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  • Hello, this is Brenda Keller from the Section of Geriatrics and Gerontology at the University of Nebraska Medical Center. In these modules we will review sleep disorders in the Elderly.
  • In module 1 our objective is to understand the epidemiology of sleep disorders in the elderly. We review changes in the sleep cycle with aging and finally discuss the impact and evaluation of sleep disorders.
  • Sleep disorders are common in the elderly. Up to 40% of older Americans have difficulty sleeping at least a few nights per month. Insomnia can be difficulty falling asleep, difficulty staying asleep or not feeling restored by sleep.
  • In younger adults, the normal sleep pattern consists of a cycle of non-rem sleep (stages 1 to 4) lasting 45 to 60 minutes followed by REM sleep. In general, deep sleep –that is non-REM sleep stages 3 and 4-predominate the first third of the night and comprise 15-25% of the total nocturnal sleep time of young adults.
  • With age, however, there are changes in this pattern. Light sleep-(non-rem stages 1 and 2) increases with age and deep sleep decreases from 25% down to 3% of total sleep. Not only do older people have less time in stages 3 and 4 sleep, they are more easily awakened during deep sleep. These changes lead to more awakenings and fragmentation of sleep. In the otherwise healthy older person, slow-wave sleep may be completely absent, particularly in males. The amount of REM sleep is the same to slightly decreased in older people. The timing of sleep is also altered in older individuals. Loss of the neurons in the suprachiasmatic nucleus may account for the age related circadian phase shift. All of these changes lead to decreased sleep quality and efficiency.
  • Circadian rhythms, the cyclic daily patterns of physiologic changes, are altered with aging. These rhythms guide the production of hormones, the body’s temperature and the sleep/wake cycle. In aging the sleep/wake cycle advances due to changes in the core body temperature and decreased light exposure. A decrease in neurons in the suprachiasmatic nucleus also plays a role in this circadian shift. The suprachiasmatic nuclei are either of a pair of neuron clusters in the hypothalamus situated directly above the optic chiasm that receive photic input from the retina via the optic nerve. They regulate the body's circadian rhythms
  • This illustration demonstrates the effect of advanced phase circadian rhythm on sleep. In the younger person, sleepiness occurs around 10 pm, the person goes to bed and falls asleep and sleeps~8 hours and awakens with the sunshine at 6 am. In the older person, sleepiness occurs much earlier, around 6 pm, the person may fall asleep then, or go to bed around 10 pm, but because the shift in rhythms has occurred, they are wide awake around 3 or 4 am. Although they have had 8+ hours of sleep, they essentially wake up in the middle of the night. The sunshine is placed at 6 pm to remind us that sunshine exposure in the early evening may be helpful in shifting the rhythm back to standard phase.
  • The duration of sleep declines approximately 27 minutes for each decade of life after mid life until the 8 th decade of life.
  • Disrupted sleep has several negative consequences. These include: daytime sleepiness, impaired attention, slow response time and impaired memory and concentration. Performance is also decreased. In fact, mortality due to the common causes of death is twice as high for people with sleep disorders as it is for those who sleep well.
  • The evaluation for sleep problems is multifactorial. A careful sleep history can help you identify the frequency and severity of the problem. It can also help you identify those individuals that are sleepy because they are trying to get by on 2-3 hours of sleep per night. The timing of insomnia can be helpful to determine if the patient has difficulty falling asleep or staying asleep. The sleep environment is also crucial for a good night’s sleep. Lights, sounds and temperature all affect the quality of sleep. A review of sleep habits can help you identify the “night owl” who is now having sleeping problems after moving to the nursing home with a in bed by 9 and up at 6 policy. The daytime effects of the sleeplessness help to guide you in your therapeutic options. In the sleep history you will also want to elicit historical features of restless leg syndrome, periodic limb movement of sleep and obstructive sleep apnea. A collateral source history can be extremely helpful in these cases. Medical disorders leading to sleep problems include asthma, gastroesophageal reflux, congestive heart failure, epilepsy, and chronic pain syndromes. A good social history will provide you with information about stressors leading to an Adjustment disorder. This is one of the most common causes of acute insomnia. It is related to an anticipated or recent event (death of loved one, anxiety over a test). Excessive caffeine intake, or caffeine intake late in the day may contribute to insomnia. Although alcohol may induce sleep initially, it disrupts sleep later in the night. Drug abuse of amphetamines, ephedrine, caffeine, nicotine, and selective serotonin reuptake inhibitors such as Prozac may lead to sleep disturbance. It is important to review the effects of all patient medications on sleep. Psychiatric disorders such as depression, mania, and schizophrenia cause approximately one-third of chronic insomnia.
  • Non-pharmacological treatment has been found to improve symptoms in 70-80% of patients with primary insomnia. These effects tend to be long lasting, with studies showing retained effectiveness for 6 months after the treatment is completed.
  • Sleep hygiene is education about health and environmental practices that effect sleep. This strategy is used in conjunction with other techniques to improve sleep. A Sleep Hygiene Tips page is available for your use on the main page of this module.
  • Many factors affect sleep, both heath related factors and environmental factors. Knowledge about these factors can overcome sleeping problems in many cases. Diet can affect sleep in a variety of ways. Heavy meals within a few hours of bedtime can contribute to acid reflux. For some people caffeine, even in small amounts early in the day, can affect sleep 10-12 hours later. Others find that avoiding caffeine 6 hours before bedtime is enough to help sleep. An exercise program of brisk walking or low impact aerobics 30 minutes 4 times a week has been associated with improved sleep quality for older adults with moderate insomnia. It is best to not exercise within 4 hours of sleep time. Substance use and abuse is also associated with sleep problems. Although alcohol has sedative properties, and may speed the beginning of sleep, it actually increases the number of awakenings. Having a nice, quiet, comfortable, darkened room may be all that is needed to induce sleep for some people with insomnia. Bright lights, noises, and uncomfortable mattress in a room that is too hot or too cold can make sleep impossible. Correcting these environmental factors is far less expensive and safer than prescribing a pill.
  • Stimulus control reinforces the temporal and environmental cues for sleep onset. The patient should go to bed only when sleepy. The bed is to be used only for sleep, not for watching TV, reading, eating, etc. Cultivating pre-bedtime routines, such as warm milk, emptying the bladder and not going to bed hungry is helpful. The patient should arise at a regular time each morning, regardless of when they went to bed and napping should be avoided.
  • The rationale for sleep restriction is to decrease the amount of time in bed to increase the sleep efficiency. The only allowed time in bed is usually spent asleep. The maximum sleep restriction is 5 hours per night. The time in bed is then increased by 15 minutes per night. Like stimulus control, the wake up time is constant, however with sleep restriction, the bedtime is adjusted per protocol. Sleep restriction does allow for short afternoon naps.
  • Cognitive therapy involves identifying dysfunctional beliefs and attitudes about sleep and replaces them with adaptive substitutes. This helps to minimize anticipatory anxiety and arousal.
  • The paradoxical intention method of sleep management is based on the premise that performance anxiety inhibits sleep onset. It involves convincing the patient to engage in the feared behavior of staying awake. The theory is that if the patient stops trying to fall asleep and genuinely attempts to stay awake, sleep may come more easily.
  • Pharmacological treatment for primary insomnia is generally reserved for those who fail non-pharmacologic therapy. For individuals with secondary insomnia, treatment is focused on the underlying disease process. Treatment of depression with antidepressants, analgesic use for pain, and dopaminergic medications for restless leg syndrome and periodic limb movement of sleep are all effective in the management of secondary insomnia. Only those items on the left part of the screen have FDA approval for insomnia. Those items on the right column should be used with caution as their effectiveness and safety for the treatment of insomnia have not been established.
  • Several general precautions are given for the pharmacological treatment of insomnia. First, start with low doses and go slow with titration. Second, as needed dosing of medications is recommended as opposed to a scheduled dose of hypnotic. Thirdly, the majority of hypnotics are recommended for short term use only. Medications should be used in concert with the non-pharmacological methods discussed in module 2.

Powerpoint Powerpoint Presentation Transcript

  • Anxiety and Sleep Disorders in the Elderly Thomas Magnuson, M.D. Assistant Professor Division of Geriatric Psychiatry Department of Psychiatry
  • What is anxiety?
    • Normal, adaptive emotion
      • Run from a tiger
      • Pass a test
    • When excessive, it is maladaptive
      • Cannot function at work, in school, in relationships
      • Paralyzing, embarrassing
  • Symptoms
    • Cognitive
      • Worry
      • Fearfulness
    • Behavioral
      • Phobias,
      • Hyperkinesis
    • Physiologic
      • Heart palpitations
      • Hyperventilation
  • Anxiety Disorders
    • Common source of anxiety is depressive disorders
      • 50% of those with depression have significant anxiety
    • Ego dystonic
      • Patients usually come to us
      • Uncomfortable
    • Most common group of mental illnesses
          • 11% of the population
          • Cause a significant amount of suffering and dysfunction
          • May even lead to disability
  • Epidemiology
    • 6 month and lifetime prevalence
      • Decline from mid-life to old age
      • 19.7% at 6 months
      • 34.1% lifetime
    • Indicates anxiety disorders are the most prevalent mental health diagnoses in elders as in adults
      • Roughly 10%
    • Leads to higher medical and psychiatric morbidity in geriatric patients
  • Anxiety Disorders
    • Panic disorder
      • With agoraphobia
      • Without agoraphobia
    • Agoraphobia without panic disorder
    • Social phobia
    • Specific phobia
    • Generalized anxiety disorder
  • Anxiety disorders
    • Obsessive-compulsive disorder (OCD)
    • Acute stress disorder
    • Posttraumatic stress disorder (PTSD)
    • Due to general medical condition
    • Substance-induced
    • NOS
  • Substance-induced Anxiety Disorder
    • More likely to happen as one ages
      • As one is more likely to be on medication(s)
    • Anxiety related to the use, abuse or withdrawl from medications or drugs
      • Alcohol, amphetamines, anticholinergics, antidepressants, anti-TB drugs, anti-HTN, caffeine, cannibus, beta-blockers (w/d), cocaine, digitalis, dopamine, ephedrine, l-dopa, methylphenidate, NSAIDs, pseudoepedrine, asa, sedative-hypnotics (w/d), steroids, theophylline, thyroid
  • Anxiety Disorder Due To General Medical Condition
      • Again more likely in the elderly
        • The elderly have more medical problems
      • This is a partial list of common conditions
        • Cardiovascular-CHF, arrhythmia, MI
        • Endocrine-hypoPTH, thyroid, hyperadrenalism
        • Immunologic- RA, SLE, TA
        • Lung disease-Asthma, COPD, PE
        • GI disease-Crohn’s, UC
        • Neurological illness-CVA, MS, MG, Neurosyphillis, postconcussive syndrome, seizures, TIAs, vertigo
  • Prevalence in the Elderly
    • Prevalent in the elderly
      • Many studies note anxiety symptoms
        • 1-19% in community dwelling elderly
          • GAD 1-14%,
          • Phobic disorders 0.7-7%
          • Panic disorder 0.1-1%
      • Anxiety leads to impairment in quality of life
        • Related to disability in some cases
          • Anxiety about existing disability
          • Anxiety can lead to disability
        • Steeper cognitive declines when anxiety untreated in dementia
          • Anxious people cannot focus or pay attention
  • Anxiety in the Elderly
    • Most coupled with depression
      • Schoerers et al., 2005
        • Those with GAD became depressed over time
          • 40% had anxiety/depression or just depression 36 mos later
    • Dementia
      • High levels of anxiety exist in demented patients
        • Great Britain Ballard, et al 1995
          • 22% subjective anxiety
          • 11% autonomic anxiety
          • 38% tension
          • 13% situational anxiety
          • 2% panic attacks
  • Anxiety in Long Term Care
    • Multiple studies
      • 1994 Australia
        • 11.2% NH residents had generalized anxiety disorder
        • 58% of those with anxiety were also depressed
      • 2005 Holland
        • 5% had only an anxiety disorder
        • 5% had both an anxiety and mood disorder
      • 2006 Holland
        • 5.7% had a diagnosable anxiety disorder
        • 4.2% had subthreshold anxiety
        • 29% had anxiety symptoms
  • Not recognized in the Elderly
    • Yet, still not diagnosed readily in the elderly
      • Not commonly noted in clinics
        • If so, commonly seen as part of a mood problem
          • There is a strong correlation
        • Various scenarios
          • Preexisting
          • Mildly present, now with stressors more problematic
          • Completely new onset
      • Older people don’t meet criteria
        • Current criteria don’t capture the quality of anxiety in the elderly
          • Anxious mood, tension, vague somatic complaints
          • Elderly do not endorse daily worry
  • Not recognized in the elderly
    • Age of onset for anxiety is presumed to be youth
        • Dementia, depression are “elderly problems”
          • Not PTSD, OCD and phobias
          • Older women are supposed to be anxious
            • Ageist assumption
        • Most anxiety disorders in the elderly are chronic, except:
          • Agoraphobia, fear of falling
          • Generalized Anxiety Disorder
  • Not recognized in the elderly
    • Less need to leave ones’ social network
        • Agoraphobia, fear of falling are common in geriatric patients
          • These patients avoid office visits
          • May not be able to travel to appointments readily
        • Anxiety doesn’t disrupt functional life
            • Though present, there is likely no work or school or partner to interfere with
            • With move into long term care these anxieties come to the top
  • Working up anxiety
    • Clinical evaluation
      • Laboratory testing
        • Rule out common conditions that lead to anxiety
      • History and physical
        • Past medical history
        • Medication use, alcohol use
        • Family and social history
        • Physical exam
          • Trembling, racing heart, rapid breathing, sweating, dry mouth
        • Mental status exam
          • Poor attention, distractibility, much motor movement, easily startled, wide-eyed, feeling of dread
          • Rarely requires special psychological testing
  • Treatment
    • Anxiolytics
      • Benzodiazepines
        • Agents that calm and relieve anxiety across the lifespan
          • So make sure you are treating anxiety
          • Most common agents
            • Alprazolam (Xanax)
            • Lorazapam (Ativan)
            • Clonazepam (Klonopin)
        • Adverse events
          • Sedating
          • Potential for gait instability
          • Dependency producing
          • Paradoxical effect more prevalent in the elderly, esp. in dementia
  • Treatment
    • Anxiolytics
      • Benzodiazepines
        • Some agents are longer lasting than others
          • Alprazolam<Lorazepam<Clonzepam
        • Longer lasting agents may accumulate in the residents system and lead to intoxication or adverse events
      • Metabolism differences
        • Some agents require less involvement of the liver
          • Lorazepam (Ativan)
          • Oxazepam (Serax)
  • Treatment
    • Anxiolytics
      • Buspirone (BuSpar)
        • A unique nonbenzodiazepine agent
          • Serotonin 1-A agonist
          • No sedation, cognitive or motor impairment
        • Takes 4-8 weeks to fully work
          • Time frame is like an antidepressant
          • Not good for panic disorder
          • Good in mixed depression-anxiety states
        • May not work as well in chronic benzodiazepine users
  • Treatment
      • Antidepressants
        • SSRIs used in GAD, panic, OCD, PTSD
          • First line agents in panic disorder and OCD
          • Safe in the elderly
          • Mild GI, headache symptoms
          • Irritability, anxiety and sexual dysfunction
        • Venlafaxine (Effexor), duloxetine (Cymbalta)
          • SNRIs used commonly for anxiety
          • Heightens blood pressure
        • Tricyclics
          • Clomipramine (Anafranil) good for OCD, but too anticholinergic for older patients
          • May employ nortriptyline (Pamelor) if cardiac disease not an issue
  • Treatment
      • Antidepressants
        • Bupropion (Wellbutrin)
          • Mechainsm a puzzle
          • Activating
          • Few drug-drug interactions
        • Mirtazapine (Remeron)
          • Sedating, appetite enhancing at low doses
          • Data exists supporting the medication being used in anxiety disorders
  • Treatment
    • Psychotherapy
      • Helpful if
        • The patient desires to be a therapy patient
          • If the patient is not motivated it will not work
          • Many elderly see therapy as proof they are now “nuts”
            • Nontraditional supportive therapists may be more palatable
            • Like ministers, priests, rabbis
        • The patient can comprehend the therapist’s instructions
          • Cognitive-behavioral therapy
          • Supportive therapy
        • Make sure the therapist has some experience working with the elderly
          • Child therapy analogy
  • Interventions for anxious patients
    • Routine
      • Structure is important since anxiety relates to loss of control
        • Many cognitively impaired residents improve with a higher level of structure because their anxiety is lessened
    • Exercise
      • Physical activity burns off anxiety
        • Pacing may be the residents way of lessening anxiety
    • Rote activity
      • Repetitive actions
        • From knitting to saying the rosary to rocking in a chair
    • Brief, regular appointments with a trusted staff
      • For patients who wish to discuss anxiety
        • Reality testing, family phone calls, simulated presence
  • Sleep Disorders in the Elderly Brenda K. Keller, MD Assistant Professor Geriatrics & Gerontology University of Nebraska Medical Center
  • Sleep disorders in the elderly person
    • Epidemiology
    • Review changes in the sleep cycle with aging
    • Non-pharmacological Management of sleep disorders
  • Epidemiology
    • 20-40% of older Americans experience insomnia at least a few nights per month
    • 2/3 of elderly in institutions experience problems with sleep
    • Insomnia may be:
      • Difficulty falling asleep 18.1%
      • Difficulty staying asleep 18.6%
      • Not feeling restored by sleep 30.9%
    Rockwood et al J Am Geriatr Soc 2001; 49:639-41
  • Normal Sleep Pattern
    • After sleep onset:
    • Sleep usually progresses through NREM stages 1 to 4 within 45 to 60 min. Slow-wave sleep (NREM stages 3 and 4) predominates in the first third of the night and comprises 15 to 25% of total nocturnal sleep time in young adults.
    • The first REM sleep episode usually occurs in the second hour of sleep.
  • Changes in sleep with age
    • Light sleep (Stages 1 and 2) increases with age =More awakenings
    • Deep sleep (Stages 3 and 4) decreases from ~25% down to 3% of total sleep time
    • The depth of slow-wave sleep , as measured by the arousal threshold to auditory stimulation, also decreases with age.
      • In the otherwise healthy older person, slow-wave sleep may be completely absent, particularly in males.
    • Decreased amount of REM sleep
    • Sleep quality and efficiency is 70-80% of younger subjects.
    • Changes occur in the day/night cycle.
  • Circadian Rhythm Disturbances
    • 24 hr. physiological rhythms
      • Affect hormones
      • Core body temperature
      • Sleep/wake cycle
    • In aging the sleep/wake cycle advances due to change in the core body temp, and decreased light exposure
  • Circadian Rhythm Changes 6:00p 7:00 8:00 9:00 10:00 11:00 MN 1:00 2:00 3:00 4:00 5:00 6:00a 7:00 8:00 9:00 Sleepy, go to bed wake up Standard phase Advanced phase Sleepy go to bed wake up
  • Decline in hours slept by age
  • Changes in sleep in LTC residents with dementia
    • Increased fragmentation of sleep
      • Leads to problems with daytime fatigue, nighttime wakefulness
      • Average hours of sleep 6.2 hours
      • But, average sleep episode was 21 minutes, peak 83 minutes
      • Commonly seen in sleep charting
  • Impact of Disrupted Sleep
    • Difficulty staying awake during the
    • day
    • Impaired attention
    • Slowed response time
    • Impaired memory and concentration
    • Decreased performance
    • Mortality due to common causes of death is 2 x higher in older people with sleep disorders than those who sleep well.
  • Evaluation
    • Sleep history
      • Timing of insomnia
      • Sleep schedule
      • Sleep environment
      • Sleep habits
      • Daytime effects
      • Symptoms of other sleep disorders
    • Medical history-
      • Social History
        • Stressors
        • ETOH/Caffeine use
      • Medication review
    • Psychiatric history
      • Depression
      • Mania
      • Psychosis
  • Sleep Environment in NH
    • Mixed up stimuli
      • High levels of night time noise and light
      • Low levels of daytime light
      • “ Casino effect”
    • Care routines do not promote sleep
      • Every two hour toileting
      • Waking patients to change them
      • Vitals being checked
    • Absence of defined “night time” routine with lowering of hall lights and TV’s.
      • Dark at night and quiet at night
        • Elementary school stop lights are reminders
  • Medical History
    • Common conditions associated with sleep disturbances
      • Arthritis
      • CHF
      • Gastrointestinal disorders
      • Asthma
      • Angina/Arrhythmias
      • Urinary symptoms
      • Neurological symptoms
  • Effectiveness of Non-pharmacological Treatment of Insomnia
    • Improve symptoms of insomnia in 70-80% of patients with primary insomnia
    • Effects last at least 6 months after treatment completed
  • Non-pharmacological Management
    • Sleep hygiene
    • Stimulus control
    • Sleep restriction
    • Cognitive therapy
    • Paradoxical intention
  • Non-pharmacological Management
    • Sleep hygiene
      • Should be entertained with any sleep problem
      • Education about health and environmental practices that affect sleep
        • For staff, family and residents
      • This strategy is used in conjunction with other techniques to improve sleep
        • A common starting point with sleep physicians
  • Sleep Hygiene
    • Health Factors
      • Diet
      • Exercise
      • Substance abuse
    • Environmental Factors
      • Light
      • Noise
      • Room temperature
      • Mattress
  • Non-pharmacological Management
    • Stimulus control
      • Reinforces temporal and environmental cues for sleep onset
      • Go to bed when sleepy
      • Use the bed only for sleep
      • Bedtime routines
      • Regular morning rise time
      • Avoid napping
        • Or a brief scheduled event
  • Non-pharmacological Management
    • Sleep restriction
      • Decrease amount of time in bed to increase sleep efficiency
        • i.e., you can only be in bed five hours
          • Sleep efficiency means how much time you are asleep when actually in bed
      • Only allowed time in bed is usually spent asleep
        • If awake…out of bed!
      • Increase by 15 minutes per night
        • 5:15, 5:30, 5:45, etc.
      • Wake time constant, bedtime adjusted
        • Always up at 6 am
      • Allows short scheduled afternoon nap
  • Non-pharmacological Management
    • Cognitive therapy
      • If a resident is not cognitively impaired
      • Involves identifying dysfunctional beliefs and attitudes about sleep and replaces them with adaptive substitutes.
      • Helps minimize anticipatory anxiety and arousal
  • Non-pharmacological Management
    • Paradoxical intention
      • Based on premise that performance
      • anxiety inhibits sleep onset
        • Involves persuading a patient to engage in the feared behavior of staying awake
        • If pt stops trying to fall asleep and genuinely attempts to stay awake, sleep may come more easily
  • Pharmacological Treatments
    • FDA Approved
    • Benzodiazepines
    • Non-Benzo hypnotics- Type I Gaba receptor agents
    • Eszopiclone
    • Rozerem
    • Non-FDA Approved
    • Herbal therapies
    • Hormones/naturopathic
    • Sedating antidepressants
    • OTC antihistamines
    Choose carefully due to risk of side effects
  • General precautions
    • Start low, go slow
    • Avoid q hs dosing
    • Use only 2-3 weeks
  • Questions?