Sleep Disorders in the Elderly

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Sleep Disorders in the Elderly

• Dr motahare mirdamadi
• psychiatrist

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Sound Familiar?

• Why am I so tired all of the time?
• I dont have any energy
• I just cant sleep well anymore
• My husbands always falling asleep, he doesnt do
  anything anymore
• I wish I could just get some rest
• I just lie awake, I cant get back to sleep

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Agenda

• Significance of sleep disorders
• Physiology Normal and Aging
• Classifying sleep disorders
• Sleep hygiene
• Evaluation for sleep disorders
• Insomnia
• (Sleep-disordered breathing)
• Other sleep disorders

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Significance of Sleep Disorders

• Survey of 9000 people gt age 65
• No sleep complaints (12)
• Difficulty initiating/maintaining (43)
• Nocturnal waking (30)
• Insomnia (29)
• Chronic sleep difficulties (gt50)
• Daytime napping (25)
• Trouble falling asleep (19)
• Waking too early (19)
• Waking without feeling rested (13)
• Ancoli-Israel S. JAGS 200553S264-S271.

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Significance of Sleep Disorders

• gt50 of sedatives are used by people age gt 65
• In age 70-100, 19 of patients were taking a
  sleep medicine (in one study)
• Mortality due to common conditions is 2 times
  higher in elderly with sleep disorders than in
  those without.
• Daytime somnolence can interfere with activities
  and function
• Sleep disorders negatively impact quality of life
• Sleep disorders can lead to depression and
  cognitive impairment

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Agenda

• Significance of sleep disorders
• Physiology Normal and Aging
• Classifying sleep disorders
• Sleep hygiene
• Evaluation for sleep disorders
• Insomnia
• Sleep-disordered breathing
• Other sleep disorders

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Normal Physiology - Basics

• Non-REM sleep
• Stage 1 very light, easy to arouse
• Stage 2 most of the nights sleep
• Stage 3,4 slow wave, deeper sleep
• REM sleep
• EEG similar to stage 1
• Low/absent muscle tone
• Dreaming occurs here
• Greatest cardiac and respiratory instability

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Normal Physiology - Basics

• Sleep Architecture
• REM latency is about 90 minutes (wide variation)
• Very short in narcolepsy
• REM normally occurs every 90 to 120 minutes
• More stage 3,4 in first half of night, more REM
  2nd half
• Brief awakenings (30 sec) common, not usually
  remembered
• Brief arousals (3 sec) are normal

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Age-Related Changes

• Non-REM
• Less slow wave sleep (stage 3 and 4), may be
  entirely absent, easier to awaken
• REM
• Shorter REM latency
• Decreased REM percentage and duration
• Architecture
• Increased overall sleep latency
• More awakenings/arousals less sleep efficiency
• Less sleep in 24 hour period
• Reduced sleep latency during day harder to stay
  awake

Espiritu JR. Clin Geriatr Med 2008241-14.
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Age-Related Changes

• Circadian cycle shifted earlier
• Decreased melatonin levels at night
• Decreased modulation of circadian rhythm between
  day and night
• More naps during the day (1 hour)
• May have little impact on night-time sleep
• May enhance cognitive and psychomotor performance
  due to increase total sleep

Espiritu JR. Clin Geriatr Med 2008241-14.
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Age Related Changes

• Less physiologic flexibility with schedule
  changes
• More comorbidities that can interfere with sleep
• It is hard to know if sleep problems are more
  common independent of other conditions
• The ability to get restorative sleep gets worse
  with age, the need for sleep does not.

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Mechanisms Underlying Sleep Complaints
Vaz Fragoso CA. JAGS 20071853-1866.
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Precipitating Factors

• Declining Health Status
• Nocturia
• Pain (DJD, neuropathy)
• Cardiac Disease
• Angina, CHF, arrhythmia
• Pulmonary Disease
• Endocrine thyroid, menopause, DM polyuria

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Precipitating Factors

• Medications impact sleep architecture and
  sleep-disordered breathing
• CNS stimulants/depressants
• Diuretics, hypoglycemics
• Neuropsychological Impairments
• Depression, Anxiety
• Cognitive Impairment/Psychosis
• Primary Sleep Disorders

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Perpetuating Factors - Psychosocial

• Caregiving
• The work of caregiving
• Associated mental and physical health problems
• Social Isolation
• Poorer sleep hygiene
• Decline in activity
• Bereavement, Widowhood, Retirement

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Agenda

• Significance of sleep disorders
• Physiology Normal and Aging
• Classifying sleep disorders
• Sleep hygiene
• Evaluation for sleep disorders
• Insomnia
• Sleep-disordered breathing
• Other sleep disorders

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Primary Sleep Disorders

• Primary Insomnia
• Sleep onset (Initial)
• Sleep maintenance (Middle)
• Sleep disordered breathing
• Obstructive sleep apnea
• Central sleep apnea
• Mixed sleep apnea
• Circadian rhythm disturbances

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Secondary Sleep Disorders

• Underlying conditions that should be addressed
  first
• Medical Illness causing nocturnal symptoms
• Psychiatric Illness
• Medications
• Social/behavioral

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Secondary Sleep Disorders

• Psychophysiologic Insomnia (stimulus/response)
• Adjustment Insomnia recent stressor
• Inadequate Sleep Hygiene
• Lack of schedule (retirement!)
• Sedentary or naps during daytime
• Voluntary sleep deprivation
• Mixed-type insomnia

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Agenda

• Significance of sleep disorders
• Normal physiology
• Age related changes
• Classifying sleep disorders
• Sleep hygiene
• Insomnia
• Sleep-disordered breathing
• Other sleep disorders

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Sleep Hygiene

• The bed is for sleeping (and sex) only
• Increase activity, decrease naps
• Avoid late meals
• Avoid caffeine, ETOH, cigarettes
• Environmental control (light, noise, temp)
• Decrease stress
• Establish a routine
• Take bath

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Polysomnography

• Formal Sleep Test indications
• Diagnosis of sleep-disordered breathing
• Suspected narcolepsy
• Suspected REM sleep movement disorder
• Difficult to diagnose parasomnias (e.g. PLMS)
• Not usually for
• RLS
• Circadian rhythm disorders
• Primary insomnia

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Agenda

• Significance of sleep disorders
• Physiology Normal and Aging
• Classifying sleep disorders
• Sleep hygiene
• Evaluation for sleep disorders
• Insomnia
• Sleep-disordered breathing
• Other sleep disorders

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Insomnia - Definition

• Difficulty with initiation, maintenance,
  duration, or quality of sleep that results in the
  impairment of daytime functioning.
• Can lead to fatigue, mood disturbance,
  interpersonal and job problems, and reduced
  quality of life.

From DSM-IV
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Insomnia - Definitions

• Sleep latency usually gt 30 minutes
• Sleep efficiency lt 85
• Transient less than 1 week
• Short-term 1-4 weeks
• Chronic gt 1 month
• May be perpetuated by worrying in bed or
  unrealistic expectations of sleep duration
• More common in women, elderly, and chronic
  disease (medical and psychiatric)

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Insomnia - Treatment

• Non-pharmacologic therapy
• Improvement in 70-80 of patients (though some
  studies used psychologists)
• Stimulus control therapy bed for sleeping only,
  1 small nap only
• Sleep restriction therapy reduce time in bed to
  achieve 90 efficiency, gradually increase (up to
  6-7 hours)
• Relaxation therapy imagery, meditation, muscle
  relaxation
• Cognitive therapy beliefs and attitudes
• Sleep hygiene education

Joshi S. Clin Geriatr Med 200824107-119.
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Insomnia - Medications

• Use lowest effective dose
• Use intermittent dosing
• Short term use (lt 1 month if possible)
• Gradual discontinuation (rebound)
• Medications with shorter half lives are preferred
  to prevent next-day sedation

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Insomnia - Medications

• Short acting medications
• More improvement with sleep latency
• More withdrawal and dependence
• Long acting
• More improvement with sleep duration
• More next day symptoms (sedation, cognitive
  impairment, falls)
• Most medications have not been studied
  extensively in the elderly or more than 6 months

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Insomnia - Medications

• Benzodiazepines GABA-A receptors
• Benefits cheap, improve sleep latency, total
  sleep time, number of awakenings, sleep quality
• Disadvantages
• More next day effects (drowsy, dizzy)
• More dependency/withdrawal
• More rebound symptoms
• More amnesia (especially with shorter acting
  agents)
• Falls and hip fracture risk (long acting)

Tariq SH. Clin Geriatr Med 20082493-105.
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Insomnia - Medications

• Benzodiazepine receptor agonists
• Advantages
• more specific targeting of GABA receptors in the
  brain so less side effects
• Disadvantages
• Not well studied in the elderly (use lower
  starting doses)
• Not compared against each other
• More expensive
• Dependence/withdrawal still occur
• Still can increase risk of falls and fractures

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Zolpidem

• Short half life (2.6 hours)
• Better for sleep onset insomnia
• Minimal impact on sleep architecture
• Can see rebound insomnia, mild next day
  drowsiness, mild antergrade amnesia

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Zaleplon (Sonata)

• Ultrashort half-life (1 hour)
• Better for sleep onset insomnia
• Can increase total sleep time and efficiency
• Can be taken after a middle of night awakening
• Rare rebound and next day effects
• Not approved for long term use
• But reported to be safe for long term use in
  elderly

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Eszopiclone (Lunesta)

• Medium half life (5-7 hours)
• Better for sleep maintenance insomnia
• Increased total sleep time 49 min
• Helps with sleep onset (27min)
• Few next day effects (but longer half life
  suggest risk for next day effects in elderly)
• Approved for long term use

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Sedative-Hypnotics Risk/Benefit

• Meta-analysis of 24 studies, gt 2400 patients
  older than age 60 treated with benzos or benzo
  receptor agonists
• Benefits compared to placebo (NNT 13)
• Small improvement in sleep quality
• Sleep time increased (25 minutes)
• Decrease number of awakenings (0.63)
• Harms (NNH 6)
• Cognitive impact (4.78 times more common)
• Psychomotor events (2.61 times as common)
• Daytime fatigue (3.82 times more common)

Glass et al. BMJ 20053311153-1212.
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Other Medications

• Melatonin receptor agonist
• Small improvement in sleep onset (8 min)
• Improved total sleep time (12 min)
• Increase prolactin levels, few other side
  effects.
• Not compared to other drugs or melatonin.
• Approved for chronic use.
• Sedating antihistamines

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Other Medications

• Sedating Antidepressants
• Tricyclics they help, but side effects
• Trazadone helps, not as much as Ambien(zolpidem)
• May improve SWS (stage 3 and 4)
• Remeron(mirtazapine) increased sleep efficiency,
  increases duration of slow wave sleep in elderly
• These drugs are not well studied (or approved)
  for insomnia in the elderly
• Best used for depression with insomnia

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Other Medications - Melatonin

• Levels correlate with circadian rhythm
• Deficiency is more common in elderly and
  associated with insomnia
• Effects (0.1 to 10mg QHS)
• 7.8 minute ? latency in primary insomnia
• 38.8 minute ? latency in delayed sleep phase
  syndrome
• No impact on sleep efficiency
• Minimal side effects, if any
• Nutritional supplement dosing?

Gooneratne NS. Clin Ger Med 200824121-138.
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Drugs vs No Drugs

• Unclear if cognitive behavioral therapy or
  medication therapy is better
• Both help
• Medications may work more quickly
• CBT may have more lasting benefit
• Hard to do cognitive therapy
• Medications not studied more than 6 months
• It is best to attempt education and
  non-pharmacologic therapy first, and continue
  even if medications are used

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Other Treaments for Insomnia

• Bright Light Therapy
• Light -gt suprachiasmatic nucleus -gt inhibits
  production of melatonin by pineal gland
• Threshold between 200-400 lux (normal indoor
  fluorescent light)
• Treatment uses 2000-10,000 lux
• Dosing, timing, duration, effectiveness not
  established in the elderly
• Best evidence for SAD in younger people

Gammack JK. Clin Geriatr Med 200824139-149.
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Agenda

• Significance of sleep disorders
• Normal physiology
• Age related changes
• Classifying sleep disorders
• Sleep hygiene
• Evaluation for sleep disorders
• Insomnia
• Sleep-disordered breathing
• Other sleep disorders

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Sleep-disordered Breathing

• Usually present with daytime somnolence
• Snoring alone is not usually a problem
• Hypopnea
• Apnea increased incidence in the elderly, can
  be seen in 10-40
• Obstructive
• Central
• Mixed

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Sleep-disordered Breathing

• Significance, Signs, and Symptoms
• Daytime somnolence, effect on function
• Decreased cognition, dementia may be worse
• CHF, arrythmias, HTN, cor-pulmonale
• Polycythemia
• Nocturia
• Personality changes
• Morning headaches
• Decreased libido, impotence
• May increase mortality

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Obstructive Sleep Apnea (OSA)

• Definition repetitive episodes of uper airway
  obstruction with continued movement of chest and
  abdominal walls, leads to desaturations and
  arousals.
• Risk factors people with classic symptoms and
• Male
• Large neck circumference (gt18 inches)
• Obesity

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OSA - Stages

• daily sleepiness during tasks that require
  significant attention (driving, conversation,
  eating, walking), marked impairment in function

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OSA - Treatment

• Unclear benefit to treating mild or minimally
  symptomatic patients
• Treatment is likely to improve
• HTN
• CHF
• Daytime function
• Cognition and health-related quality of life

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OSA - Treatment

• Weight loss, avoid supine position (tennis balls)
• Avoid sedating drugs
• Prescription drugs not helpful
• CPAP/BIPAP Most efficacious
• Compliance issues
• Oral appliance less effective, use for mild
  cases or if CPAP not tolerated
• Surgery trach, uvuloplasty

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Central Sleep Apnea - CSA

• Definition Periodic complete cessation of
  airflow and respiratory effort, followed by
  desaturations and arousals.
• Related to chemoreceptors and CO2 physiology.

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CSA Associated Conditions

• Congestive heart failure
• Prior Stroke and cerebrovascular disease
• Other neurologic disorders ALS, mucular
  dystrophy
• Chronic renal failure
• Hypothyroidism
• Baseline CO2 retainers (COPD, kyphoscoliosis)

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CSA Diagnosis and Treatment

• Diagnosis Polysomnography
• Treatment
• CPAP/BIPAP can help
• Nocturnal Oxygen can help (offsets overshoot)
• Consult your local pulmonologist

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Agenda

• Significance of sleep disorders
• Normal physiology
• Age related changes
• Classifying sleep disorders
• Sleep hygiene
• Evaluation for sleep disorders
• Insomnia
• Sleep-disordered breathing
• Other sleep disorders

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Other Sleep Disorders

• Restless Legs Syndrome
• Periodic Limb Movements of Sleep
• REM Sleep Behavior Disorder
• Nocturnal Leg Cramps
• Circadian Rhythm Disturbances

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Restless Legs Syndrome (RLS)

• Sensorimotor neurologic condition, possibly
  caused by abnormal iron metabolism and
  dopaminergic dysfunction unclear
• Compelling urge to move limbs (legsgtarms)
• Worse at rest
• Worse at night
• May have dysesthesia or pain
• Relieved with movement
• Disrupts sleep, alertness, daytime function, QOL

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RLS Facts

• 5-15 prevalence, increased in the elderly, more
  common in women
• Associated features
• FH positive in 60
• PLMS in 80 (but 30 PLMS pts have RLS)
• Diagnosis
• Classic symptoms
• Responds to trial of therapy

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RLS Associated Conditions

• Pregnancy
• ESRD
• Fe Deficiency
• Check ferritin, iron
• Parkinsons
• Radiculopathy
• Neuropathy
• Rheumatoid arthritis
• DM
• Depression/anxiety

• Drugs can exacerbate
• Sedating antihistamines
• Metoclopramide
• Calcium channel blockers
• Neuroleptics
• TCAs
• SSRIs
• Caffeine
• Nicotine
• ETOH

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RLS Treatment

• Non-pharmacologic
• Avoid caffeine, ETOH, associated medications
• Sleep hygiene
• Bedtime bath
• Mild exercise before bedtime
• Pharmacologic
• most drugs used off label
• 70-100 effective

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RLS Treatment

• Dopaminergics
• Requip/ropinirole and Mirapex/pramipexole only
  FDA approved meds)
• Use for daily or intermittent symptoms
• First line treatment (most studied)
• Benzos intermittent use, klonopin is best
  choice
• Opioids daily or intermittent use
• Neurontin daily use, similar efficacy to Requip
  (average dose 800mg)
• Neuropsychobiology 200348(2)82-6.
• Magnesium, folate have slight evidence

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Periodic Limb Movements of Sleep

• PLMS Periodic episodes of repetitive and highly
  stereotypc limb movements during sleep
• 34-45 prevalence in the elderly, increases with
  age
• Associated with RLS, arousals, difficulty
  achieving and maintaining sleep
• Most are asymptomatic
• Unclear significance
• Associated conditions similar to RLS

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PLMS Diagnosis and Treatment

• Diagnosis
• Clinical history and response to treatment
• Polysomnography can be used
• Treatment
• Dopamine agonists
• Benzos decrease arousals but not movements
• Opioids

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REM Sleep Behavior Disorder

• Lack of normally low muscle tone during REM sleep
• Cause unknown
• Usually male, onset age 50-60
• Act out dreams which can be violent
• Vivid memory of dreams
• Can diagnose with polysomnography
• 1/3 of Patients will develop Parkinsons
• Treat with benzo (klonopin 90 effective)

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Nocturnal Leg Cramps

• Cause not known
• Associated factors
• Meds (diuretics, nifedipine, beta agonists,
  steroids, morphine, cimetidine, statins, lithium)
• Conditions (uremia, DM, thyroid, electrolyte
  d/os)
• Diagnosis history, check labs

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Nocturnal Leg Cramps

• Treatment
• Review associated factors
• Calf stretching exercises
• Quinine (200-300mg QHS)
• Evidence of moderate benefit
• Toxicity careful in elderly, kidney/liver
  disease
• Digoxin interaction
• Hematologic (thrombocytopenia)
• Cinchonism
• Blindness, arrhythmias, death!
• Tonic Water

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Circadian Rhythm Disturbance

• Advanced sleep phase syndrome
• Neurologic control of rhythms is altered
• Early to bed, early to rise
• Can interfere with societal norms
• Total sleep time and daytime function usually not
  affected
• Melatonin and light therapy are theorized to help
• Reassure patients

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Summary

• Sleep problems are very common in the elderly
• Sleep problems have significant impact on health
  and quality of life
• Be as specific as possible in diagnosing sleep
  disorders
• Treatment should include all contributing
  factors, and should include counseling
• Avoid a pill for every symptom