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Sleep Disorders in Long-Term Care

Sleep Disorders in Long-Term Care. Thomas Magnuson, M.D. Assistant Professor Division of Geriatric Psychiatry UNMC. To Get Your Nursing CEUs. After this program go to www.unmc.edu/nursing/mk . Your program ID number for the July 12 th program is 10CE028. Instructions are on the website.

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Sleep Disorders in Long-Term Care

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  1. Sleep Disorders in Long-Term Care Thomas Magnuson, M.D. Assistant Professor Division of Geriatric Psychiatry UNMC

  2. To Get Your Nursing CEUs • After this program go to www.unmc.edu/nursing/mk. • Your program ID number for the July 12th program is 10CE028. • Instructions are on the website. • **All questions about continuing education credit and payment can be directed towards the College of Nursing at UNMC.** Heidi KaschkeProgram Associate, Continuing Nursing Education402-559-7487hkaschke@unmc.edu

  3. Objectives • Discuss the causes of sleep disruption in long-term care • Identify non-pharmacologic interventions possible to remedy sleep disruption • Assess pharmacologic interventions for sleep disruption

  4. Impact • Significant problem • Many residents with sleep problems • 50% of the elderly have sleep problems • 65% in Los Angeles area ALFs • Effect • Cognition • Physical health • Mood • Quality of life • Staff morale

  5. Well Elderly • Spend more time in bed to get the same amount of sleep • Total sleep time only mildly decreased from when younger • Increase in nighttime awakenings and daytime napping • Earlier bedtimes • Increased time to fall asleep • More easily aroused by sound • Daytime sleepiness not part of normal aging

  6. Long-Term Care • More often self-report sleep problems • More severe self-report • Asleep at all hours, even mealtimes • Wake and sleep fragmentation • Wakefullness interrupted by brief sleep • Leads to extreme sleep-wake disruption • Distributed across the entire day • Rarely awake or asleep for hours

  7. Effects of Poor Sleep • Variety of problems • Irritability • Poor concentration • Decreased memory • Lessened reaction time • Poorer performance on tasks • Community dwelling elderly • More falls • Increased mortality

  8. Case • 78-year-old demented female • Up at night, loud and disruptive • Sleeps much of the day • No activities • CAD, HTN, depression, hypothyroidism, h/o breast cancer, arthritis, GERD, constipation, incontinence • ASA, APAP, sertraline, synthroid, esomeprazole, metoprolol, furosemide, senna, MOM, oxybutynin, donepezil, memantine, hydrocodone/APAP

  9. First Questions • How much are they sleeping? • Usually no one really knows • Up at night…sleeping pill • Up in the day…stimulant • Shifts need to talk to each other • Sleep is poorly documented • When are they sleeping? • Daytime? • Nighttime? • Both?

  10. First Intervention • Sleep chart • Daily • Every hour, on the hour • Not 4:01, just 4:00 • 24 hours a day • For a week • Good general idea • Usually is around 9-11 hours a day

  11. Causes • Primary sleep disorders • Medical conditions • Psychiatric disorders • Medications/polypharmacy • Circadian rhythm problems • Environment • Noise and light at night • Low daytime light • Behavioral • Physical inactivity • More time in bed

  12. Primary Sleep Disorders • Sleep disordered breathing (SDB) • Restless Leg Syndrome (RLS) • Periodic Limb Movement Disorder (PLMD) • REM sleep behavior disorder (RBD)

  13. Sleep Disordered Breathing (SDB) • Airflow interrupted • Obesity common cause • Apnea/hypopnea • 10 second episodes • 15 times an hour • Low oxygen to brain • Disrupts sleep • LTC residents • 50-66% have at least mild SDB • Treatment is CPAP • Air forces airway open

  14. Restless Leg Syndrome (RLS) • Uncomfortable feeling in legs • Relieved by moving legs • Worse later in the day • Falling asleep is hard • Symptoms come on and worsen with age • Possible cause of motor restlessness and wandering • Treatment • ropinerole (Requip) and pramipexole (Mirapex)

  15. Periodic Limb Movement Disorder (PLMD) • Legs kick, jerk during nighttime sleep • Easier to identify if one has asleep partner • Causes sleep fragmentation • Treatment • Much as RLS • ropinerole (Requip) • pramipexole (Mirapex)

  16. REM Sleep Behavior Disorder (RBD) • Usually CNS motor is paralyzed in REM • Except for breathing • Act out dreams • Prominent in older men, certain dementias • Safety is an issue • Treatment • clonazepam (Klonopin) • Secure the environment

  17. Case • Workup • Sleep chart • Broken up • Averages 9.4 hours a day • Range 4-13 hours a day • Lab, medical tests • Oxygen saturation unremarkable • TSH normal • CBC, BMP normal

  18. Medications • Near bedtime • Lung medications/bronchodilators • caffeine, albuterol • Stimulants • methylphenidate (Ritalin) • Daytime sedation • Antihistamines • promethazine (Phenergan) • Anticholinergics • diphenhydramine (Benedryl) • Sedating antidepressants • nortriptyline, mirtazapine (Remeron) less than 30mg/d

  19. Medical Conditions • Common • Pain • Parasthesias • Nighttime cough • Dyspnea • GERD • Incontinence or frequent nighttime urination • Neurodegenerative disorders • Parkinson’s disease, e.g.

  20. Dementia • Common sleep problems • More sleep disruption • Lower sleep efficiency • More light sleep • Less deep sleep • Less REM • Sundowning

  21. Circadian Rhythm • Body’s pattern of sleep/wake • Elderly • Blunted in amplitude • Less time in each sleep/wake cycle • Shifted in time • More daytime somnolence, nighttime awakenings • Less stable in LTC than in the community • May correlate with degree of dementia • Decreases survival in LTC

  22. Circadian Rhythm • Exerts much influence on the timing of sleep • Weak CR or reset CR may strongly influence sleep problems • How to try and fix • Exposure to bright light in the daytime • Regular scheduled exposure • Physical activity less important than light • Bright in the day, dark at night

  23. Case • Medical conditions • GERD • Well controlled, no evidence of nighttime heartburn • No food for an hour before bedtime • Pain • No complaints on routine APAP • Signs of worsened pain not present • Incontinence • Oblivious at night • Toileting right before bedtime

  24. Case • Medical conditions • Mood • Stable symptoms • Hypothyroidism • TSH normal • Primary sleep disorders • Oxygenation normal • No noted movements awake or asleep that resemble RLS or PLMD • No odd or unusual nighttime behavior • Dementia • Pattern of sleep problem sounds familiar

  25. Case • Medications • hydrocodone/APAP (Vicodin) • Pain controlled well on APAP • Not used in awhile • sertraline (Zoloft) • Not a sedating antidepressant • Could give at nighttime • oxybutynin (Ditropan) • Anticholinergic, antihistaminergic • Can choose a less concerning agent • L-thyroxine (Synthroid) • Only if underused

  26. Night in LTC • Many sleep problems in the environment • Shared rooms • Frequent noise and light interruptions • Extended, nightly basis • Most noise caused by workers • Doing personal cares • Room level light • Suppresses melatonin • Disrupts sleep • Changes CR

  27. Treatment • Nonpharmacologic • Timed light exposure • More alert right after exposure • More active in the day • Mixed results • Lower noise and light levels • Hard to change the environment

  28. Treatment • Mixed approach • Daytime light exposure • Increased physical activity • Bedtime routine • Less time in bed • Minimize nighttime disruption • Results • Lessened daytime sedation • More social energy • More physically active • Hard to change nighttime noise and light levels

  29. Treatment • Pharmacologic treatment • Hypnotics • zolpidem (Ambien) • zaleplon (Sonata) • ramelteon (Rozerem) • Adverse events • Dizziness • Drowsiness • Falls • Not efficacious • Don’t give to someone sleeping 13 hours a day • Psychological dependence

  30. Treatment • Pharmacologic • Benzodiazepines • alprazolam (Xanax) • lorazepam (Ativan) • clonazepam (Klonopin) • Adverse events • Falls • Confusion • Sedation • Dependency

  31. Treatment • Pharmacologic • Sedating antidepressants • Tricyclics • Nortriptyline • Amitriptyline • Trazodone • Mirtazapine • Adverse events • Daytime sedation • Falls, orthostasis • Confusion, bladder retention, constipation, tachycardia

  32. Treatment • Melatonin • Hormone • Mixed results • Bad idea • Antipsychotics • Alcohol • Caffeine • Exercise prior to bedtime

  33. Case • No noisy roommate • No routine awakenings • Environment is noisy • Often sitting in chair near front door • Falls asleep in her room • Rarely goes outside

  34. Case • Likely dementia related • Timed light therapy • Take outdoors to sit in the sun • Discontinue prn narcotic • Changed oxybutynin • Allowed timed naps to limit time in bed • Made rigid bedtime routine • Dark at night, bright in the daytime • No sleeping pill

  35. Objectives • Discuss causes of sleep disruption in long-term care • Identify non-pharmacologic interventions possible to remedy sleep disruption • Assess pharmacologic interventions for sleep disruption

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