Sleep Disorders in the Elderly Module one

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

2. PROCESS Series of 3 modules and questions on • Diagnosis and impact of Sleep Disorders • Non-pharmacological treatment insomnia • Pharmacological treatments insomnia Step #1 Power point module with voice overlay Step #2 Case-based question and answer Step #3 Proceed to additional modules or take a break

3. Module 1 ObjectivesSleep disorders in the elderly person • Epidemiology • Review changes in the sleep cycle with aging • Impact of insomnia • Evaluation of Insomnia

4. Epidemiology • 20-40% of older Americans experience insomnia at least a few nights per month • Insomnia may be: • Difficulty falling asleep 18.1% • Difficulty staying asleep 18.6% • Not feeling restored by sleep 30.9% Rockwood et al J Am Geriatr Soc 2001; 49:639-41

5. Normal Sleep Pattern After sleep onset: • Sleep usually progresses through NREM stages 1 to 4 within 45 to 60 min. Slow-wave sleep (NREM stages 3 and 4) predominates in the first third of the night and comprises 15 to 25% of total nocturnal sleep time in young adults. • The first REM sleep episode usually occurs in the second hour of sleep.

6. Changes in sleep with age • Light sleep (Stages 1 and 2) increases with age =More awakenings • Deep sleep (Stages 3 and 4) decreases from ~25% down to 3% of total sleep time • The depth of slow-wave sleep, as measured by the arousal threshold to auditory stimulation, also decreases with age. • In the otherwise healthy older person, slow-wave sleep may be completely absent, particularly in males. • Decreased amount of REM sleep • Sleep quality and efficiency is 70-80% of younger subjects. • Loss of neurons in the suprachiasmatic nucleus with advanced age may account for the age related circadian phase shift

7. Circadian Rhythm Disturbances • 24 hr. physiological rhythms • Affect hormones • Core body temperature • Sleep/wake cycle • In aging the sleep/wake cycle advances due to change in the core body temp, and decreased light exposure

8. Circadian Rhythm Changes Sleepy, go to bed wake up Standard phase 6:00p 7:00 8:00 9:00 10:00 11:00 MN 1:00 2:00 3:00 4:00 5:00 6:00a 7:00 8:00 9:00 Advanced phase Sleepy go to bed wake up

9. Decline in hours slept by age

10. Impact of Disrupted Sleep • Difficulty staying awake during the day • Impaired attention • Slowed response time • Impaired memory and concentration • Decreased performance • Mortality due to common causes of death is 2 x higher in older people with sleep disorders than those who sleep well.

11. Sleep history Timing of insomnia Sleep schedule Sleep environment Sleep habits Daytime effects Symptoms of other sleep disorders Medical history- Social History Stressors ETOH/Caffeine use Medication review Psychiatric history Depression Mania Psychosis Evaluation

12. Sleep Disordered Breathing • Recurrent hypopnea and apnea episodes during sleep leading to repeated arousals from sleep, and hypoxemia • Prevalence Men > Women • Associated with HTN, cardiac and pulmonary dx. • Main Sx is: snoring, pauses in respiration and excessive daytime sleepiness. • Treatment- CPAP, weight loss, use of dental/mechanical devices, & surgery

13. Periodic Limb Movements of Sleep • Clusters of repeated leg jerking during sleep • Dx made when PLMI is >5. • Prevalence 45% in elderly population • No gender difference. Treatment: • Avoid alcohol, caffeine and TCA’s • Dopaminergic agents: Levodopa/carbidopa, pergolide, pramipexole, ropinirole, gabapentin

14. Restless Leg Syndrome • Dysesthesia in the legs, usually creepy crawling sensation or pins and needles • Only relieved with movement • Sensations often occur when pt is in a restful relaxed state. • High association with PLMS • Treatment with dopaminergic agents.

15. Summary • Epidemiology • Review changes in the sleep cycle with aging • Impact of insomnia • Evaluation of Insomnia

16. Post-test question 1 • An 83-year-old woman who resides in a long-term-care facility complains of chronic insomnia. She is bedridden and is legally blind secondary to diabetes mellitus. Which of the following age-related changes most likely contributes to this patient’s sleep disturbance? A. A reduction in total sleep time B. A reduction in melatonin secretion C. A reduction in the percentage of stage 3 and 4 sleep D. An increase in the percentage of rapid eye movement (REM) sleep E. A breakdown in the segregation of sleep and wakefulness 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.

17. Correct Answer:  E.  A breakdown in the segregation of sleep and wakefulness Feedback A fundamental change occurs in the circadian physiology of older adults. Decreased nocturnal sleep, the tendency to nap, and daytime sleepiness suggest that the segregation of sleep and wakefulness in the light–dark cycle breaks down with age. Moreover, older adults exhibit a “flattened” (ie, less prominent day–night demarcation) circadian rhythm with respect to basal body temperature and cortisol production. This patient, who is blind and bedridden, likely has relatively few social and environmental cues to indicate day or night. Thus, she may sleep randomly during a 24-hour period and experience nighttime awakenings or insomnia. Total sleep time decreases only moderately between the third and ninth decade, and older persons generally are able to maintain normal sleep patterns. Compared with a younger individual, an older person’s sleep is less efficient, with substantial reduction in deep (stages 3 and 4) sleep, as well as a tendency to experience more awakenings because of environmental noise or temperature change.

18. The relative percentage of REM sleep changes little with age, although the temporal distribution does “flatten” (ie, more uniform percentage of REM sleep in both halves of the night). Age-related changes in both REM and deep sleep may contribute to this patient’s sleep disturbance, but these factors are not clinically significant. Although circulating levels of melatonin decrease with advancing age, the biologic and clinical implications of this change are not clear. In this patient, a relative deficiency of melatonin is not sufficient to explain the clinical presentation.

19. Post-test question 2 • A 78-year-old man presents with complaints of restless sleep at night and daytime fatigue and sleepiness. These problems have been worsening over the past 5 years. He describes social detachment and vivid nightmares about his experiences during World War II. His wife confirms the restless sleep and recently decided to sleep in a separate bedroom because of his loud snoring and occasional tendency to hit her unknowingly during sleep. Which of the following represents the best diagnostic approach? A. Obtain a detailed 2-week sleep diary. B. Obtain a measurement of serum melatonin and growth hormone levels. C. Obtain neuropsychologic testing. D. Obtain a psychiatric evaluation. E. Obtain a sleep laboratory (polysomnographic) study.

20. Correct Answer:  E.  Obtain a sleep laboratory (polysomnographic) study. • This case involves clinical features that are not unusual in sleep disorders of older persons and suggests a multifactorial disturbance in the sleep-wake cycle. The diagnosis in this case is directed toward the disorder that would have the most significant impact, including medical morbidity, and the treatment that would significantly enhance quality of life. The primary diagnosis for any patient who complains of daytime sleepiness is sleep apnea syndrome. This primary sleep disorder is characterized by daytime sleepiness and loud snoring. It is caused by repetitive apneas (often hundreds of times during a night’s sleep) brought about by collapse of upper-airway muscles, leading to partial or total obstruction. The loud snoring results from inspiratory efforts to overcome the obstruction and leads to arousals necessary for restoration of airway muscle tonus. Sleep apnea syndrome is associated with significant medical morbidity, including systemic hypertension, congestive heart failure, and cognitive dysfunction.

21. Risk factors for sleep apnea, present in this case, include male sex, advanced age, history of loud snoring, and significant daytime sleepiness. Because of poor correlations between clinical complaints and objective measures of sleep apnea, the clinician is advised to maintain a low threshold for referring patients to a sleep evaluation center to assess sleep apnea syndrome. The clinical history also suggests a diagnosis of restless legs syndrome or periodic limb movements (PLM) disorder, or both. Sleep laboratory (polysomnographic) testing should be obtained for this patient in order to document the presence and extent of myoclonic activity in the lower extremities during sleep as well as the association of arousal during sleep. The history of the patient’s wife sleeping in another room to avoid being hit by her husband raises the clinical suspicion that this patient may be suffering from a parasomnia, such as sleepwalking or rapid-eye movement (REM) sleep behavior disorder. In the latter condition, the normal muscle atonia of REM sleep is absent, allowing patients to engage in dream-enacting behavior.

22. Not uncommonly, patients with PLM disorder will intermittently kick their bed partners; this results from larger involuntary limb movements associated with the PLM disorder. In this patient, a former war experience with recurrent traumatic dreams also should prompt consideration of the diagnosis of posttraumatic stress disorder. Patients with this disorder are known to have a greater frequency of PLM disorder as well as a greater frequency of dream and acting behaviors related to the traumatic experience. The use of a sleep diary may be helpful in assessment of cases where it is suspected that poor sleep habits (that is, poor sleep hygiene) or other clinical factors are operating to disrupt sleep. Psychiatric evaluation and neuropsychologic testing are most often useful where prominent psychiatric symptoms are present; these approaches may also be helpful following a sleep laboratory evaluation in order to assess comorbid psychiatric conditions. The measurement of serum levels of growth hormone, melatonin, or other hormonal factors known to facilitate normal sleep is of no value in this case. End