Download Aging Demographics and Psychiatric Diagnoses in the Elderly

‫הפרעות שינה‬
‫בגיל המבוגר‬
‫דר' דורון גרפינקל‬
‫מנהל מחלקה גריאטרית ‪ -‬פליאטיבית‬
‫שהם – המרכז המשולב לרפואת הגיל השלישי‪,‬‬
‫פרדס חנה‪.‬‬
Sleep is Essential to Our Overall
Health and Well-Being
 Key
to our health, performance,
safety and quality of life
 As essential a component as
good nutrition and exercise
to optimal health
 Essential to our ability to perform
both cognitive and physical tasks,
engage
fully in life and function in
an effective, safe and productive way
Sleep and Aging

How does sleep change as we age?

Do we need less sleep as we get older?
Can a person expect to experience
more sleep problems or have a sleep
disorder as they advance in age?
As we age, how does sleep affect our
overall health, medical conditions and
general well being?

What can we do to get good sleep?
Specific Problems - Snoring

Partial blockage of airway causing
abnormal breathing & sleep disruptions
90 million in the US; 37 million
experience on a regular basis
 Males

 Those
who are overweight
and with large neck size
most at risk

Loud snoring can be a
symptom of sleep apnea
Specific Problems - Sleep Apnea
Increases as we age: affecting 4%
and 2% of middle-aged men and
women and close to 27% and 19%
of older men and women
 Characterized by pauses or gaps in
breathing due to an obstruction of
the airway RESPIRATORY SLEEP DISORDERS

Specific Problems - Sleep Apnea
(continued)

Signs and Symptoms



Loud, regular snoring
Large neck size
Obesity
Associated with
major medical
conditions
 Most common
treatment


CPAP
RESPIRATORY SLEEP DISORDERS
Restless Legs Syndrome - RLS
 Unpleasant/uncomfortable
feelings in
the legs during rest, evening...
 creeping,
 Urge
 Any

crawling, tingling, aching...
to move, improves by moving
age, increases with age
Sleeping problems
 Causes
(imbalance of dopamin?)
Periodic Limb Movement Disorder (PLMD)
Neurological movement disorders
/nighttime leg twitching / myoclonus
 Involuntary jerking of legs > arms
during sleep (periodic, flex/extend),
without being aware...
 If severe, may also occur while awake
 Not all patients with PLMD have RLS
BUT most patients with RLS
have PLMD

Primary RLS

Overall prevalence: 3-15%

Mean age of onset: 34 +/- 20 years

Highly variable course

Primary (idiopathic) RLS make up
majority of cases;

majority are hereditary
Secondary RLS






Iron deficiency (5% of patients with RLS
have iron deficiency; 25-30% of patients
with iron deficiency anemia have RLS)
Renal failure
Pregnancy
Parkinson’s Disease
Neuropathy
Medications may aggravate:
antihistamines, TCAs, SSRIs, DA receptor
LITHIUM, CAFFEIN,
RLS / PLMS - Treatment
 Healthy
lifestyle – baths, massages,
warm packs, meditation – yoga
 EXERCISE
 Avoid alcohol, tobacco, caffein
 Sleep hygiene
Medications:
Dopaminergic, Opioids, muscle
relaxants & sleep medications
(clonex), Gabapentin
Specific Problems - Insomnia
A perception or complaint of inadequate
or poor sleep
 Difficulty falling asleep
 Frequent awakenings
 Waking too early and
having difficulty falling back to sleep
 Waking unrefreshed
 A highly prevalent condition affecting
as many as 48% of older persons
 Next day consequences

Sleep Disturbances
in the Elderly
Prevalence of Insomnia
by age group* :
Age 18-34 – 14%
Age 35-49 – 15%
Age 50-64 – 20%
Age 65-79 – 25%
*Mellinger GD et al. Arch Gen Psychiatry 1985;42:225-232.
Sleep Problems/Disorders
Prevalent Among Older Persons
SYMPTOMS OF SLEEP PROBLEMS BY AGE
Symptoms: a few nights
a week or more
55-64
Insomnia
49%
Snoring
41%
Sleep Apnea
9%
Restless Legs Syndrome (RLS) 15%
65-74
46%
28%
6%
17%
75-84
50%
22%
7%
21%
SLEEP DISORDERS
IN THE ELDERLY
POINTS FOR CONSIDERATION
 SLEEP DISORDERS IN THE ELDERLY
 SLEEP DISTURBANCES IN NURSING
HOMES & GERIATRIC WARDS
 NOCTURNAL RESPIRATORY DISTURBANCES
 THE ROLE OF MELATONIN IN SLEEP
 THE ROLE OF HYPNOTICS (SLEEPING
 THE RATIONAL DIAGNOSTIC &
THERAPEUTIC APPROACH
PILLS)
Sleep and
Aging Well
The information in this publication was independently developed by the National Sleep Foundation. © 2003 National Sleep Foundation
The Sleep Cycle in Adults
Awake
REM
REM
3
REM
REM
2
REM
Stages
1
4
0
1
2
3
4
5
Hours in Sleep
6
7
8
Normal Sleep and Aging:
Less Deep Sleep
The ability to get
continuous and
consolidated sleep
may become more
difficult as we age
Health and Environment
Affect Our Sleep
With age, we become
more sensitive to:
 Hormonal Changes
 Physiological Conditions
 Environmental Conditions
Light
Noise
Temperature
SLEEP DISTURBANCES
IN THE ELDERLY
A MAJOR
CLINICAL & SOCIAL
PROBLEM
SLEEP DISORDERS
IN THE ELDERLY
WITH AGE, THE INCIDENCE OF SLEEP DISORDERS
INCREASES & THE QUALITY OF SLEEP DECREASES
HEALTHY ELDRLY INDIVIDUALS:
 TAKE LONGER TIME TO FALL ASLEEP (
LATENCY)
 HAVE DECREASED TOTAL SLEEP TIME and
DECREASED “SLOW WAVE” SLEEP
 HAVE INCREASED FREQUENCY & DURATION OF
ARAUSALS DURING SLEEP
(W.A.S.O.)
 HAVE AN INCREASED INCIDENCE OF DAYTIME SLEEPINESS
Normal Sleep and Normal Aging:
Sleep Efficiency
Sleep Efficiency
(% Time in Bed Sleeping)
Changes with age
Age
Men
Women
SLEEP DISORDERS
IN THE ELDERLY
MANY ELDERLY PEOPLE WHO REPORT ON
SUBJECTIVE DIFFICULTIES TO FALL ASLEEP
AND MANY AWAKENINGS, MAY BE FOUND TO
HAVE NORMAL LATENCY AND W.A.S.O.
ON THE OTHER HAND, SOME ELDERS
WHO REPORT A “GOOD NIGHT SLEEP”,
ARE FOUND TO HAVE SEVERE SLEEP
DISTURBANCES WHEN OBJECTIVELY
ASSESSED BY ACTIGRAPHY
A POINT OF CRUCIAL IMPORTANCE IN RESPIRATORY SLEEP DISORDERS
THE “BAD SIDE” OF AGING:
AGE-RELATED DISEASES & DISFUNCTIONS
ATHEROSCLEROSIS
C A N C E R
DEMENTIA
D E P R E S S I O N (ANXIETY)
IMPAIRED IMMUNITY
INCONTINENCE
OSTEOPOROSIS & OSTEOARTHROSIS
DIABETES MELLITUS , F A L L S (#)
CATARACT, GLAUCOMA, AMD, HEARING LOSS,
PROSTATIC HYPERTROPHY, PARKINSON’S DISEASE
G.I. PROBLEMS, SKIN PROBLEMS
SLEEP DISORDERS
IN THE ELDERLY
POSSIBLE
CAUSES
1. SECONDARY TO THE INCREASED INCIDENCE
OF DISEASES ASSOCIATED WITH PAIN, DYSPNEA,
NOCTURIA, G. I. DISCOMFORT ETC.
2. SECONDARY TO THE INCREASED CONSUMPTION
OF DRUGS: SPECIFIC ADVERSE EFFECTS ON
SLEEP, OR NONSPECIFIC (PALPITATIONS, NAUSEA,
URINATION, PRURITUS ETC.)
3. A PRIMARY ENDOGENOUS AGE - RELATED
SLEEP DISORDER ( MELATONIN ?)
Medications Can Also
Cause Sleep Problems
The Use of Alcohol, Caffeine and
Nicotine Impacts on Sleep
Examples of ‘Legal’ Drugs That
Cause Insomnia
 Alcohol







Decongestants
CNS stimulants
Stimulating
antidepressants
Beta-blockers
Diuretics
Thyroid hormones
Bronchodilators
 Nicotine

Calcium channel
blockers
 Caffeine





Corticosteriods
CNS Depressants
Quinidine
Anticonvulsants
Antiparkinsonian
agents
Summary:
Sleep Changes

Sleep during the night changes with age:
 Less
deep sleep / more lighter sleep
 More
difficulty maintaining sleep
due to arousals & awakenings
 Sleep
is less efficient and more fragmented

The internal biological clock shifts to earlier
bed and wake times

Older persons experience a higher prevalence
of medical conditions and take more
medications that are associated with sleep
problems/disorder
Summary:
Consequences of Sleep Changes

Tendency to stay in bed longer to get
a sufficient amount of sleep results in
worse sleep

More likely to take more naps to meet
sleep need - may result in worse sleep

Inadequate or poor sleep results in
daytime sleepiness and fatigue

Ability to function well, enjoy life and
overall quality of life is affected
Consequences of Poor Sleep
in older adults





Difficulty sustaining
 Increased risk of falls
attention & slowed
 Shorter survival
response time
 Increased
Decreased ability to
institutionalization rate
accomplish daily tasks
Impairments in memory  Inability to enjoy social
& concentration
relationships
Increased consumption
 Decreased QOL
of healthcare resources
 Increased incidence of
higher incidence of
cognitive decline
symptoms related to
depression and anxiety  Increased incidence of pain
Ancoli-Israel s, Cook JR. J Am Geriatr Soc 2005;53 (suppl):S264-S271
APPROACH TO SLEEP DISORDERS
(IN THE NURSING HOME SETTING)
SLEEP DISORDERS
SHOULD BE HANDLED BY THE PHYSICIAN
IN THE SAME CLINICAL APPROACH AS THAT
USED FOR OTHER SYMPTOMS OR SIGNS:
FIRST OF ALL,
DEFINE THE UNDERLYING CAUSE
& MAKE THE CORRECT DIAGNOSIS
Evaluating Causes of Insomnia

Situational factors that are major stressors such
as a life trauma or an upcoming important event

Environmental factors such as too much noise,
temperature that are too hot or too cold, or
working a night shift

Factors related to medications, both prescription
and nonprescription (i.e. CNS stimulants/
activating antidepressants)

Medical problems such as pain, endocrine,
menopause, BPH, incontinence, CHF, PUD/GERD,
COPD, allergic rhinitis, seizure d/o
APPROACH TO SLEEP DISORDERS
(IN THE NURSING HOME SETTING)
1. RULE OUT AND TREAT SITUATIONS LEADING
TO SECONDARY SLEEP DISORDERS PARTICULARY
SLEEP APNEA (PATIENT’S STORY, ANXIETY,
DEPRESSION, PHYSICAL, IMAGING & LAB FINDINGS).
2. NO APPARENT UNDERLYING CAUSE FOR SLEEP
DISORDER and ADVANCED AGE CONSIDER A PRIMARY MELATONIN DISORDER
3. A. PROVE IT: CHECK OVERNIGHT URINE FOR 6-STM
B. CONSIDER A THERAPEUTIC TRIAL WITH 2mg OF
CONTROLLED - RELEASE MELATONIN . . .. . OR
4. TRY A SLEEPING PILL… PREFERABLY NOT A
BENZODIAZEPINE AS THE FIRST CHOISE
How To Enhance Your Sleep:
Practical Tips for Good Sleep
Establish a regular schedule with
consistent bed and wake times
 Maintain a relaxing bedtime routine
 Create a sleep-promoting
environment that is
comfortable, quiet, dark
and preferably cool

Sleep Tips (continued)
Limit fluids and don’t eat too much
close to bedtime
 Avoid caffeine, nicotine and alcohol
too close to bedtime and
even after lunch
 Exercise, but not within 3 hours
before bedtime

If You Have Difficulty Sleeping
 Limit
time in bed
 Use
your bed only for sleep
and satisfying sex
 Avoid
 Limit
watching the clock
naps
Keep a Sleep Diary to Identify
Your Sleep Habits and Patterns
SLEEP WELL !