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Sleep Disorders in the Elderly

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Title: Sleep Disorders in the Elderly


1
Sleep Disorders in the Elderly
  • Dr motahare mirdamadi
  • psychiatrist

2
Sound Familiar?
  • Why am I so tired all of the time?
  • I dont have any energy
  • I just cant sleep well anymore
  • My husbands always falling asleep, he doesnt do
    anything anymore
  • I wish I could just get some rest
  • I just lie awake, I cant get back to sleep

3
Agenda
  • Significance of sleep disorders
  • Physiology Normal and Aging
  • Classifying sleep disorders
  • Sleep hygiene
  • Evaluation for sleep disorders
  • Insomnia
  • (Sleep-disordered breathing)
  • Other sleep disorders

4
Significance of Sleep Disorders
  • Survey of 9000 people gt age 65
  • No sleep complaints (12)
  • Difficulty initiating/maintaining (43)
  • Nocturnal waking (30)
  • Insomnia (29)
  • Chronic sleep difficulties (gt50)
  • Daytime napping (25)
  • Trouble falling asleep (19)
  • Waking too early (19)
  • Waking without feeling rested (13)
  • Ancoli-Israel S. JAGS 200553S264-S271.

5
Significance of Sleep Disorders
  • gt50 of sedatives are used by people age gt 65
  • In age 70-100, 19 of patients were taking a
    sleep medicine (in one study)
  • Mortality due to common conditions is 2 times
    higher in elderly with sleep disorders than in
    those without.
  • Daytime somnolence can interfere with activities
    and function
  • Sleep disorders negatively impact quality of life
  • Sleep disorders can lead to depression and
    cognitive impairment

6
Agenda
  • Significance of sleep disorders
  • Physiology Normal and Aging
  • Classifying sleep disorders
  • Sleep hygiene
  • Evaluation for sleep disorders
  • Insomnia
  • Sleep-disordered breathing
  • Other sleep disorders

7
Normal Physiology - Basics
  • Non-REM sleep
  • Stage 1 very light, easy to arouse
  • Stage 2 most of the nights sleep
  • Stage 3,4 slow wave, deeper sleep
  • REM sleep
  • EEG similar to stage 1
  • Low/absent muscle tone
  • Dreaming occurs here
  • Greatest cardiac and respiratory instability

8
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9
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10
Normal Physiology - Basics
  • Sleep Architecture
  • REM latency is about 90 minutes (wide variation)
  • Very short in narcolepsy
  • REM normally occurs every 90 to 120 minutes
  • More stage 3,4 in first half of night, more REM
    2nd half
  • Brief awakenings (30 sec) common, not usually
    remembered
  • Brief arousals (3 sec) are normal

11
Age-Related Changes
  • Non-REM
  • Less slow wave sleep (stage 3 and 4), may be
    entirely absent, easier to awaken
  • REM
  • Shorter REM latency
  • Decreased REM percentage and duration
  • Architecture
  • Increased overall sleep latency
  • More awakenings/arousals less sleep efficiency
  • Less sleep in 24 hour period
  • Reduced sleep latency during day harder to stay
    awake

Espiritu JR. Clin Geriatr Med 2008241-14.
12
Age-Related Changes
  • Circadian cycle shifted earlier
  • Decreased melatonin levels at night
  • Decreased modulation of circadian rhythm between
    day and night
  • More naps during the day (1 hour)
  • May have little impact on night-time sleep
  • May enhance cognitive and psychomotor performance
    due to increase total sleep

Espiritu JR. Clin Geriatr Med 2008241-14.
13
Age Related Changes
  • Less physiologic flexibility with schedule
    changes
  • More comorbidities that can interfere with sleep
  • It is hard to know if sleep problems are more
    common independent of other conditions
  • The ability to get restorative sleep gets worse
    with age, the need for sleep does not.

14
Mechanisms Underlying Sleep Complaints
Vaz Fragoso CA. JAGS 20071853-1866.
15
Precipitating Factors
  • Declining Health Status
  • Nocturia
  • Pain (DJD, neuropathy)
  • Cardiac Disease
  • Angina, CHF, arrhythmia
  • Pulmonary Disease
  • Endocrine thyroid, menopause, DM polyuria

16
Precipitating Factors
  • Medications impact sleep architecture and
    sleep-disordered breathing
  • CNS stimulants/depressants
  • Diuretics, hypoglycemics
  • Neuropsychological Impairments
  • Depression, Anxiety
  • Cognitive Impairment/Psychosis
  • Primary Sleep Disorders

17
Perpetuating Factors - Psychosocial
  • Caregiving
  • The work of caregiving
  • Associated mental and physical health problems
  • Social Isolation
  • Poorer sleep hygiene
  • Decline in activity
  • Bereavement, Widowhood, Retirement

18
Agenda
  • Significance of sleep disorders
  • Physiology Normal and Aging
  • Classifying sleep disorders
  • Sleep hygiene
  • Evaluation for sleep disorders
  • Insomnia
  • Sleep-disordered breathing
  • Other sleep disorders

19
Primary Sleep Disorders
  • Primary Insomnia
  • Sleep onset (Initial)
  • Sleep maintenance (Middle)
  • Sleep disordered breathing
  • Obstructive sleep apnea
  • Central sleep apnea
  • Mixed sleep apnea
  • Circadian rhythm disturbances

20
Secondary Sleep Disorders
  • Underlying conditions that should be addressed
    first
  • Medical Illness causing nocturnal symptoms
  • Psychiatric Illness
  • Medications
  • Social/behavioral

21
Secondary Sleep Disorders
  • Psychophysiologic Insomnia (stimulus/response)
  • Adjustment Insomnia recent stressor
  • Inadequate Sleep Hygiene
  • Lack of schedule (retirement!)
  • Sedentary or naps during daytime
  • Voluntary sleep deprivation
  • Mixed-type insomnia

22
Agenda
  • Significance of sleep disorders
  • Normal physiology
  • Age related changes
  • Classifying sleep disorders
  • Sleep hygiene
  • Insomnia
  • Sleep-disordered breathing
  • Other sleep disorders

23
Sleep Hygiene
  • The bed is for sleeping (and sex) only
  • Increase activity, decrease naps
  • Avoid late meals
  • Avoid caffeine, ETOH, cigarettes
  • Environmental control (light, noise, temp)
  • Decrease stress
  • Establish a routine
  • Take bath

24
Polysomnography
  • Formal Sleep Test indications
  • Diagnosis of sleep-disordered breathing
  • Suspected narcolepsy
  • Suspected REM sleep movement disorder
  • Difficult to diagnose parasomnias (e.g. PLMS)
  • Not usually for
  • RLS
  • Circadian rhythm disorders
  • Primary insomnia

25
Agenda
  • Significance of sleep disorders
  • Physiology Normal and Aging
  • Classifying sleep disorders
  • Sleep hygiene
  • Evaluation for sleep disorders
  • Insomnia
  • Sleep-disordered breathing
  • Other sleep disorders

26
Insomnia - Definition
  • Difficulty with initiation, maintenance,
    duration, or quality of sleep that results in the
    impairment of daytime functioning.
  • Can lead to fatigue, mood disturbance,
    interpersonal and job problems, and reduced
    quality of life.

From DSM-IV
27
Insomnia - Definitions
  • Sleep latency usually gt 30 minutes
  • Sleep efficiency lt 85
  • Transient less than 1 week
  • Short-term 1-4 weeks
  • Chronic gt 1 month
  • May be perpetuated by worrying in bed or
    unrealistic expectations of sleep duration
  • More common in women, elderly, and chronic
    disease (medical and psychiatric)

28
Insomnia - Treatment
  • Non-pharmacologic therapy
  • Improvement in 70-80 of patients (though some
    studies used psychologists)
  • Stimulus control therapy bed for sleeping only,
    1 small nap only
  • Sleep restriction therapy reduce time in bed to
    achieve 90 efficiency, gradually increase (up to
    6-7 hours)
  • Relaxation therapy imagery, meditation, muscle
    relaxation
  • Cognitive therapy beliefs and attitudes
  • Sleep hygiene education

Joshi S. Clin Geriatr Med 200824107-119.
29
Insomnia - Medications
  • Use lowest effective dose
  • Use intermittent dosing
  • Short term use (lt 1 month if possible)
  • Gradual discontinuation (rebound)
  • Medications with shorter half lives are preferred
    to prevent next-day sedation

30
Insomnia - Medications
  • Short acting medications
  • More improvement with sleep latency
  • More withdrawal and dependence
  • Long acting
  • More improvement with sleep duration
  • More next day symptoms (sedation, cognitive
    impairment, falls)
  • Most medications have not been studied
    extensively in the elderly or more than 6 months

31
Insomnia - Medications
  • Benzodiazepines GABA-A receptors
  • Benefits cheap, improve sleep latency, total
    sleep time, number of awakenings, sleep quality
  • Disadvantages
  • More next day effects (drowsy, dizzy)
  • More dependency/withdrawal
  • More rebound symptoms
  • More amnesia (especially with shorter acting
    agents)
  • Falls and hip fracture risk (long acting)

Tariq SH. Clin Geriatr Med 20082493-105.
32
Insomnia - Medications
  • Benzodiazepine receptor agonists
  • Advantages
  • more specific targeting of GABA receptors in the
    brain so less side effects
  • Disadvantages
  • Not well studied in the elderly (use lower
    starting doses)
  • Not compared against each other
  • More expensive
  • Dependence/withdrawal still occur
  • Still can increase risk of falls and fractures

33
Zolpidem
  • Short half life (2.6 hours)
  • Better for sleep onset insomnia
  • Minimal impact on sleep architecture
  • Can see rebound insomnia, mild next day
    drowsiness, mild antergrade amnesia

34
Zaleplon (Sonata)
  • Ultrashort half-life (1 hour)
  • Better for sleep onset insomnia
  • Can increase total sleep time and efficiency
  • Can be taken after a middle of night awakening
  • Rare rebound and next day effects
  • Not approved for long term use
  • But reported to be safe for long term use in
    elderly

35
Eszopiclone (Lunesta)
  • Medium half life (5-7 hours)
  • Better for sleep maintenance insomnia
  • Increased total sleep time 49 min
  • Helps with sleep onset (27min)
  • Few next day effects (but longer half life
    suggest risk for next day effects in elderly)
  • Approved for long term use

36
Sedative-Hypnotics Risk/Benefit
  • Meta-analysis of 24 studies, gt 2400 patients
    older than age 60 treated with benzos or benzo
    receptor agonists
  • Benefits compared to placebo (NNT 13)
  • Small improvement in sleep quality
  • Sleep time increased (25 minutes)
  • Decrease number of awakenings (0.63)
  • Harms (NNH 6)
  • Cognitive impact (4.78 times more common)
  • Psychomotor events (2.61 times as common)
  • Daytime fatigue (3.82 times more common)

Glass et al. BMJ 20053311153-1212.
37
Other Medications
  • Melatonin receptor agonist
  • Small improvement in sleep onset (8 min)
  • Improved total sleep time (12 min)
  • Increase prolactin levels, few other side
    effects.
  • Not compared to other drugs or melatonin.
  • Approved for chronic use.
  • Sedating antihistamines

38
Other Medications
  • Sedating Antidepressants
  • Tricyclics they help, but side effects
  • Trazadone helps, not as much as Ambien(zolpidem)
  • May improve SWS (stage 3 and 4)
  • Remeron(mirtazapine) increased sleep efficiency,
    increases duration of slow wave sleep in elderly
  • These drugs are not well studied (or approved)
    for insomnia in the elderly
  • Best used for depression with insomnia

39
Other Medications - Melatonin
  • Levels correlate with circadian rhythm
  • Deficiency is more common in elderly and
    associated with insomnia
  • Effects (0.1 to 10mg QHS)
  • 7.8 minute ? latency in primary insomnia
  • 38.8 minute ? latency in delayed sleep phase
    syndrome
  • No impact on sleep efficiency
  • Minimal side effects, if any
  • Nutritional supplement dosing?

Gooneratne NS. Clin Ger Med 200824121-138.
40
Drugs vs No Drugs
  • Unclear if cognitive behavioral therapy or
    medication therapy is better
  • Both help
  • Medications may work more quickly
  • CBT may have more lasting benefit
  • Hard to do cognitive therapy
  • Medications not studied more than 6 months
  • It is best to attempt education and
    non-pharmacologic therapy first, and continue
    even if medications are used

41
Other Treaments for Insomnia
  • Bright Light Therapy
  • Light -gt suprachiasmatic nucleus -gt inhibits
    production of melatonin by pineal gland
  • Threshold between 200-400 lux (normal indoor
    fluorescent light)
  • Treatment uses 2000-10,000 lux
  • Dosing, timing, duration, effectiveness not
    established in the elderly
  • Best evidence for SAD in younger people

Gammack JK. Clin Geriatr Med 200824139-149.
42
Agenda
  • Significance of sleep disorders
  • Normal physiology
  • Age related changes
  • Classifying sleep disorders
  • Sleep hygiene
  • Evaluation for sleep disorders
  • Insomnia
  • Sleep-disordered breathing
  • Other sleep disorders

43
Sleep-disordered Breathing
  • Usually present with daytime somnolence
  • Snoring alone is not usually a problem
  • Hypopnea
  • Apnea increased incidence in the elderly, can
    be seen in 10-40
  • Obstructive
  • Central
  • Mixed

44
Sleep-disordered Breathing
  • Significance, Signs, and Symptoms
  • Daytime somnolence, effect on function
  • Decreased cognition, dementia may be worse
  • CHF, arrythmias, HTN, cor-pulmonale
  • Polycythemia
  • Nocturia
  • Personality changes
  • Morning headaches
  • Decreased libido, impotence
  • May increase mortality

45
Obstructive Sleep Apnea (OSA)
  • Definition repetitive episodes of uper airway
    obstruction with continued movement of chest and
    abdominal walls, leads to desaturations and
    arousals.
  • Risk factors people with classic symptoms and
  • Male
  • Large neck circumference (gt18 inches)
  • Obesity

46
OSA - Stages
  • daily sleepiness during tasks that require
    significant attention (driving, conversation,
    eating, walking), marked impairment in function

47
OSA - Treatment
  • Unclear benefit to treating mild or minimally
    symptomatic patients
  • Treatment is likely to improve
  • HTN
  • CHF
  • Daytime function
  • Cognition and health-related quality of life

48
OSA - Treatment
  • Weight loss, avoid supine position (tennis balls)
  • Avoid sedating drugs
  • Prescription drugs not helpful
  • CPAP/BIPAP Most efficacious
  • Compliance issues
  • Oral appliance less effective, use for mild
    cases or if CPAP not tolerated
  • Surgery trach, uvuloplasty

49
Central Sleep Apnea - CSA
  • Definition Periodic complete cessation of
    airflow and respiratory effort, followed by
    desaturations and arousals.
  • Related to chemoreceptors and CO2 physiology.

50
CSA Associated Conditions
  • Congestive heart failure
  • Prior Stroke and cerebrovascular disease
  • Other neurologic disorders ALS, mucular
    dystrophy
  • Chronic renal failure
  • Hypothyroidism
  • Baseline CO2 retainers (COPD, kyphoscoliosis)

51
CSA Diagnosis and Treatment
  • Diagnosis Polysomnography
  • Treatment
  • CPAP/BIPAP can help
  • Nocturnal Oxygen can help (offsets overshoot)
  • Consult your local pulmonologist

52
Agenda
  • Significance of sleep disorders
  • Normal physiology
  • Age related changes
  • Classifying sleep disorders
  • Sleep hygiene
  • Evaluation for sleep disorders
  • Insomnia
  • Sleep-disordered breathing
  • Other sleep disorders

53
Other Sleep Disorders
  • Restless Legs Syndrome
  • Periodic Limb Movements of Sleep
  • REM Sleep Behavior Disorder
  • Nocturnal Leg Cramps
  • Circadian Rhythm Disturbances

54
Restless Legs Syndrome (RLS)
  • Sensorimotor neurologic condition, possibly
    caused by abnormal iron metabolism and
    dopaminergic dysfunction unclear
  • Compelling urge to move limbs (legsgtarms)
  • Worse at rest
  • Worse at night
  • May have dysesthesia or pain
  • Relieved with movement
  • Disrupts sleep, alertness, daytime function, QOL

55
RLS Facts
  • 5-15 prevalence, increased in the elderly, more
    common in women
  • Associated features
  • FH positive in 60
  • PLMS in 80 (but 30 PLMS pts have RLS)
  • Diagnosis
  • Classic symptoms
  • Responds to trial of therapy

56
RLS Associated Conditions
  • Pregnancy
  • ESRD
  • Fe Deficiency
  • Check ferritin, iron
  • Parkinsons
  • Radiculopathy
  • Neuropathy
  • Rheumatoid arthritis
  • DM
  • Depression/anxiety
  • Drugs can exacerbate
  • Sedating antihistamines
  • Metoclopramide
  • Calcium channel blockers
  • Neuroleptics
  • TCAs
  • SSRIs
  • Caffeine
  • Nicotine
  • ETOH

57
RLS Treatment
  • Non-pharmacologic
  • Avoid caffeine, ETOH, associated medications
  • Sleep hygiene
  • Bedtime bath
  • Mild exercise before bedtime
  • Pharmacologic
  • most drugs used off label
  • 70-100 effective

58
RLS Treatment
  • Dopaminergics
  • Requip/ropinirole and Mirapex/pramipexole only
    FDA approved meds)
  • Use for daily or intermittent symptoms
  • First line treatment (most studied)
  • Benzos intermittent use, klonopin is best
    choice
  • Opioids daily or intermittent use
  • Neurontin daily use, similar efficacy to Requip
    (average dose 800mg)
  • Neuropsychobiology 200348(2)82-6.
  • Magnesium, folate have slight evidence

59
Periodic Limb Movements of Sleep
  • PLMS Periodic episodes of repetitive and highly
    stereotypc limb movements during sleep
  • 34-45 prevalence in the elderly, increases with
    age
  • Associated with RLS, arousals, difficulty
    achieving and maintaining sleep
  • Most are asymptomatic
  • Unclear significance
  • Associated conditions similar to RLS

60
PLMS Diagnosis and Treatment
  • Diagnosis
  • Clinical history and response to treatment
  • Polysomnography can be used
  • Treatment
  • Dopamine agonists
  • Benzos decrease arousals but not movements
  • Opioids

61
REM Sleep Behavior Disorder
  • Lack of normally low muscle tone during REM sleep
  • Cause unknown
  • Usually male, onset age 50-60
  • Act out dreams which can be violent
  • Vivid memory of dreams
  • Can diagnose with polysomnography
  • 1/3 of Patients will develop Parkinsons
  • Treat with benzo (klonopin 90 effective)

62
Nocturnal Leg Cramps
  • Cause not known
  • Associated factors
  • Meds (diuretics, nifedipine, beta agonists,
    steroids, morphine, cimetidine, statins, lithium)
  • Conditions (uremia, DM, thyroid, electrolyte
    d/os)
  • Diagnosis history, check labs

63
Nocturnal Leg Cramps
  • Treatment
  • Review associated factors
  • Calf stretching exercises
  • Quinine (200-300mg QHS)
  • Evidence of moderate benefit
  • Toxicity careful in elderly, kidney/liver
    disease
  • Digoxin interaction
  • Hematologic (thrombocytopenia)
  • Cinchonism
  • Blindness, arrhythmias, death!
  • Tonic Water

64
Circadian Rhythm Disturbance
  • Advanced sleep phase syndrome
  • Neurologic control of rhythms is altered
  • Early to bed, early to rise
  • Can interfere with societal norms
  • Total sleep time and daytime function usually not
    affected
  • Melatonin and light therapy are theorized to help
  • Reassure patients

65
Summary
  • Sleep problems are very common in the elderly
  • Sleep problems have significant impact on health
    and quality of life
  • Be as specific as possible in diagnosing sleep
    disorders
  • Treatment should include all contributing
    factors, and should include counseling
  • Avoid a pill for every symptom
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