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INSOMNIA IN ELDERLY

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??????????????? ? ???????????????, ??????????????????????? ??. ... Contraindications: severe hepatic impairment, fluvoxamine. II. Herbal/Homeopathic Remedies ... – PowerPoint PPT presentation

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Title: INSOMNIA IN ELDERLY


1
INSOMNIA IN ELDERLY
  • ???
  • ?????????????????????????????????? ???????????
  • ??????????????????? ?????????????
  • ?????????????????????

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???????????????
  • ???????????????????????????????????????????
    30-45 ????
  • ??????????????? ? ???????????????,
    ??????????????????????? ??.
  • ??????????????????????????????????????
  • ??????????????????????? ?????????????????????????
    ???????????????

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Sleep Cycles
  • Sleep is divided into
  • Rapid Eye Movement (REM) sleep
  • Non-REM sleep
  • Non-REM sleep is then divided into 4 stages
  • Stage 1
  • Stage 2
  • Stage 3
  • Stage 4

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Sleep Cycle
10
  • Initiation of Sleep Time to fall asleep
  • - standard less than 30 minutes
  • Sleep Efficiency Time sleeping / time in bed
  • - standard Greater than 85

11
Sleep Changes in the Elderly
  • Takes longer to initiate sleep
  • Increased time spent in lighter sleep  (Non-
  • REM Stages 1 and 2)
  • Less time spent in slow wave sleep (Non
  • -REM Stages 3 and 4)
  • Increased latency to REM sleep
  • Experience frequent/early morning awakenings
  • Reduced sleep efficiency/quality

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  • Transient Insomnia symptoms present for less than
    one week
  • Short Term Insomnia symptoms for 1-4 weeks
  • Chronic Insomnia Symptoms present for more
    than one month

15
Importance  of  Sleep 
  • ? Active state that affects both physical and
    mental well-being
  • ? Body  rest and energy restoration
  • Infants   16-18 hours of sleep/day
  • Teenagers 9 hours/day
  • Adults  7-8 hours/day
  • ? Prompted by brains natural cycles of activity 

16
Sleep Stage Importance
  • REM sleep is associated with dreaming
  • 80-90 of subjects if awakened
  • A person is actively paralyzed when dreaming
  • Stage 3 4 sleep is where most brain and body
    restoration/rejuvenation occurs
  • AKA delta sleep or slow wave sleep
  • Brain repair and memory consolidation
  • Important for full alertness the following day

17
Insomnia resultant problems
  • Reduction in motivation, energy or initiative
  • Proneness for errors or accidents at work or
    while driving
  • Tension, headaches or gastrointestinal symptoms
    in response to sleep loss
  • Concerns or worries about sleep
  • Secondary psychiatric problems

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Insomnia and ItsHealth Consequences
  • Insomnia is associated with dementia,
  • and may exacerbate cognitive deficits
  • Nocturnal agitation
  • Sundowning
  • Daytime cognitive impairment
  • Attention
  • Concentration
  • Memory

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Neurochemistry
  • Several neurotransmitters have been implicated in
    inducing, preventing, or regulating sleep
  • Norepinephrine, histamine, and acetylcholine
    promote wakefulness
  • GABA promotes sedation and sleep
  • Serotonin modulates movement thru sleep
    stages
  • Melatonin promotes sleep induction in
    darkness
  • Newly discovered Orexin or Hypocretin also
    modulate sleep cycles

23
???????????????????????
  • ????????????????????????????? ???????????????????
    ??
  • ????????
  • 1) ??????????????????? ???????????????????
    ???????????????????????
  • 2) ?????????????????????
  • 3) ??????????? ??????????????????????
  • 4) ?????????????????????? ????????????
    ?????????? ?
  • 5) ????????????????????????? ????????????????????
    ?????????????????????????????????????

24
???????????????????????????
  • ??????????????
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  • ?????????? ?????????? ?????????????????????

25
???????????????????????????????
I
  • 1. ???????????? ?????????????????? ???????????
    ??????????????? ???????????? ??????
    ????????????? (Adjustment disorders),
    ????????????????????????????

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???????????????????????????????
II
  • 2. ????????? ?????????????????????????????????
    ???? ?????????? ? ???????? ??????
    ??????????????????? ?????????????????????
    ????????????? ????????????????????
    ????????????????

30
???????????????????????????????????????
  • ?????????????????
  • ???????????????? - Parkinson, dementia
  • ????????????????????
  • ?????????
  • ???????
  • ??????????? ? ???? ??????????
  • ??????????????????????? ?????? gastrointestinal
    reflux ???????????????

31
???????????????????????????????
III
  • ??????????? ????????????????????????????
  • - Amphetamine / Methylphenidate
  • - Pseudo ephedrine
  • - Decongestants / Theophylline
  • - Methyldopa, antihypertensive drug ??????
    resupine clonidine
  • - SSRI, eg. Fluoxetine, sertraline,
    venlafaxin , bupoprion
  • - Cimetidine, alcohol, caffeine, thyroid
    hormone antineoplasties, ?????????

32
???????????????????????????????
IV
????????????????????? ??????????????
?????????????????????????? ??????????????????????
??????? ????????????????? ????????????????????
???? ????????????????????????????????
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???? ?????????????????????????????????? ? ?? ?
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?????????????????????
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Assessing Insomnia in the Geriatric Patient
  • Conduct physical examination
  • Ask specific questions about sleep patterns 
  • and complaints
  • Obtain Comprehensive Medical History 
  • Current Medications (diuretics, 
  • benzodiazepines, stimulants, polypharmacy)
  • Substance Use (alcohol, nicotine, caffeine)
  • Sleep hygiene

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40
????????
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  • ?????????????????????? ???????????????????????
    ?????????????????????????? ?????????????? ???
  • ?????????????????????????????????????????? 6
    ?????

41
  • ??????????????????????????? ?????????????????????
    ??????????????????????????
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    ?????????????
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  • ?????????????? ??????????????????
  • ??????????????????????? ??????????????

42
Cognitive Model of Insomnia
Sleep initiation problems
Acute insomnia
Life stress Problem solving Rumination and
worry
Physiologic arousal Cognitive arousal

insomnia
Sleep maintenance problem
Nonerstorative Sleep
Worry about sleep
Chronic insomnia
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Cognitive therapy
I
  • ?????????????????????????????????????
  • ??????????????????????
  • ?????????????????????

45
CBT
II
  • ???
  • - ????????????????????????????????????????????????
    ??????? ??????????????? ??????????????????????????
    ???
  • ??????????? ?????????? ???????????????????????
  • ????????????????? ? ??????????????????????????????
    ???????????? ??? biofeedback ???????????
  • ???????????????????????? ???????????????? ? REM
    ??? REM rebound ?????????????????????????

46
?????????????????????????????
  • ???????????? 8 ??. ???????
  • ?????????? ????????????????, ???????
  • ?????????????
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    ???????????????
  • ???????????????????????????????????

47
  • ??????????????? 4 ??./??????
  • ???????????????????????
  • ???????????????????????????
  • ?????????????? 5 ???
  • sleep efficiency ??????????????
    ?????????????????? ??????????? 85 ???????? 15
    ????
  • ???????????? ??? efficiency gt 80 ?????????????
  • 30 ????

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Combining PharmacologicTreatment with
CBTResearch Findings
  • Pharmacologic treatment provides
  • immediate benefit
  • ? CBT takes longer to help, but the gains are
    maintained for up to 2 years later

CBT Cognitive Behavior Therapy.
51
Pharmacologic Treatments
  • FDA-approved drugs
  • Benzodiazepine receptor agonists
  • Melatonin receptor agonist
  • Drugs used off-label (not FDA approved for
    insomnia)
  • Sedating antidepressants
  • Antipsychotics
  • Self medication
  • Alcohol
  • H1 antihistamines (OTC sleep aids)
  • Herbal remedies

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53
????????????????????????
??????????????
  • ??????????????????? ?????????
    ???????????????????? ??????????? ??? rebound
    insomnia ???????????????????????????????
    ??????????????????????????????????????????????????
    ??????????????? ?????????????????????????????????
    ? ????????????????????????????????????????

54
  • ????????????????????????????
    ???????????????? ?????????????? ???????????
    ???????? ??????????????????????? ???????????????
    ??????????? ??????????????? ?????????????????

55
????????????????????????
  • Benzodiazepines
  • ?????????????????????? ?????????? short ????
    intermediate acting ???? lorazepam ???
    temazepam clonazepam ???? long half life
  • ????? benzodiazepine ??? ? ???????????????
    visuospatial impairment
  • cognitive impairment
  • ??????????????????? dementia ????????
    ???????????????? benzodiazepine
    ???????????????????????????? ????????
    ??????????? hyperkinesias

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Sum Up Benzodiazepines
  • Improve Intermediate/Long
  • Sleep latency acting BZD
  • Total sleep time Total sleep time
  • Number of Major side effect
  • awakenings Memory impairment
  • Short acting BZD Abuse potential
  • Good for sleep Hang over effects
  • latency

58
  • Non-benzodiazepines hypnotics
  • Zopidem
  • ?????????????????? ?????????? ???????????????
    ??? rebound insomnia

59
Trazodone (Desyrel)
  • Non-tri-cyclic antidepressant inhibits seratonin 
  • re-uptake
  • T1/2 7-8 h
  • Unlabeled use sedative/hypnotic
  • 25-50 mg before bedtime max 75-150 mg/day
  • Common SE somnolence, dizziness,lightheadedness
  • Serious SE orthostatic hypotension, priapism, 
  • arrhythmias, suicidal ideation

60
  • - Trazodone - ?????????????????????????? ???
    induction ???? aggravation of atrial ???
    ventricular arrhythmia ????????? ??????
    ??????????????????????????

61
Diphenhydramine
  • Mechanism of action
  • Blockade of H1 receptors (basal forebrain,
    preoptic
  • area of hypothalamus)
  • Blockade of cholinergic, serotonergic,
    adrenergic
  • receptors
  • Dose 25-100 mg
  • Elimination half-life 3.4-5.0 hours
  • Common adverse events
  • Sedation, dizziness, incoordination,
    nervousness,
  • anticholinergic effects

62
  • ???????? ????????? Antihistamine - mental
    confusion, urinary retention, coustipation
    tolerance 1-2 ???????
  • - Melatonin - large variation in formulation,
    purity ??? potency

63
Ramelteon (Rozerem)
I
  • Highly selective melatonin MT1 and MT2 
    receptor agonist
  • Chronic insomnia in the elderly
  • T1/2 1-2.6 h , 2-5 h
  • 8 mg tablet before bedtime
  • Rapid onset of action sleep onset

64
Ramelteon (Rozerem)
II
  • Do not administer with high fat meal
  • Common SE headache, fatigue, dizziness
  • SE ideation  Serious suicidal ideation, worsening
      of depression, complex sleep related  behavior
  • Contraindications severe hepatic
    impairment, fluvoxamine 

65
Herbal/Homeopathic Remedies
  • Natural ZZZ
  • Herbal blend
  • Valerian root
  • Inhibits reuptake of and stimulates the
    release of GABA in the CNS. (Commission
    E approved)
  • Jujube seed
  • Shown to calm, relax, reduce stress
  • Passion flower
  • Flavonoids play a role in binding to GABA
  • Commission E approved
  • L-Theanine
  • Found in green tea
  • Considered a relaxant
  • Increases alpha brain waves

66
????????????????????????????????????????????
  • Restless legs syndrome ???? RLS
  • ????????????????????????????????? ??????? ????
    ??????????? ???????????? ? ???????????????????????
    ????????????????????????????????????????????????
    ??? ????????????????????????????
    ??????????????????????????????????????????????????
  • ?????????????????????????????????????????????
  • ???????????????????????????????????
    ?????????????????????????

67
???????????????????????????????????????????? (RLS)
  • ???????????????????????? RLS ???????? ??????
    ????????????????????????, Peripheral neuropathy,
    rheumatoid arthritis

68
????????
  • Clonazepam, carbidopa/levodopa (simemet),
    pramipexole (sifrol) ??? opiates (oxycodone)

69
PERIODIC LIMB MOVEMENTS IN SLEEP (PLMS)
69
70
????????????????????????????????????????????
  • Periodic limb movement disorder ???? PLMD
  • ????????????????????????????? ????????????????????
    ???? ?????????????????????? ????????????????????
    ?????????????????????????????
    ??????????????????????????????????????????
    ??????????? ?????????? ???????????????????????????
    ?????????????????? ?????????????????????????
  • Incidence 45 ?????????????
  • ?????? ???????
  • ???????? ??????????? Restless leg syndrome

71
???????????????????????????????????????
  • ??????
  • ?????
  • 1. ??????????????????? sleep apnea ??????
  • ?????????????????????????????????????
  • 2. ???????????????????????????????????????
  • ?????????? ????????????????????
  • 3. ????????????????????????????

72
Obstructive sleep apnea-hypopnea syndrome
  • ??????
  • ??????????????????????????????????????????????????
    ??????????????????????????????????? ? ??????????
    ??????????? ?????????? ?????????
    ????????????????? ????????? ?????????????????????
    ??? ???????
  • ????????????????????
  • ????????????????????? ? ???????? ??????????
    ????????? ????????

73
????????
  • ???????????????? ?????????? ?????? ????????????
    ?????????????????????????? ???????????????????
    ? ????????? ????????????????
    ???????????????
  • ?????????????????????????????????????????? ?
    ???????? ????????? ???????????????????????????????
    ??????????

74
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  • ??????????
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  • ??????????????????????????????????????????????????
    ?
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  • ??????????????????????????????? ?????????
  • ?????????????????????????????????
  • ????????????????????????

75
??????????????????????
  • ??????????????????? ???? ?????????????????????????
    ?????????????????
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  • ???????????????????? ? ???????????
  • ?????????????????? ???? ???????
  • ??????????????????????????? ? ????????????????????
  • ?????????????? ???????????????????????????????????
    ??????????????

76
??????????????????????????????????????????
77
??????????????? 73 ?? ??????????????????????
???????????????????????????????? 7 ?????????
????????????????????????????????????? ??????????
??????????????????????? ?????????????????????????
?????? ?????????????? ?????????????????????
??????????????????????????? ??????????????????????
???? 3 ???? ????????????????????
?????????????????????????????
78
??????????? ???? 78 ?? ??????????????????????
???????????? ???????? ????? Dormicum ?? 15 ??
???????????????? ????????????? ??????????????
??????????????? ????????? ????????????????
??????????????
79
??????????????? 65 ?? ??????????????????
?????????? ????????????????????????????
80
  • ??????????????? 60 ?? ?????????????????????????
    ?????????? ????? xanax ??? ????????? ????????
    ?????????

81
?????????????????????????????????????????????
??????????????????????????????????
????????????????????????
??????????????????????????????????????????????????
?
???????????????????????
???????? (gt 1 ?????)
?????????
  • 1. ???? ??????????????????????
  • ??????????????????????? (sleep hygiene)
  • 3. ???????????????????? ???????????????????? 2
    ???????

??????????? ????????????????????
Primary sleep disorder ???? sleep apnea
syndrome, PLMD
??????????????????????
??????????????
82
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