Sleep Disorders in the Elderly Module 2

1. Sleep Disorders in the ElderlyModule 2 Brenda K. Keller, MD Assistant Professor Geriatrics & Gerontology University of Nebraska Medical Center

2. Module 2Non-pharmacological Management • Sleep hygiene • Stimulus control • Sleep restriction • Cognitive therapy • Paradoxical intention McCall JAGS July 2005-Vol 53, No. 7 pS272-S277

3. 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

4. Non-pharmacological Management • Sleep hygiene • Education about health and environmental practices that affect sleep • This strategy is used in conjunction with other techniques to improve sleep

5. Health Factors Diet Exercise Substance abuse Environmental Factors Light Noise Room temperature Mattress Sleep Hygiene

6. 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

7. Non-pharmacological Management • Sleep restriction • Decrease amount of time in bed to increase sleep efficiency • Only allowed time in bed is usually spent asleep • Increase by 15 minutes per night • Wake time constant, bedtime adjusted • Allows short afternoon naps

8. Non-pharmacological Management • Cognitive therapy • Involves identifying dysfunctional beliefs and attitudes about sleep and replaces them with adaptive substitutes. • Helps minimize anticipatory anxiety and arousal

9. 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

10. Summary

11. Post-test Question 1 • A 67-year-old woman asks you to prescribe sleeping pills for her. She reports initial insomnia and restless sleep with frequent awakenings. The patient is retired and leads a sedentary life style. She frequently reads or watches television in bed and often naps, despite caffeine intake throughout the day. Physical examination is unremarkable. Which of the following is most likely to ameliorate this patient’s sleep disturbance? A. Exposure to early morning daylight B. Proper sleep habits C. Sustained-release melatonin D. Zolpidem E. Referral for polysomnography Used with permission from: Murphy JB, et. Al. Case Based Geriatrics Review: 500 Questions and Critiques from the Geriatric Review Syllabus. AGS 2002 New York, NY.

12. Correct Answer:  B.  Proper sleep habits • Poor sleep habits may be the most common cause of sleep problems in older adults. Irregular sleep–wake patterns, related to the life style in this patient, can undermine the ability of the circadian system to effectively provide sleepiness and wakefulness at appropriate times. Caffeine intake in the afternoon can have alerting effects for many hours, thus impairing nighttime sleep. Excessive wake time in bed may cause increased arousal that is reinforced nightly. Other factors (eg, medical illness, medications, psychiatric disorders, and primary sleep disorders) also should be considered. However, proper sleep habits should be implemented. These include regularity of sleep and wake times; avoidance of excessive time in bed; relaxing bedtime routine; daily activity and exercise; avoidance of caffeine, alcohol, and nicotine in the afternoon and evening; and elimination of loud noise, excessive light, and uncomfortable room temperature. Even if poor sleep habits are not responsible for insomnia, their elimination minimizes any perpetuating influence.

13. Use of a short-acting hypnotic agent is not an appropriate first step in the management of simple insomnia. Hypnotics should be used only in limited circumstances, following evaluation of the patient’s symptoms and in the context of proper sleep habits. Similarly, melatonin has not definitively been shown to benefit age-related sleep-maintenance insomnia. Exposure to early morning light can be useful for delayed or advanced sleep-phase syndrome or jet lag. Polysomnography can be useful for evaluating chronic insomnia or for suspicion of primary sleep disorders, such as sleep apnea, periodic limb movement disorder, or rapid eye movement (REM)–behavior disorder, but referral to a sleep specialist is not warranted for this patient.

14. Post–test 2 A 75-year-old man on no medications has awakened frequently during the night for the past year. He is not tired during the day, and has no symptoms associated with awakening. What is the best next step? A. Education on age-related changes in sleep patterns B. Referral to a sleep laboratory C. Diazepam 5 mg at bedtime D. Diphenhydramine 25 mg at bedtime E. Lorazepam 0.25 mg at bedtime

15. Correct Answer:  A.  Education on age-related changes in sleep patterns • Problems with sleep are common in otherwise healthy older persons. With normal aging, time spent in stages 3 and 4 sleep, the deeper levels of sleep, decreases, and time spent in stages 1 and 2, the lighter periods of sleep, increases. These shifts account for the frequent awakenings of older persons. However, there are other causes of sleep disturbance, such as pain, anxiety, or urinary urgency, that should be evaluated before it is assumed that the patient’s sleep changes are associated with normal aging. In cases of short-term insomnia (eg, acute grief, change in residence), appropriate treatment may include a low dose of a benzodiazepine taken every other night for 1 to 2 weeks. Short- and intermediate-acting benzodiazepines such as lorazepam, oxazepam, and temazepam are most appropriate.

16. You as • Long-acting agents such as flurazepam and diazepam, which have active metabolites, are not recommended. For an older patient with difficulty sleeping, absence of daytime sleepiness, and no associated stresses or medications, the most likely cause is normal changes of aging. The most appropriate management of this 75-year-old man is to educate him about age-related changes in sleep patterns. No pharmacologic intervention is needed. Diphenhydramine is a weak sedative-hypnotic that is associated with multiple anticholinergic side effects and should not be used in older persons. Referral to a sleep laboratory is indicated for patients with evidence of sleep apnea or unexplained secondary causes of insomnia. End