9 26 09,,,Sleeping Problems 52 Slides

Editor's Notes

• #2: Topic Slide Suggestions for Lecturer -1-hour lecture -Use slides alone or to supplement your own teaching materials. -Refer to GRS6 , pp. 249 – 259, for further discussion of sleep problems. -Supplement lecture with handouts, such as standardized sleep questionnaires (for examples see Moul DE et al, Sleep Med Rev. 2004;8:177-198). -See GRS6 questions 35, 62, 68, 158, and 185 for additional case vignettes on sleep disturbances.
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• #5: Topic Slide Several studies have documented a high prevalence of sleep problems among older people. In one representative sample, the most common sleeping complaints among community-dwelling older people were found to be difficulty falling asleep (37% of the sample), nighttime awakening (29%), and early morning awakening (19%). Daytime sleepiness is also common, with 20% of non-institutionalized Americans reporting that they are “usually sleepy in the daytime.” As a result of such complaints, at least one half of community-dwelling older people use either over-the-counter or prescription sleeping medications. Unfortunately, late-life insomnia is commonly a chronic problem. A study of older people in Britain found that 36% of those with insomnia at baseline reported severely disrupted sleep 4 years later. Of those who reported the use of prescription hypnotics at baseline, 32% were still using these agents 4 years later. Another study of a volunteer sample of urban women aged 85 years and older found that all had health problems and sleeping difficulties, and the majority regularly used alcohol, an over-the-counter sleeping medication, or both, in an effort to improve their sleep. Previous research has suggested that insomnia is a predictor of death and nursing-home placement in older men, but not in older women.
• #6: Topic Slide Three large epidemiologic studies of older people found an association between sleep complaints and risk factors for sleep disturbance but little association with older age, suggesting that these risk factors, rather than aging per se, account for insomnia in the majority of those studied. However, some primary sleep disorders, such as sleep apnea and periodic limb movements in sleep, increase in prevalence with age. Although some studies have shown an increased risk of sleep complaints in women, others have not. Studies have shown that self-reported sleeping difficulties are more common in older black Americans, particularly women and those with depression and chronic illness.
• #7: Topic Slide Notable age-related changes in sleep structure include a decrease in stage 3 and stage 4 sleep (the deeper stages of sleep). Stages 1 and 2 (the lighter stages of sleep) increase or remain the same. The decline in deep sleep seems to begin in early adulthood and progresses throughout life. In persons over age 90 years, stages 3 and 4 may disappear completely. The significance of age-related changes in sleep is unclear. Most experts believe that the decreased sleep in older people is due to a decreased ability to sleep, rather than a decreased need for sleep. However, some research has shown that after a period of sleep deprivation older people show less daytime sleepiness, less evidence of decline in performance measures, and a quicker recovery of normal sleep structure than younger people. Older people have more sleep disturbance with jet lag and shift work, which may reflect physiologic changes in circadian rhythm. Neither is it clear to what extent changes in sleep are due to changes of normal aging or to pathologic changes from other processes. In studies comparing good sleepers with poor sleepers, poor sleepers were found to take more medications, make more physician visits, and have poorer self-ratings of health. In addition, as noted above, chronologic age per se does not seem to correlate with higher prevalence of poor sleep.
• #8: Topic Slide To aid in screening older patients for sleep problems, several years ago the National Institutes of Health Consensus Statement on the Treatment of Sleep Disorders of Older People suggested that clinicians ask these three simple questions. Transient sleep problems (eg, those lasting less than 2 to 3 weeks) are usually situational; persistent sleep problems are likely to require more detailed evaluation.
• #9: Topic Slide The initial and subsequent office evaluations of a patient with persistent sleep complaints can be rather lengthy. To obtain a careful description of the sleep complaint, it may be helpful to have the patient keep a sleep log, recording each morning the time spent in bed, the estimated amount of sleep, the number of awakenings, the time of morning awakening, and any symptoms that occurred during the night. The focused physical examination depends on evidence from the history. For example, reports of painful joints should be followed by a careful examination of the affected areas. Reports of nocturia that disrupts sleep should be followed by evaluation for cardiac, renal, or prostatic disease, or diabetes mellitus.
• #10: Topic Slide Portable monitoring systems for use in the home are used primarily to screen for sleep apnea. These systems generally measure pulse oximetry, heart rate, respiration, and nasal airflow. Although they are used extensively, research that tests the validity of these systems is ongoing. Another methodology is a wrist-activity monitor, which estimates sleep versus wakefulness on the basis of the person’s wrist activity. Some studies have demonstrated that the wrist monitor is sensitive enough to assess the efficacy of treatment for insomnia in older people.
• #11: Topic Slide In one large study of patients of all ages referred to sleep disorders centers, insomnia was found to be most commonly due to psychiatric illness, psychophysiologic problems, drug or alcohol dependence, or restless legs syndrome; excessive daytime sleepiness was found to be most commonly due to sleep apnea, periodic limb movement disorder, or narcolepsy. However, patients referred to sleep centers are a select population, and the most common causes of excessive sleepiness in the community are probably chronic insufficient sleep (either voluntarily or because of work schedules), medical problems, or sleep-disruptive environmental conditions.
• #12: Topic Slide Many studies report that psychiatric disorders are the cause of sleep problems in more than half of all patients presenting with insomnia. Bereavement without major depression is not associated with significant changes in sleep measures, but people with bereavement and depression and those with major depression have identical sleep patterns. These sleep abnormalities improve with treatment of depression. Anxiety and stress can also be associated with sleeping difficulty, usually difficulty with initiating sleep or perhaps early awakening. Patients may have difficulty falling asleep because of excessive worrying at bedtime. Research has found that older caregivers report more sleep complaints than do similarly aged noncaregivers. In one study, nearly 40% of older women who were family caregivers of adults with dementia reported using a sleeping medication for themselves in the past month.
• #13: Topic Slide Some persons try to treat their sleeping difficulties with alcohol. Older persons with poor sleep should be instructed to avoid nighttime alcohol, because although alcohol causes an initial drowsiness, it can impair sleep later in the night.
• #14: Topic Slide In patients with sleeping difficulties who describe pain at night, assessment and management of the painful condition is the appropriate approach. Examples of stimulating agents are caffeine, sympathomimetics, and bronchodilators. Required medications that are sedating (eg, sedating antidepressants) should be given at bedtime if possible.
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• #16: Topic Slide One nursing-home study found that sleep apnea is associated with dementia, and the sleep disorder was found to be positively correlated with the severity of dementia. However, another study concluded that sleep-disordered breathing in Alzheimer’s patients is mild and not associated with mental status or behavioral changes.
• #17: Topic Slide CPAP = continuous positive airway pressure The importance of mild degrees of sleep-disordered breathing in elderly persons is unclear. One study found no association between mild or moderate sleep-disordered breathing and subjective sleep-wake disturbance. The long-term consequences of asymptomatic sleep-disordered breathing are also unclear.
• #18: Topic Slide The leg movements associated with PLMS occur every 20 to 40 seconds and can last hours or even much of the night. Each movement may be associated with an arousal. One study found evidence of PLMS in over one third of community-dwelling older persons. Correlates of PLMS included dissatisfaction with sleep, sleeping alone, and reported kicking at night. Some authors have suggested that the high prevalence of PLMS with age is associated with delayed motor and sensory latencies noted on nerve conduction testing.
• #19: Topic Slide The diagnosis of restless legs syndrome is based on the patient’s description of symptoms. The patient’s complaint is usually of nighttime leg discomfort or difficulty in initiating sleep. There may be a family history of the condition and, in some cases, an underlying medical disorder (eg, anemia, or renal or neurologic disease).
• #20: Topic Slide Some patients may describe a shift of their symptoms to daytime hours with successful treatment of symptoms at night. There is some evidence that patients with restless legs syndrome and a low serum ferritin level may improve with iron replacement therapy. Benzodiazepines, anticonvulsants, and narcotics have also been used for restless leg syndrome but likely have more adverse effects in older people than the dopaminergic agents.
• #21: Topic Slide Disturbances in the sleep-wake cycle may be transient, as in jet lag, or associated with an obvious cause (eg, shift work). Some patients have persistent sleep-phase disturbance, in which circadian rhythms and sleeping period have become completely desynchronized (eg, persons who are always asleep during the day and awake at night), or sleep-wake cycles are irregular and sleep habits are very disjointed. It is unclear to what degree, if any, changes in sleep pattern in older people (such as increased daytime napping and disrupted nighttime sleep) are due to alterations in the circadian rhythm. Although results are mixed, several studies have shown age-related decreases in hormonal levels and evidence of earlier circadian rises in certain hormones, suggesting the existence of age-related alteration in circadian rhythm. Dementia and delirium may cause sleep-wake disturbance, frequent nighttime awakenings, nighttime wandering, and nighttime agitation.
• #22: Topic Slide REM sleep behavior disorder may be acute or chronic, and it is more common in older men. There may be a family predisposition. Transient REM sleep behavior disorder has been associated with toxic-metabolic abnormalities, primarily drug or alcohol withdrawal or intoxication. The chronic form of the disorder is usually idiopathic, or associated with a neurologic abnormality (eg, drug intoxication, vascular disease, tumor, infection, neurodegeneration disorders such as Parkinson’s disease, or trauma). Several psychiatric medications have been associated with this disorder, including tricyclic antidepressants, monoamine oxidase inhibitors, fluoxetine, venlafaxine, cholinesterase inhibitors, and other agents.
• #23: Topic Slide Examples of environmental safety interventions are removing dangerous objects from the bedroom, putting cushions on the floor around the bed, protecting windows, and, in some cases, putting the mattress on the floor.
• #24: Topic Slide Most studies of sleep in dementia have focused on Alzheimer’s disease. Unfortunately, the baseline slowing of electroencephalographic activity often seen with dementia can cloud the distinction between sleep and wakefulness and the distinctions among the various stages of non-REM sleep in the sleep laboratory. Some authors have noted a decreased percentage of sleep spent in REM, but this has not been reported in all studies. Of interest, some studies suggest that older persons with dementia have less sleep disturbance than older depressed persons.
• #25: Topic Slide Acute hospitalization is commonly cited as one of the stressors that can precipitate transient or short-term insomnia. Some nursing-based nonpharmacologic interventions to improve sleep have been tested. One small uncontrolled study described increased nighttime melatonin levels in hospitalized older patients treated with daytime bright-light exposure. Another small study implemented “flexible medication times” that allowed inpatients to sleep longer in the morning, and their resulting in-hospital sleeping patterns were more similar to their at-home sleeping patterns. However, adherence with nonpharmacologic interventions may be difficult to achieve in the acute hospital. For example, one large clinical trial of nonpharmacologic interventions to prevent delirium in hospitalized older people reported only a 10% adherence rate for the sleep protocol portion of the intervention. A large study found that a nonpharmacologic sleep protocol for hospitalized older patients (consisting of a back rub, warm drink, and relaxation tapes) was successful in reducing sedative hypnotic drug use. In fact, the nonpharmacologic protocol was more strongly associated with improved quality of sleep than was the use of sedative hypnotic drugs.
• #26: Topic Slide There is little research comparing the use of different sleeping medications in the acute hospital setting. Because of increased sensitivity in elderly patients, smaller doses of benzodiazepine agonists may be effective as well as safer. Sedating antihistamines should not be used because of possible complications related to anticholinergic adverse effects (eg, delirium, urinary retention, and constipation). Regarding sleep-related breathing disorders, a large random sample of older men on medicine wards in a Veterans Affairs hospital found a shorter survival among patients with heart failure with central sleep apnea than among heart failure patients without evidence of this disorder. An English study found that nearly one fourth of hospitalized patients (mean age 74 years) with an acute stroke who had normal oxygen levels during the daytime had 30 minutes or more of “unexpected” nocturnal hypoxia. A small study in Hong Kong found significant sleep-disordered breathing in nearly half of patients (mean age 64 years) hospitalized with an acute stroke. Another study found that one third of severely obese hospitalized people had unexplained hypoventilation, which was associated with more reported sleepiness and excess morbidity and mortality than was found in severely obese persons without hypoventilation. The implications of these findings for the recognition and treatment of sleep-disordered breathing in the acute hospital setting are unknown.
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• #28: Topic Slide Studies of sleep in nursing-home residents have demonstrated marked sleep disruptions and frequent nighttime arousals. Many residents nap on and off throughout the day and have frequent awakenings during the night. One study found that 65% of residents reported problems with their sleep and that the use of hypnotic medications was common, but no association was found between the use of sedative hypnotics and the presence, absence, or change in sleep complaints after 6 months of follow-up.
• #29: Topic Slide A study of institutionalized demented residents with sleep and behavior problems found morning exposure to bright light to be associated with better nighttime sleep and less daytime agitation. Another study of residents with dementia and behavioral problems found that a program of social interaction with nurses was effective in reducing behavioral problems and sleep-wake rhythm disorders in 30% of the residents. A small trial of incontinent nursing-home residents demonstrated increased nighttime sleep and less agitation among those randomized to receive a combined daytime physical activity program plus nighttime intervention to decrease noise and light disruption. Another trial combined an enforced schedule of structured social and physical activity for 2 weeks in a small sample of assisted-living residents and found that treated residents had enhanced slow-wave sleep and improved performance in memory-oriented tasks. A recent large trial of nonpharmacologic interventions on sleep in nursing home residents was most successful in decreasing daytime sleeping.
• #30: Topic Slide In the older patient with chronic insomnia, sedative hypnotic agents should be used cautiously. The chronic use of benzodiazepines can lead to dependence or cognitive impairment. It must be noted that there is increasing debate among sleep experts on the risks and benefits of long-term use of sleeping medications in adults of all ages. However, there is good evidence of increased risk of confusion, falls, and fracture with chronic sedative use by older people. Regardless, in chronic insomnia, it is imperative that the clinician exclude primary sleep disorders and review medications and other medical conditions that may be contributory.
• #31: Topic Slide If the initial history and physical examination do not suggest a serious underlying cause for the sleep problem, a trial of improved sleep habits (sleep hygiene) is usually the best first approach. If the patient takes daytime naps, it is important to determine whether these are needed rest periods or due to inactivity, boredom, or sedating medications. It is important to explain to the person that daytime naps will decrease nighttime sleep. Bathing before sleep has been demonstrated to enhance the quality of sleep in older people, perhaps related to changes in body temperature with bathing. Moderate-intensity exercise has also been shown to improve sleep in healthy, sedentary people aged 50 and older who reported moderate sleep complaints at baseline. However, strenuous exercise should not be performed immediately before bedtime.
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• #33: Topic Slide Trials have shown that nonpharmacologic interventions can be quite effective in improving sleep in older people. A review of more than 12 studies of behavioral interventions in community-dwelling older people with insomnia concluded that these interventions produce reliable and durable therapeutic benefits, including improved sleep efficiency, sleep continuity, and satisfaction with sleep; treatment is also helpful in reducing chronic hypnotic use. Stimulus control and sleep restriction, which focus on poor sleep habits, seem to be especially helpful for older persons with insomnia.
• #34: Topic Slide Cognitive and educational interventions are also important in changing inaccurate beliefs and attitudes about sleep. Relaxation-based interventions seem less effective for older persons. One large randomized trial of insomniacs with a mean age of 65 years compared cognitive behavior therapy (stimulus control, sleep restriction, sleep hygiene, and cognitive therapy), pharmacotherapy (with temazepam), both cognitive behavioral therapy and pharmacotherapy, and placebo. All three active treatments were found to be effective in short-term follow-up in improving sleep, as indicated by sleep diaries and polysomnography. However, people reported more satisfaction with the cognitive behavioral therapy, and sleep improvements were found to be better sustained over time (up to 2 years) with behavioral treatment.
• #35: Topic Slide Several small studies have tested the effectiveness of exposure to bright light (either natural sunlight or with commercially available light boxes) on the sleep of older persons with insomnia. Positive effects on sleep have been demonstrated with light exposure of various intensities for various durations and at various times during the day. Evening exposure seems to be particularly useful in the older person with an advanced sleep phase. One author recommends that older persons with sleep-maintenance insomnia be treated with 2 hours of bright-light exposure equal to the amount of outdoor light found at mid-day or artificial bright light of at least 2500 lux. However, even short durations of bright light in the morning have been shown to improve sleep complaints in healthy older people. Beneficial effects have been reported in older people using a visor that provided 2000 lux to each eye and was worn for only 30 minutes in the evening.
• #36: Topic Slide Medications commonly used are shown on the next four slides.
• #37: Topic Slide Eszopiclone, zaleplon, and zolpidem are nonbenzodiazepine hypnotics. These agents are structurally unrelated to the benzodiazepines, but they share some of the pharmacologic properties of benzodiazepines and have been shown to interact with the central nervous system γ-aminobutyric acid (GABA) receptor complex at benzodiazepine (GABA-BZ) receptors. The selectivity of these newer agents to the GABA-BZ receptor may account for their decreased muscle-relaxant, anxiolytic, and anticonvulsant effects in comparison with benzodiazepines in some studies. Eszopiclone has been recently approved by the Food and Drug Administration for use in the United States. There is some evidence that it is effective in long-term management of insomnia.
• #38: Topic Slide Zaleplon is a nonbenzodiazepine hypnotic from the pyrazolopyrimidine class, which has been studied for short-term use by older persons with insomnia. Zolpidem is a nonbenzodiazepine imidazopyridine that has also been studied in older persons with insomnia. In older patients, studies suggest that zolpidem does not produce rebound insomnia, agitation, or anxiety with cessation; does not seem to produce impaired daytime performance on cognitive and psychomotor performance tests; and may have a therapeutic effect that outlasts the period of drug treatment. Because of their rapid onset of action, zolpidem and zaleplon should be taken only immediately before bedtime or after the patient has gone to bed and has been unable to fall asleep. Guidelines recommend that, like benzodiazepines, zolpidem or zaleplon should be used only for a short term (2 or 3 weeks) and that, if used longer, these agents should be used no more than 2 or 3 nights per week. Concerns remain regarding the risks of confusion, falls, and fracture with chronic use of these medications in older people, and caution is warranted even with these newer agents. Triazolam is a short-acting benzodiazepine that is not listed in these tables because it has been associated with nocturnal amnesia and confusion and is generally not recommended for older persons.
• #39: Topic Slide Low doses of sedating antidepressants such as mirtazapine or trazodone at bedtime may be used as a sleeping aid, particularly for patients with depression. These agents have been suggested for use as a nighttime adjuvant for sleep in depressed patients receiving another antidepressant at therapeutic doses during the daytime. Other indications may be a history of psychoactive substance use problems, failure with other sleeping medications, suspected untreated sleep apnea (where further respiratory depression is a concern), and fibromyalgia (where there is some evidence for antidepressant medication treatment effect). However, the adverse effects of sedating antidepressants may limit their usefulness.
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• #41: Topic Slide Several studies have shown that the bulk of prescription sleeping medication use occurs among chronic users. A cross-sectional study in Spain found that 88% of prescription hypnotic users reported daily use of the drug, and 72% of people reported use for more than 3 months. Long-term use was 2 to 3 times more common in older people than in middle-aged respondents. Likewise, studies in Canada and France have shown that sleeping medications were prescribed for a year or longer in more than two thirds of people taking these medications. Studies in the United States have also demonstrated more benzodiazepine use by older persons and by women, with chronic use being more common in older people. One small controlled trial in older women found that decreasing the hypnotic dose by one half for 2 weeks, followed by full withdrawal (perhaps with the use of a substitute pill to maintain the ritual of nightly pill taking) was effective (over short-term follow-up) in eliminating hypnotic use without adverse effects on nighttime sleep, depressive symptoms, or daytime sleepiness. Another small controlled trial, which involved tapering benzodiazepine use to complete withdrawal over as many as 6 weeks, found better success in persons randomized to receive a nightly dose of 2 mg of controlled-release melatonin than in those assigned to placebo. At follow-up 6 months later, nearly 80% of persons who successfully discontinued benzodiazepines continued to report good sleep quality.
• #42: Topic Slide Sedating antihistamines (eg, diphenhydramine) are common ingredients in over-the-counter sleeping agents as well as in combination analgesic–sleeping agents that are marketed for nighttime use. Diphenhydramine has potent anticholinergic effects, and tolerance to its sedating effects develops after several weeks, so it is generally not recommended for older people. Although alcohol causes some initial drowsiness, it can interfere with sleep later in the night and may actually worsen sleeping difficulties. Evidence is mixed regarding the effectiveness of melatonin as a treatment for insomnia. There is some evidence in older people with insomnia that melatonin administration decreases sleep latency (time to fall asleep) and wake time after sleep onset, and increases sleep efficiency. However, a small trial did not find polysomnographic evidence of improved sleep in persons aged 55 years and older with sleep-maintenance insomnia who were treated with either 0.5 mg of transbuccal melatonin or placebo for 4 days. Because of these mixed results and the lack of regulatory control of melatonin products, it is difficult for the clinician to recommend their use. The exception may be chronic hypnotic users. Valerian is an herbal product with mild sedative action that has been marketed for insomnia. The mechanism of action of valerian is uncertain, and it contains several potentially active compounds. Given this information, its use is not recommended.
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• #46: Topic Slide Answer: B Symptoms of sleep apnea include loud snoring and excessive daytime sleepiness, both of which increase at least up to age 70. Increased body weight is a risk factor because it enhances upper airway collapsibility and is associated with decreased muscle strength and endurance. Sleep apnea is also more likely with anatomic changes that occur with age, including lengthening of the soft palate, an increase in the size of pharyngeal fat pads, and changes in the shape of bony structures of the pharyngeal airway. In persons with sleep apnea and heart failure, mean survival is less than 2.7 years. The treatment of choice is continuous positive airway pressure, a device that applies positive pressure through a nosepiece to keep the airway open at night. This device is useful in older adults, including those with mild dementia, and may have an added benefit of improving depressive symptoms in dementia patients and their caregivers. Sedating agents such as zolpidem and lorazepam may worsen the condition. Bright-light therapy may be useful in treatment of advanced sleep phase in older adults, but it has not been shown to be useful in sleep apnea. Focusing on sleep hygiene alone may be useful but does not produce a therapeutic effect or address the basic biologic disturbances that lead to sleep apnea.
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• #49: Topic Slide Answer: C According to actigraphic data (from a device usually worn on the wrist that measures activity), nursing-home patients are rarely asleep or awake for a full hour throughout the night and day. Low lighting, noise, and interruptions by staff to wake and turn patients are partially responsible for poor sleep consolidation. Patients in nursing homes need to be in bright environments during the day and in a quiet, dark environment at night. Awakenings at night are often accompanied by agitation and may result in greater daytime agitation. Even severely demented nursing-home patients spontaneously change shoulder and hip position throughout the night, obviating the need to awaken them to prevent bedsores related to incontinence. Exercise may be generally helpful, but it does not address the environmental concerns and nighttime awakening that are likely responsible for this patient’s agitation. Similarly, removing the television does not address the daytime low light and napping. Fluid restriction, enforced sleep hours, and prevention of napping are not reasonable expectations of the staff. The provision of a nightlight, orienting objects, and a familiar nonthreatening environment is useful in dementia syndromes and delirium, especially for patients with “sundowning” or loss of orientation, which is not the case with this patient.
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• #52: Topic Slide Answer: B Depression is a common cause of insomnia in older adults. Untreated depression is likely to lead to insomnia; conversely, untreated insomnia may result in depression. Antidepressant medications such as mirtazapine are effective in older adults with depression and insomnia. Recently bereaved patients commonly have disturbed sleep. They may have a full depressive syndrome, accompanied by lower sleep efficiency, decreased sleep quality, early morning awakening, shorter REM sleep latency, greater proportion of REM sleep, and lower rates of delta-wave sleep when compared with nondepressed bereaved adults. The use of temazepam, zolpidem, and other hypnotics does not effectively address sleep disturbance associated with major depressive disorder. However, judicious use of a hypnotic with an antidepressant may be warranted. Both temazepam and zolpidem are reasonable choices in this regard. Melatonin does not address mood disturbance, and its hypnotic effect is unclear. Alcohol is sometimes used to induce sleepiness, but its use is accompanied by rebound awakening during the night. Alcohol abuse, as well as depression, can be responsible for early morning awakening; generally, alcohol should be avoided as a medicinal agent.
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