SHEEP COUNT

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3. 3 INSOMNIA IN THE ELDERLY

4. 4 OUTLINE

5. 5 INSOMNIA IN THE ELDERLY Insomnia is a highly prevalent complaint of older adults. Half of elders aged 65 and older experience sleep difficulties. Many patients with insomnia remain undiagnosed or inadequately treated. The challenge of clinical practice is to determine which individuals should receive medical attention and how the differences between those with insomnia should affect treatment decisions.

6. 6 CLASSIFICATIONS OF INSOMNIA Classified by symptom type Classified by symptom duration Classified by underlying cause

7. 7 CLASSIFYING INSOMNIA BY SYMPTOM TYPE

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9. 9 TOOLS FOR DISTINGUISHING SYMPTOM TYPES (1) Thorough history The most important tool A daily sleep log Useful tool for obtaining historical information, particularly in the elderly � Circadian rhythm disturbance

10. 10 TOOLS FOR DISTINGUISHING SYMPTOM TYPES(2) Polysomnogram Not indicated in the routine evaluation of insomnia Recommended if - the diagnosis is uncertain, suspect sleep apnea or periodic movements of sleep, fail usual treatment Actigraphy A wearing device on the wrist, much like a wristwatch Useful to identify alterations in circadian rhythm

11. 11 CLASSIFYING INSOMNIA BY DURATION

12. 12 CLASSIFYING INSOMNIA BASED ON ITS � CAUSE�

13. 13 CONSEQUENCES OF POOR SLEEP Insomnia in the elderly can cause clinically relevant daytime impairments Difficulty sustaining attention A slowed response time Impairment in memory Increased incidence of pain and sense of being poor health Decreased ability to accomplish daily tasks Increased consumption of healthcare resources

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15. 15 SLEEP STAGES AND CYCLES(1)

16. 16 SLEEP STAGES AND CYCLES(2)

17. 17 HOW AGE AFFECTS SLEEP

18. 18 CIRCADIAN RHYTHM DISTURBANCES(1) Circadian rhythms--24-hour physiologic rhythms Endogenous hormone secretions Core body temperature The sleep-wake cycle controlled by internal pacemaker which is housed in the suprachiasmatic nucleus in the anterior hypothalamus Time-givers or cues, such as sunlight, synchronize circadian rhythms to the 24-hour day

19. 19 CIRCADIAN RHYTHM DISTURBANCES(2) In the elderly Loss of neuron in the suprachiasnatic nucleus ? age-related circadian phase shift The sleep/wake circadian rhythm becomes less synchronized ( may no longer have the same response to external cues) becomes less robust ( less-consistent periods of sleep/wake across the 24-hour day)

20. 20 ADVANCED SLEEP PHASE SYNDROME (ASPS) Symptoms Sleepy in the early evening ?core body temperature drops earlier in the evening Wake up in the early morning hours ?core body temperature rises about 8 hours later Unable to return to sleep

21. 21 Standard versus advanced phase sleep

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23. 23 ADVANCED SLEEP PHASE SYNDROME (ASPS)-cont Not a medical disorder No need to be treated To delay the advanced sleep/wake rhythm? patients should be exposed to very bright light during late afternoon to early evening

24. 24 PRIMARY SLEEP DISORDERS Four common disorders in the elderly Periodic limb movements in sleep (PLMS) Restless leg syndrome (RLS) Sleep-disordered breathing (SDB) Rapid eye movement sleep behavior disorder (RBD)

25. 25 PERIODIC LIMB MOVEMENTS IN SLEEP (PLMS)

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27. 27 PERIODIC LIMB MOVEMENTS IN SLEEP (PLMS) - cont.

28. 28 RESTLESS LEGS SYNDROME (RLS)

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30. 30 RESTLESS LEGS SYNDROME (RLS) - cont.

31. 31 SLEEP DISORDERED BREATHING (SDB )

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34. 34 SLEEP DISORDERED BREATHING (SDB ) cont.

35. 35 RAPID EYE MOVEMENT SLEEP BEHAVIOUR DISORDER (RBD) Characterized by loss of normal muscle skeletal atonia during REM sleep associated with vivid, usually frightening or disturbing dreams ? �act out� dreams Prevalence of RBD Men, typical age onset of 6th �7th decade of life 90%

36. 36 RAPID EYE MOVEMENT SLEEP BEHAVIOUR DISORDER (RBD) cont. In several series RBD may herald the onset of parkinsonism and dementia, particularly PD and DLB by years to decades > 60% of patients

37. 37 MEDICAL / PSYCHIATRIC ILLNESSES CONTRIBUTING TO INSOMNIA Chronic illnesses or conditions Arthritis or other musculoskeletal pain, malignancy, menopause, dementia / Alzheimer�s disease, Parkinson�s disease, angina pectoris, congestive heart failure, asthma, stroke, chronic obstructive pulmonary disease, gastroesophageal reflux disease, and nocturia Psychiatric disorders Depression, anxiety

38. 38 DEMENTIA AND INSOMNIA(1) Dementia contributes to poor sleep In one study of nursing home patients with dementia Tool: Actigraphy Result: Patients spent the entire 24-hour day dozing and waking without being ever being completely awake or completely asleep for a full hour

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40. 40 DEMENTIA AND INSOMNIA(2) Important contributing factor�Light exposure In nursing home�less daytime light exposure but too much nighttime light exposure Regardless of dementia level The greater daytime light exposure, the fewer awakenings at night

41. 41 DRUGS / MEDICATIONS CONTRIBUTING TO INSOMNIA Central nervous system stimulants, beta blockers, bronchodilators, calcium channel blockers, corticosteroids, decongestants, stimulating antidepressants, thyroid hormone Alcohol Caffeine Nicotine

42. 42 PSYCHOSOCIAL FACTORS CONTRIBUTING TO INSOMNIA Decreased activity Retirement Isolation Bereavement

43. 43 DIAGNOSIS AND MANAGEMENT OF INSOMNIA  Five basic steps Step 1: Detection of insomnia Step 2: Elaboration of the problem Step 3: Is there a medical / psychiatric emergency? Step 4: Further evaluation of chronic insomnia Step 5: Intervention

44. 44 DIAGNOSIS OF INSOMNIA(1) 1.One or more of the following sleep related complaints: Difficulty initiating sleep Difficulty maintaining sleep Wake up too early chronic non-restorative or poor quality sleep 2.must occur despite adequate opportunity and circumstances for sleep

45. 45 DIAGNOSIS OF INSOMNIA(2) 3.must be associated with at least one of the following forms of daytime impairments: Fatigue / malaise Attention concentration or memory impairment Social / vocational dysfunction Mood disturbance / irritability Daytime sleepiness Motivation / energy / initiative reduction Proneness to error or accidents at work or while driving Tension headache and GI symptoms in response to sleep loss Concerns or worries about sleep

46. 46 STEP 1: DETECTION OF INSOMNIA Clinicians caring for older patients should ask at least one question about sleep at each new patient evaluation

47. 47 STEP 2: ELABORATION OF THE PROBLEM Clinicians should assess for the nature of insomnia Patent�s age at onset Sleep symptoms and their effects on daytime functioning Associated precipitating and perpetuating symptoms or factors (environmental, medical, psychosocial)

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54. 54 STEP3: IS THERE A MEDICAL / PSYCHIATRIC EMERGENCY? Sleep emergencies Psychiatric disorder in crisis Medical sleep emergencies: Fulminant heart failure in severe untreated OSA Status Cataplecticus Sleep-walking Parasomnias

55. 55 STEP4: FURTHER EVALUATION OF CHRONIC INSOMNIA A thorough sleep history from patient and patient�s sleep partner A 2-week sleep diary of patient The Epworth Sleepiness Scale A depression screening scale A polysomnography�only in suspicious cases of PLMS or OSA A serum iron panel�only in suspicious case of RLS secondary to iron deficiency

56. 56 Epworth Sleepiness Scale

57. 57 STEP5: INTERVENTION First-Stage Intervention Second-Stage Intervention

58. 58 FIRST-STAGE INTERVENTION(1) Discussion / education to set realistic expectations Reinforce good sleep habits Treatment of associated conditions Goals of treatment Improvement of nocturnal complaints Maintenance�if not enhancement �of daytime functioning

59. 59 FIRST-STAGE INTERVENTION(2) 1st line intervention of primary insomnia--Nonpharmacologic strategies 70%-80% of patients have durable efficacy lasting at least 6 months after treatment completion 1st line intervention of psychiatric crises / sleep emergencies--Pharmacological therapy

60. 60 NONPHARMACOLOGIC STRATEGIES IN TREATMENT OF INSOMNIA Stimulus control Relaxation therapy Paradoxical intention Sleep restriction Cognitive-behavioral therapy Sleep hygiene education

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62. 62 SLEEP HYGIENE EDUCATION IN NURSING HOME(1) Time in bed during the day should be limited Naps should be 1 hour or less, early in the afternoon Sleep�wake schedule should be regular and similar to prior home routine Meal times should be regular and meals should not be eaten in bed Caffeinated beverages and food should be avoided Nighttime noise should be decreased Patient room should be as dark as possible at night

63. 63 SLEEP HYGIENE EDUCATION IN NURSING HOME(2) Patient environment should be brightly lit during the day Exercise appropriate for each patient should be encouraged Roommates should be matched on sleep�wake and agitated behavior Patients should be assessed for possible sleep disorders and specific treatment initiated Medications should be checked for sedating-alerting effects

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65. 65 SECOND STAGE INTERVENTION Pharmacological therapy with hypnotics should be considered only in these following patients: patients with chronic insomnia who cannot or will not comply with nonpharmacologic strategies patients with chronic insomnia who fail to sufficiently relieve after treatment of primary cause

66. 66 CURRENTLY AVAILABLE PHARMACOLOGICAL TREATMENTS FOR INSOMNIA Hormones or other naturopathic therapies (e.g. melatonin) Over-the-counter antihistamines Sedating antidepressants (e.g. Trazodone) True hypnotics (e.g. Benzodiazepines)

67. 67 Summary of Commonly Prescribed Hypnotics

68. 68 ADVERSE EFFECTS OF HYPNOTICS The longer durations of usage and the higher dosages, the more adverse effects Adverse effects of hypnotics Drowsiness? increase risk of fall and motor vehicle accident Confusion Anterograde amnesia Weakness Drug dependence and tolerance

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71. 71 SUMMARY

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