Sleep Disorders in the Elderly

1. Sleep Disorders in the Elderly Dr motahare mirdamadi psychiatrist

2. Sound Familiar? • Why am I so tired all of the time? • I don’t have any energy… • I just can’t sleep well anymore… • My husband’s always falling asleep, he doesn’t do anything anymore… • I wish I could just get some rest… • I just lie awake, I can’t get back to sleep…

3. 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

4. Significance of Sleep Disorders Survey of 9000 people > age 65 • No sleep complaints (12%) • Difficulty initiating/maintaining (43%) • Nocturnal waking (30%) • Insomnia (29%) • Chronic sleep difficulties (>50%) • Daytime napping (25%) • Trouble falling asleep (19%) • Waking too early (19%) • Waking without feeling rested (13%) Ancoli-Israel S. JAGS 2005;53:S264-S271.

5. Significance of Sleep Disorders • >50% of sedatives are used by people age > 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

6. 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

7. Normal Physiology - Basics • Non-REM sleep • Stage 1: very light, easy to arouse • Stage 2: most of the night’s 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

10. 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

11. 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 2008;24:1-14.

12. 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 2008;24:1-14.

13. 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.

14. Mechanisms Underlying Sleep Complaints Vaz Fragoso CA. JAGS 2007;1853-1866.`

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

16. 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

17. 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

18. 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

19. 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

20. Secondary Sleep Disorders • Underlying conditions that should be addressed first • Medical Illness – causing nocturnal symptoms • Psychiatric Illness • Medications • Social/behavioral

21. 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

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

23. 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

24. 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

25. 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

26. 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

27. Insomnia - Definitions • Sleep latency usually > 30 minutes • Sleep efficiency < 85% • Transient: less than 1 week • Short-term: 1-4 weeks • Chronic: > 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)

28. 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 2008;24:107-119.

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

30. 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

31. 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 2008;24:93-105.

32. 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

33. 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

34. 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

35. 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

36. Sedative-Hypnotics Risk/Benefit • Meta-analysis of 24 studies, > 2400 patients older than age 60 treated with benzo’s 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 2005;331:1153-1212.

37. 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

38. 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

39. 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 2008;24:121-138.

40. 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

41. Other Treaments for Insomnia • Bright Light Therapy • Light -> suprachiasmatic nucleus -> 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 2008;24:139-149.

42. 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

43. 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

44. 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

45. 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 (>18 inches) • Obesity

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

47. 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

48. 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

49. Central Sleep Apnea - CSA • Definition – Periodic complete cessation of airflow and respiratory effort, followed by desaturations and arousals. • Related to chemoreceptors and CO2 physiology.

50. 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)