy meals at bedtime

Slide 31

MEASURES TO IMPROVESLEEP HYGIENE (2 of 2)

• Limit or eliminate alcohol, caffeine, nicotine

• Wind down before bedtime, and maintain a routine period of preparation for bed

• Control the nighttime environment with comfortable cool temperature, quiet, and darkness

• Try a fan or other “white noise” machine

• If unable to fall asleep within 30 minutes, get out of bed and perform soothing activity (avoid bright light)

• Get adequate exposure to bright light during the day

Slide 32

NONPHARMACOLOGIC INTERVENTIONS (1 of 3)

Intervention Goal Description

Stimulus control

To recondition maladaptive sleep-related behaviors

Patient is instructed to go to bed only when sleepy, not use the bed for eating or watching television, get out of bed if unable to fall asleep, return to bed only when sleepy, get up at the same time each morning, not take naps during the day.

Sleep restriction

To improve sleep efficiency (time asleep divided by time in bed) by causing sleep deprivation

Patient first collects a 2-week sleep diary to determine average total daily sleep time, then stays in bed only that duration plus 15 minutes, gets up at same time each morning, takes no naps in the daytime, gradually increases time allowed in bed as sleep efficiency improves.

Slide 33



Cognitive interventions

To change misunderstandings and false beliefs regarding sleep

Patient’s dysfunctional beliefs and attitudes about sleep are identified; patient is educated to change these false beliefs and attitudes, including normal changes in sleep with increased age and changes that are pathologic.

Relaxation techniques

To recognize and relieve tension and anxiety

Progressive muscle relaxation: teach patient to tense and relax each muscle group. Electromyographic biofeedback: give patient feedback regarding muscle tension and teach techniques to relieve it. Meditation or imagery techniques are taught to relieve racing thoughts or anxiety.

Slide 34



Bright light To correct circadian rhythm causes of sleeping difficulty (ie, sleep-phase problems)

The patient is exposed to sunlight or a light box. Best evidence is from treatment of seasonal affective disorder (from 2500 lux for 2 hours/day to 10,000 lux for 30 minutes/day). For delayed sleep phase, 2 hours early morning light at 2500 lux. For advanced sleep phase, 2 hours evening light at 2500 lux. Shorter durations may be as effective. Routine eye examination is recommended before treatment; avoid light boxes with ultraviolet exposure.

Slide 35

SLEEP MEDICATIONS (1 of 5)

• Short-acting agents are recommended for problems with initiating sleep

Lower associations with falls and hip fractures

But produce the most pronounced rebound and withdrawal syndromes after discontinuation

Rebound insomnia is dose-dependent and can be reduced by tapering the dosage prior to discontinuing the drug

• Intermediate-acting agents are recommended for problems with sleep maintenance

Slide 36

Class, Drug Starting Dose

Usual Dose

HalfLife(hrs)

Comments

Intermediate-acting benzodiazepine

Temazepam 7.5 mg 7.5–30 mg

8.8 Psychomotor impairment, increases risk of falls

Short-acting nonbenzodiazepines

Eszopiclone 1 mg 1–2 mg

6 Reportedly effective for long-term use in selected individuals; may unpleasant taste, headache; avoid administration with high-fat meal


Slide 37


Usual Dose

HalfLife(hrs)

Comments

Short-acting nonbenzodiazepinesZaleplon (pyra-zolopyrimidine)

5 mg 5–10 mg

1* Reportedly little daytime carryover, tolerance, or rebound insomnia

Zolpidem (imidazo-pyridine)

5 mg 5–10 mg

1.5–4.5†

Reportedly little daytime carryover, tolerance, or rebound insomnia


*Reportedly unchanged in elderly persons†3 in elderly persons, 10 in hepatic cirrhosis

Slide 38


Usual Dose

HalfLife(hrs)

Comments

Sedating antidepressants

Mirtazapine (off-label)

15 mg 5–45 mg

31–39 in older adults; 13–34 in younger adults; mean = 21

Increased appetite, weight gain, headache, dizziness, daytime carryover; used for insomnia with depression


Slide 39


Usual Dose

HalfLife(hrs)

Comments

Sedating antidepressants

Trazodone (off-label)

25–50 mg

25–150 mg

Reportedly 6 ± 2; prolonged in elderly and obese persons

Moderate orthostatic effects; reportedly effective for insomnia with depression; administration after food minimizes sedation and postural hypotension


Slide 40

CHRONIC HYPNOTIC USE

• Studies of benzodiazepines:

Prevalence of use increases with age

Chronic use increases morbidity and mortality

Chronic use may exacerbate sleep problems

To assist patients to eliminate use:

Decrease dose by half for 2 weeks prior to full withdrawal; may need to taper more slowly

Add replacement tablet (eg, nighttime acetaminophen or melatonin) after tapering off benzodiazepine

Slide 41

NONPRESCRIPTION SLEEP PRODUCTS

• Used by nearly half of all older adults

• Acetaminophen is preferable to combination analgesic/antihistamine agents

• Not generally recommended: Sedating antihistamines (anti-cholinergic side effects)

Alcohol (interferes with sleep later in night)

Melatonin (however, there is evidence for usefulness in blindness, jet lag, and shift work)

Valerian (herbal product, little effectiveness)

Slide 42

SUMMARY

• Risk factors, not aging per se, account for insomnia in most older people

• Insomnia is usually due to psychiatric, medical, or neurologic illness; excessive daytime sleepiness is usually due to a primary sleep disorder

• Polysomnography is indicated if a primary sleep disorder is suspected

• Nonpharmacologic interventions are often quite effective in improving sleep in older adults

Slide 43

CASE 1 (1 of 3)

• A 72-year-old obese man who is not depressed comes to the office because he has insomnia and fatigue.

• His wife reports hearing him snoring loudly in a separate bedroom and notes that he sleeps a lot during the day.

• The patient’s history includes hypertension and mild heart failure. His body mass index is 40.

Slide 44

CASE 1 (2 of 3)

Which of the following is most likely to be helpful for this patient?

(A) Bright-light therapy from 7 PM to 9 PM

(B) Nasal continuous positive airway pressure

(C) Implementation of sleep hygiene routines

(D) Lorazepam 1 mg administered at bedtime

(E) Zolpidem 10 mg administered at bedtime

Slide 45

CASE 1 (3 of 3)

Which of the following is most likely to be helpful for this patient?

(A) Bright-light therapy from 7 PM to 9 PM

(B) Nasal continuous positive airway pressure

(C) Implementation of sleep hygiene routines

(D) Lorazepam 1 mg administered at bedtime

(E) Zolpidem 10 mg administered at bedtime

Slide 46

CASE 2 (1 of 3)

• An 82-year-old woman who lives in a long-term-care facility is evaluated for agitation that occurs during the day and when she awakens from sleep.

• The patient has mild Alzheimer’s dementia. She spends most of the day in front of a TV in a lounge with low lights, occasionally dozing off. The patient is mobile and fully participates in all basic ADLs.

• Review of her medications and physical exam reveal no apparent cause for the agitation. Mental status examination reveals only mild cognitive impairment.

Slide 47

CASE 2 (2 of 3)

Which of the following interventions is most likely to benefit this patient?

(A) Exercise the patient twice daily.

(B) Discourage the patient from watching TV and introduce nighttime diapers.

(C) Keep the patient in a bright environment during the day and in a quiet, dark environment at night.

(D) Prevent daytime napping and implement enforced sleeping hours, with restriction of evening fluid intake.

(E) Provide the patient with a soft nightlight, familiar items at the bedside, and orienting objects, such as a clock.

Slide 48

CASE 2 (3 of 3)

Which of the following interventions is most likely to benefit this patient?

(A) Exercise the patient twice daily.

(B) Discourage the patient from watching TV and introduce nighttime diapers.

(C) Keep the patient in a bright environment during the day and in a quiet, dark environment at night.

(D) Prevent daytime napping and implement enforced sleeping hours, with restriction of evening fluid intake.

(E) Provide the patient with a soft nightlight, familiar items at the bedside, and orienting objects, such as a clock.

Slide 49

CASE 3 (1 of 3)

• A 70-year-old man describes a 6-month history of severe insomnia and fatigue. He has initial insomnia and interrupted sleep with multiple awakenings throughout the night.

• The insomnia began shortly after his wife died and has gradually worsened. He also describes fatigue, loss of energy, poor concentration, and anxiety, and he is now less active at home and in the community.

• The patient is generally in good health and has no history of sleep or psychiatric disturbance. Physical examination is normal.

Slide 50

CASE 3 (2 of 3)

Bedtime administration of which of these agents is most likely to help the patient?

(A) Melatonin, 2 mg sustained release

(B) Mirtazapine, 15 mg

(C) Red wine, 6 oz

(D) Temazepam, 7.5 mg

(E) Zolpidem, 10 mg

Slide 51

CASE 3 (3 of 3)

Bedtime administration of which of these agents is most likely to help the patient?

(A) Melatonin, 2 mg sustained release

(B) Mirtazapine, 15 mg

(C) Red wine, 6 oz

(D) Temazepam, 7.5 mg

(E) Zolpidem, 10 mg

Slide 52

ACKNOWLEDGMENTS

GRS6 Chapter Author: Cathy A. Alessi, MD

GRS6 Question Writer: David G. Folks, MD

Medical Writers: Beverly A. Caley

Faith Reidenbach

Managing Editor: Andrea N. Sherman, MS

© American Geriatrics Society

Health & Medicine

9 26 09,,,Sleeping Problems 52 Slides