Steven R. Barczi, M.D. Madison V.A. GRECC Section of Geriatrics/Gerontology University of Wisconsin School of Medicine and...
Part One:  Age-Related Changes in Sleep and Conditions that Impair Sleep in Older People
Karacan et al, 1976; Vitiello et al, 2004 Sleep Complaints as We Age Age 50 40 30  20 10 0 Percent 10-19   20-29   30-39  ...
2003 Sleep in America Poll National Sleep Foundation survey; US adults aged 55 – 84 (N = 1506) www.sleepfoundation.org 28%...
The Consequences of Poor Sleep/ Daytime Sleepiness   <ul><li>Decrements in attention, vigilance and memory  Dinges DF, ‘97...
The Basic Principles of Sleep <ul><li>Non-REM sleep </li></ul><ul><ul><li>stage 1- transitional </li></ul></ul><ul><ul><li...
Changes in Sleep with Aging The ability to  stay asleep changes  most markedly with aging Sleep is  cyclical
Modified from: Carskadon MA et al. J Geriatr Psychiatry. 1980;13:135-151; Reprinted from: Ancoli-Israel S. All I Want Is a...
Causes of Disturbed Sleep in Aging   Circadian Changes Sleep Problem Medical Illness & Medications Psychiatric & Neurologi...
Selected Medical Conditions that Disrupt Sleep <ul><li>Pain:  arthritis, cancer, neuropathy </li></ul><ul><li>Cardiac and ...
Medications that Influence Sleep & Wakefulness <ul><li>Agents that affect sleep character </li></ul><ul><li>OTC decongesta...
Psychiatric/ Neurological Causes of Insomnia <ul><li>Depression   (sleep maintenance, early am awakenings, short REM laten...
Prevalence of Primary Sleep Disorders Condition   All Adults   Elderly Sleep Apnea   1%-10%   24%-40% Periodic Limb Moveme...
Part Two:  Clinical approaches to sleep problems including non-pharmacological and pharmacological interventions
Obstructive Sleep Apnea <ul><li>“ typical patient” = obese, sleepy, snorer with hypertension </li></ul><ul><li>exam:  obes...
High Risk for Sleep Apnea (2 of 3 categories required) <ul><li>Sleepiness </li></ul><ul><ul><li>3-4x/week or </li></ul></u...
Sleep Apnea Consequences <ul><li>Increased car accidents </li></ul><ul><li>Impaired memory </li></ul><ul><li>High blood pr...
When to Treat Sleep Apnea  in the Elderly? <ul><li>Symptomatic from sleepiness </li></ul><ul><li>When co-morbid conditions...
Treatment of Sleep Apnea <ul><li>Continuous positive airway pressure (nasal CPAP, BiPAP, Auto-CPAP, VPAP) </li></ul><ul><l...
Periodic Limb Movements  of Sleep (PLMS) <ul><li>Periodic episodes of  repetitive  (q 20-40 sec),  stereotyped  limb movem...
PLMS in Aging <ul><li>in Parkinsonism, renal disease, diabetes and spinal disease  </li></ul><ul><li>Prevalence is higher ...
PLMS Management <ul><li>Modify medications (if possible) </li></ul><ul><li>Encourage modest PM exercise </li></ul><ul><li>...
Features of Restless Legs Syndrome (RLS) <ul><li>Urge to move  extremities associated with paresthesias/  dysesthesias </l...
RLS: Risks and Associated Conditions <ul><li>Family history </li></ul><ul><li>Medical conditions: Fe deficiency anemia, Re...
RLS Management <ul><li>Dopamine agonists> Sinemet    </li></ul><ul><li>Opioids  </li></ul><ul><li>Gabapentin/ Carbamazapin...
REM Sleep Behavior Disorder <ul><li>major features: </li></ul><ul><ul><li>vigorous motor behaviors and vivid dreams </li><...
Insomnia is a   symptom   as much as a diagnosis (one needs to seek out the cause)
Evaluation of Sleep Problems <ul><li>Interview </li></ul><ul><li>Sleep log, sleep questionnaires </li></ul><ul><li>Focused...
The Sleep Interview <ul><li>Is there a complaint of poor sleep or unsatisfactory sleep?  (daytime consequences?) </li></ul...
Treatment Options for Later Life Insomnia <ul><li>Behavioral Approaches (CBT) </li></ul><ul><ul><li>Stimulus control, slee...
Cognitive-Behavioral Therapy <ul><li>Nine randomized controlled trials support efficacy of cognitive-behavioral therapy (C...
Common non-pharmacological measures to improve sleep <ul><li>regular bedtime/ rising time </li></ul><ul><li>go to bed only...
RCT: CBT vs. Pharmacotherapy for Insomnia in Older Adults Morin C et al.  JAMA  1999; 281:11 PCT was Temazepam
Hypnotic Use in Older Adults <ul><li>32% of adults 65 yrs and older have taken medications to aid sleep in past yr   NSF 2...
Psychotropic Use:  Hip Fracture Cases vs. Age and Gender-Matched Controls Glynn, 2001
Medications Approved by the FDA for Insomnia   <ul><li>Medication    Duration of Action  ½ life   Dose </li></ul><ul><li>B...
Hypnotics Trials in the Elderly DB= double blind, RCT= randomized controlled trial, TST= total sleep time NC – cognition N...
Pharmacologic Approaches – Agents to Avoid <ul><li>Based upon Geriatrics Literature,  side effect profiles exceed benefit ...
Pharmacologic Approaches - Antidepressants <ul><li>The role for these agents in non-depressed agents is actively debated (...
Part Three:  Sleep in Institutional Settings: the Hospital and the Nursing Home
Insomnia in Hospitalized Patients <ul><li>Very little literature focuses on management of insomnia in hospitalized adults…...
In Hospital Causes for Awakenings (N=52, 24 women, mean age= 57.4) <ul><li>Nocturia  73% </li></ul><ul><li>Noise  48%  </l...
Noise in Hospital Cmiel et al., Am J Nursing 2004 104:40-48 EPA-recommended average noise level for hospital in daytime = ...
RN Sleep Promotion Team- Noise Reduction Cmiel et al., Am J Nursing 2004 104:40-48 Staff Interventions-  report in designa...
A Non-pharmacologic Sleep Protocol in an Acute Hospital Setting   ( McDowell et al., JAGS  1998, 46(6):700-705) <ul><li>Pr...
Many factors contribute to sleep problems in NH residents <ul><li>Age-related changes in sleep </li></ul><ul><li>Dementia,...
Benzodiazepines increase the risk of falls in NH residents  ( Ray et al. JAGS 48:682-685, 2000)   (N = 2510 residents in 5...
Effects of light treatment on sleep and circadian rhythms in demented NH residents (Ancoli-Israel et al. JAGS 50:282-289, ...
Daily social and physical activity intervention: effects on sleep and memory (Naylor et al. Sleep 23:87-95, 2000) <ul><li>...
RCT of a nonpharmacological intervention to improve sleep in NH residents (N=118 residents from 4 NHs)  Alessi et al, JAGS...
Summary: Sleep Changes in Older Adults <ul><li>Complex interplay of  multiple factors  (rarely does one factor cause chang...
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    1. 1. Steven R. Barczi, M.D. Madison V.A. GRECC Section of Geriatrics/Gerontology University of Wisconsin School of Medicine and Public Health Sleep Disorders in Older Persons Cathy A. Alessi, MD VA Greater Los Angeles GRECC – Sepulveda Campus UCLA Multicampus Program in Geriatric Medicine and Gerontology
    2. 2. Part One: Age-Related Changes in Sleep and Conditions that Impair Sleep in Older People
    3. 3. Karacan et al, 1976; Vitiello et al, 2004 Sleep Complaints as We Age Age 50 40 30 20 10 0 Percent 10-19 20-29 30-39 40-49 50-59 60-69 70+
    4. 4. 2003 Sleep in America Poll National Sleep Foundation survey; US adults aged 55 – 84 (N = 1506) www.sleepfoundation.org 28% 28% Daytime sleepiness interferes with daily activities 35% 33% Awake a lot during the night 16% 19% Difficulty falling asleep 24% 10% Naps 4 – 7 times per week Age 75 - 84 Age 55 – 64
    5. 5. The Consequences of Poor Sleep/ Daytime Sleepiness <ul><li>Decrements in attention, vigilance and memory Dinges DF, ‘97 </li></ul><ul><li>Increased depression Ford DE, 1989 </li></ul><ul><li>Increased problems with balance and falls when using sedatives Schorr RI, ‘94; Tinetti M </li></ul><ul><li>Increased MVAs Lyznicki JM 1998 </li></ul><ul><li>Increased HTN, CVD morbidity and mortality in those with OSA Newman AB 2000 </li></ul>
    6. 6. The Basic Principles of Sleep <ul><li>Non-REM sleep </li></ul><ul><ul><li>stage 1- transitional </li></ul></ul><ul><ul><li>stage 2- majority of sleep time </li></ul></ul><ul><ul><li>stages 3 & 4 - slow wave sleep; restorative </li></ul></ul><ul><li>REM sleep </li></ul><ul><ul><li>active EEG, dreams, rapid eye movements, skeletal muscle paralysis, autonomic activation, respiratory instability </li></ul></ul><ul><ul><li>related to memory </li></ul></ul>
    7. 7. Changes in Sleep with Aging The ability to stay asleep changes most markedly with aging Sleep is cyclical
    8. 8. Modified from: Carskadon MA et al. J Geriatr Psychiatry. 1980;13:135-151; Reprinted from: Ancoli-Israel S. All I Want Is a Good Night’s Sleep. Mosby; 1996 Average Time to Fall Asleep (Minutes) Time of Day 1000 1200 1400 1600 1800 20 15 10 5 0 Adolescents Younger Adults Older Adults Sleep Apnea Narcolepsy Sleepiness Across Lifespan
    9. 9. Causes of Disturbed Sleep in Aging Circadian Changes Sleep Problem Medical Illness & Medications Psychiatric & Neurologic Primary Sleep Disorders Circadian Changes Poor Sleep Behaviors Poor Sleep Behaviors
    10. 10. Selected Medical Conditions that Disrupt Sleep <ul><li>Pain: arthritis, cancer, neuropathy </li></ul><ul><li>Cardiac and Vascular: angina, CHF, PVD </li></ul><ul><li>Pulmonary: COPD, secretions, bronchospasm, </li></ul><ul><li>Gastrointestinal: GE reflux, ulcer pain, hunger </li></ul><ul><li>Endocrine: hypo/hyperthyroidism, diabetes </li></ul><ul><li>Genitourinary: BPH and nocturia, incontinance </li></ul>
    11. 11. Medications that Influence Sleep & Wakefulness <ul><li>Agents that affect sleep character </li></ul><ul><li>OTC decongestants </li></ul><ul><li>Beta agonist MDI’s </li></ul><ul><li>Caffeine containing OTCs </li></ul><ul><li>Theophylline </li></ul><ul><li>Activating antidepressants </li></ul><ul><li>Selegeline </li></ul><ul><li>Corticosteroids </li></ul><ul><li>Beta blockers </li></ul><ul><li>Acetylcholinesterase Inhibitors </li></ul><ul><li>Certain antiarrhythmics </li></ul><ul><li>Agents that cause sleepiness </li></ul><ul><li>Analgesics (e.g., narcotics) </li></ul><ul><li>Antidepressants (e.g., imipramine, trazodone) </li></ul><ul><li>Antihypertensives (e.g., clonidine) </li></ul><ul><li>Antihistamines </li></ul><ul><li>Antimuscarinics (e.g. Ditropan) </li></ul><ul><li>Dopamine Agonists </li></ul><ul><li>Antiepileptics (e.g. Neurontin) </li></ul>Almost one-third of all prescription medications in PDR list insomnia as a possible side effect
    12. 12. Psychiatric/ Neurological Causes of Insomnia <ul><li>Depression (sleep maintenance, early am awakenings, short REM latency) </li></ul><ul><li>Anxiety/ PTSD (sleep initiation, sleep awakenings, parasomnias) </li></ul><ul><li>Dementia ( sleep wake dysregulation , sleep maintenance, nocturnal wandering) </li></ul><ul><li>Parkinsonism (sleep maintenance, restless legs, periodic limb movements, REM sleep behavior disorder) </li></ul>
    13. 13. Prevalence of Primary Sleep Disorders Condition All Adults Elderly Sleep Apnea 1%-10% 24%-40% Periodic Limb Movements 5% 30%-45% Restless Leg Syndrome 2%-15% 12%-30% REM Sleep Behavior D/O 0.5% 0.5%-2% Young T, et al., Ancoli-Israel S, et al., Sleep 2001; Mant E, et al., Age and Ageing 1992; Ancoli-Israel S, et al. Sleep 1993; Phillips BA, et al., Sleep 1994; Hoch CC, et al., Sleep 1994; O’Keefe ST, et al., Age and Ageing 1994; Phillips B, et al., Arch Int Med 2000; Allen R, et al. Arch Int Med 2005
    14. 14. Part Two: Clinical approaches to sleep problems including non-pharmacological and pharmacological interventions
    15. 15. Obstructive Sleep Apnea <ul><li>“ typical patient” = obese, sleepy, snorer with hypertension </li></ul><ul><li>exam: obesity, large neck, crowded oropharynx </li></ul><ul><li>common symptoms: </li></ul><ul><ul><li>poor sleep restoration, excessive daytime sleepiness, </li></ul></ul><ul><ul><li>loud crescendo snoring , cessation of breathing, choking sounds during sleep </li></ul></ul><ul><ul><li>nocturia, nighttime confusion, morning headache, </li></ul></ul><ul><ul><li>poor memory, irritability, personality changes </li></ul></ul><ul><ul><li>hypertension, right heart failure, arrhythmias </li></ul></ul>
    16. 16. High Risk for Sleep Apnea (2 of 3 categories required) <ul><li>Sleepiness </li></ul><ul><ul><li>3-4x/week or </li></ul></ul><ul><ul><li>asleep while driving </li></ul></ul><ul><li>Associated conditions </li></ul><ul><ul><li>hypertension or </li></ul></ul><ul><ul><li>Obesity w BMI >30 kg/m 2 </li></ul></ul><ul><li>Snoring </li></ul><ul><ul><li>louder than speech or </li></ul></ul><ul><ul><li>3-4x/week or </li></ul></ul><ul><ul><li>bothered others or </li></ul></ul><ul><ul><li>observed breathing pauses 3-4x/week </li></ul></ul>Berlin (Cleveland) Sleep Questionnaire- Netzer N, Ann Int Med 1999
    17. 17. Sleep Apnea Consequences <ul><li>Increased car accidents </li></ul><ul><li>Impaired memory </li></ul><ul><li>High blood pressure </li></ul><ul><li>Increased stroke risk </li></ul><ul><li>Increased heart rhythm disturbances </li></ul><ul><li>Worsened heart failure </li></ul><ul><li>Increased mortality in heart failure </li></ul>Ancoli-Israel, et al. Sleep, 1996 Peppard PE, et al. NEJM 2000; Newman AB, et al. Am J Epidemiol 2001; Lanfranchi PA, et al. Circulation 1999; Mallon L, et al. J Intern Med 2002; Yaggi H et al, NEJM; 2005. Days Cumulative Proportion Surviving
    18. 18. When to Treat Sleep Apnea in the Elderly? <ul><li>Symptomatic from sleepiness </li></ul><ul><li>When co-morbid conditions may benefit from treatment </li></ul><ul><ul><li>Cognitive dysfunction </li></ul></ul><ul><ul><li>Congestive Heart Failure </li></ul></ul><ul><ul><li>Hypertension </li></ul></ul><ul><ul><li>Nocturia </li></ul></ul><ul><li>When AHI or desaturations are severe </li></ul>
    19. 19. Treatment of Sleep Apnea <ul><li>Continuous positive airway pressure (nasal CPAP, BiPAP, Auto-CPAP, VPAP) </li></ul><ul><li>Oral appliances </li></ul><ul><li>Surgery </li></ul><ul><ul><li>UPPP or LAUP </li></ul></ul><ul><ul><li>Mandibular advancement </li></ul></ul><ul><li>Other (wt loss, tobacco cessation, supine preclusion, modafinil) </li></ul>www.sleepapnea.org Less favorable outcomes over age 50 Improve QOL, sleepiness and cognition
    20. 20. Periodic Limb Movements of Sleep (PLMS) <ul><li>Periodic episodes of repetitive (q 20-40 sec), stereotyped limb movements during sleep (extend big toe, dorsiflex ankle, flex knee) </li></ul><ul><li>Limb movements may result in arousals, sleep fragmentation and daytime sleepiness </li></ul>
    21. 21. PLMS in Aging <ul><li>in Parkinsonism, renal disease, diabetes and spinal disease </li></ul><ul><li>Prevalence is higher but severity does not worsen with increasing age Gehrman 2002 </li></ul><ul><li>Medications can exacerbate problem: TCAs & SSRIs antidepressants, anti-psychotics , Lithium, ETOH </li></ul>
    22. 22. PLMS Management <ul><li>Modify medications (if possible) </li></ul><ul><li>Encourage modest PM exercise </li></ul><ul><li>Dopamine agonists or L-Dopa </li></ul><ul><li>Gabapentin </li></ul><ul><li>Benzodiazepines </li></ul><ul><li>Opioids </li></ul>Second line agents due to adverse effect profiles Not FDA approved for this condition
    23. 23. Features of Restless Legs Syndrome (RLS) <ul><li>Urge to move extremities associated with paresthesias/ dysesthesias </li></ul><ul><li>Worsening of symptoms at rest with temporary relief with movement </li></ul><ul><li>Worsening of symptoms in evening/ at bedtime (circadian component) </li></ul><ul><li>www.rls.org </li></ul>
    24. 24. RLS: Risks and Associated Conditions <ul><li>Family history </li></ul><ul><li>Medical conditions: Fe deficiency anemia, Renal Insufficiency, Neuropathy (DM, RA) </li></ul><ul><li>Periodic limb movements </li></ul><ul><li>Medications can exacerbate: Caffeine, antihistamines, TCAs, SSRIs, antipsychotics, metoclopramide </li></ul>NIH Publication #00-3788, 2000
    25. 25. RLS Management <ul><li>Dopamine agonists> Sinemet </li></ul><ul><li>Opioids </li></ul><ul><li>Gabapentin/ Carbamazapine </li></ul><ul><li>Iron replacement (if ferritin <50mcg)) </li></ul><ul><li>? Clonidine </li></ul><ul><li>? Magnesium </li></ul><ul><li>? Clonazepam/ BZDs (No RCT supports efficacy) </li></ul><ul><li>Allen 2001 </li></ul>Efficacy supported by RCTs (OFF LABEL USE except Ropinirole )
    26. 26. REM Sleep Behavior Disorder <ul><li>major features: </li></ul><ul><ul><li>vigorous motor behaviors and vivid dreams </li></ul></ul><ul><ul><li>lack of muscle atonia during REM sleep= “acting out dreams” </li></ul></ul><ul><ul><li>may result in injury; > 85% of cases are men </li></ul></ul><ul><li>etiology (males>> females) </li></ul><ul><ul><li>acute : drug-induced (e.g., SSRIs, TCAs) and drug withdrawal </li></ul></ul><ul><ul><li>chronic : idiopathic, synucleinopathies (e.g., Parkinson’s disease, Lewy body dementia, multi-system atrophy), psychiatric illness </li></ul></ul><ul><li>diagnosis: polysomnography </li></ul><ul><li>treatment </li></ul><ul><ul><li>environmental safety </li></ul></ul><ul><ul><li>Melatonin or donepazil if cognitive impairment, neurodegenerative </li></ul></ul><ul><ul><li>alternatives: clonazepam or temazepam </li></ul></ul>
    27. 27. Insomnia is a symptom as much as a diagnosis (one needs to seek out the cause)
    28. 28. Evaluation of Sleep Problems <ul><li>Interview </li></ul><ul><li>Sleep log, sleep questionnaires </li></ul><ul><li>Focused physical exam & laboratory testing </li></ul><ul><li>Indications for polysomnography*: </li></ul><ul><ul><li>When sleep-related breathing disorder or periodic limb movement disorder is suspected </li></ul></ul><ul><ul><li>When initial diagnosis is uncertain, treatment fails (behavioral or pharmacologic), or precipitous arousals occur with violent or injurious behavior </li></ul></ul><ul><li>Littner et al. American Academy of Sleep Medicine. Standards of Practice Committee. Sleep 26(6):754-760, 2003 . </li></ul>
    29. 29. The Sleep Interview <ul><li>Is there a complaint of poor sleep or unsatisfactory sleep? (daytime consequences?) </li></ul><ul><li>Is there a complaint of excessive daytime sleepiness? </li></ul><ul><li>Sleep Schedule and Napping </li></ul><ul><li>Snoring, apneas, abnormal movements </li></ul><ul><li>Alcohol / caffeine use </li></ul><ul><li>Amount and timing of daily light exposure </li></ul><ul><li>Daily exercise </li></ul>Sateai et al. Evaluation of Chronic Insomnia. SLEEP. 23(2):243-308, 2000.
    30. 30. Treatment Options for Later Life Insomnia <ul><li>Behavioral Approaches (CBT) </li></ul><ul><ul><li>Stimulus control, sleep restriction, relaxation, cognitive restructuring </li></ul></ul><ul><li>Bright Light Therapy </li></ul><ul><li>Sedative-Hypnotics </li></ul><ul><li>Sedating Antidepressants </li></ul>
    31. 31. Cognitive-Behavioral Therapy <ul><li>Nine randomized controlled trials support efficacy of cognitive-behavioral therapy (CBT) for improved sleep maintenance in older adults </li></ul><ul><li>2 RCTs support that patients with chronic insomnia have more sustained improvement when receiving CBT (compared to drug tx) Morin 1999, Sivertsen 2006 </li></ul>
    32. 32. Common non-pharmacological measures to improve sleep <ul><li>regular bedtime/ rising time </li></ul><ul><li>go to bed only when sleepy </li></ul><ul><li>get out of bed if unable to fall asleep </li></ul><ul><li>decrease/eliminate daytime naps </li></ul><ul><li>exercise (am, afternoon) </li></ul><ul><li>use bed only for sleeping </li></ul><ul><li>eliminate alcohol/ tobacco before bedtime </li></ul><ul><li>wind down, relax </li></ul><ul><li>control environment, follow bedtime ritual </li></ul>
    33. 33. RCT: CBT vs. Pharmacotherapy for Insomnia in Older Adults Morin C et al. JAMA 1999; 281:11 PCT was Temazepam
    34. 34. Hypnotic Use in Older Adults <ul><li>32% of adults 65 yrs and older have taken medications to aid sleep in past yr NSF 2000 </li></ul><ul><li>Adults over age 65 comprise 13% of the population but use 40% of all sedative-hypnotics prescribed. Mellinger 1985 </li></ul>National Sleep Foundation Poll 2003 Roehrs 1989 Beers 1988
    35. 35. Psychotropic Use: Hip Fracture Cases vs. Age and Gender-Matched Controls Glynn, 2001
    36. 36. Medications Approved by the FDA for Insomnia <ul><li>Medication Duration of Action ½ life Dose </li></ul><ul><li>Benzodiazepines </li></ul><ul><li>Triazolam (Halcion) Short 2-5 hrs 0.125-0.25mg </li></ul><ul><li>Temazepam (Restoril) Intermediate 8-15 hrs 7.5-30mg </li></ul><ul><li>Estazolam (ProSom) Intermediate 10-24 hrs 0.5-2 mg </li></ul><ul><li>BZD Receptor Agonists </li></ul><ul><li>Zaleplon (Sonata) Ultra-short 1 hr 5-20 mg </li></ul><ul><li>Zolpidem (Ambien Short 1.5-4.5 hrs 5-10 mg </li></ul><ul><li>Zolpidem CR (Ambien CR) Short-Intermed 1.5-4.5 hrs 6.25-12.5 mg </li></ul><ul><li>Eszopiclone (Lunesta) Intermediate 6-9 hrs 1-3 mg </li></ul><ul><li>Melatonin Receptor </li></ul><ul><li>Agonist </li></ul><ul><li>Ramelteon (Rozerem) Short 2-5 hrs 8mg </li></ul>
    37. 37. Hypnotics Trials in the Elderly DB= double blind, RCT= randomized controlled trial, TST= total sleep time NC – cognition No falls data Subj + sleep latency, + TST RCT/ 14 days Zaleplon Hedner ’00 Dec memory triazolam> zolp Subjective; inc sleep quality DB placebo cont/ 21 days Triazolam Zolpidem Roger ’93 N=221 NC- cognition, no falls Subj + sleep quality, +TST RCT/ 2 wks; 2 wks Eszopiclone Unpublished ’03 N=292, N=231 “ no memory changes” Subj; inc sleep time DB placebo cont/ 7 days Temazepam Vgontzas ’94 N=8 None measured Subjective; inc TST DB placebo cont/ 21 days Zolpidem Shaw ’92 N=119 Neuro-psych: dec learning Subjective; + sleep latency DB /single dose Temazepam Triazolam Nakra ’92 N=45 Geriatric Outcomes Efficacy Type/ Duration Drug Study
    38. 38. Pharmacologic Approaches – Agents to Avoid <ul><li>Based upon Geriatrics Literature, side effect profiles exceed benefit with: </li></ul><ul><ul><li>Antihistamines </li></ul></ul><ul><ul><li>Barbiturates </li></ul></ul><ul><ul><li>Long half-life benzodiazepines </li></ul></ul><ul><ul><li>High-anticholinergic tricyclic antidepressants </li></ul></ul>
    39. 39. Pharmacologic Approaches - Antidepressants <ul><li>The role for these agents in non-depressed agents is actively debated (This is OFF LABEL USE ) </li></ul><ul><li>Trazodone- most widely prescribed hypnotic (used for dementia) but limited efficacy data, orthostasis & rebound insomnia </li></ul><ul><li>Mirtazapine is sedating but data regarding long term adverse effects and efficacy is absent </li></ul>
    40. 40. Part Three: Sleep in Institutional Settings: the Hospital and the Nursing Home
    41. 41. Insomnia in Hospitalized Patients <ul><li>Very little literature focuses on management of insomnia in hospitalized adults… </li></ul><ul><li>Factors associated with sleep changes include: </li></ul><ul><ul><li>Acute physical symptoms (e.g. pain, dypnea) </li></ul></ul><ul><ul><li>Psychological response (anxiety, depression) </li></ul></ul><ul><ul><li>Shift in sleep-wake cycle due to environment </li></ul></ul><ul><ul><li>Sustained bed rest/ daytime napping </li></ul></ul><ul><ul><li>Delirium </li></ul></ul>
    42. 42. In Hospital Causes for Awakenings (N=52, 24 women, mean age= 57.4) <ul><li>Nocturia 73% </li></ul><ul><li>Noise 48% </li></ul><ul><li>(RN-RN and RN-patient conversations, machinery) </li></ul><ul><li>RN checks/ observation 40% </li></ul><ul><li>Medication passes 40% </li></ul><ul><li>Pain or discomfort 30% </li></ul><ul><li>Lights 27% </li></ul><ul><li>(RN station, corridors, flashlights) </li></ul>Jarman et al., Int J Nursing Prac 8:75-80, 2002
    43. 43. Noise in Hospital Cmiel et al., Am J Nursing 2004 104:40-48 EPA-recommended average noise level for hospital in daytime = 45 dB; nighttime average = 35dB Conversational speech – 60 dB Empty semiprivate room – 53 dB Heavy truck traffic – 81 dB Bedside monitor alarms – 75 dB Motorcycle – 95 dB Portable X-ray machine – 98 dB Jackhammer – 111 dB Loudest transient at change of shift – 113 dB Comparable Sounds Hospital Sounds
    44. 44. RN Sleep Promotion Team- Noise Reduction Cmiel et al., Am J Nursing 2004 104:40-48 Staff Interventions- report in designated rooms, close patient doors, cover IV pump speakers, change time of supply staff deliveries, avoid housekeeping staff shortcuts, eliminate unit overhead pages between 9pm-7am; reschedule non-urgent X-ray and lab times Equipment interventions- adjust cardiac monitor alarm volumes, padded pneumatic tube receptacles, alter paper towel dispensers Shift change peak 86 dB Shift change peak 113 dB Post-intervention Pre-intervention
    45. 45. A Non-pharmacologic Sleep Protocol in an Acute Hospital Setting ( McDowell et al., JAGS 1998, 46(6):700-705) <ul><li>Prospective Cohort of 111 patients, mean age 79.3 (± 6.4), 68% women </li></ul><ul><li>Intervention: warm drink, relaxation tapes and back massage at HS; option for hypnotic therapy (HT) if ineffective </li></ul><ul><li>Outcomes: </li></ul><ul><li>Absolute reduction of 23% for HT use from pre- to post intervention </li></ul><ul><li>Overall adherence rate was 400/539 (74%) patient-days </li></ul><ul><li>The sleep protocol had a stronger association with quality of sleep (rho = .75, P = .001) than did HT (rho = .07, P = .45) </li></ul>
    46. 46. Many factors contribute to sleep problems in NH residents <ul><li>Age-related changes in sleep </li></ul><ul><li>Dementia, depression </li></ul><ul><li>Other illnesses </li></ul><ul><li>Medications (including sedatives) </li></ul><ul><li>Increased prevalence of sleep disorders (e.g., sleep apnea) </li></ul><ul><li>Poor sleep hygiene, lack of bright light exposure </li></ul><ul><li>Sleep-disruptive NH environment and routines </li></ul>
    47. 47. Benzodiazepines increase the risk of falls in NH residents ( Ray et al. JAGS 48:682-685, 2000) (N = 2510 residents in 53 Tennessee NHs) *Includes temazepam, oxazepam, zolpidem, triazolam Rate ratios (95% confidence intervals); adjusted for age, gender, race, time since admission to facility and since zero time, BMI, ambulatory status, ADL dependency, incontinence, cognitive impairment, physical restraint use, past falls, and use of anticonvulsants, antiparkinsonian drugs, antidepressants, antipsychotics, and other sedatives. Reference group is non-users, no benzos in preceding 7 days. 1.80 (1.14-2.83) 1.77 (1.38-2.26) Long-acting (half-life > 24 hrs) 1.68 (1.39-2.02) 1.43 (1.29-1.59) Intermediate-acting (half-life 12-23 hrs) 2.19 (1.59-3.03) NS Short-acting* (half-life< 12 hours) 1.83 (1.55-2.15) 1.38 (1.25-1.51) Any benzodiazepine Nighttime falls (8 pm – 7 am) Daytime falls (7 am – 8 pm)
    48. 48. Effects of light treatment on sleep and circadian rhythms in demented NH residents (Ancoli-Israel et al. JAGS 50:282-289, 2002) <ul><li>RCT, N = 77 demented residents in 2 NHs </li></ul><ul><li>Treatment groups (10 day treatment) : </li></ul><ul><ul><li>Evening bright light (2500 lux 5:30 pm – 7:30 pm) </li></ul></ul><ul><ul><li>Morning bright light (2500 lux 9:30 am – 11:30 am) </li></ul></ul><ul><ul><li>Daytime sleep restriction (attended to 6 hrs each day by research staff to restrict daytime sleeping) </li></ul></ul><ul><ul><li>Evening dim red light (<50 lux 5:30 pm – 7:30 pm) </li></ul></ul><ul><li>Wrist actigraphy outcomes: </li></ul><ul><ul><li>No effects on nighttime sleep or daytime alertness. </li></ul></ul><ul><ul><li>Significant effects on circadian rhythms of activity </li></ul></ul>
    49. 49. Daily social and physical activity intervention: effects on sleep and memory (Naylor et al. Sleep 23:87-95, 2000) <ul><li>Controlled trial, N = 23 residents in a continued care retirement facility </li></ul><ul><li>Intervention: </li></ul><ul><ul><li>Enforced schedule of structured social and physical activity (9 – 10:30 am, 7 pm – 8:30 pm; daily for two weeks) </li></ul></ul><ul><li>Results: </li></ul><ul><ul><li>Increased slow wave sleep (by polysomnography) </li></ul></ul><ul><ul><li>Improvement in memory-oriented tasks (by neuropsychological testing) </li></ul></ul>
    50. 50. RCT of a nonpharmacological intervention to improve sleep in NH residents (N=118 residents from 4 NHs) Alessi et al, JAGS 53:803-810, 2005 <ul><li>Intervention combined efforts to : </li></ul><ul><ul><li>↓ daytime in-bed time </li></ul></ul><ul><ul><li>↑ daytime sunlight exposure </li></ul></ul><ul><ul><li>↑ daytime physical activity </li></ul></ul><ul><ul><li>↓ nighttime noise and light </li></ul></ul><ul><ul><li>provide bedtime routine </li></ul></ul><ul><li>Results : </li></ul><ul><ul><li>Modest decrease in duration of nighttime awakenings </li></ul></ul><ul><ul><li>Nearly 50% decrease in daytime sleeping </li></ul></ul><ul><ul><li>Increased participation in social and physical activities and social conversation </li></ul></ul>
    51. 51. Summary: Sleep Changes in Older Adults <ul><li>Complex interplay of multiple factors (rarely does one factor cause changes) </li></ul><ul><li>Medical and psychological factors play increasing role in later life </li></ul><ul><li>Primary sleep disorders are more prevalent in older persons </li></ul><ul><li>Improving sleep behavioral factors and treating illness is first step </li></ul><ul><li>Risks for hypnotic use increase with age </li></ul>Circadian Changes Sleep Problem Poor Sleep Behavior Medical Illness & Medications Psychiatric and Neurologic Primary Sleep Disorders

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