Download Sleep Lect for WI Bd Review 2004

Sleep Disorders
in Older Persons
Steven R. Barczi, M.D.
Madison V.A. GRECC
Section of Geriatrics/Gerontology
University of Wisconsin School of
Medicine and Public Health
Cathy A. Alessi, MD
VA Greater Los Angeles GRECC –
Sepulveda Campus
UCLA Multicampus Program in
Geriatric Medicine and Gerontology
Part One:
Age-Related Changes in Sleep
and Conditions that Impair
Sleep in Older People
2
Sleep Complaints as We Age
50
40
30
20
10
0
10-19
20-29
30-39
40-49
50-59
60-69
70+
Age
Karacan et al, 1976;
Vitiello et al, 2004
3
2003 Sleep in America Poll
National Sleep Foundation survey; US adults aged 55 – 84 (N = 1506)
Age 55 – 64 Age 75 - 84
Naps 4 – 7 times per week
10%
24%
Difficulty falling asleep
19%
16%
Awake a lot during the
night
33%
35%
Daytime sleepiness
interferes with daily
activities
28%
28%
www.sleepfoundation.org
4
The Consequences of Poor
Sleep/ Daytime Sleepiness
• Decrements in attention, vigilance and
•
•
•
•
memory Dinges DF, ‘97
Increased depression Ford DE, 1989
Increased problems with balance and falls
when using sedatives Schorr RI, ‘94; Tinetti M
Increased MVAs Lyznicki JM 1998
Increased HTN, CVD morbidity and mortality in
those with OSA Newman AB 2000
5
The Basic Principles of Sleep
• Non-REM sleep
– stage 1- transitional
– stage 2- majority of sleep time
– stages 3 & 4 - slow wave sleep; restorative
• REM sleep
– active EEG, dreams, rapid eye movements,
skeletal muscle paralysis, autonomic
activation, respiratory instability
– related to memory
6
Changes in Sleep with Aging
Sleep is
cyclical
The ability to
stay asleep
changes most
markedly with
aging
7
Sleepiness Across Lifespan
20
Adolescents
Younger Adults
15
Older Adults
10
5
Sleep Apnea
Narcolepsy
0
1000
1200
1400
1600
1800
Time of Day
Modified from: Carskadon MA et al. J Geriatr Psychiatry. 1980;13:135-151; Reprinted from: 8
Ancoli-Israel S. All I Want Is a Good Night’s Sleep. Mosby; 1996
Causes of Disturbed Sleep in Aging
Poor Sleep
Behaviors
Primary Sleep
Disorders
Psychiatric &
Neurologic
Sleep
Problem
Medical Illness
& Medications
Circadian
Changes
9
Selected Medical Conditions
that Disrupt Sleep
Pain: arthritis, cancer, neuropathy
Cardiac and Vascular: angina, CHF, PVD
Pulmonary: COPD, secretions, bronchospasm,
Gastrointestinal: GE reflux, ulcer pain, hunger
Endocrine: hypo/hyperthyroidism, diabetes
Genitourinary: BPH and nocturia, incontinance
10
Medications that Influence
Sleep & Wakefulness
Agents that affect sleep character
• OTC decongestants
• Beta agonist MDI’s
• Caffeine containing OTCs
• Theophylline
• Activating antidepressants
• Selegeline
• Corticosteroids
• Beta blockers
• Acetylcholinesterase Inhibitors
• Certain antiarrhythmics
Agents that cause sleepiness
• Analgesics (e.g., narcotics)
• Antidepressants (e.g.,
imipramine, trazodone)
• Antihypertensives (e.g.,
clonidine)
• Antihistamines
• Antimuscarinics (e.g.
Ditropan)
• Dopamine Agonists
• Antiepileptics (e.g.
Neurontin)
Almost one-third of all prescription medications in PDR list
insomnia as a possible side effect
11
Psychiatric/ Neurological Causes
of Insomnia
• Depression (sleep maintenance, early am
awakenings, short REM latency)
• Anxiety/ PTSD (sleep initiation, sleep
awakenings, parasomnias)
• Dementia (sleep wake dysregulation, sleep
maintenance, nocturnal wandering)
• Parkinsonism (sleep maintenance, restless
legs, periodic limb movements, REM sleep
behavior disorder)
12
Prevalence of Primary Sleep
Disorders
Condition
All Adults
Sleep Apnea
1%-10%
24%-40%
5%
30%-45%
Restless Leg Syndrome
2%-15%
12%-30%
REM Sleep Behavior D/O
0.5%
0.5%-2%
Periodic Limb Movements
Elderly
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., 13
Arch Int Med 2000; Allen R, et al. Arch Int Med 2005
Part Two:
Clinical approaches to sleep
problems including nonpharmacological and
pharmacological interventions
14
Obstructive Sleep Apnea
• “typical patient” = obese, sleepy, snorer with
•
•
hypertension
exam: obesity, large neck, crowded oropharynx
common symptoms:
– poor sleep restoration, excessive daytime
sleepiness,
– loud crescendo snoring, cessation of breathing,
choking sounds during sleep
– nocturia, nighttime confusion, morning headache,
– poor memory, irritability, personality changes
– hypertension, right heart failure, arrhythmias
15
High Risk for Sleep Apnea
(2 of 3 categories required)
• Sleepiness
• Snoring
– 3-4x/week or
– asleep while driving
– louder than speech
or
– 3-4x/week or
– bothered others or
– observed breathing
pauses 3-4x/week
• Associated
conditions
– hypertension or
– Obesity w BMI >30
kg/m2
Berlin (Cleveland) Sleep Questionnaire- Netzer N, Ann Int Med 1999
16
•Increased car accidents
•Impaired memory
•High blood pressure
•Increased stroke risk
•Increased heart rhythm
disturbances
•Worsened heart failure
•Increased mortality in
heart failure
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.
Cumulative Proportion Surviving
Sleep Apnea Consequences
Days
Ancoli-Israel, et al. Sleep, 1996
17
When to Treat Sleep Apnea
in the Elderly?
• Symptomatic from sleepiness
• When co-morbid conditions may benefit
from treatment
– Cognitive dysfunction
– Congestive Heart Failure
– Hypertension
– Nocturia
• When AHI or desaturations are severe
Treatment of Sleep Apnea
• Continuous positive airway
•
•
•
pressure (nasal CPAP,
BiPAP, Auto-CPAP, VPAP)
Oral appliances
Surgery
– UPPP or LAUP
– Mandibular advancement
Other (wt loss, tobacco
cessation, supine preclusion,
modafinil)
Improve QOL,
sleepiness and
cognition
Less favorable
outcomes over
age 50
www.sleepapnea.org
19
Periodic Limb Movements
of Sleep (PLMS)
• Periodic episodes of repetitive (q 20-40 sec),
•
stereotyped limb movements during sleep
(extend big toe, dorsiflex ankle, flex knee)
Limb movements may result in arousals, sleep
fragmentation and daytime sleepiness
20
PLMS in Aging
•
in Parkinsonism, renal disease,
diabetes and spinal disease
• Prevalence is higher but severity does
not worsen with increasing age
Gehrman 2002
• Medications can exacerbate problem:
TCAs & SSRIs antidepressants, antipsychotics, Lithium, ETOH
21
PLMS Management
•
•
•
•
•
•
Modify medications (if possible)
Encourage modest PM exercise
Dopamine agonists or L-Dopa
Gabapentin
Second line agents
Benzodiazepines
due to adverse effect
Opioids
profiles
Not FDA approved for
this condition
22
Features of Restless Legs
Syndrome (RLS)
• Urge to move extremities associated
with paresthesias/ dysesthesias
• Worsening of symptoms at rest with
temporary relief with movement
• Worsening of symptoms in evening/
at bedtime (circadian component)
www.rls.org
23
RLS: Risks and
Associated Conditions
• Family history
• Medical conditions: Fe deficiency
anemia, Renal Insufficiency,
Neuropathy (DM, RA)
• Periodic limb movements
• Medications can exacerbate:
Caffeine, antihistamines, TCAs, SSRIs,
antipsychotics, metoclopramide
NIH Publication #00-3788, 2000
24
RLS Management
•
•
•
•
Dopamine agonists> Sinemet
Opioids
Gabapentin/ Carbamazapine
Iron replacement
(if ferritin <50mcg))
Efficacy
supported by
RCTs (OFF
LABEL USE
except Ropinirole)
• ? Clonidine
• ? Magnesium
• ? Clonazepam/ BZDs (No RCT supports efficacy)
Allen 2001
25
REM Sleep Behavior Disorder
• major features:
– vigorous motor behaviors and vivid dreams
– lack of muscle atonia during REM sleep= “acting out dreams”
– may result in injury; > 85% of cases are men
• etiology (males>> females)
– acute: drug-induced (e.g., SSRIs, TCAs) and drug withdrawal
– chronic: idiopathic, synucleinopathies (e.g., Parkinson’s disease,
Lewy body dementia, multi-system atrophy), psychiatric illness
• diagnosis: polysomnography
• treatment
– environmental safety
– Melatonin or donepazil if cognitive impairment, neurodegenerative
– alternatives: clonazepam or temazepam
26
Insomnia is a symptom as
much as a diagnosis
(one needs to seek out the cause)
27
Evaluation of Sleep Problems
• Interview
• Sleep log, sleep questionnaires
• Focused physical exam & laboratory testing
• Indications for polysomnography*:
– When sleep-related breathing disorder or periodic limb
movement disorder is suspected
– When initial diagnosis is uncertain, treatment fails
(behavioral or pharmacologic), or precipitous arousals
occur with violent or injurious behavior
•Littner et al. American Academy of Sleep Medicine. Standards of Practice Committee.
28
Sleep 26(6):754-760, 2003.
The Sleep Interview
Is there a complaint of poor sleep or
unsatisfactory sleep? (daytime consequences?)
Is there a complaint of excessive daytime
sleepiness?
Sleep Schedule and Napping
Snoring, apneas, abnormal movements
Alcohol / caffeine use
Amount and timing of daily light exposure
Daily exercise
Sateai et al. Evaluation of Chronic Insomnia. SLEEP. 23(2):243-308, 2000.
29
Treatment Options for Later
Life Insomnia
• Behavioral Approaches (CBT)
– Stimulus control, sleep restriction,
relaxation, cognitive restructuring
• Bright Light Therapy
• Sedative-Hypnotics
• Sedating Antidepressants
30
Cognitive-Behavioral Therapy
• Nine randomized controlled trials support
efficacy of cognitive-behavioral therapy
(CBT) for improved sleep maintenance in
older adults
• 2 RCTs support that patients with chronic
insomnia have more sustained
improvement when receiving CBT
(compared to drug tx) Morin 1999, Sivertsen 2006
31
Common non-pharmacological
measures to improve sleep
•
•
•
•
•
•
•
•
•
regular bedtime/ rising time
go to bed only when sleepy
get out of bed if unable to fall asleep
decrease/eliminate daytime naps
exercise (am, afternoon)
use bed only for sleeping
eliminate alcohol/ tobacco before bedtime
wind down, relax
control environment, follow bedtime ritual
32
Total Score
RCT: CBT vs. Pharmacotherapy
for Insomnia in Older Adults
24
22
20
18
16
14
12
10
e
r
P
a
e
r
-t
Placebo
PCT
Combined
CBT
t
n
e
m
t
t
n
e
m
t
a
re
T
ts
Po
3
os
m
f/ u
12
m
os
Assessment
Morin C et al. JAMA 1999; 281:11
f/u
24
m
os
f/u
PCT was Temazepam
33
Hypnotic Use in Older Adults
and older have taken
medications to aid
sleep in past yr NSF 2000
• Adults over age 65
comprise 13% of the
population but use
40% of all sedativehypnotics
prescribed. Mellinger
1985
Prevalence
• 32% of adults 65 yrs
50
45
40
35
30
25
20
15
10
5
0
Community (daily)
Community (episodic)
Hospitalized
Nursing Home
Selected Elderly Populations
National Sleep Foundation Poll 2003
Roehrs 1989
Beers 1988
34
Psychotropic Use: Hip Fracture Cases
vs. Age and Gender-Matched Controls
odds ratio
2
1.5
1
0.5
0
A
A
ep
id
nt
an
ss
re
t
e
in
ep
ic
ot
ch
az
di
zo
en
sy
ip
nt
B
em
id
lp
Zo
Glynn, 2001
35
Medications Approved by the FDA
for Insomnia
Medication
Duration of Action
Benzodiazepines
Triazolam (Halcion)
Short
Temazepam (Restoril)
Intermediate
Estazolam (ProSom)
Intermediate
½ life
2-5 hrs
8-15 hrs
10-24 hrs
BZD Receptor Agonists
Zaleplon (Sonata)
Ultra-short
1 hr
Zolpidem (Ambien
Short
1.5-4.5 hrs
Zolpidem CR (Ambien CR) Short-Intermed 1.5-4.5 hrs
Eszopiclone (Lunesta)
Intermediate
6-9 hrs
Melatonin Receptor
Agonist
Ramelteon (Rozerem)
Short
2-5 hrs
Dose
0.125-0.25mg
7.5-30mg
0.5-2 mg
5-20 mg
5-10 mg
6.25-12.5 mg
1-3 mg
8mg
36
Hypnotics Trials in the Elderly
Study
Drug
Type/
Duration
Efficacy
Geriatric
Outcomes
Nakra ’92 N=45
Temazepam
Triazolam
DB /single
dose
Subjective; +
sleep latency
Neuro-psych: dec
learning
Shaw ’92 N=119
Zolpidem
DB placebo
cont/ 21 days
Subjective; inc
TST
None measured
Roger ’93 N=221
Triazolam
Zolpidem
DB placebo
cont/ 21 days
Subjective; inc
sleep quality
Dec memory
triazolam> zolp
Vgontzas ’94 N=8
Temazepam
DB placebo
cont/ 7 days
Subj; inc sleep
time
“no memory
changes”
Hedner ’00
Zaleplon
RCT/ 14 days
Subj + sleep
latency, + TST
NC – cognition
No falls data
Unpublished ’03
N=292, N=231
Eszopiclone
RCT/ 2 wks; 2
wks
Subj + sleep
quality, +TST
NC- cognition,
no falls
DB= double blind, RCT= randomized controlled trial, TST= total sleep time
37
Pharmacologic Approaches
– Agents to Avoid
Based upon Geriatrics Literature,
side effect profiles exceed benefit
with:
– Antihistamines
– Barbiturates
– Long half-life benzodiazepines
– High-anticholinergic tricyclic
antidepressants
38
Pharmacologic Approaches Antidepressants
• The role for these agents in non-depressed
•
•
agents is actively debated (This is OFF LABEL
USE)
Trazodone- most widely prescribed hypnotic
(used for dementia) but limited efficacy data,
orthostasis & rebound insomnia
Mirtazapine is sedating but data regarding long
term adverse effects and efficacy is absent
39
Part Three:
Sleep in Institutional Settings:
the Hospital and the Nursing
Home
40
Insomnia in Hospitalized Patients
Very little literature focuses on management of
insomnia in hospitalized adults…
Factors associated with sleep changes include:
–
–
–
–
–
Acute physical symptoms (e.g. pain, dypnea)
Psychological response (anxiety, depression)
Shift in sleep-wake cycle due to environment
Sustained bed rest/ daytime napping
Delirium
41
In Hospital Causes for Awakenings
(N=52, 24 women, mean age= 57.4)
• Nocturia
• Noise
73%
48%
(RN-RN and RN-patient conversations, machinery)
•
•
•
•
RN checks/ observation
Medication passes
Pain or discomfort
Lights
40%
40%
30%
27%
(RN station, corridors, flashlights)
Jarman et al., Int J Nursing Prac 8:75-80, 2002
42
Noise in Hospital
Hospital Sounds
Comparable Sounds
Loudest transient at change of
shift – 113 dB
Portable X-ray machine – 98 dB
Jackhammer – 111 dB
Bedside monitor alarms – 75 dB
Heavy truck traffic – 81 dB
Empty semiprivate room – 53 dB
Conversational speech – 60 dB
Motorcycle – 95 dB
EPA-recommended average noise level for hospital in daytime =
45 dB; nighttime average = 35dB
Cmiel et al., Am J Nursing 2004 104:40-48
43
RN Sleep Promotion TeamNoise Reduction
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
Pre-intervention
Shift change peak 113 dB
Post-intervention
Shift change peak 86 dB
Cmiel et al., Am J Nursing 2004 104:40-48
44
A Non-pharmacologic Sleep Protocol
in an Acute Hospital Setting
(McDowell et al., JAGS 1998, 46(6):700-705)
Prospective Cohort of 111 patients, mean age 79.3 (± 6.4),
68% women
Intervention: warm drink, relaxation tapes and back
massage at HS; option for hypnotic therapy (HT) if
ineffective
Outcomes:
• Absolute reduction of 23% for HT use from pre- to post
intervention
• Overall adherence rate was 400/539 (74%) patient-days
• The sleep protocol had a stronger association with
quality of sleep (rho = .75, P = .001) than did HT (rho =
45
.07, P = .45)
Many factors contribute to
sleep problems in NH residents
•
•
•
•
•
•
•
Age-related changes in sleep
Dementia, depression
Other illnesses
Medications (including sedatives)
Increased prevalence of sleep disorders (e.g.,
sleep apnea)
Poor sleep hygiene, lack of bright light exposure
Sleep-disruptive NH environment and routines
46
Benzodiazepines increase the risk of falls
in NH residents (Ray et al. JAGS 48:682-685, 2000)
(N = 2510 residents in 53 Tennessee NHs)
Daytime falls
Nighttime falls
(7 am – 8 pm)
(8 pm – 7 am)
Any benzodiazepine 1.38 (1.25-1.51)
1.83 (1.55-2.15)
Short-acting*
NS
2.19 (1.59-3.03)
1.43 (1.29-1.59)
1.68 (1.39-2.02)
1.77 (1.38-2.26)
1.80 (1.14-2.83)
(half-life< 12 hours)
Intermediateacting
(half-life 12-23 hrs)
Long-acting
(half-life > 24 hrs)
*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
47
days.
Effects of light treatment on sleep and
circadian rhythms in demented NH residents
(Ancoli-Israel et al. JAGS 50:282-289, 2002)
• RCT, N = 77 demented residents in 2 NHs
• Treatment groups (10 day treatment):
– Evening bright light (2500 lux 5:30 pm – 7:30 pm)
– Morning bright light (2500 lux 9:30 am – 11:30 am)
– Daytime sleep restriction (attended to 6 hrs each day by research staff to restrict
daytime sleeping)
– Evening dim red light
(<50 lux 5:30 pm – 7:30 pm)
• Wrist actigraphy outcomes:
– No effects on nighttime sleep or daytime alertness.
– Significant effects on circadian rhythms of activity
48
Daily social and physical activity intervention:
effects on sleep and memory
(Naylor et al. Sleep 23:87-95, 2000)
• Controlled trial, N = 23 residents in a continued
•
care retirement facility
Intervention:
– Enforced schedule of structured social and physical
activity (9 – 10:30 am, 7 pm – 8:30 pm; daily for two
weeks)
• Results:
– Increased slow wave sleep (by polysomnography)
– Improvement in memory-oriented tasks (by
neuropsychological testing)
49
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
• Intervention combined efforts to:
–
–
–
–
–
↓ daytime in-bed time
↑ daytime sunlight exposure
↑ daytime physical activity
↓ nighttime noise and light
provide bedtime routine
• Results:
– Modest decrease in duration of nighttime awakenings
– Nearly 50% decrease in daytime sleeping
– Increased participation in social and physical activities and social
conversation
50
Summary: Sleep Changes
in Older Adults
• Complex interplay of multiple
•
•
•
•
factors (rarely does one factor
cause changes)
Medical and psychological
factors play increasing role in
later life
Primary sleep disorders are
more prevalent in older persons
Improving sleep behavioral
factors and treating illness is
first step
Risks for hypnotic use increase
with age
Poor Sleep
Behavior
Primary
Sleep
Disorders
Psychiatric
and
Neurologic
Sleep
Problem
Medical
Illness &
Medications
Circadian
Changes
51