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Sleep Disorders in Long-Term Care

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Title: Sleep Disorders in Long-Term Care


1
Sleep Disorders in Long-Term Care
  • Thomas Magnuson, M.D.
  • Assistant Professor
  • Division of Geriatric Psychiatry
  • UNMC

2
To Get Your Nursing CEUs
  • After this program go to www.unmc.edu/nursing/mk.
  • Your program ID number for the July 12th program
    is 10CE028.
  • Instructions are on the website.
  • All questions about continuing education credit
    and payment can be directed towards the College
    of Nursing at UNMC.
  • Heidi KaschkeProgram Associate, Continuing
    Nursing Education402-559-7487hkaschke_at_unmc.edu

3
Objectives
  • Discuss the causes of sleep disruption in
    long-term care
  • Identify non-pharmacologic interventions possible
    to remedy sleep disruption
  • Assess pharmacologic interventions for sleep
    disruption

4
Impact
  • Significant problem
  • Many residents with sleep problems
  • 50 of the elderly have sleep problems
  • 65 in Los Angeles area ALFs
  • Effect
  • Cognition
  • Physical health
  • Mood
  • Quality of life
  • Staff morale

5
Well Elderly
  • Spend more time in bed to get the same amount of
    sleep
  • Total sleep time only mildly decreased from when
    younger
  • Increase in nighttime awakenings and daytime
    napping
  • Earlier bedtimes
  • Increased time to fall asleep
  • More easily aroused by sound
  • Daytime sleepiness not part of normal aging

6
Long-Term Care
  • More often self-report sleep problems
  • More severe self-report
  • Asleep at all hours, even mealtimes
  • Wake and sleep fragmentation
  • Wakefullness interrupted by brief sleep
  • Leads to extreme sleep-wake disruption
  • Distributed across the entire day
  • Rarely awake or asleep for hours

7
Effects of Poor Sleep
  • Variety of problems
  • Irritability
  • Poor concentration
  • Decreased memory
  • Lessened reaction time
  • Poorer performance on tasks
  • Community dwelling elderly
  • More falls
  • Increased mortality

8
Case
  • 78-year-old demented female
  • Up at night, loud and disruptive
  • Sleeps much of the day
  • No activities
  • CAD, HTN, depression, hypothyroidism, h/o breast
    cancer, arthritis, GERD, constipation,
    incontinence
  • ASA, APAP, sertraline, synthroid, esomeprazole,
    metoprolol, furosemide, senna, MOM, oxybutynin,
    donepezil, memantine, hydrocodone/APAP

9
First Questions
  • How much are they sleeping?
  • Usually no one really knows
  • Up at nightsleeping pill
  • Up in the daystimulant
  • Shifts need to talk to each other
  • Sleep is poorly documented
  • When are they sleeping?
  • Daytime?
  • Nighttime?
  • Both?

10
First Intervention
  • Sleep chart
  • Daily
  • Every hour, on the hour
  • Not 401, just 400
  • 24 hours a day
  • For a week
  • Good general idea
  • Usually is around 9-11 hours a day

11
Causes
  • Primary sleep disorders
  • Medical conditions
  • Psychiatric disorders
  • Medications/polypharmacy
  • Circadian rhythm problems
  • Environment
  • Noise and light at night
  • Low daytime light
  • Behavioral
  • Physical inactivity
  • More time in bed

12
Primary Sleep Disorders
  • Sleep disordered breathing (SDB)
  • Restless Leg Syndrome (RLS)
  • Periodic Limb Movement Disorder (PLMD)
  • REM sleep behavior disorder (RBD)

13
Sleep Disordered Breathing (SDB)
  • Airflow interrupted
  • Obesity common cause
  • Apnea/hypopnea
  • 10 second episodes
  • 15 times an hour
  • Low oxygen to brain
  • Disrupts sleep
  • LTC residents
  • 50-66 have at least mild SDB
  • Treatment is CPAP
  • Air forces airway open

14
Restless Leg Syndrome (RLS)
  • Uncomfortable feeling in legs
  • Relieved by moving legs
  • Worse later in the day
  • Falling asleep is hard
  • Symptoms come on and worsen with age
  • Possible cause of motor restlessness and
    wandering
  • Treatment
  • ropinerole (Requip) and pramipexole (Mirapex)

15
Periodic Limb Movement Disorder (PLMD)
  • Legs kick, jerk during nighttime sleep
  • Easier to identify if one has asleep partner
  • Causes sleep fragmentation
  • Treatment
  • Much as RLS
  • ropinerole (Requip)
  • pramipexole (Mirapex)

16
REM Sleep Behavior Disorder (RBD)
  • Usually CNS motor is paralyzed in REM
  • Except for breathing
  • Act out dreams
  • Prominent in older men, certain dementias
  • Safety is an issue
  • Treatment
  • clonazepam (Klonopin)
  • Secure the environment

17
Case
  • Workup
  • Sleep chart
  • Broken up
  • Averages 9.4 hours a day
  • Range 4-13 hours a day
  • Lab, medical tests
  • Oxygen saturation unremarkable
  • TSH normal
  • CBC, BMP normal

18
Medications
  • Near bedtime
  • Lung medications/bronchodilators
  • caffeine, albuterol
  • Stimulants
  • methylphenidate (Ritalin)
  • Daytime sedation
  • Antihistamines
  • promethazine (Phenergan)
  • Anticholinergics
  • diphenhydramine (Benedryl)
  • Sedating antidepressants
  • nortriptyline, mirtazapine (Remeron) less than
    30mg/d

19
Medical Conditions
  • Common
  • Pain
  • Parasthesias
  • Nighttime cough
  • Dyspnea
  • GERD
  • Incontinence or frequent nighttime urination
  • Neurodegenerative disorders
  • Parkinsons disease, e.g.

20
Dementia
  • Common sleep problems
  • More sleep disruption
  • Lower sleep efficiency
  • More light sleep
  • Less deep sleep
  • Less REM
  • Sundowning

21
Circadian Rhythm
  • Bodys pattern of sleep/wake
  • Elderly
  • Blunted in amplitude
  • Less time in each sleep/wake cycle
  • Shifted in time
  • More daytime somnolence, nighttime awakenings
  • Less stable in LTC than in the community
  • May correlate with degree of dementia
  • Decreases survival in LTC

22
Circadian Rhythm
  • Exerts much influence on the timing of sleep
  • Weak CR or reset CR may strongly influence sleep
    problems
  • How to try and fix
  • Exposure to bright light in the daytime
  • Regular scheduled exposure
  • Physical activity less important than light
  • Bright in the day, dark at night

23
Case
  • Medical conditions
  • GERD
  • Well controlled, no evidence of nighttime
    heartburn
  • No food for an hour before bedtime
  • Pain
  • No complaints on routine APAP
  • Signs of worsened pain not present
  • Incontinence
  • Oblivious at night
  • Toileting right before bedtime

24
Case
  • Medical conditions
  • Mood
  • Stable symptoms
  • Hypothyroidism
  • TSH normal
  • Primary sleep disorders
  • Oxygenation normal
  • No noted movements awake or asleep that resemble
    RLS or PLMD
  • No odd or unusual nighttime behavior
  • Dementia
  • Pattern of sleep problem sounds familiar

25
Case
  • Medications
  • hydrocodone/APAP (Vicodin)
  • Pain controlled well on APAP
  • Not used in awhile
  • sertraline (Zoloft)
  • Not a sedating antidepressant
  • Could give at nighttime
  • oxybutynin (Ditropan)
  • Anticholinergic, antihistaminergic
  • Can choose a less concerning agent
  • L-thyroxine (Synthroid)
  • Only if underused

26
Night in LTC
  • Many sleep problems in the environment
  • Shared rooms
  • Frequent noise and light interruptions
  • Extended, nightly basis
  • Most noise caused by workers
  • Doing personal cares
  • Room level light
  • Suppresses melatonin
  • Disrupts sleep
  • Changes CR

27
Treatment
  • Nonpharmacologic
  • Timed light exposure
  • More alert right after exposure
  • More active in the day
  • Mixed results
  • Lower noise and light levels
  • Hard to change the environment

28
Treatment
  • Mixed approach
  • Daytime light exposure
  • Increased physical activity
  • Bedtime routine
  • Less time in bed
  • Minimize nighttime disruption
  • Results
  • Lessened daytime sedation
  • More social energy
  • More physically active
  • Hard to change nighttime noise and light levels

29
Treatment
  • Pharmacologic treatment
  • Hypnotics
  • zolpidem (Ambien)
  • zaleplon (Sonata)
  • ramelteon (Rozerem)
  • Adverse events
  • Dizziness
  • Drowsiness
  • Falls
  • Not efficacious
  • Dont give to someone sleeping 13 hours a day
  • Psychological dependence

30
Treatment
  • Pharmacologic
  • Benzodiazepines
  • alprazolam (Xanax)
  • lorazepam (Ativan)
  • clonazepam (Klonopin)
  • Adverse events
  • Falls
  • Confusion
  • Sedation
  • Dependency

31
Treatment
  • Pharmacologic
  • Sedating antidepressants
  • Tricyclics
  • Nortriptyline
  • Amitriptyline
  • Trazodone
  • Mirtazapine
  • Adverse events
  • Daytime sedation
  • Falls, orthostasis
  • Confusion, bladder retention, constipation,
    tachycardia

32
Treatment
  • Melatonin
  • Hormone
  • Mixed results
  • Bad idea
  • Antipsychotics
  • Alcohol
  • Caffeine
  • Exercise prior to bedtime

33
Case
  • No noisy roommate
  • No routine awakenings
  • Environment is noisy
  • Often sitting in chair near front door
  • Falls asleep in her room
  • Rarely goes outside

34
Case
  • Likely dementia related
  • Timed light therapy
  • Take outdoors to sit in the sun
  • Discontinue prn narcotic
  • Changed oxybutynin
  • Allowed timed naps to limit time in bed
  • Made rigid bedtime routine
  • Dark at night, bright in the daytime
  • No sleeping pill

35
Objectives
  • Discuss causes of sleep disruption in long-term
    care
  • Identify non-pharmacologic interventions possible
    to remedy sleep disruption
  • Assess pharmacologic interventions for sleep
    disruption
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