C A N A D I A N G E R I AT R I C S J O U R N A L O F

CME Providing Continuing Education for Doctors Who Care for Older Patients

V O L U M E 6 , I S S U E 1 2 0 1 6

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GERIATRIC ASSESSMENT UNITS (GAUs): OPTIMIZING EVIDENCE-BASED INPATIENT CARE IN THE MODERN HOSPITAL

AD-AID : A PRACTICAL APPROACH TO THE ASSESSMENT OF ORTHOSTATIC HYPOTENSION IN OLDER PATIENTS

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CONTENTS

1. Editorial Frank Molnar

2. Geriatric Assessment Units (GAUs): Optimizing Evidence-Based

Inpatient Care in the Modern Hospital Phil St. John

3. 4D-AID: A Practical Approach to the Assessment of Orthostatic

Hypotension in Older Patients Jason MacDonald, Amandeep Klair, Laura Khoury, Frank Molnar

4. Insomnia in the Elderly: Update on Assessment and Management

Soojin Chun, Elliott Kyung Lee

5. Communication Health and Aging: Caring for Older Adults

Chantal Kealey, Marnie Loeb

6. Choosing Wisely Canada: Geriatrics

Karen Fruetel, Nathan Herrmann, Janya Holroyd-Leduc, Robert

Lam, Jacqueline McMillian, Jose Morais, Adrian Wagg

FOR AUTHOR AND SUBMISSION INSTRUCTIONS, PLEASE VISIT WWW.CANADIANGERIATRICS.CA

Editorial

Misunderstanding the roles and benefits of Specialized Geriatric Services – is the choice of terms

we use to label our services contributing to external lack of understanding of what we do and,

thereby, increasing the vulnerability of Specialized Geriatric Services?

Upon reviewing the article by Dr. St. John I was struck by an impression – that we have much to learn in

labelling the services our teams provide and that this poor, often confusing, labelling (in some instances

mislabelling) directly contributes to the lack of understanding our roles and contributions by decision makers

and funders.

In some instances we use the same term to describe different services. Dr. St. John highlights the use of the

term GEM to describe Geriatric inpatient units in the US. This is bound to cause confusion as we also use the

term GEM for our Geriatric Emergency Management teams in emergency departments. The label ACE has

come to represent an ever growing list of very different models. No wonder those outside our

field are confused.

The above lack of standardization of labels is frustrating but is not as dangerous as what I would view as

outright mislabelling of the services and care we provide. The term GAU has been problematic as long as I

have practised geriatrics. I cannot tell you how often I have encountered administrators who question the

value of “a unit that only assesses.” The label we have selected for our units clearly does not reflect the many

additional critical roles these units play – investigation, diagnosis, intervention, treatment, future planning,

creation of durable discharge plans that prevent readmission, etc. By adhering to a name that does not reflect

our full value we perpetuate lack of understanding and appreciation thereby leading to unnecessary

questioning of the value of these units and creating avoidable vulnerability.

I now see the same situation being played out with InterRAI – promoted as a form of Comprehensive Geriatric

Assessment (CGA). Decision makers are asking a very reasonable question – “if InterRAI performs CGA how is

this different from what Specialized Geriatric Services provide and what is the added value of Specialized

Geriatric Services?”. The question highlights the danger of employing a term, CGA, that does not accurately

reflect the full scope and benefits of Specialized Geriatric Services – once again we have not incorporated

critical roles including investigation, diagnosis, intervention, treatment, future planning and the creation of

durable discharge plans that prevent readmission.

To stimulate discussion I would suggest we need a more complete moniker – my straw dog suggestion would

be CGAIDT (Pronounced ‘C-GAIT’ with a silent ’D’). The components are spelled out in the table below and

are contrasted with a more limited CGA (e.g., InterRAI).

CGA vs. CGAIDT

InterRAI Specialized

Geriatric

Services

Comprehensive C C

Geriatric G G

Assessment

(Screening to

detect potential

problems)

A A

Investigation I

Diagnosis D

Treatment /

Intervention

T

1

Some (the vast majority I suspect) may find the term ungainly. If CGAIDT does nothing more than provoke a

robust open and honest discussion regarding how we can more accurately label our services then CGAIDT will

have been a success. Considering names that clearly outline the significant differences between InterRAI and

Specialized Geriatric Services may be a profitable place to start.

I look forward to discussing the above impressions and ideas with CGS members to learn how we can do

better in communicating our full value. I welcome ideas directed to my email below.

Dr. Frank Molnar

Editor-in-chief, CGS CME Journal

Chair, CGS Advocacy Committee

fmolnar@ottawahospital.on.ca

2

GERIATRIC ASSESSMENT UNITS (GAUs): OPTIMIZING EVIDENCE-BASED INPATIENT CARE IN THE MODERN HOSPITAL

Abstract

Geriatric Assessment Units (GAUs) are wards that admit frail older

inpatients for a process of multidisciplinary assessment, review and

therapy. They are late acute, sub-acute and post-acute units aimed at

restoring the functional status of frail older adults who are no longer in

the life-threatening stage of an acute illness or are recovering from an

acute illness. The restoration of functional status after acute illness is

important in reducing or preventing a number of undesirable outcomes

such as long-term disability, prolonged hospital stays, Alternate Level of

Care (ALC), avoidable readmissions to hospital and avoidable/premature

institutionalization. There are randomized controlled clinical trials

supporting this approach, and such units (GAUs) should be a prominent

feature in all modern hospitals.

Les Unités de Courte Durée Gériatrique (UCDG) (Geriatric Assessment

Units) sont des unités hospitalières où sont admis des patients âgés

fragiles dans le but de procéder à une évaluation et des interventions

thérapeutiques médicales et multidisciplinaires. Ce sont des unités

aiguës, subaiguës et post-aiguës visant à rétablir l'état fonctionnel des

patients qui ne sont plus au stade de maladie aiguë potentiellement

mortelle ou qui se remettent d’une maladie aiguë. La récupération

fonctionnelle suite un épisode aigu est importante dans la prévention

d'un certain nombre d’issues défavorables telles que la perte

d’autonomie permanente, la prolongation inappropriée du séjour à

l’hôpital, les réadmissions évitables, ainsi que l’institutionnalisation

prématurée. Des essais cliniques randomisés et contrôlés soutiennent la

prise en charge en UCDG et elle devrait être disponible dans tout

hôpital moderne.

This article has been peer reviewed.

Conflict of Interest: Dr. St. John is a geriatrician who attends on

a GAU.

This article was published in May 2016.

Phil St. John

MPH, MD, FRCPC

Associate Professor, Head,

Section of Geriatric

Medicine, University of

Manitoba

Corresponding Author:

Phil St. John

pstjohn@hsc.mb.ca

Key words: Geriatric

Assessment Unit, inpatient

geriatrics, acute care

hospitals, senior strategy,

modern hospitals, Hospital

Acquired Disability,

deconditioning, delirium

Canadian Geriatrics Society

To see other CME articles, go to: www.cmegeriatrics.ca www.geriatricsjournal.ca

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3

Key points

1. Hospital acquired disability is common and preventable.

2. Geriatric Assessment Units (GAUs) are inpatient wards that are designed to care for frail older adults.

3. GAUs have been shown to reduce functional decline, reduce rates of institutionalization and reduce

rates of cognitive loss compared to usual care.

4. GAUs should be a prominent feature of modern acute care hospitals.

Background Geriatric Assessment Units (GAUs) are also called Geriatric Evaluation and Management Units (GEM Units),

particularly in the US. A GAU is ‘‘a ward that admits frail older inpatients for a process of multidisciplinary

assessment, review and therapy.”1 They are late acute, sub-acute and post-acute units aimed at restoring the

functional status of frail older adults who are no longer in the life-threatening stage of an acute illness or are

recovering from an acute illness. Those wishing a non-interventional, non-aggressive approach to care may

also be admitted to GAUs. Functional and cognitive recovery often lag biomedical recovery (NEMJ)2, and the

restoration of functional status after acute illness is important in reducing or preventing a number of

undesirable outcomes such as long-term disability, prolonged hospital stays, Alternate Level of Care (ALC),

avoidable readmissions to hospital and avoidable/premature institutionalization.

What is the rationale for GAUs? Frail older adults are at higher risk of hospitalization3. When they are hospitalized, they are more likely to

experience delirium, falls, urinary and fecal incontinence and functional decline3, all of which can contribute to

unnecessarily long Lengths of Stay (LOS) and avoidable Alternate Level of Care (ALC) status. Indeed, nearly

one half of the disability in community-living older adults is acquired in hospital4,5. Even small effects on

reducing hospital-acquired disability may have a large effect on community disability, readmissions to

hospital and the need for long-term care. Since hospital-acquired disability is associated with longer LOS,

GAUs also have the potential to improve patient flow. Moreover, returning to their own home and avoiding

institutionalization is extremely important to older adults themselves: Older adults, the main users of acute

care hospitals, value functional autonomy and independence very highly.

What is the evidence for GAUs? A large number of randomized clinical trials (RCTs) have been conducted in many countries over several

decades – meta-analyses of these RCTs have repeatedly demonstrated a number of positive benefits to

seniors and to the health care system:

1. Older adults treated on GAUs are less likely to be institutionalized and more likely to be alive and in

their own home one year later than those cared for in the usual manner (JAGS)1.

2. Those cared for on geriatric units also showed better functional outcomes: the NNT is approximately 17

to prevent worsening disability or death (The BMJ).6 Cognition was also better in those treated on

geriatric units compared to usual care.6

3. A recent systematic review of RCTs (which included all inpatient geriatric units, including GAUs and

Acute Care of the Elderly Units) showed that the number needed to treat (NNT) is about 20 people over

one year to prevent one unnecessary death or admission to residential care, compared with general

medical care (Wiley Online Library).

The costs were variable in these RCTs, and the results could not be pooled. However, the costs were lower in

the GAU group in every included RCT that considered hospital costs. Medium- to long-term costs, such as the

costs of avoidable or premature nursing home placement were not determined in any RCT, but would likely be

4

lower among those treated on GAUs, since the rates of nursing home use were lower. Other potential cost

savings of GAUs such as cost savings due to the lower readmission rates experienced in many GAU settings

has not been studied and represents a needed future area of research. Analysis of cost savings due to reduced

readmission to hospital would likely further bolster the cost-effectiveness of GAUs.

Since geriatric inpatients have complex issues in multiple domains, they require complex interventions in

multiple domains. Efforts to identify any single feature, which predicts success, have been difficult as this

appears to be an aggregate effect of multiple components of GAUs. The overall structure and process of care

on the GAUs included in the trials was similar in most studies6. Factors include a multidimensional

assessment, regular team meetings, identification of issues and setting goals of care and a care environment

that prioritizes and actively promotes progressive ambulation.

Central team members in these RCTS were a geriatrician (i.e., specialist in Geriatric Medicine) as the

attending physician, nurses, social workers, physiotherapists and occupational therapists with expertise in

geriatrics. Other important team members include dietitians, psychologists, recreation therapists, speech-

language pathologists and pharmacists.

Targeting: Who benefits from GAUs and who may not? Older adults benefit from GAU if they have functional decline after acute illness, and the natural history of

their disease is not one of inevitable decline. Older adults with terminal illness, multiple end stage organ

failure, or severe irreversible functional decline are usually not able to benefit from the GAU model of care;

nor are those who cannot participate in basic rehabilitation. Patients must be medically stable. Conversely,

those with few functional deficits usually do not require GAU.

Design: What are the characteristics of GAUs? Setting: GAUs can be in acute care hospitals (late acute care) or rehabilitation hospitals (sub-acute or

post-acute care) – setting will impact on patient selection (i.e., how soon after admission they can be

considered for transfer).

Structure of Care: The ward should be quiet, clean and free from clutter. Doors and washrooms should be

wheelchair accessible. The hallways should be clear, wide and with chairs to rest upon. There should be a

dining room and space for group activities and exercises. There should be onsite rehabilitation space. Rooms

should be as private as possible7-9.

Process of Care:

Assessment: In addition to the routine history, physical examination and basic investigations; functional

status, cognitive status, mood and nutrition should be assessed early in the stay. Social supports, social

networks, caregiver stress and living situation are also assessed as they are critical to preventing readmission

to hospital. Patient and family goals should be identified. Based upon this, a care plan should be put in place

that is flexible. This plan should identify issues in all relevant domains, should identify therapy goals and a

time frame of intervention. Patients and families should be involved in these plans, and the plan should be

reviewed in regular team meetings.

General approach: Early and frequent ambulation is critical to prevent deconditioning. Central to this is

adequate attendant staff, adequate footwear and assessment of gait aides. The patient’s hearing aides and

glasses should be provided. Orientation aides (such as clocks and calendars) should be in the rooms. Patients

should be encouraged to participate in rehabilitation and engage in activities of daily living as soon as

possible. Their own clothing should be brought from home. Nighttime should be for sleeping, and meal times

for eating and socialization; rather than for diagnostic testing. The general approach should be to make the

care environment as supportive and home-like as possible. Post-discharge follow-up plans should be made

since most chronic diseases remain active after discharge.

5

Characteristics of successful GAUs The mandate of the GAU must be clear and patients targeted appropriately. There may be pressure to transfer

medically unstable patients or patients with severe end stage disease to GAUs. These people are unlikely to

benefit in the long term10,11. The pressure to accept care of such patients is not new in the history of

geriatrics9, but it can be intense. The medical care that they require may be more than the standard GAU can

offer, and the results may not be congruent with patient and family expectations12.

The care goals of referring physicians and families need to be similar to the care goals of the team on the

GAU. Differences of opinion about the likelihood of functional recovery and/or long-term survival can be

difficult to reconcile and lead to unclear care treatment goals and nebulous rehab endpoints.

Summary – GAUs’ critical role in the modern hospital

GAUs are inpatient units for frail older adults who are not in the life threatening early stage of an acute illness

or who are recovering from acute illness but are relatively stable. They should be the standard of care for frail

older adults when discharge home or to another community setting is a realistic goal. Most of the

interventions are straightforward and inexpensive, yet often overlooked in modern medicine. GAUs reduce

hospital-acquired disability (e.g., deconditioning with loss of mobility, delirium) and thereby prevent

premature institutional (nursing home) placement.

GAUs were described decades ago, are common-sense and have been studied in thousands of patients in

numerous clinical trials in many countries. Much of the focus is on encouraging basic humane care. Yet this

can be overlooked in modern medicine13,14, with its focus on biomedical measures and rapid early discharge

with little view to the long term goals of seniors to remain independent at home for as long as possible.

Despite the clear evidence that GAUs are highly effective models of care for frail seniors, as evidenced by the

meta-analyses cited above, sustaining GAUs can be challenging and they require ongoing evaluation and

support. In an effort to reduce costs, many hospitals have eliminated or are considering eliminating GAUs

based on a narrow short-term view focused only on the speed of care and discharge while ignoring

readmission rates or rates of premature institutional placement. This focus on the cost of a single episode of

care (GAUs may add a few days to the LOS) does not consider the cost savings to the health care system as a

whole that GAUs achieve by preventing readmissions and preventing/delaying long-term care (nursing home)

placement.

More importantly, seniors and their families expect compassionate care, which reduces long-term disability,

lowers rates of premature institutional placement and promotes safe enduring discharges to the community.

Older adults want to stay in their homes as long as possible and the evidence clearly demonstrates that GAUs

achieve this goal without increasing health care costs. As the world’s population ages, health care planners

must insist that a GAU be a necessary component in modern hospitals.

REFERENCES:

1. Van Craen K, Braes T, Wellens N, et al. The effectiveness of inpatient geriatric evaluation and management

units: a systematic review and meta-analysis. Journal of the American Geriatrics Society. Jan 2010;58(1):

83-92.

2. Krumholz HM. Post-hospital syndrome--an acquired, transient condition of generalized risk. The New

England journal of medicine. Jan 10 2013;368(2):100-102.

3. A Focus on Seniors and Aging. Ottawa: Canadian Institute for Health Information 2011.

4. Gill TM, Allore HG, Holford TR, Guo Z. Hospitalization, restricted activity, and the development of disability

among older persons. JAMA: the journal of the American Medical Association. Nov 3 2004;292(17):2115-

2124.

6

5. Gill TM, Gahbauer EA, Han L, Allore HG. The role of intervening hospital admissions on trajectories of

disability in the last year of life: prospective cohort study of older people. BMJ. 2015;350:h2361.

6. Ellis G, Whitehead MA, Robinson D, O'Neill D, Langhorne P. Comprehensive geriatric assessment for older

adults admitted to hospital: meta-analysis of randomised controlled trials. BMJ. 2011;343:d6553.

7. Ellis G, Whitehead MA, O'Neill D, Langhorne P, Robinson D. Comprehensive geriatric assessment for older

adults admitted to hospital. Cochrane database of systematic reviews (Online). 2011(7):CD006211.

8. Bachmann S, Finger C, Huss A, Egger M, Stuck AE, Clough-Gorr KM. Inpatient rehabilitation specifically

designed for geriatric patients: systematic review and meta-analysis of randomised controlled trials. BMJ.

2010;340:c1718.

9. Warren M. CARE OF THE CHRONIC AGED SICK. The Lancet. 6/8/ 1946;247(6406):841-843.

10. Warren MW. Care of Chronic Sick. BMJ. 1943-12-25 00:00:00 1943;2(4329):822-823.

11. St John PD, Hogan DB. The relevance of Marjory Warren's writings today. The Gerontologist. Feb

2014;54(1):21-29.

12.Reuben DB, Tinetti ME. The hospital-dependent patient. The New England journal of medicine. Feb 20

2014;370(8):694-697.

13. Connolly B, Salisbury L, O'Neill B, et al. Exercise rehabilitation following intensive care unit discharge for

recovery from critical illness. Cochrane database of systematic reviews (Online). 2015;6:CD008632.

14. Lamas D. Chronic critical illness. The New England journal of medicine. Jan 9 2014;370(2):175-177.

15. O'Brien MR, Rosenthal MS, Dharmarajan K, Krumholz HM. Balloon Animals, Guitars, and Fewer Blood

Draws: Applying Strategies From Pediatrics to the Treatment of Hospitalized AdultsBalloon Animals, Guitars,

and Fewer Blood Draws. Annals of internal medicine. 2015;162(10):726-727.

16. St John PD. Applying Strategies From Pediatrics to the Treatment of Hospitalized Adults. Annals of internal

medicine. Dec 15 2015;163(12):959.

7

4D-AID: A PRACTICAL APPROACH TO THE ASSESSMENT OF ORTHOSTATIC HYPOTENSION IN OLDER PATIENTS

Abstract

Orthostatic Hypotension (OH) is a common geriatric syndrome, usually

involving failure of one or more intrinsic mechanisms that help maintain

perfusion of the brain during times of orthostatic stress. OH remains

underdiagnosed despite the availability of consensus-recognized blood

pressure cut-offs, largely due to lack of awareness of the prevalence of

this condition in older patients as well as the fact that measurement of

postural BP is not considered part of the routine physical examination.

The common causes of OH in older patients are described and the

4D-AID mnemonic, which organizes the approach to OH into a practical

and easy-to-remember format for busy clinicians, is presented in the

context of an illustrative case.

L’hypotension orthostatique (HO) est un syndrome gériatrique fréquent,

impliquant habituellement la défaillance d’un ou de plusieurs

mécanismes intrinsèques qui permettent de maintenir la perfusion

cérébrale lors des stress orthostatiques. L’HO demeure

sous-diagnostiquée malgré la présence de critères bien établis,

probablement car la prévalence de ce syndrome est sous-estimée chez

les personnes âgées et que la mesure des signes vitaux orthostatiques

ne fait pas partie de l’examen physique de routine.

Les causes les plus fréquentes de l’HO dans la population âgée sont

décrites dans cet article en utilisant l’acronyme mnémotechnique

‘4D-AID’. Le ‘4D-AID’ se veut une façon pratique et facile à mémoriser

d’évaluer la problématique de l’HO et est présentée ici à l’aide d’un

cas clinique.

This article has been peer reviewed.

Conflict of Interest: The authors report no conflicts of interest.

This article was published in May 2016.

M. Jason MacDonald

MD (Geriatric Fellow)

Department of Medicine,

University of Ottawa; Division

of Geriatric Medicine, the

Ottawa Hospital

Amandeep (Kiddy) Klair

MD (Geriatric Fellow)

Department of Medicine,

University of Ottawa; Division

of Geriatric Medicine, the

Ottawa Hospital

Lara Khoury

MD, FRCPC

Department of Medicine,

University of Ottawa; Division

of Geriatric Medicine, the

Ottawa Hospital

Frank J. Molnar

MSc, MDCM, FRCPC

Department of Medicine,

University of Ottawa; Division

of Geriatric Medicine, the

Ottawa Hospital; Ottawa

Hospital Research Institute;

Bruyere Research Institute

Corresponding Author:

Dr. Frank Molnar

fmolnar@ottawahospital.on.ca

Key words:

Postural hypotension,

orthostatic, falls,

medications,

blood pressure

Canadian Geriatrics Society

To see other CME articles, go to: www.cmegeriatrics.ca www.geriatricsjournal.ca

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8

Key points

The need for humans to maintain continuous intracranial perfusion despite the persistent effect of

gravity is a concept easily understood by physicians, patients and caregivers – a useful factor when it

comes to patient self-monitoring and reporting of symptoms as well as compliance with behavioural

management techniques.

Based on consensus-derived cut-offs, orthostatic hypotension (OH) is defined as a sustained reduction

in systolic blood pressure (SBP) of at least 20 mm Hg or diastolic blood pressure of 10 mm Hg within

three minutes of standing. Because the magnitude of the fall in blood pressure is dependent on the

baseline blood pressure, a fall in SBP of 30 mm Hg has recently been adopted for patients with

supine hypertension.

Failure of the heart rate to increase in the setting of OH may be a clue to underlying autonomic

pathology (or beta blockade), while exaggerated HR increase is more suggestive of intravascular

volume depletion as a contributing factor.

Timing of testing has been shown to be important due to the variability of blood pressure throughout

the day and the observation that patients tend to be most symptomatic from OH in the morning.

Other high yield times to test are after meals (due to splanchnic vasodilatation) and when BP

medications are expected to have peak effect.

In spite of well-recognized consensus cut-offs for a blood pressure-based diagnosis of OH, patient-

reported symptoms take precedent in situations where patients are symptomatic but lack a

“significant” (i.e., consensus-based cut-off) drop in BP upon standing, a situation termed orthostatic

intolerance (OI).

Introduction Symptomatic OH represents a significant source of morbidity among both community-dwelling and

institutionalized older persons.1 The standard approach to this common phenomenon taught during medical

school is unfortunately fraught with discrepancies over diagnostic technique and intimidating unstructured lists

of potential causes.

Much has been learned regarding the pathophysiology that underlies and contributes to the syndrome of OH in

the 90 years since its first description in the literature by Bradbury and Eggleston in 1925.2 Those first case

reports involving younger subjects with severe OH likely represented disorders that would be classified today

among a group of neurodegenerative conditions that manifest with failure of the autonomic nervous system.

While these conditions still exist and should be considered as part of a comprehensive evaluation of OH, the

majority of clinically relevant cases of OH seen among our increasingly elderly population are due to much

more common aetiologies. The purpose of this article will be to review practical techniques for documenting

the presence of OH and to provide a framework for identifying the causes of this common yet often

unrecognized geriatric syndrome.

Case Mr. B is a 72-year-old male being assessed by his family physician. He describes reduced appetite and several

falls over the past months. He was last seen six months prior for reassessment of a cholinesterase inhibitor

that was started one year prior for a diagnosis of dementia. His CT scan at the time of diagnosis revealed

moderate subcortical microangiopathic disease as well as evidence of several old lacunar strokes that he was

unaware of. His MoCA at the time of diagnosis was 18/30. For the past year, his wife has been performing all

instrumental activities of daily living (ADLs) and helping her husband with some basic ADLs, such as

getting dressed.

Past medical history is significant for hypertension, type 2 diabetes (most recent A1c 7.7%), coronary artery

disease with previous MI and ischemic cardiomyopathy (with most recent left-ventricular ejection fraction 32%

9

on echocardiogram 18 months prior), hypothyroidism and BPH. His medications include bisoprolol, perindopril,

digoxin, furosemide, ASA, metformin, pantoprazole, levothyroxine, donepezil and tamsulosin. Review of

systems reveals that over the past year Mr. B has lost roughly 20 lb due to decreased appetite. When asked

about his falls, Mr. B is unable to recall the circumstances, but his wife confirms that most have occurred while

getting up to urinate during the night. Mrs. B says she has no concerns during the day since her husband is

now using a walker.

On physical exam, BMI is approximately 20. Lying blood pressure is 118/62 mmHg, HR 88 (regular rhythm).

BP repeated in the standing position after one minute is 100/55, HR 95 (regular rhythm). Mr. B denies

dizziness but reports feeling weak after standing for approximately two minutes and requests to sit back

down. He appears to become tremulous and is blinking his eyes and swaying, but still denies dizziness.

Mucous membranes appear dry. Cardiovascular examination discloses no jugular venous distension and no

peripheral edema. He has a grade II/VI systolic murmur heard best at the left upper sternal border that

radiates to the right carotid area. Respiratory examination reveals clear lungs on auscultation. Abdomen is

soft with no tenderness. MoCA is now 15/30 and his wife reports the cholinesterase inhibitor has not slowed

down the rate of cognitive decline. Routine blood work is unrevealing except for a mild anemia with an

elevated MCV of 102.

Physiology – WHY we need to measure postural BP in older patients The need for humans to maintain continuous intracranial perfusion despite the persistent effect of gravity is a

concept easily understood by physicians, patients and caregivers. Standing from a supine position causes

approximately 10% to 15% of our blood to pool in the venous beds of the lower extremities and splanchnic

system.3 Early studies of patients with severe OH demonstrated pooling of no more than the normal amount

of blood in these patients, suggesting that OH must represent an abnormal response to an expected shift in

blood volume.4 The expected response is triggered by the immediate decrease in cardiac preload that results

from blood pooling. This stimulates afferent nerve terminals located in the carotid sinus and aortic arch to

trigger a baroreceptor reflex mediated by decreased vagal (parasympathetic) tone and increased sympathetic

output, thereby increasing both the cardiac output and systemic vascular tone.5 In chronic states of reduced

intravascular volume and cardiac output, the hormones renin, angiotensin and aldosterone act both on the

blood vessels and at the level of the kidneys to maintain blood volume and pressure, and ultimately to

preserve cerebral perfusion.6 Older patients are more prone to hypovolemia due to a loss of ability to conserve

water and sodium due to a reduction of renin, angiotensin and aldosterone as well as increased natriuretic

peptides. This may be compounded by an age-related decrease in thirst reflex.

Clinical implications – WHEN to measure postural BP OH becomes clinically relevant when it predisposes to symptoms. In elderly persons, the most feared

consequence of OH is falls and potential injury. A fear of falling due to recurrent dizziness or previous falls can

result, which effectively worsens existing states of immobility by contributing to deconditioning. Evaluation for

OH should be done in all older patients presenting with presyncope, syncope or falls.7 In our clinical

experience, all patients with functional decline, generalized weakness, near falls, falls, postural dizziness and

decreased cognition also merit a measurement of postural BP.

Diagnostic technique – HOW to measure postural BP Unfortunately, there is no simple bedside test to reliably measure cerebral perfusion upon standing.8

Therefore, clinician inference based on patient reported symptoms, observation and non-invasive peripheral

blood pressure measurements allow for the recognition and diagnosis of OH. Based on consensus-derived

cut-offs, OH is defined as a sustained reduction in systolic blood pressure (SBP) of at least 20 mm Hg or of

diastolic blood pressure of 10 mm Hg within three minutes of standing.9 Because the magnitude of the fall of

the blood pressure is dependent on the baseline blood pressure, a fall in SBP of 30 mm Hg has recently been

10

adopted for patients with supine hypertension.9 Measurement is typically performed using either a manual or

electronic cuff to record blood pressure supine (usually after several minutes in that position to allow for

equilibration of blood volume) and after one and three minutes of standing.10 Failure of the heart rate to

increase in the setting of OH may be a clue to underlying autonomic pathology (or beta blockade), while

exaggerated HR increase is more suggestive of intravascular volume depletion as a contributing factor.

Timing of testing has been shown to be important due to the variability of blood pressure throughout the day

and the observation that patients tend to be most symptomatic from OH in the morning.10 Other high yield

times to test are after meals (due to splanchnic vasodilatation) and when BP medications are expected to

have peak effect. Consequently, repeat postural BP measurements are essential for confidence in ruling in or

ruling out the diagnosis. In spite of well-recognized consensus cut-offs for a blood pressure-based diagnosis of

OH, patient-reported symptoms (e.g., postural syncope, presyncope, dizziness, headache, postural

unsteadiness etc.) take precedent in situations where patients are symptomatic but lack a “significant” (i.e.,

consensus-based cut-off) drop in BP upon standing, a situation termed orthostatic intolerance(OI).11 This goes

back to our opening thought in this section, which is that short of a technique for directly measuring a

reduction in cerebral perfusion at the bedside, all other maneuvers represent surrogates and therefore must

be interpreted in the context of patient symptoms – clinical judgment regarding whether the postural BP drops

are causing symptoms supersedes consensus-based cut-offs.

Differential diagnosis – WHAT causes postural hypotension?

The increasing prevalence of OH in the elderly, in part reflects age-related degeneration of the delicate

neurologic and endocrine reflex pathways described above, but can also be accounted for by the age-

associated accumulation of chronic diseases and medications. The myriad causes of OH can be organized

utilizing the 4D-AID mnemonic (Table 1) and are detailed in the subsequent paragraphs of this article. All

causes act by blunting one or more of the normal physiologic mechanisms, and thus are best remembered

using a pathophysiologic framework.

11

Table 1: DDX of postural hypotension - 4D-AID acronym

i. Causes associated with a compensatory tachycardia – 4Ds

Deconditioning

Dysfunctional heart

o Myocardium (very low left ventricular ejection fraction)

o Aortic stenosis

Dehydration

o Disease (e.g., acute illness, adrenal insufficiency)

o Dialysis (post-dialysis dry weight too low)

o Drugs

Diuretics

Anorexic drugs – narcotics, digoxin, antibiotics, cholinesterase inhibitors

Drugs – 6 ANTIs

o Anti-hypertensives

o Anti-anginals

o Anti-parkinsonian medications (e.g., levodopa)

o Anti-depressants (e.g., anti-cholinergic tricyclics)

o Anti-psychotics (anti-cholinergic effect)

o Anti-BPH (e.g., terazosin, tamsulosin)

ii. Causes that present with lack of compensatory tachycardia – AID

Autonomic dysfunction

o Diabetic autonomic neuropathy (consider if patient has peripheral neuropathy)

o Low B12

o Hypothyroidism

o ETOH abuse

o Parkinsonism (Parkinson’s disease, progressive supranuclear palsy, multisystem atrophy;

e.g., Shy-Drager syndrome)

o Amyloid

Idiopathic (Bradbury-Eggleston)

o Depletion of norepinephrine from sympathetic nerve terminals

Drugs

o Beta-blockers

Previously published as 3D-AID in Canadian Family Physician (Reproduced with permission of Canadian Family

Physicians (CFP Nov 2010; 56: p1123 – 1129)

Working through the 4D-AID acronym Deconditioning

OH prevalence increases in populations with prolonged bed rest12 and low BMI13. Several studies have shown

higher rates of OH among elderly patients living in nursing homes compared with the community setting,

which in part reflects higher degrees of deconditioning and overall frailty among such individuals. OH and OI

should be screened for in all elderly individuals deemed to be at least mildly frail.11

The following frailty scale can be used to identify who should be screened

(See Faculty of Medicine, Geriatric Research Journal) In the case described above, Mr. B is moderately frail as

a result of his underlying cognitive impairment and functional limitations. He is likely also deconditioned based

on his weight loss and history of physical inactivity.

12

Dysfunctional heart

Since the ability to adjust cardiac output and systemic vascular resistance quickly and efficiently during times

of orthostatic stress is our primary guard against orthostatic hypotension, it should come as no surprise that

patients with cardiac dysfunction experience a higher prevalence of OH. Assessment should include evaluation

for left ventricular dysfunction. In this case, Mr. B has known systolic dysfunction due to ischemic

cardiomyopathy, which can contribute to his OH.

Aortic stenosis is the most common valvular heart disease in developed countries and disproportionately

affects the elderly.14 Among elderly patients with severe aortic stenosis, 75.6% are symptomatic14, and the

development of syncope or presyncope in these patients is associated with an average survival of only three

years without intervention.15 All patients with orthostatic hypotension should be screened for cardiac murmurs

and an echocardiogram should be considered if findings are suggestive of valvular pathology

(emedicine.medscape.com/article/150638-clinical#b3). In this case, Mr. B has a murmur suggestive of

possible aortic stenosis.

Dehydration

Elderly patients are particularly prone to dehydration as a result of impaired thirst mechanisms and impaired

ability of the kidney to retain salt and water during periods of reduced fluid intake or volume loss.10 The

pathologic state of adrenal insufficiency, seen commonly among the elderly in the setting of prolonged

exogenous glucocorticoid use as treatment for other conditions, is associated with prominent OH that occurs

through essentially the same mechanisms (impaired renal sodium retention) as a consequence of insufficient

circulating aldosterone.16 Volume depletion should be suspected during the assessment of OH when a

compensatory HR increase of >15 beats per minute is observed upon standing.10 However, due to possible

underlying autonomic dysfunction, the sensitivity of this finding is reduced and its absence does not rule out

volume contraction in the elderly. A high index of suspicion is required for dehydration and subsequent

volume contraction in patients presenting with OH and a history of anorexia, medications that reduce

intravascular blood volume such as diuretics (both affecting Mr. B in our case) or recent acute illness (i.e.,

older hospitalized patients as well as seniors presenting to emergency departments should have postural BP

routinely monitored).

Drugs

Several classes of medications are closely linked to OH. Most antihypertensive medications directly interfere

with the normal hemodynamic homeostatic responses by the cardiovascular system to orthostatic stress.17

The targets for antihypertensive control must be balanced against the potential for postural hypotension and

are reviewed in another article in this journal

(See Canadian Geriatric Society Journal of CME). Anti-anginals (such as nitroglycerin) act by reducing vascular

resistance in both venous and arterial vessels. Many drugs possess anti-cholinergic properties, which can

produce profound impairments in orthostatic mechanisms through autonomic nervous system disruption.

These include antipsychotics such as risperidone, SSRIs such as trazodone, TCAs such as amitriptyline and

H2-blockers such as ranitidine. One of the most challenging clinical situations is the patient with Parkinson’s

disease taking carbidopa-levodopa formulations (e.g., sinemet, prolopa), since both the disease and the

therapy are known to cause OH.5 Commonly used medications to treat symptoms of bladder outlet obstruction

from prostatic hypertrophy such as alpha-blockers (terazosin, tamsulosin) directly interfere with the

sympathetic vasoconstrictor limb of the baroreceptor reflex and frequently contribute to OH. In our case,

Mr. B is taking several medications that may directly worsen OH (perindopril, furosemide and tamsulosin).

He is also taking medications that have been associated with anorexia (donepezil and digoxin) and may be

contributing to OH indirectly through malnutrition and dehydration. To review other medications that can

contribute to anorexia and weight loss see Table 2 in CMAJ.

Autonomic dysfunction

As described in the pathophysiology section above, the autonomic nervous system orchestrates the various

cardiovascular responses that act to achieve hemodynamic homeostasis during an orthostatic challenge.

13

Clues that autonomic dysfunction may be playing a prominent role in the pathogenesis of OH include the

presence of autonomic pathology in other organ systems, such as disorders of the bowel and bladder,

impotence and anhidrosis and the absence of a compensatory increase in heart rate in the presence of

orthostatic hypotension.5,18 Common underlying conditions that are associated with secondary autonomic

pathology include diabetes mellitus, hypothyroidism, vitamin B12 deficiency and alcoholism. Given Mr. B’s

diabetes, he is at risk for autonomic dysfunction which, in turn, will make him more sensitive to the

medications listed above. His use of a PPI19 (e.g., pantoprazole) and metformin20 both place him at increased

risk of low B12.

Although primary autonomic degenerative disorders are rare in comparison to secondary causes, examination

for features of parkinsonism (cogwheel rigidity, resting tremor, bradykinesia), which is seen in many of these

disorders (see Table 1), is essential in the assessment of OH.10

Conclusion Although specific consensus-based blood pressure cutoffs are helpful tools in the definition of OH, we must not

slavishly adhere to such consensus-based guidelines in lieu of our clinical judgment, recognizing that patients’

symptoms are the most important feature and are sufficient to establish the diagnosis in many patients even

if their blood pressure drops do not meet consensus-based cut-offs. From the case presented at the beginning

of this article, Mr. B should be considered to have OH based on his symptoms and multiple risk factors.

The 4D-AID mnemonic introduced in this article provides clinicians with a systematic approach to identifying

the contributing causes in complex patients like Mr. B in order to guide management.

REFERENCES:

1. Ooi WL, Barrett S, Hossain M, Kelley-Gagnon M, Lipsitz LA. Patterns of orthostatic blood pressure change

and their clinical correlates in a frail, elderly population. JAMA 1997; 277(16):1299-304.

2. Bradbury S, Eggleston C. Postural hypotension: A report of three cases. American Heart Journal, St. Louis

1925; 1:73-86.

3. Sclater A, Alagiakrishnan K. Orthostatic Hypotension: A primary care primer for assessment and treatment.

Geriatrics 2004; 59(8): 22-27.

4. Stead EA, Ebert RV. Postural hypotension, a disease of the sympathetic nervous system. Archives of

Internal Medicine 1941; 67: 546.

5. Freeman R. Neurogenic Orthostatic Hypotension. NEJM 2008;358:615-24.

6. Hajjar I. Postural Blood Pressure Changes and Orthostatic Hypotension in the Elderly Patient: Impact of

Antihypertensive Medications. Drugs Aging 2005; 22(1):55-68.

7. Sarasin FP, et al. Prevalence of orthostatic hypotension among patients presenting with syncope in the ED.

American Journal of Emergency Medicine 2002; 20:497-501.

8. Tan RS, Philip P. Orthostatic Hypotension in the Elderly. Part I: Role of Drugs in Etiology. Clinical Geriatrics

1998; 6(9): 37-57.

9. Freeman R, et al. Consensus statement on the definition of orthostatic hypotension, neurally mediated

syncope and the postural tachycardia syndrome. Clin Auton Res 2011;21:69-72.

10. Shibao C, Lipsitz LA, Biaggioni I. ASH Position Paper: Evaluation and Treatment of Orthostatic

Hypotension. Journal of Clinical Hypertension 2013; 15(3): 147-153.

14

11. O’Connell M, et al. Orthostatic hypotension, orthostatic intolerance and frailty: The Irish Longitudinal

Study on Aging-TILDA. Archives of Gerontology and Geriatrics 2015; 60(3): 507-13.

12. Tonkin AL. Postural hypotension. Med J Aust 1995; 162(8):436-8.

13. Applegate WB, et al. Prevalence of postural hypotension at baseline in the Systolic Hypertension in the

Elderly Program (SHEP) cohort. J Am Geriatr Soc 1991;39(11):1057-64.

14. Osnabrugge RLJ, et al. Aortic stenosis in the elderly. J Am Coll Cardiol 2013; 62(11): 1002-12.

15. Aronow WS. Recognition and Management of Aortic Stenosis in the Elderly. Geriatrics 2007; 62(12):23-

32.

16. Charmandari E, et al. Adrenal insufficiency. Lancet 2014; 383(9935): 2152-2167.

17. Madden K. Orthostatic Hypotension Screening in Older Adults Taking Antihypertensive Agents. Geriatrics &

Aging 2009;12(5):254-58.

18. Rosecan MD, et al. Orthostatic Hypotension, Anhidrosis, and Impotence. Circulation 1952; 6: 30-40

19. Heidelbaugh JJ. Proton pump inhbitors and risk of vitamin and mineral deficiency: evidence and clinical

implications. Ther Adv Drug Saf 2013; 4(3): 125-133.

20. Liu KW, et al. Metformin-related B12 deficiency. Age and Ageing 2006;35: 200-201.

15

CGS JOURNAL OF CME | VOLUME 6, ISSUE 1, 2016

INSOMNIA IN THE ELDERLY: UPDATE ON ASSESSMENT AND MANAGEMENT

Abstract

Insomnia disorder is one of the most common sleep-wake disorders seen

in the geriatric population, and is associated with multiple psychiatric

and medical consequences. Insomnia is a subjective complaint of

difficulty falling and/or staying asleep, or experiencing non-restorative

sleep, associated with significant daytime consequences including

difficulty concentrating, fatigue and mood disturbances. There is no

single diagnostic tool to assess insomnia. Consequently, an insomnia

assessment requires thorough history taking including a sleep inquiry,

medical history, psychiatric history, substance use history and a relevant

physical examination. Insomnia is often multifactorial in origin, and

routinely is associated with multiple other psychiatric and medical

disorders. Therefore, predisposing, precipitating and perpetuating factors

must be carefully examined in the context of an evaluation of insomnia

symptoms. Other specific sleep assessments (e.g., overnight

polysomnography) can be completed to rule out other sleep-wake

disorders. For management, a cognitive-behavioural approach (including

sleep restriction therapy, stimulus control therapy) is commonly

accepted as an effective, first-line treatment for insomnia disorder.

A brief version of CBT-I focusing on behavioural interventions (Brief

Behavioural Treatment of Insomnia, BBT-I) has also demonstrated

efficacy in the geriatric patient population. Pharmacological treatments

can be considered if cognitive-behavioural approaches have failed.

L’insomnie est un des troubles les plus fréquents du sommeil et de l’éveil

rencontré chez la population âgée et est associée à de multiples

conséquences tant psychiatriques que médicales. L’insomnie est une

plainte subjective de difficulté à initier ou maintenir le sommeil ou de

sommeil non réparateur, associée à des conséquences diurnes telles que

les troubles de la concentration, la fatigue et les troubles de l’humeur.

Il n’y a pas d’outil diagnostique simple pour évaluer l’insomnie. En

conséquence, l’évaluation de l’insomnie requiert une évaluation globale

comprenant un questionnaire concernant le sommeil, l’histoire médicale,

l’histoire psychiatrique et les habitudes de vie, ainsi qu’un examen

physique ciblé. L’insomnie est souvent multifactorielle, associée à

plusieurs comorbidités médicales et psychiatriques. Ainsi, il est

important de s’attarder aux facteurs prédisposant à l’insomnie, ainsi qu’à

ceux qui précipitent et perpétuent celle-ci. D’autres évaluations ciblées

(par exemple une polysomnographie nocturne) peuvent être nécessaires

pour éliminer d’autres causes de troubles du sommeil et de l’éveil. En ce

qui concerne le traitement, une approche cognitivo-comportementale

(incluant par ex. la restriction de sommeil ou le contrôle des stimuli) est

favorisée comme approche thérapeutique initiale. Une version brève de

cette approche ciblant les aspects comportementaux (Brief Behavioural

Soojin Chun

MSc., MD FRCP(C)

Geriatric Psychiatry

Subspecialty Resident

(PGY-6), University of

Ottawa

Elliott Kyung Lee

MD, FRCP(C), D. ABPN

Sleep Med, Addiction

Psych, D. ABSM, F. AASM,

F. APA, Sleep Specialist,

Royal Ottawa Mental

Health Centre, Assistant

Professor, University of

Ottawa

Corresponding Author:

Elliott Kyung Lee

Elliott.lee@theroyal.ca

Key words:

Sleep, insomnia, sleep

disorders, sleep medicine,

sleep changes with aging

Canadian Geriatrics Society

To see other CME articles, go to: www.cmegeriatrics.ca www.geriatricsjournal.ca

If you are interested in receiving this publication on a regular basis, please consider becoming a member.

16

CHUN AND LEE | INSOMNIA IN THE ELDERLY: UPDATE ON ASSESSMENT AND MANAGEMENT

CGS JOURNAL OF CME | VOLUME 6, ISSUE 1, 2016

Treatment of Insomnia, BBT-I) a aussi été prouvée efficace chez les personnes âgées. Les traitements

pharmacologiques ne devraient être considérés qu’en cas d’échec des approches cognitivo-

comportementales.

This article has been peer reviewed.

Conflict of Interest: None

This article was published in May 2016.

Key points

1. Insomnia is common in the elderly; about 40% of patients over the age of 65 will complain of

this symptom.

2. The etiology can be complex, with age, biological and psychosocial factors playing a role.

3. Evaluation should consist of a full history and physical exam, including screening for common sleep

disorders such as obstructive sleep apnea, restless legs syndrome and periodic limb movement

disorder. If there is a clinical suspicion of a sleep disorder, a referral to a sleep specialist and

subsequent polysomnogram should be strongly considered.

4. For insomnia disorder, where there is no suspicion of an underlying sleep disorder or other medical

or psychiatric disorder causing insomnia, a non-pharmacological approach, including

cognitive-behavioural therapy is preferred.

5. Benzodiazepines and non-benzodiazepine benzodiazepine receptor agonists (Z-drugs) can have

acute benefits for insomnia BUT are associated with significant side effects with long term use;

consequently long-term use should be avoided.

Case A 68-year-old male is referred for an evaluation of insomnia. He reports waking up 2-3 times during the

night for the last 3 years ever since his mother passed away and his family had been conflicted about the

estate. His wife says that he moves around a lot at night and makes funny noises with his breathing. He

says: “doesn’t everybody do this when they get to my age doctor?”

Introduction Insomnia is one of the most common sleep-wake disorders with multiple psychiatric and medical

comorbidities and consequences. Population-based estimates indicate that one-third of adults report

insomnia symptoms1 and 12-20% have symptoms that meet criteria for insomnia disorder2. The

prevalence of insomnia increases to up to 40% of people older than 653,4.

Insomnia disorder presents as a predominant complaint of dissatisfaction with either sleep quantity or

quality. Problems may include difficulties with initiating sleep (initial insomnia), maintaining sleep (middle

insomnia) or early morning awakenings with an inability to fall back to sleep.1 DSM-5 also specifies that

the sleep difficulty must occur at least 3 nights per week for at least 3 months, that the disorder result in

significant distress or functional impairment and that there be no other etiologies (e.g., no other

sleep-wake disorder, substance use or mental health/medical conditions that could explain the

symptoms)1. For a complete review of DSM-5 criteria go to www.dsm5.org/Pages/Default.aspx. Insomnia

disorder is diagnosed only if it is severe enough to warrant independent clinical attention, as various

medical or psychiatric comorbidities can present with insomnia as a symptom. Most older people with

insomnia have one or more comorbid conditions; a review by Foley5 et al. (1995) demonstrated that

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CGS JOURNAL OF CME | VOLUME 6, ISSUE 1, 2016

among 6800 elderly patients with insomnia, 93% had one or more comorbid conditions. Common

conditions include depression, chronic pain, cancer, chronic obstructive pulmonary disease (COPD) and

cardiovascular disease5.

Untreated insomnia has numerous consequences, including interpersonal, social and occupational

problems1. These problems may develop as a result of lack of sleep or excessive concern with sleep,

increased day time irritability and poor concentration. Older patients with insomnia are more likely to

experience impaired daytime functioning and psychomotor impairment. Negative consequences associated

with chronic insomnia include an increased risk of depressive disorder, hypertension, myocardial

infarction, falls, reduced productivity at work and decreased quality of life1,6. Furthermore, recent studies

even suggest an association between poor sleep quality and the subsequent development of a

neurocognitive disorder.7 Investigators conjecture that increased beta-amyloid deposition associated with

sleep fragmentation may play a role in the development of cognitive impairment7.

Insomnia frequently is multifactorial in origin. Consequently, a holistic approach is recommended for

addressing insomnia, with consideration given to predisposing, precipitating and perpetuating factors

(Figure 1)8. These factors may directly or indirectly contribute to the hyperarousal that is inherent in

insomnia disorder2. For example, aging can predispose a person to have insomnia but acute stressors

(e.g., recent death of loved one or acute illness) may trigger the onset of the disorder (i.e., precipitating

factor). The insomnia disorder of an individual may be perpetuated by factors such as increased cognitive

arousal, preoccupation and frustration with lack of sleep as well as ongoing medical and

psychiatric conditions.

Figure 1: Predisposing, Precipitating and Perpetuating Factors to Insomnia (medications and

substances contributing to insomnia include alcohol, caffeine, nicotine, cholinesterase inhibitors,

analgesics, antihypertensives, psychotropics, anti-Parkinsonian medications, bronchodilators etc.)11,12

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Aging and sleep

Significant changes occur in sleep and circadian rhythms with aging. One of the most striking differences

in the sleep of older patients is their frequent nocturnal awakenings (i.e., sleep fragmentation)10. Other

changes that occur with age include decreases in total sleep, reduced sleep efficiency (time spent asleep

as a percentage of time in bed), decreased slow-wave (Stage N3 or deep sleep) and rapid eye movement

(REM) sleep and increased stage N1 and N2 sleep9,10.

The 24-hour sleep-wake cycle becomes less robust with aging and is accompanied by a decreased diurnal

24-hour body temperature rhythm13,14. Older adults are more likely to have a temporally advanced sleep

phase (falling asleep early and waking up early15). Furthermore, earlier awakening may result in frequent

naps during the day, which may further perpetuate nocturnal insomnia9.

In addition to the inherent biological changes that occur with aging, elderly patients may experience a

deterioration of their daily routines that entrain an individual’s biological day-night rhythm. Important

zeitgebers (“time makers”) for the circadian rhythm may erode (e.g., no fixed work schedule, irregular

meal time) with aging, which may contribute to further sleep difficulty.

Evaluation/investigation Diagnosis of insomnia is based on a thorough clinical interview of both the patient and their bed partner.

Important sleep questions include: onset and duration of the insomnia, sleep routine (time of sleep onset,

wake up time, number of awakenings at night), daytime somnolence, and impact on functioning, including

the effect on driving. In many instances the history provided by the partner is dramatically different from

the patient, underlining the importance of the bed partner history. History can include a review of the 6

Ps: Pain, Paroxysmal Nocturnal Dyspnea (PND), Pharmaceuticals/Pills (see Figure 1), Pee (ensure the

patient is not on a late day diuretic and is restricting PM oral fluids), Partner (with sleep issues), Physical

environment not conducive to sleeping. The clinical evaluation should include screening questions for

obstructive sleep apnea and restless legs syndrome (see Table 1). Any precipitating factors, such as acute

stressors and acute/chronic pain should be reviewed. It is important to include an inquiry for any

psychiatric disorders, such as major depressive disorder and any anxiety disorder as well as for

medical/neurological disorders (e.g., Parkinson’s disease). Medications should be reviewed as certain

medications are known to contribute to insomnia, including cholinesterase inhibitors, analgesics,

anti-Parkinsonian medications, antihypertensives, psychotropics and bronchodilators (Figure 1).

Additionally, it is important to obtain a substance use history, evaluating the consumption of alcohol,

cigarettes, caffeinated drinks and any over the counter medications that can affect the quality and

quantity of sleep. Other habits and social history can provide additional information – for example,

excessive nightly use of electronic devices (e.g., i-Pad, computer games) at bedtime can suppress

nocturnal melatonin production and adversely affect circadian rhythm16. Sleep diaries can be helpful to

assess circadian patterns as well as helpful and detrimental sleep habits. Collateral information from the

bed partner is important particularly to rule out any other sleep disorders (see Table 1).

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Table 1. Common sleep disorders, screening tools/questions and action plans for

positive screening

Sleep

Disorder

Screening

Questions/Assessment

If Screen is Positive… Extra

Comments

Obstructive

sleep apnea

(OSA)

STOP BANG17

≥2/4 in STOP, or

≥3/4 of STOP BANG has high

sensitivity/specificity for OSA

S – Do you SNORE?

T – Are you TIRED in the day?

O – Any OBSERVED apneas?

P – Do you have high blood

PRESSURE?

BMI >35 kg/m2

Age >50

NECK circumference over

40 cm?

GENDER – Male

Referral to a sleep clinic for a

polysomnogram to confirm

suspicions

Consider driving safety as per

CMA driving guidelines

Important to ask

patient’s partner

if the patient

snores, and if

they have

evidence of any

unusual

breathing.

Patients

themselves are

often unaware of

potential issues.

Restless Legs

Syndrome

(RLS)

URGE Criteria18,19

(4/4 symptoms strongly

suggests RLS)

U – Do you have the URGE to

move your legs at night?

R – Are they worse at REST?

(e.g. prolonged inactivity, long

car rides, airplane, sitting in a

theatre)

G – Do symptoms GET BETTER

with movement?

E – Are symptoms worse in the

EVENINGS?

Check ferritin – if <50 mcg/L,

initiate iron replacement.

If no contraindications, and no

secondary causes of RLS are

seen, and symptoms are

occurring ≥3 x per week, consider

pramipexole at 0.125 mg by

mouth 2 hours before bedtime,

and increasing by 0.125 mg by

mouth every 2 days until

symptoms resolve, or until

maximum of 0.5 mg. Common

potential side effects include nasal

congestion and stomach upset.

Rare, but more serious side

effects include impulse control

problems (e.g., pathological

gambling, sexual indiscretions),

sleep attacks (caution for driving)

and psychotic symptoms. If

problems persist, consider referral

to a sleep specialist.

Periodic Limb

Movement

Disorder

(PLM-D)

Does your partner ever complain

that you kick your legs at night?

Are your covers messy in

mornings?

Referral to sleep specialist for

possible polysomnography.

Important to ask

the patient’s

partner if they

notice any

kicking.

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If indicated, a focused physical exam (see Table 2) should be performed along with appropriate

investigations (e.g., blood work to rule out thyroid disease). No investigation is gold standard or

diagnostic. Overnight sleep assessment (polysomnography) and other studies can be used to rule out

other sleep disorders but are never solely indicated to diagnose a patient with insomnia. While the level I

(attended, in laboratory, >7 channel) polysomnography is considered the gold standard for assessing for

sleep disordered breathing, level III polysomnography studies (“home sleep studies”) have been assessed

to have reasonable sensitivity and specificity for screening for sleep disordered breathing when the pretest

probability is considered high for moderate or severe obstructive sleep apnea and there are no significant

comorbidities. For more information regarding home sleep studies see

www.aasmnet.org/resources/clinicalguidelines/030713.pdf and

www.ncbi.nlm.nih.gov/pmc/articles/PMC2975504/. The point about the absence of significant medical

comorbidities may limit the utility of the level III polysomnography study in the elderly population, since

this group frequently has significant medical comorbidities. See Table 1 for screening questions for

common sleep disorders associated with insomnia and action plans.

Treatment Although changes in sleep are known to occur with age, insomnia is not an inevitable consequence of

aging. Untreated persistent insomnia may lead to multiple medical and psychosocial consequences –

therefore, treatment of insomnia is not only encouraged but warranted. There are two main types of

treatment for insomnia: 1) psychological treatments for insomnia, including cognitive behavioural therapy

for insomnia (CBT-I) and 2) pharmacological approaches. Due to the paucity of data on pharmacological

soporific agents and their known side effects, a cognitive-behavioural approach is accepted as the first-line

treatment for insomnia at any age according to the most recent practice parameters published by the

American Academy of Sleep Medicine (AASM – www.aasmnet.org/PracticeGuidelines.aspx)20.

Psychological Treatments for Insomnia, including Stimulus Control, Sleep Restriction and

Cognitive-Behavioural Therapy for Insomnia (CBT-I).

Psychological approaches are summarized in Table 3. Behavioural and cognitive approaches to insomnia

are safe and effective ways to treat insomnia in older adults20,21. One of the most common first steps in

addressing insomnia is called stimulus-control-therapy (SCT). SCT is especially useful for those who have

a cycle of excessive daytime napping and resultant night time insomnia. See Table 3 for specific

techniques and instructions for patients. Instructions can be given in one visit but a follow-up visit should

be scheduled to assess compliance and to solve problems. Many elements of SCT are commonly referred

to as “sleep hygiene.”

Sleep-restriction-therapy (SRT)22 is another common approach to insomnia in older adults. Elderly

patients have a reduced homeostatic sleep drive and may spend excessive time in bed “trying to sleep.”

SRT aims at minimizing time spent in bed awake and helps patients accumulate sleep debt (see Table 3).

This therapy requires multiple follow-up visits to adjust time-in-bed (TIB) prescriptions and ensure patient

compliance.

More recently, the term cognitive-behavioural therapy for insomnia (CBT-I) has been used to refer to a

combination of SCT, SRT and cognitive strategies to address maladaptive sleep-related beliefs (i.e.,

cognitive distortions). Some common sleep related cognitive distortions include, “everyone should sleep at

least 8 hours every night, otherwise there will be serious day time consequences,” and “poor sleep is

normal in older adults.”

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Table 2. A focused physical exam for the assessment of sleep disorders (Note: physical exam

must be personalized considering the individual’s medical history)

Systems Focused Examination

General Body weight and height (calculate Body Mass Index (BMI); ≥35

kg/m2 has high risk for OSA, but in the elderly, BMI may be

poorly predictive for OSA23)

Head, Nose and

Neck

Nasal patency and alignment

Mouth exam (assess for tonsillar hypertrophy and tongue

enlargement, +/- mallampati score

(emedicine.medscape.com/article/2172419-overview), overbite,

loose teeth, dentures)

Neck circumference, goitre or any mass

Micrognathia/retrognathia

Cardiovascular

including

peripheral vascular

disease

Hypertension

Arrhythmia, murmurs

Peripheral edema

Neurological Gait (Parkinsonism), evidence of peripheral neuropathy

Cognitive approaches will identify these maladaptive beliefs about sleep and help patients generate more

balanced or alternative beliefs about sleep using techniques such as thought records. This treatment is

ideally administered by trained psychologists, though several elements can be delivered by primary care

physicians and/or psychiatrists. Access to CBT-I can be challenging due to financial constraints and a

paucity of available psychological resources. Due to these limitations, a shorter form of CBT-I called Brief

Behavioural Therapy for Insomnia (BBT-I) has been developed24 as a simplified and shortened version of

CBT-I that focuses on the behavioural elements of CBT-I based on the circadian and homeostatic

regulation of sleep. BBT-I can be delivered over 2 sessions by a nurse, and has been shown to be effective

for insomnia treatment in the geriatric population, with benefits persisting even after 6 months24. Several

online resources and applications (“apps” – see Table 4) have been developed recently in an effort to

improve accessibility.

Pharmacological Treatment Options for Insomnia in the Elderly.

There are extensive pharmacological treatment options available for insomnia in the elderly and a full

review of these is beyond the scope of this paper. Nonetheless, if other comorbidities are excluded and the

insomnia disorder is chronic and persistent, general guidelines regarding pharmacological options should

be considered. In the US, 4 medications are FDA approved for the treatment of chronic insomnia:

non-benzodiazepine benzodiazepine receptor agonists (e.g., zolpidem), benzodiazepines, melatonin

receptor agonists (not available in Canada) and the hypocretin receptor antagonist suvorexant (not

available in Canada). Health Canada consequently only has the first 2 agents approved as sleep aids

(Healthy Canadians). Other agents that are frequently considered for chronic insomnia in the elderly

include alpha 2 delta drugs, sedating antidepressants, antihistamines, melatonin and atypical

antipsychotics.

Non-Benzodiazepine Benzodiazepine Receptor Agonists: Z Drugs – zolpidem, zopiclone.

In general these medications have been shown to be efficacious for the treatment of insomnia in the

elderly, but no head to head trials exist regarding comparative efficacy. These medications have more

selectivity in targeting the alpha 1 subunit of the gamma amino butyric acid (GABA) receptors compared

to benzodiazepines (which target the cleft between the alpha and gamma subunit)25, and this may help

explain the decreased potential for some adverse events compared to benzodiazepines. For instance,

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these drugs have less liability for falls and fractures compared to benzodiazepines, though they still

contribute to elevated risk26. There is also risk for complex sleep related behaviours27 and abuse

potential28. Zolpidem has a shorter half-life (T½ = 2.5-3 hours, time to maximal concentration = 1-2

hours*) and consequently may have less potential for residual daytime adverse effects than zopiclone

(T½=5-6 hours, time to maximal concentration = 1.5-2 hours*). Soporific effects for both of these drugs

are expected to begin within 15-30 minutes of ingestion and consequently these can be helpful for initial

insomnia25. The shorter half-life of zolpidem, however, may limit this drug’s utility for sleep maintenance

insomnia, although a controlled release (CR) formulation was recently introduced in Canada modestly

addressing this issue (T½=2.5-3 hours, time to maximal concentration = 1.5-2.5 hours*). Zopiclone has

been shown to have more risk for activities requiring daytime vigilance such as driving29,30, and these

effects may be greater than those seen with the shorter acting benzodiazepine temazepam31. As a result

of these concerns, the maximum recommended dose per Health Canada for those over 65 years of age for

zopiclone is 5.0 mg as of November 2014, with a recommended starting dose of 3.75 mg (Health Canada)

Some studies suggest zopiclone is less effective than CBT-I for the treatment of chronic insomnia32.

Although evidence suggests these drugs have efficacy for insomnia, data for use in the elderly is limited.

Consequently these agents should be used cautiously if pursued, with the lowest dose possible, and for

the shortest time, preferably less than 4 weeks8,33.

* Numbers are determined for healthy young adults. These numbers may need to be adjusted in the

elderly population and so should be considered with caution in the geriatric population.

Table 3. Psychological therapies for insomnia

Therapy Techniques used

Sleep Hygiene Maintain a regular sleep pattern

Avoid napping in the day

Avoid substances that can impair sleep, including caffeine,

alcohol, nicotine

Establish a relaxing bedtime routine

Associate the bed with sleep (avoid watching TV, working on

the computer etc. in bed)

Stimulus-Control

Therapy (SCT)

(Incorporates

elements of sleep

hygiene and

builds on

associating bed

with sleep)

Only go to bed when sleepy

Establish a standard wake-up time

Get out of bed whenever he or she is awake for more than

15-20 minutes

Avoid reading, watching TV, eating, worrying and engaging

in sleep incompatible behaviours in the bed and bedroom

Avoid clock watching

Maximize daylight exposure and minimize light exposure

in evening

Avoid day time napping

Sleep Restriction

Therapy (SRT)

Step 1: Sleep log for 2-3 weeks

Step 2: Calculate the average total sleep time (TST)

Step 3: Prescribe initial time-in-bed (TIB) at the average

TST or average TST plus amount of time that is deemed to

be normal nocturnal wakefulness (e.g., 30 min). TIB should

not be more than 7.5 hours per night in the

elderly population

Step 4: At follow-up sessions, typically weekly, increase TIB

in 15-20 minute increments when sleep efficiency exceeds

85%. Sleep efficiency = time asleep/TIB. Note that wake-up

time is fixed, so bedtime is advanced by 15-20 minutes, and

bedtime should not be later than 2 a.m.

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Health Canada recommends not using zopiclone for more than 7-10 days. The Beers criteria is a list of

potentially inappropriate medications for elderly patients that is maintained and updated by the American

Geriatric Society. The most recent Beers criteria in 2015 strongly suggest the non-benzodiazepine

benzodiazepine receptor agonists should be avoided for treatment of insomnia in the elderly because of

their unfavourable side effect profile relative to their effects for insomnia34.

Benzodiazepines These medications have been used for decades for the treatment of insomnia in the elderly, but have been

associated with several adverse consequences including an increased risk for falls, motor vehicle crashes,

residual daytime sedation, anterograde amnesia and rebound insomnia35-37. Novel studies have even

implicated benzodiazepine use in the subsequent development of neurocognitive disorders38. The sleep

induction effects of most of the benzodiazepines are expected to begin within 30 minutes, with oxazepam

and temazepam having an onset of action of up to 60 minutes25. Although some studies have suggested

short or intermediate acting agents such as temazepam are preferred in the elderly compared to longer

acting agents such as flurazepam20,39, the recent 2015 Beers criteria strongly suggested avoiding chronic

benzodiazepine use altogether in the elderly34, and this has been echoed by others33.

Sedating antidepressants Trazodone is perhaps the most frequently used medication among the sedating antidepressants, but data

demonstrating efficacy are limited with no evidence of sustained efficacy12,40. Potential side effects

including sedation, dizziness, cardiac arrhythmias, orthostatic hypotension and potential priapism can be

significant in the elderly population40,41. Mirtazapine, another sedating antidepressant, has demonstrated

benefits for insomnia in patients with a major depressive disorder but requires monitoring for somnolence

and weight gain42,43. Onset of soporific effects for both of these drugs is expected to begin within 30

minutes of ingestion25. Doxepin, a tricyclic antidepressant with significant sedative properties as a result of

significant antihistaminergic actions, has recently been demonstrated to have efficacy without significant

adverse events in the treatment of primary insomnia in elderly patients in low doses (1-6 mg)44,45, but

further study is needed to replicate these results. Onset of action was seen within 30 minutes of ingestion.

Potential complications of tricyclic antidepressants including sedation, weight gain, postural hypotension,

cardiac arrhythmias (QTc prolongation), urinary retention and anticholinergic side effects. These effects

generally limit the utility of these medications for treatment of insomnia disorder in elderly patients in the

absence of a comorbid mood disorder43. Use of other antihistaminergic agents (e.g., dimenhydrinate)

including over the counter agents is not recommended in the elderly population20,46.

Other drugs: atypical antipsychotics, alpha 2 delta drugs, melatonin Although use of the atypical antipsychotics may have some benefits for sleep initiation and maintenance in

certain circumstances where a comorbid psychiatric disorder is present47, their adverse side effect profile

(including increased risk of stroke, sudden cardiac death) and lack of efficacy data in the geriatric

Sleep Restriction Therapy

sleepanddreams.com/?p=170

Cognitive-

Behavioural

Therapy for

Insomnia (CBT-I)

Cognitive therapy, sleep hygiene, relaxation training, SCT

and SRT are important elements of CBT-I

Cognitive therapy: Identifying sleep-related maladaptive

beliefs (cognitive distortion) and evaluating them using

various tools, such as thought record

CBTI

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population argue against their use for chronic primary insomnia in this group of patients20,33. Similarly,

there are no data available on the use of alpha 2 delta drugs such as gabapentin or pregabalin for

treatment of insomnia disorder in the elderly population. However, these medications may have some

utility if insomnia symptoms may be related to anxiety48, alcohol withdrawal49, neuropathic pain50 or

restless legs syndrome51,52. Our clinical experience has suggested rarely if ever needing to go beyond

600 mg a night with gabapentin for insomnia, or 150 mg at night with pregabalin, and in most instances

elderly patients can get benefits from far smaller doses. Onset of sleep induction effects is anticipated to

begin within 30 minutes of consumption. Patients should be cautioned about potential cognitive side

effects, dizziness and potential psychiatric symptoms including suicidal thoughts50,53,54. Melatonin has been

demonstrated to have some modest benefits for primary insomnia in the elderly population55,56. Even a

0.3 mg dose can be effective and provides a physiologic quantity of melatonin57. Doses above 3 mg for

elderly already result in supraphysiologic melatonin levels, which can persist into the day, leading to

potential daytime impairment; therefore, doses above 3 mg are not recommended57. Side effects can

include daytime sedation, headaches and dizziness, but long-term studies in the elderly are lacking58,59.

While generally considered safe, significant adverse events can include impairment in glucose tolerance60

and interactions with warfarin61.

Table 4. Self-help applications (“apps”) available to deliver CBT-I.

Note all apps in Table 4 are free to download.

Application Comments

CBT-I Coach

Developed in Stanford for patients with insomnia. Has suggestions for patients

troubled by trauma in the past. Ideally used in conjunction with CBT-I. Gives tips

on sleep hygiene and strengthening cues for sleep.

Sleepio

Developed in Oxford. Six week online course offering users personalized feedback

based on information inputted by users. Can extract data from tracking devices.

Go!to Sleep

Developed in Cleveland Clinic.

Six week interactive mobile app. Users register and enter sleep data and get a

sleep efficiency report and suggestions for sleep improvement.

Case Follow-up

Elderly patients will have age related biological changes, as well as medical issues and psychosocial factors

that may predispose patients to experiencing insomnia. Given the wife’s recollection of breathing issues

and restlessness at night, a polysomnogram would be prudent to consider. A full history and evaluation

including an evaluation of the patient’s sleep routine as well as an interview with his wife would be

indicated. If sleep disordered breathing and other potential sleep disorders such as restless legs syndrome

or periodic limb movement disorder are treated or ruled out, a non-pharmacological approach including

cognitive behavioural therapy is the treatment of choice. Medications can be considered in selected

circumstances, and if used are generally indicated for only short-term use. If obstructive sleep apnea is

diagnosed then the Canadian Medical Association fitness-to-drive guidelines should be followed with

respect to counselling temporary driving cessation (or permanent driving cessation if OSA is severe

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enough and patient is not responding or resistant to treatment as per CMA guidelines) and reporting to

the Ministry of Transportation as per provincial regulations.

Summary

Insomnia disorder is a complex disorder that is common in the elderly. Various factors may play a role

including biological, psychiatric and psychosocial factors. Some patients are more predisposed to

experiencing chronic insomnia difficulties, including women and those with more psychiatric or medical

comorbidities. Diagnostic evaluation should consist of a thorough history, including a detailed sleep

enquiry, a partner interview, and focused physical exam. Treatment options should then be directed at the

underlying contributing factors to insomnia symptoms. The insomnia disorder diagnosis is a paradigm shift

in the DSM-5, in recognition of the fact that insomnia often co-occurs with other medical and psychiatric

issues and that it needs to be treated in its own right to assure optimal outcomes. Concurrent treatment

of insomnia disorder with comorbid treatment of medical/psychiatric disorders can lead to improved

clinical outcomes, while failure to address this disorder can lead to diminished quality of life and increase

the risk of (re)lapse to a psychiatric disorder. If the diagnostic suspicion is insomnia disorder, a

Cognitive-behavioural approach is generally favored over a pharmacologic approach. Should a

pharmacological approach be considered, there is limited data to support use of short acting

benzodiazepine receptor agonists (Z drugs), as well as melatonin and doxepin but long term studies are

lacking and these agents should be used cautiously if use is necessary. Benzodiazepine use is discouraged

due to their unfavourable side effect profile. The paucity of data on other pharmacologic agents with

putative sedative properties limits support for utility of other agents though in circumstances with

significant comorbidities their use may be helpful (e.g., sedating antidepressant use such as mirtazapine

in the presence of a mood disorder). If insomnia problems persist despite treatment efforts, referral to a

sleep specialist should be considered, particularly if there is an elevated suspicion for a sleep disorder that

contributes to treatment resistance, such as a sleep related breathing disorder or underlying neurologic

disorder such as restless legs syndrome.

Acknowledgements: We would like to thank Dr. Lisa McMurray and Dr. Charles F. Reynolds III for their

thoughtful suggestions for this manuscript.

REFERENCES:

1. Association AP. Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5). Arlington,

VA: American Psychiatric Publishing; 2013.

2. Buysse DJ. Insomnia. Jama 2013;309:706-16.

3. Crowley K. Sleep and sleep disorders in older adults. Neuropsychology review 2011;21:41-53.

4. Foley D, Ancoli-Israel S, Britz P, Walsh J. Sleep disturbances and chronic disease in older adults: results

of the 2003 National Sleep Foundation Sleep in America Survey. Journal of psychosomatic research

2004;56:497-502.

5. Foley DJ, Monjan AA, Brown SL, Simonsick EM, Wallace RB, Blazer DG. Sleep complaints among elderly

persons: an epidemiologic study of three communities. Sleep 1995;18:425-32.

6. Cooke JR, Ancoli-Israel S. Sleep and its disorders in older adults. The Psychiatric clinics of North

America 2006;29:1077-93; abstract x-xi.

7. Yaffe K, Falvey CM, Hoang T. Connections between sleep and cognition in older adults. The Lancet

Neurology 2014;13:1017-28.

26

CHUN AND LEE | INSOMNIA IN THE ELDERLY: UPDATE ON ASSESSMENT AND MANAGEMENT

CGS JOURNAL OF CME | VOLUME 6, ISSUE 1, 2016

8. Morgan K, Kucharczyk E, Gregory P. Insomnia: evidence-based approaches to assessment and

management. Clin Med 2011;11:278-81.

9. Ancoli-Israel S, Ayalon L, Salzman C. Sleep in the elderly: normal variations and common sleep

disorders. Harvard review of psychiatry 2008;16:279-86.

10. Ohayon MM, Carskadon MA, Guilleminault C, Vitiello MV. Meta-analysis of quantitative sleep

parameters from childhood to old age in healthy individuals: developing normative sleep values across the

human lifespan. Sleep 2004;27:1255-73.

11. Paniagua MA, Paniagua EW. The demented elder with insomnia. Clinics in geriatric medicine

2008;24:69-81, vii.

12. McCall WV. Diagnosis and management of insomnia in older people. Journal of the American Geriatrics

Society 2005;53:S272-7.

13. Czeisler CA, Duffy JF, Shanahan TL, et al. Stability, precision, and near-24-hour period of the human

circadian pacemaker. Science 1999;284:2177-81.

14. Richardson GS, Carskadon MA, Orav EJ, Dement WC. Circadian variation of sleep tendency in elderly

and young adult subjects. Sleep 1982;5 Suppl 2:S82-94.

15. Monk TH. Aging human circadian rhythms: conventional wisdom may not always be right. J Biol

Rhythms 2005;20:366-74.

16. Wood B, Rea MS, Plitnick B, Figueiro MG. Light level and duration of exposure determine the impact of

self-luminous tablets on melatonin suppression. Appl Ergon 2013;44:237-40.

17. Chung F, Yegneswaran B, Liao P, et al. STOP questionnaire: a tool to screen patients for obstructive

sleep apnea. Anesthesiology 2008;108:812-21.

18. Allen RP, Picchietti D, Hening WA, et al. Restless legs syndrome: diagnostic criteria, special

considerations, and epidemiology. A report from the restless legs syndrome diagnosis and epidemiology

workshop at the National Institutes of Health. Sleep medicine 2003;4:101-19.

19. Bogan RK, Cheray JA. Restless legs syndrome: a review of diagnosis and management in primary

care. Postgrad Med 2013;125:99-111.

20. Schutte-Rodin S, Broch L, Buysse D, Dorsey C, Sateia M. Clinical guideline for the evaluation and

management of chronic insomnia in adults. Journal of clinical sleep medicine : JCSM : official publication of

the American Academy of Sleep Medicine 2008;4:487-504.

21. Smith MT, Perlis ML, Park A, et al. Comparative meta-analysis of pharmacotherapy and behaviour

therapy for persistent insomnia. Am J Psychiatry 2002;159:5-11.

22. Spielman AJ, Saskin P, Thorpy MJ. Treatment of chronic insomnia by restriction of time in bed. Sleep

1987;10:45-56.

23. Young T, Shahar E, Nieto FJ, et al. Predictors of sleep-disordered breathing in community-dwelling

adults: the Sleep Heart Health Study. Archives of internal medicine 2002;162:893-900.

24. Buysse DJ, Germain A, Moul DE, et al. Efficacy of brief behavioural treatment for chronic insomnia in

older adults. Archives of internal medicine 2011;171:887-95.

27

CHUN AND LEE | INSOMNIA IN THE ELDERLY: UPDATE ON ASSESSMENT AND MANAGEMENT

CGS JOURNAL OF CME | VOLUME 6, ISSUE 1, 2016

25. Jacobson SA. Clinical Manual of Geriatric Psychopharmacology. 2nd ed. Washington, DC: American

Psychiatric Publishing; 2014.

26. Allain H, Bentue-Ferrer D, Polard E, Akwa Y, Patat A. Postural instability and consequent falls and hip

fractures associated with use of hypnotics in the elderly: a comparative review. Drugs Aging

2005;22:749-65.

27. Gunja N. In the Zzz zone: the effects of Z-drugs on human performance and driving. J Med Toxicol

2013;9:163-71.

28. McCrae CS. Late-life comorbid insomnia: diagnosis and treatment. The American journal of managed

care 2009;15 Suppl:S14-23.

29. Verster JC, Spence DW, Shahid A, Pandi-Perumal SR, Roth T. Zopiclone as positive control in studies

examining the residual effects of hypnotic drugs on driving ability. Curr Drug Saf 2011;6:209-18.

30. Leufkens TR, Ramaekers JG, de Weerd AW, Riedel WJ, Vermeeren A. Residual effects of zopiclone 7.5

mg on highway driving performance in insomnia patients and healthy controls: a placebo controlled

crossover study. Psychopharmacology (Berl) 2014;231:2785-98.

31. Leufkens TR, Vermeeren A. Highway driving in the elderly the morning after bedtime use of hypnotics:

a comparison between temazepam 20 mg, zopiclone 7.5 mg, and placebo. J Clin Psychopharmacol

2009;29:432-8.

32. Sivertsen B, Omvik S, Pallesen S, et al. Cognitive behavioural therapy vs zopiclone for treatment of

chronic primary insomnia in older adults: a randomized controlled trial. Jama 2006;295:2851-8.

33. McMillan JM, Aitken E, Holroyd-Leduc JM. Management of insomnia and long-term use of sedative-

hypnotic drugs in older patients. CMAJ : Canadian Medical Association journal = journal de l'Association

medicale canadienne 2013;185:1499-505.

34. By the American Geriatrics Society Beers Criteria Update Expert P. American Geriatrics Society 2015

Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. Journal of the

American Geriatrics Society 2015;63:2227-46.

35. Taylor SR, Weiss JS. Review of insomnia pharmacotherapy options for the elderly: implications for

managed care. Popul Health Manag 2009;12:317-23.

36. Hemmelgarn B, Suissa S, Huang A, Boivin JF, Pinard G. Benzodiazepine use and the risk of motor

vehicle crash in the elderly. Jama 1997;278:27-31.

37. Meuleners LB, Duke J, Lee AH, Palamara P, Hildebrand J, Ng JQ. Psychoactive medications and crash

involvement requiring hospitalization for older drivers: a population-based study. Journal of the American

Geriatrics Society 2011;59:1575-80.

38. Billioti de Gage S, Moride Y, Ducruet T, et al. Benzodiazepine use and risk of Alzheimer's disease:

case-control study. BMJ 2014;349:g5205.

39. Bloom HG, Ahmed I, Alessi CA, et al. Evidence-based recommendations for the assessment and

management of sleep disorders in older persons. Journal of the American Geriatrics Society 2009;57:

761-89.

28

CHUN AND LEE | INSOMNIA IN THE ELDERLY: UPDATE ON ASSESSMENT AND MANAGEMENT

CGS JOURNAL OF CME | VOLUME 6, ISSUE 1, 2016

40. Mendelson WB. A review of the evidence for the efficacy and safety of trazodone in insomnia. The

Journal of clinical psychiatry 2005;66:469-76.

41. James SP, Mendelson WB. The use of trazodone as a hypnotic: a critical review. The Journal of clinical

psychiatry 2004;65:752-5.

42. Winokur A, DeMartinis NA, 3rd, McNally DP, Gary EM, Cormier JL, Gary KA. Comparative effects of

mirtazapine and fluoxetine on sleep physiology measures in patients with major depression and insomnia.

The Journal of clinical psychiatry 2003;64:1224-9.

43. Bain KT. Management of chronic insomnia in elderly persons. Am J Geriatr Pharmacother 2006;4:

168-92.

44. Krystal AD, Durrence HH, Scharf M, et al. Efficacy and Safety of Doxepin 1 mg and 3 mg in a 12-week

Sleep Laboratory and Outpatient Trial of Elderly Subjects with Chronic Primary Insomnia. Sleep

2010;33:1553-61.

45. Lankford A, Rogowski R, Essink B, Ludington E, Heith Durrence H, Roth T. Efficacy and safety of

doxepin 6 mg in a four-week outpatient trial of elderly adults with chronic primary insomnia. Sleep

medicine 2012;13:133-8.

46. American Geriatrics Society Beers Criteria Update Expert P. American Geriatrics Society updated Beers

Criteria for potentially inappropriate medication use in older adults. Journal of the American Geriatrics

Society 2012;60:616-31.

47. Kyung Lee E, Douglass AB. Sleep in psychiatric disorders: where are we now? Can J Psychiatry

2010;55:403-12.

48. Altamura AC, Moliterno D, Paletta S, Maffini M, Mauri MC, Bareggi S. Understanding the

pharmacokinetics of anxiolytic drugs. Expert Opin Drug Metab Toxicol 2013;9:423-40.

49. Leung JG, Hall-Flavin D, Nelson S, Schmidt KA, Schak KM. The Role of Gabapentin in the Management

of Alcohol Withdrawal and Dependence. Ann Pharmacother 2015;49:897-906.

50. Moore RA, Wiffen PJ, Derry S, Toelle T, Rice AS. Gabapentin for chronic neuropathic pain and

fibromyalgia in adults. Cochrane Database Syst Rev 2014;4:CD007938.

51. Ferini-Strambi L, Marelli S. Pharmacotherapy for restless legs syndrome. Expert Opin Pharmacother

2014;15:1127-38.

52. Ramar K, Olson EJ. Management of common sleep disorders. Am Fam Physician 2013;88:231-8.

53. Gabapentin for Adults with Neuropathic Pain: A Review of the Clinical Efficacy and Safety. Ottawa

(ON)2015.

54. Gibbons RD, Hur K, Brown CH, Mann JJ. Relationship between antiepileptic drugs and suicide attempts

in patients with bipolar disorder. Arch Gen Psychiatry 2009;66:1354-60.

55. Lemoine P, Wade AG, Katz A, Nir T, Zisapel N. Efficacy and safety of prolonged-release melatonin for

insomnia in middle-aged and elderly patients with hypertension: a combined analysis of controlled clinical

trials. Integr Blood Press Control 2012;5:9-17.

29

CHUN AND LEE | INSOMNIA IN THE ELDERLY: UPDATE ON ASSESSMENT AND MANAGEMENT

CGS JOURNAL OF CME | VOLUME 6, ISSUE 1, 2016

56. Riemersma-van der Lek RF, Swaab DF, Twisk J, Hol EM, Hoogendijk WJ, Van Someren EJ. Effect of

bright light and melatonin on cognitive and noncognitive function in elderly residents of group care

facilities: a randomized controlled trial. Jama 2008;299:2642-55.

57. Vural EM, van Munster BC, de Rooij SE. Optimal dosages for melatonin supplementation therapy in

older adults: a systematic review of current literature. Drugs Aging 2014;31:441-51.

58. Buscemi N, Vandermeer B, Hooton N, et al. The efficacy and safety of exogenous melatonin for

primary sleep disorders. A meta-analysis. J Gen Intern Med 2005;20:1151-8.

59. Lyseng-Williamson KA. Melatonin prolonged release: in the treatment of insomnia in patients aged

>/=55 years. Drugs Aging 2012;29:911-23.

60. Rubio-Sastre P, Scheer FA, Gomez-Abellan P, Madrid JA, Garaulet M. Acute melatonin administration

in humans impairs glucose tolerance in both the morning and evening. Sleep 2014;37:1715-9.

61. Herxheimer A, Petrie KJ. Melatonin for the prevention and treatment of jet lag. Cochrane Database

Syst Rev 2002:CD001520.

30

COMMUNICATION HEALTH AND AGING: CARING FOR OLDER ADULTS

Abstract

Communication disorders affect people of all ages, but older adults are

particularly at risk of developing speech, language, swallowing, hearing

and other auditory and balance disorders. Hearing and communication

disorders (collectively referred to as “communication disorders”

throughout the article) in the elderly are frequently the result of stroke,

certain cancers, head injury, neurodegenerative diseases (e.g.,

dementia, Parkinson’s disease, amyotrophic lateral sclerosis), noise

exposure, certain medications or are part of the normal aging process.

It is important for those who care for seniors to understand the impact,

signs and symptoms of communication disorders.

Early referral to a speech-language pathologist or audiologist for

assessment and treatment is essential, since early intervention for

hearing and communication disorders can significantly reduce their

impact on a patient’s quality of life. This article provides readers with

strategies and resources for caring for older adults with a variety of

communication disorders, focusing on hearing loss and dementia.

Les troubles de la communication affectent les personnes de tout âge,

mais les personnes âgées sont particulièrement à risque de développer

des atteintes de la parole, du langage, de la déglutition, de l'ouïe et de

l'équilibre. Les troubles auditifs et de la communication (collectivement

appelés «troubles de la communication» tout au long de l'article) chez

les personnes âgées sont souvent la conséquence d'accidents vasculaires

cérébraux, de certains cancers, de traumatismes crâniens, de maladies

neurodégénératives (par exemple, la démence, la maladie de Parkinson

ou la sclérose latérale amyotrophique), de l'exposition au bruit ou de

certains médicaments, ou sont tout simplement la conséquence du

processus normal de vieillissement. Il est important pour les

intervenants auprès de personnes âgées de bien comprendre l'impact,

les signes et les symptômes des troubles de la communication. La

référence précoce en orthophonie ou en audiologie pour l'évaluation et le

traitement des troubles de la communication est essentielle, puisqu’une

intervention précoce peut réduire considérablement leur impact négatif

sur la qualité de vie des patients. Cet article fournit aux lecteurs des

stratégies et des ressources dans le but de mieux prendre soin des

personnes âgées souffrant de divers troubles de la communication, avec

un accent particulier sur la perte de l’audition et la démence.

Chantal Kealey

AuD, Aud(C)

Doctor of Audiology;

Director of Audiology and

Communication Health

Assistants, Speech-

Language & Audiology

Canada

Marnie Loeb

M.Cl.Sc., S-LP(C)

Speech-Language

Pathology Advisor,

Speech-Language &

Audiology Canada

Corresponding Author:

Chantal Kealey

chantal@sac-oac.ca

Key words:

Dementia, long-term

care/nursing home,

neurology, preventive care,

psychiatric disorders/

mental health

Canadian Geriatrics Society

To see other CME articles, go to: www.cmegeriatrics.ca www.geriatricsjournal.ca

If you are interested in receiving this publication on a regular basis, please consider becoming a member.

31

This article has been peer reviewed.

Conflict of Interest: The authors report no conflicts of interest.

This article was published in May 2016

Key points

1. Nearly all patients with a neurodegenerative disease, such as dementia, Parkinson’s disease

and ALS, will experience difficulty communicating. Communication challenges are among the

most difficult for families to cope with during the course of these diseases.

2. Patients with hearing loss are more likely to develop dementia.4,5

3. Identification of and intervention for a communication disorder early on can make a significant

difference to a patient’s treatment outcomes, quality of life and the impact of a disease.

4. Patients should be referred to a speech-language pathologist or audiologist as soon as possible

if they show signs of a communication disorder. Patients should also be referred to an

audiologist if they have never had an audiological assessment.

5. Health care professionals can use this printable questionnaire to know when to make a referral

and refer to the resources provided in this article to improve interactions with patients with

communication disorders.

Introduction Communication disorders can have a far-reaching impact on an individual’s life. The ability to

communicate is directly linked to a person’s physical, emotional, social, vocational and financial

well-being, but many seniors may not know how to recognize a communication disorder or where to go for

help when they suspect a problem.

Since the risk of hearing loss and neurodegenerative disease increases with age, it is important for

health care professionals who care for seniors to be aware of the signs and symptoms of hearing and

communication disorders. Patients are more likely to benefit from rehabilitative and compensatory

strategies and experience improved quality of life when referred to a speech-language pathologist or

audiologist for assessment and treatment early on. Caregivers also benefit from counselling and education

regarding their loved ones’ communication and hearing difficulties.

Some of the most common symptoms of neurodegenerative disease (e.g., dementia, Parkinson’s disease,

amyotrophic lateral sclerosis) are communication and swallowing impairments. Ensuring that patients can

hear and understand directions, and that their hearing aids are working properly, improves the validity of

cognitive testing as well as patients’ understanding of and ability to participate in health care discussions

(thereby improving health literacy and adherence to medical recommendations). Speech-language

pathologists, audiologists and communication health assistants - known collectively as communication

health professionals - are integral members of health care teams that treat patients with these and many

other conditions.

Communication health professionals provide services to individuals with hearing, communication and

swallowing difficulties. Speech-language pathologists are professionals who work with people of all ages to

assess and treat speech, language, voice, swallowing and cognitive communication disorders. Audiologists

are professionals who work with people of all ages to assess and treat hearing loss, tinnitus (ringing in the

ears), other auditory disorders and balance disorders. Audiologists are distinct from hearing instrument

practitioners. Communication health assistants are employed in a role supporting the delivery of speech-

language pathology and/or audiology services and work under the supervision of speech-language

pathologists and audiologists.

32

Caring for Patients with Communication Disorders

Patients who have difficulty communicating may require extra assistance when visiting your office, clinic

or hospital. Speech-Language and Audiology Canada (SAC) has two tip sheets to help health care

professionals and members of the public communicate with patients who have a speech and language

disorder or a hearing or other auditory disorder. Download the speech and language disorder tip sheet and

hearing and other auditory disorder tip sheet and see below for additional information regarding

interacting with patients with hearing loss and dementia.

If you suspect that a patient may have a communication disorder, it is important that you refer that

patient to an audiologist and/or speech-language pathologist early on and throughout the progression of

age-related conditions such as neurodegenerative diseases. Please use this printable questionnaire to

help you decide when to make a referral.

In addition to being aware of local speech-language and audiology services, health care professionals can

use the Find a Professional Directory on the SAC website to find a speech-language pathologist or

audiologist. You can also print copies of SAC’s Communication Health and Aging brochure for your

waiting room.

Case Jack and his wife Maria knew about the early signs and symptoms of dementia. They consulted their

family doctor when Jack began to have difficulty remembering things and participating in meaningful

conversations. Following an assessment, he was diagnosed with Alzheimer’s disease. As time passed,

Jack’s illness became increasingly demanding both physically and emotionally; however, the biggest

challenge for Jack and Maria was communication.

Though Jack already had hearing aids, he had not been wearing them regularly and was overdue for an

appointment to see his audiologist. An assessment revealed that Jack’s hearing had declined significantly.

The audiologist recommended hearing aids that would provide the amplification Jack needed, in a hearing

aid style that he could easily manipulate given his reduced dexterity.

The audiologist counselled Jack and Maria about the importance of wearing the hearing aids, attending

necessary follow-up visits and offered aural rehab classes1 - which can benefit both patients with cognitive

decline and their caregivers2 - to help maximize Jack’s communication potential. The new hearing aids

helped Jack to better participate in conversations, follow instructions and be aware of his surroundings

and potential safety hazards. Maria felt like she had a piece of her husband back.

Maria also arranged for Jack to be assessed by a speech-language pathologist, who determined that Jack

understood written communications better than verbal ones. Maria began using notes to help Jack through

his daily routine. Maria also attended group communication training classes for caregivers where she

learned strategies for improving interactions with Jack, and came away with a new support network.

The speech-language pathologist also asked Maria about how Jack was eating and drinking. Jack had been

steadily losing weight and was coughing at mealtimes. The speech-language pathologist provided

strategies to help him swallow more safely and eat and drink more efficiently, and counselled Maria that

Jack’s swallowing function might progressively decline as his dementia progressed. Maria was also advised

to check with Jack’s physician to assess if his medications, such as his cholinesterase inhibitor, were

contributing to his weight loss. Together with an inter-professional health care team, the speech-language

pathologist helped Jack and Maria make advanced care decisions.3

33

Throughout the course of Jack’s illness both Jack and Maria benefited from the services provided by the

speech-language pathologist and audiologist, including their involvement on his end-of-life care team.

Patients with Hearing Loss

Follow these tips when communicating with people with hearing loss:

1. Get the person’s attention before you start talking.

2. Speak clearly and loudly enough to be heard, but do NOT shout. Shouting distorts speech sounds.

3. Be patient and provide the person with extra time to respond.

4. Avoid putting anything around your face and mouth when you are speaking (e.g., pens, phones,

hands). People with hearing loss use visual cues to help them understand the message.

5. Create an ideal listening environment: move away from noise sources and choose a place with

good lighting.

6. Position yourself across from the listener and look at the person while talking.

7. During group discussions, ensure that only one person speaks at a time.

In addition to using the above tips for communicating with someone who has a hearing disorder, you

should be aware of the technology that may be used by your patient. There are many styles of hearing

aids that have a wide variety of features, ranging from remote-controlled programs for different listening

environments to Bluetooth capability and cell phone compatibility.

Hearing Aid Troubleshooting

If you suspect your patient’s hearing aids are not working properly, try the following:

1. Cup the hearing aid in your hands to induce feedback or squealing. If there is no feedback, there

could be something wrong with the hearing aid. (You can also cup your hand to the patient’s

hearing aid in his/her ear to check for feedback.)

2. Visually inspect the hearing aid. Is there wax or debris covering one of the sound openings? If so,

try removing the buildup by gently wiping the device with a soft cloth. Is the casing cracked? If the

hearing aid has a tube, is it blocked or cracked?

3. Check the battery. Is it working? Is the battery inserted properly? Confirm that the “+” sign is in

line with the “+” sign on the cover. Make sure the battery door is fully closed.

For more troubleshooting tips, read this brief orientation to hearing aids.

Patients with Dementia

Follow these tips when communicating with people with dementia:

1. Be patient and give the person time to respond.

2. Situate yourself in front of your patients to make it easy for them to look at you. Use their

names to get their attention.

3. Use actions to convey what you are asking them to do (e.g., show them the gown you would

like them to put on).

4. Speak in a calm, soft tone to show them you care and have empathy. Being confrontational

reduces the likelihood they will cooperate.

5. Watch patients’ reactions (e.g., body language, facial expressions) for non-verbal cues as to

how they are feeling about your interactions.

6. Give simple, one-step directions and be prepared to repeat your instructions, either verbatim or

in a different way (e.g., if “Turn on the water” does not work, try “Turn the tap on”).

7. Tell your patients what you are going to do before doing it.

8. Reassure and praise them for what they are doing well.

34

Additional Dementia Resources

Information about dementia in other languages (for families whose first language is

not English.)

Strategies for managing dysphagia (swallowing disorders) in individuals with dementia (Note:

A thorough communication/swallowing assessment and follow-up by a speech-language

pathologist is necessary to make appropriate recommendations.)

Summary

Health care professionals can improve their patients’ overall health, function and quality of life by referring

to a speech-language pathologist or audiologist at the first sign of a communication disorder. Identifying

and treating speech, language, swallowing, hearing, other auditory disorders and balance disorders early

on may significantly slow an inevitable decline or, in reversible conditions, increase a person’s chances

of improvement.

For more information about communication disorders, please see Speech-Language and Audiology

Canada’s website. We encourage health care professionals to download our information sheets and

Communication Health and Aging brochure for further information about the prevalence of communication

disorders and what communication health professionals do, and invite them to read our peer-reviewed,

open-source academic journal, the Canadian Journal of Speech-Language Pathology and Audiology.

Did You Know?

● 1 in 6 people in Canada has a speech, language or hearing disorder.6

● A study released in 2015 revealed that 47% of Canadians aged 60-79 were significantly more

likely to have hearing loss compared with younger adults. However, about 70% of these

patients did not realize that they had a hearing problem.7

● Among adults with hearing loss aged 70 and older who could benefit from hearing aids, fewer

than one in three (30%) has ever tried them.8 Only 1 in 4 adults who need a hearing aid

actually uses one.9

● Studies suggest that individuals with hearing loss are 2 to 5 times more likely to develop

dementia10 and there is evidence that the use of hearing aids may slow the progression and

impact of cognitive decline.11,12,13,14

● The incidence of language impairment in dementia is estimated to be between 88% and 95%

and is close to 100% in Alzheimer’s disease.15

● Dysphagia (swallowing impairment) affects up to 68% of elderly nursing home (long-term care)

residents, up to 30% of elderly admitted to the hospital, up to 64% of patients after stroke and

13% to 38% of seniors who live independently.16

● Since communication disorders have proven to be among the strongest predictors for

discriminating among dementia subtypes, speech-language pathologists can contribute to the

accuracy of dementia diagnoses.17

● There is evidence that communication skills training with caregivers and health care

professionals improves the quality of life and well-being of patients with dementia. Such

training also has the added effect of improving behavioural issues and improving interactions

with caregivers.18,19

● Speech-language pathologists play a key role in end of life care. For example, they are part of

teams who counsel patients with severe dementia and their families regarding artificial

hydration and nutrition.

● Both audiologists and speech-language pathologists can facilitate communication for patients

with hearing impairments and nonverbal patients, sometimes using high- or low-tech

communication devices.

35

REFERENCES:

1. Pichora-Fuller MK, Dupuis K, Reed M, et al. Helping older people with cognitive decline communicate:

hearing aids as part of a broader rehabilitation approach. Semin Hear 2013;34:308-30.

2. Pichora-Fuller MK, Dupuis K, Reed M, et al. Helping older people with cognitive decline communicate:

hearing aids as part of a broader rehabilitation approach. Semin Hear 2013;34:308-30.

3. Lambert H. The allied health care professionals role in assisting medical decision making at the end of

life. Top Lang Disord 2012;32:119-36.

4. Lin FR, Yaffe K, Xia J, et al. Hearing loss and cognitive decline in older adults. JAMA Intern Med

2013;173: 293-299.

5. Lin FR, Ferrucci L, Metter EJ, et al. Hearing loss and cognition in the Baltimore longitudinal study of

aging. Neuropsychology 2011;25:763-770.

6. American Speech-Language-Hearing Association. Speech-language pathology medical review

guidelines. 2011. Available at: http://www.asha.org/uploadedFiles/SLP-Medical-Review-Guidelines.pdf.

7. Statistics Canada. Canadian Health Measures Survey: Hearing loss of Canadians, 2012 and 2013.

Health Fact Sheets 2015. Available at: http://www.statcan.gc.ca/pub/82-625-x/2015001/article/14156-

eng.htm.

8. National Institute on Deafness and Other Communication Disorders. Quick statistics. 2015. Available at:

http://www.nidcd.nih.gov/health/statistics/pages/quick.aspx.

9. Kochkin S. Marke Trak VIII: 25-Year trends in the hearing health market. Hear Rev 2009;16;12-31.

10. Lin FR, Ferrucci L, Metter EJ, et al. Hearing loss and cognition in the Baltimore longitudinal study of

aging. Neuropsychology 2011;25:763-770.

11. Deal JA, Richey Sharrett A, Albert MS, et al. Hearing impairment and cognitive decline: a pilot study

conducted within the atherosclerosis risk in communities neurocognitive study. Am J Epidemiol

2015;181:680-90.

12. Lin FR, Metter EJ, O'Brien RJ, et al. Hearing loss and incident dementia. Arch Neurol 2011;68:214-20.

13. Lin FR, Ferrucci L, Metter EJ, et al. Hearing loss and cognition in the Baltimore longitudinal study of

aging. Neuropsychology 2011;25:763-770.

14. Pichora-Fuller, K. Hearing loss, part 2: Is hearing loss linked to dementia? 2014. Available at:

http://www.mcmasteroptimalaging.org/citizens/blogs/detail/blog/2014/09/30/hearing-loss-part-2-is-

hearing-loss-linked-to-dementia.

15. Kempler D, Zelinski EM. Language in dementia and normal aging. In: Huppert FA, Brayne C, O'Connor

DW, eds. Dementia and Normal Aging. Cambridge: Cambridge University Press; 1994:331-365.

16. Sura L, Madhavan A, Carnaby G, et al. Dysphagia in the elderly: management and nutritional

considerations. J Clin Interv Aging 2012;7:287-198.

36

17. Reilly J, Rodriguez A, Lamy M, et al. Cognition, language, and clinical pathological features of non-

Alzheimer's dementias: an overview. J Commun Disord 2010;43:438-452.

18. Eggenberger E, Heimerl K, Bennett M. Communication skills training in dementia care: a systematic

review of effectiveness, training content, and didactic methods in different care settings. Int Psychogeriatr

2013;25:345-358.

19 McGilton KS, Boscart V, Fox M, et al. A systematic review of the effectiveness of communication

interventions for health care providers caring for patients in residential care settings. Worldviews Evid

Based Nurs 2009;6:149-59.

37

CHOOSING WISELY CANADA: GERIATRICS

This article has been peer reviewed.

Conflict of Interest: Dr. Herrmann was a member of the CPA/CAGP

Choosing Wisely Writing Group. He has received research support from

Lundbeck and Roche and consultation fees from Astellas, Merck, AbbVie

and Lilly. This article was published in May 2016.

1. Don’t use antimicrobials to treat bacteriuria in older adults

unless specific urinary tract symptoms are present.

Adrian Wagg

2. Don’t use benzodiazepines or other sedative hypnotics in

older adults as first line choice of insomnia, agitation

or delirium.

Jayna Holroyd-Leduc and Jacqueline McMillan

3. Don’t recommend percutaneous feeding tubes in patients with

advances dementia: instead offer oral feeding.

Robert Lam and Jose Morais

4. Don’t use antipsychotics as first choice to treat behavioural

and psychological symptoms of dementia (BPSD).

Nathan Herrmann

5. Avoid using medications known to cause hypoglycemia to

achieve hemoglobin A1c <7.5%; in many adults age 65 and

older moderate control is generally better.

Jayna Holroyd-Leduc and Jacqueline McMillan

Karen Fruetel Med, MD, FRCPC Associate Professor, Cumming School of Medicine

Nathan Herrmann MD, FRCPC Professor, Faculty of Medicine,

University of Toronto; Head, Division of Geriatric Psychiatry, Sunnybrook Health

Sciences Centre Jayna M. Holroyd-Leduc MD, FRCPC Resident, Department of Medicine, Section of Geriatric Medicine, University of

Calgary

Robert Lam MD, MS, CCFP, FCFP

Associate Professor of Family

Medicine, University of Toronto Jacqueline McMillan MD

Department of Medicine, Section of Geriatric Medicine, University of Calgary

Jose Morais MD, FRCPC Associate Professor and Director Division of Geriatric Medicine, McGill University

Adrian Wagg

MB, FRCP (Lond), FRCP (Edin), FHEA (MD) Capital Health Endowed Chair in Healthy Aging;

Department of Medicine University of Alberta Key words: Choosing Wisely Canada, geriatrics, asymptomatic bacteriuria, insomnia, agitation, delirium,

benzodiazepines, sedative hypnotics, percutaneous feeding tube, advanced dementia, antipsychotics,

behavioural and psychological symptoms of dementia,

diabetes, hypoglycaemia

Canadian Geriatrics Society

To see other CME articles, go to: www.cmegeriatrics.ca www.geriatricsjournal.ca

If you are interested in receiving this publication on a regular basis, please consider becoming a member.

38

Introduction The Canadian Geriatrics Society (www.canadiangeriatrics.ca) has been proud to partner with Choosing

Wisely Canada (CWC), a campaign to help physicians and patients engage in conversations about

unnecessary tests, treatments or procedures. CWC was launched in 2012 with 6 specialties making

recommendations on “Five Things Physicians and Patients Should Question.” It has now grown to include a

total of 166 recommendations from 29 specialty associations.

In Geriatrics, the Five Things Physicians and Patients Should Question include:

1. Don’t use antimicrobials to treat bacteriuria in older adults unless specific urinary tract symptoms

are present;

2. Don’t use benzodiazepines or other sedative-hypnotics in older adults as first choice for insomnia,

agitation or delirium;

3. Don’t recommend percutaneous feeding tubes in patients with advanced dementia, instead offer

oral feeding;

4. Don't use antipsychotics as first choice to treat behavioural and psychological symptoms of

dementia; and

5. Avoid using medications known to cause hypoglycemia to achieve hemoglobin A1c <7.5% in many

adults age 65 and older; moderate control is generally better.

This issue of the Canadian Geriatrics Society Journal of CME (www.geriatricsjournal.ca) is devoted to Five

Things that Physicians and Patients Should Question in Geriatrics. The contributors to this issue have all

been involved in the development of the recommendations and have collaborated to provide an article

outlining the recommendations and the rationale behind them.

The Choosing Wisely Canada website (www.choosingwiselycanada.org) includes the physician

recommendations from all participating societies. Some of the other specialty societies have

recommendations that may be of relevance to our patient population, such as testing testosterone levels,

x-rays in back pain with no red flags, routine self-glucose monitoring in adults with stable type 2 diabetes

or the use of long term proton pump inhibitors to name a few. The Canadian Geriatrics Society

recommendations can be found at www.choosingwiselycanada.org/recommendations/geriatrics/

The CWC website also has patient materials that physicians might find helpful in engaging patients in

these discussions that promote truly informed consent (see www.choosingwiselycanada.org/materials/).

There are patient materials that support the CGS recommendations including:

1. Antibiotics for urinary tract infections in older people: When you need them – and when you don’t

2. Treating disruptive behaviour in people with dementia: Antipsychotic drugs are usually not the best

choice

3. Insomnia and anxiety in older people: Sleeping pills are usually not the best solution

4. Feeding tubes for people with Alzheimer’s disease: When you need them – and when you don’t

We hope you find this issue illuminating and encourage you to check out the CWC website and review

other recommendations.

39

1. Don’t use antimicrobials to treat bacteriuria in older adults unless specific urinary tract symptoms are present.

Despite being common in older adults, urinary tract infection (UTI) is poorly understood and often

incorrectly diagnosed; furthermore, its assessment and management lacks a robust evidence base.

Urinary tract infection requires invasion of the epithelium of the urinary tract by pathogenic bacteria; the

presence of bacteria in the urine is not synonymous with UTI but UTI is a significant cause of mortality,

with bacteraemic UTI carrying a mortality of up to 33% in older adults.1

The diagnosis of UTI in older persons is often challenging, with older patients being less likely to present

with classical symptoms or fever2, and with asymptomatic bacteriuria being highly prevalent.3-5 It has

been estimated that in hospitalised older people up to half of diagnoses of UTI are incorrect.6

Asymptomatic bacteriuria (ASB) too is common in older adults, with estimates of prevalence ranging from

5-20% among ambulatory older people and up to 50% of those living in institutions.5 It is defined by the

Infectious Diseases Society of America as 2 consecutive voided urine specimens with isolation of the same

bacterial strain in quantitative counts <105 cfu/ml in women or a single sample in men.7 Repeatedly

treating asymptomatic bacteriuria is of no benefit either in terms of symptoms or mortality.5,7,8

Asymptomatic bacteriuria in men has been shown to resolve spontaneously in 76% of cases.4 Unnecessary

antibiotics are associated with significant risks including Clostridium difficile infection as well as the

development of resistant bacteria. Resistance rates to uropathogens are rising, with over 25% of

E. coli resistant to trimethoprim in the United States.9 Antibiotic stewardship programs and adherence to

local antibiotic guidelines are crucial.

Fundamentally, the diagnosis of UTI is a clinical one, based on symptoms and signs. UTI should be

considered in those with a fever and who do not have 2 symptoms or signs of a non-urinary infection,

such as cough, sputum, diarrhea, rash or swelling, and who do have one or more symptoms of UTI, such

as dysuria, urgency, flank or suprapubic pain, incontinence, frequency or haematuria. In individuals with a

urinary catheter, UTI should be considered in those with fever or in apyrexial individuals with new

costovertebral tenderness, delirium or rigors. In the presence of sepsis, and in particular when presenting

with confusion or tachypnea (possibly as a result of metabolic acidosis), the possibility of a urinary source

should be considered, urine cultured and appropriate antimicrobial treatment given.10

There is a pervasive and persistent belief that urinary tract infection in older people presents with

non-specific symptoms of lethargy, malaise and anorexia, despite being demonstrated to be untrue almost

30 years ago.11 Urinary tract infection typically presents with dysuria, frequency, urgency or incontinence

and the absence of symptoms ascribable to the lower urinary tract should prompt a search for an

alternative explanation, even in the presence of a positive urine dip or urine culture. Older women with

UTI are more likely than younger women to present with urgency, painful voiding and incontinence rather

than increased urinary frequency.12 Urinary tract infection is also often held to be a cause of delirium;

however, a systematic review of the evidence for this found the strength of association between UTI and

delirium “modest” at best, and bacteriuria without symptoms of UTI – dysuria, frequency, bladder

discomfort or fever – was not a likely cause of delirium.13

In residents of nursing homes only those with convincing signs of active infection should be treated with

antibiotics.14 However, this can lead to a considerable diagnostic dilemma, particularly in cognitively

impaired persons (in nursing homes and other settings) unable to communicate their symptoms, where

things are “not quite right” and there is pyuria on dipstick urinalysis. Pragmatically, if a thorough search

for alternative causes for being “not quite right” has been performed, then a clinical decision based upon

the best interests of the patient needs to be made.

40

The aim of this review is not to outlaw the prescribing of any antibiotics but to move away from the

default position, so often seen, of a positive urinalysis being treated without thought as to its relevance.

To learn more regarding this topic and urinary incontinence in general please go to Urinary Incontinence in

the Frail Elderly.

2. Don’t use benzodiazepines or other sedative hypnotics in older adults as first line choice for insomnia, agitation or delirium. Benzodiazepines and other sedative hypnotics continue to be prescribed for older adults despite frequent

adverse events. For every 13 people treated with a sedative hypnotic 1 will experience an improvement in

their quality of sleep, whereas 1 person will experience harm for every 6 people prescribed a sedative.1

Specifically, sedative hypnotic use for the management of insomnia has been associated with increased

risk of adverse cognitive (OR 4.78 [95% CI: 1.47-15.47]) and psychomotor outcomes (OR 2.25 [95% CI:

0.93 - 4.51]).1

A literature review of medications used to treat insomnia, including non-benzodiazepine Z-drugs, found a

two-fold increased risk of falls and hip fractures with the use of these medications among older adults.2

Zolpidem has been found to increase the risk of hip fracture on a similar order of magnitude as

benzodiazepines.3 In adults over the age of 65 years, zolpidem was associated with a greater risk of

non-vertebral fracture than alprazolam and possibly lorazepam, with a similar risk of fracture to

temazepam.4 Furthermore, Health Canada has issued an advisory for zolpidem following reports of

complex sleep-related behaviours.5 Other psychotropic medications, including antidepressants and

antiepileptics, were also associated with an increased risk of falls.2 For a comprehensive review of

medications that can contribute to falls see Interventions to Reduce Medication-Related Falls.

The American Geriatrics Society 2012 Updated Beers’ Criteria makes a strong recommendation based on

high quality evidence to avoid all type of benzodiazepines (short and long-acting) for the treatment of

insomnia, agitation and delirium in older adults. Notable exceptions include the use of benzodiazepines for

the treatment of severe generalized anxiety disorder, alcohol or benzodiazepine withdrawal, delirium

tremens, rapid eye movement sleep disorders and end-of-life care.6 The Updated Beers’ Criteria also

makes a strong recommendation, based on moderate quality evidence, to avoid long-term use (>90 days)

of Z-drugs due to similar risk of adverse events and only minimal improvement in sleep parameters.6

For more resources on polypharmacy see the Medication Optimization/Polypharmacy section at

www.geriatricsjournal.ca.

Hospital prescribing practices can have implications for long-term sedative use. Among persons

discharged from hospital in the preceding 30 days, individuals were more likely to discontinue regular

sleep medication use if they did not receive them during the hospitalization

(OR 3.58 [95% CI: 1.56 - 8.21]). Similarly, individuals were more likely to initiate regular use of sleep

medications if they were initiated in hospital (OR 3.57, 95% CI: 1.66 - 8.08).7

There is a paucity of evidence to support the use of other pharmacological agents to help promote sleep.

There is currently insufficient safety and efficacy data to support the use of melatonin, ramelteon,

diphenhydramine and doxepin, and there are no studies on the use of atypical antipsychotics, trazodone

or other antidepressants for the treatment of insomnia, despite the use of these medications for their

sedating properties.8

A recently published cohort study found that individuals with the highest cumulative exposure to

anticholinergic medications had a statistically significant increased risk of dementia (adjusted hazard ratio

1.54 [95% CI: 1.21-1.96]), and in particular Alzheimer Disease (adjusted HR 1.63 [95% CI: 1.24 - 2.14])

compared with those with no use.9 High cumulative exposure in this study was the equivalent of three

years of daily use of a tricyclic antidepressant, antimuscarinic or first generation antihistamines.9 These

three classes of medication together accounted for greater than 90% of anticholinergic exposure in the

study.9

41

Effective strategies for discontinuing sedative hypnotic medications include cognitive-behavioural therapy,

brief behavioural intervention and tapering protocols, both alone and in combination.8 Readers are

directed to an article on discontinuing psychotropic medications (see Strategies for Discontinuing

Psychotropic Medications).

Cognitive-behavioural therapy and brief behavioural intervention have also been found to be effective

therapies to help manage insomnia. Brief behavioural intervention consists of a series of brief sessions

that promote good sleep hygiene. Exercise, such as tai chi, can also help address insomnia.10,11 Among

persons with dementia, sleep education provided to caregivers may help to improve sleep.12 Overall,

non-pharmacological therapies should be considered as first-line treatment in the management of

insomnia. For more information on the diagnosis and treatment of insomnia refer to the relevant article at

www.geriatricsjournal.ca.

3. Don’t recommend percutaneous feeding tubes in patients with advanced dementia; instead offer oral feeding. The prevalence of dementia in Canada has now risen to over 700,000 cases and Canadian physicians will

need to address associated care needs1. In the advanced stages of dementia, almost all patients develop

swallowing problems. A large prospective cohort study following 323 nursing home residents with a

Mini-Mental State Examination score of 5 or less, found that 85% had eating difficulties and their 6-month

mortality was almost 40%2. Given the limited life expectancy of patients with advanced dementia, the

risks and benefits of all medical interventions must be carefully weighed.

While feeding tubes can help some patients with localized swallowing problems, such as those with

cerebrovascular accidents, there is now almost general consensus that feeding tubes do not benefit

patients with advanced dementia. Examining the evidence from observational controlled studies involving

nasogastric tubes, percutaneous endoscopic gastrostomy tubes or a combination of types of feeding

tubes, a Cochrane review found insufficient evidence that feeding tubes enhance survival or quality of life,

or that they reduce pneumonia or pressure ulcers3.

Careful hand-feeding with an appropriate food texture may be preferable to tube-feeding. Although a

direct comparison is not available, evidence suggests that careful hand-feeding is as good as tube-feeding

in terms of complications and survival4. Hand-feeding may be best provided in small quantities, with more

frequent administration intervals, to minimize choking. Although this is more time consuming,

hand-feeding does provide caregivers a way to express care and allows patients the enjoyment of

natural eating5.

Patients at the end of life may feel only transient hunger and thirst6. Family members and substitute

decision-makers are often concerned about this when deciding on feeding interventions. Withholding

hydration and nutrition in end-of-life situations accompanying advanced dementia is felt to not be

associated with discomfort so long as adequate mouth care is provided7.

Most feeding tubes (68%) are given to residents of nursing homes during an admission to hospital for

acute care8. If patients are transferred to the emergency room in a state of delirium related to an acute

medical issue, then the extent of the patient’s underlying dementia may be unclear to the hospital staff.

Even if there is a diagnosis of dementia on the transfer note, because there is a wide spectrum of severity

in dementia, a feeding tube may be initiated. Deciding on its removal at a later time can be difficult for a

substitute decision-maker.

Family physicians in the outpatient setting and those attending long term care facilities in Canada who

have developed significant relationships with their elderly patients may be in the ideal position to initiate

discussions regarding advance directives. These discussions should include family members and those

chosen as substitute decision-makers. Feeding decisions are best discussed well before an admission to

42

hospital. A randomized controlled trial showed that substitute decision-makers had more knowledge and

less decisional angst about decisions pertaining to feeding options after watching an educational video

(decisionaid.ohri.ca/tools.html)9. Decision aids such as this may enhance the quality of subsequent

discussions. For more information on Advance Care Planning go to www.advancecareplanning.ca.

4. Don’t use antipsychotics as first choice to treat behavioural and psychological symptoms of dementia (BPSD). “People with dementia often exhibit challenging behavioural symptoms such as aggression and psychosis.

In such instances, antipsychotic medicines may be necessary, but should be prescribed cautiously as they

provide limited benefit and can cause serious harm, including premature death. Use of these drugs should

be limited in dementia to cases where nonpharmacologic measures have failed, and where the symptoms

either cause significant suffering, distress and/or pose an imminent threat to the patient or others. A

thorough assessment that includes identifying and addressing causes of behaviour change can make use

of these medications unnecessary. Epidemiological studies suggest that typical (i.e., first generation)

antipsychotics (i.e., haloperidol) are associated with at least the same risk of adverse events. This

recommendation does not apply to the treatment of delirium or major mental illnesses such as mood

disorders or schizophrenia.”1

This Choosing Wisely recommendation was made by the Canadian Psychiatric Association and the

Canadian Academy of Geriatric Psychiatry. In similar (but fewer) words, the Canadian Geriatric Society

also recommended against using antipsychotics as first line therapy for neuropsychiatric symptoms in

dementia2 and in fact, virtually identical but separate recommendations for Choosing Wisely US were

made by the American Psychiatric Association3, the American Geriatric Society4 and the American

Association of Medical Directors5. So, if everyone agrees, why was it so important for all these prestigious,

important organizations to make similar recommendations? If you are a clinician that treats people with

Alzheimer’s disease or other dementias, you are keenly aware of how common agitation, aggression

psychosis and anxiety are in these patients, how much suffering they cause for patients, families and

caregivers, and how they contribute to the cost of care and increase the risk of institutionalization.6

With respect to all these Choosing Wisely recommendations, here are the facts:

1) Antipsychotics, both typical and atypical, are the best studied pharmacological interventions to

treat agitation, aggression and psychosis in dementia and provide modest, but reliable benefit.7

2) Antipsychotics are associated with significant potential adverse events including increased risk of

mortality (NNH = 100), cerebrovascular adverse events, extrapyramidal symptoms, falls and hip

fractures, worsening cognitive impairment, weight gain and metabolic problems

(e.g., hyperlipidemia and hyperglycemia). These adverse effects have been documented in

randomized placebo controlled trials as well as administrative health database studies.8,9

3) Alternative pharmacological interventions (e.g., antidepressants, anticonvulsants etc.) have been

studied in a very small number of studies, but none have demonstrated enough consistent benefit

and safety to be included in evidence-based clinical practice guidelines.10

4) While non-pharmacological and behavioural interventions are less well studied they are probably as

effective as, and certainly safer than antipsychotics. Unfortunately, it is often difficult to implement

these therapies because of lack of available resources.10

These 4 “facts” have led to a situation whereby the use of antipsychotics for patients with dementia has

continued to climb in spite of the Black Box warnings for cerebrovascular adverse events and mortality

that were first issued by Health Canada over a decade ago.11

In order to avoid the use of antipsychotics, I recommend the “4 –Ize/ise” (Temporize, Optimize,

Improvise and Compromise). By temporize, I mean not rushing in to prescribe any medication. Make sure

the change in behaviour is not due to an inter-current medical condition or another medication. Ask the

43

caregiver to provide a diary for a week that records the antecedents of the behaviour, the type and

severity of behaviour, and the consequences of the behaviour. Neuropsychiatric symptoms are not always

persistent, and structured observation actually helps caregivers predict and deal with the behaviours.

Optimize involves making sure they are benefiting from and tolerating their anti-dementia medications

(cholinesterase inhibitors and/or memantine). These medications can have modest behavioural benefits.

Improvise means considering behavioural interventions by utilizing day programs, home care services and

support groups from the local Alzheimer Society. At times, low doses of an antidepressant like

escitalopram may improve depressive symptoms, anxiety and irritability and lead to a decrease in

agitation and aggression. Finally, if all else fails and there’s a risk to patient and caregiver, compromise by

using a low dose of an antipsychotic like risperidone, olanzapine or aripiprazole. This can be justified, as

long as the caregiver has been informed of and appreciates the balance of benefits and risks. If an

antipsychotic is prescribed, attempts to withdraw after a period of behavioural stability are

strongly recommended.

To learn more regarding the management of Behavioural and Psychological Symptoms of Dementia

(BPSD) see Practical Tips for Recognition and Management of Behavioural and Psychological Symptoms of

Demetia.

5. Avoid using medications known to cause hypoglycemia to achieve hemoglobin A1c <7.5%; in many adults age 65 and older moderate control is generally better. Despite having the highest prevalence of diabetes, older adults are often excluded from randomized

controlled trials of diabetes treatment, and as a result there is little clinical trial data on glycemic control in

this population.1 The United Kingdom Prospective Diabetes Study (UKPDS) provided evidence for glycemic

control in preventing microvascular complications in diabetes; however, only enrolled middle-aged

patients with newly diagnosed type 2 diabetes and excluded those over the age of 65 years.1

Intense control has been consistently shown to produce higher rates of hypoglycemia. Individuals over 75

years of age have twice the rate of emergency department visits for hypoglycemia than the general

population with diabetes.2 Furthermore, asymptomatic hypoglycemia detected by continuous glucose

monitoring is common in the elderly.3 Age appears to affect the counter-regulatory response to

hypoglycemia, with older adults having fewer autonomic and neuroglycopenic symptoms in response to

hypoglycemia than do middle-aged patients.1

The Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial, the Action in Diabetes and Vascular

Disease: Preterax and Diamicron MR Controlled Evaluation (ADVANCE) trial and the Veterans Affairs

Diabetes Trial (VADT) were designed to evaluate the role of glycemic control in preventing the

complications of cardiovascular disease in middle aged and older patients with type 2 Diabetes Mellitus.1

ACCORD randomized over 10,000 patients (mean age 62 years) to intensive glycemic control (A1c <6%)

versus more modest control (7-7.9% in control arm). The trial was discontinued early (at 3.5 years) due

to higher mortality rates in the intensive therapy group.4 VADT randomized over 1700 veterans with type

2 diabetes to intensive or standard glucose control (intensive = 1.5% reduction in A1c with median A1c

achieved = 6.9%, compared with standard therapy = 8.4%). VADT found no significant between group

differences in the primary outcomes of MI, stroke or death from cardiovascular causes, and no significant

differences in microvascular complications.5 ADVANCE randomized over 11,000 patients to either standard

therapy or intensive glucose control (gliclazide plus other drugs as needed to achieve an A1c target

<6.5%). The trial found no significant difference in major macrovascular events, death from

cardiovascular causes or death from any cause, but intensive glucose control did result in a significant

reduction in the incidence of nephropathy (4.1% versus 5.2%; hazard ratio 0.79; 95% CI: 0.77 - 0.97).6

A U-shaped association has been found between A1c and mortality. Both low and high mean A1c values

have been shown to be associated with increased all-cause mortality and cardiovascular disease events.7

44

Given the long time-frame (8 years)8 to achieve theorized benefit of intense control, glycemic targets

should reflect patient goals, health status and life expectancy. Reasonable glycemic targets of 7-7.5% in

healthy older adults with long life expectancy, 7.5-8% in those with moderate comorbidity and a life

expectancy <10 years, and 8-8.5% in those with multiple comorbidities and shorter life expectancy are

recommended in the Canadian Diabetes Association Clinical Practice Guidelines.9

Treatment approaches may be individualized based on the patient’s cognitive ability and degree of

independence. In older adults with cognitive impairment, glucose monitoring and insulin adjustments are

more difficult and potentially prone to error.1 The clock-drawing test can be used to predict which elderly

patients may have difficulty with insulin management.10 When it comes to oral hypoglycemic agents,

sulfonylureas should be used with caution because of the exponential increased risk of hypoglycemia with

advancing age.9

To learn more regarding diabetic control in older patients, go to Management of Diabetes Among Frail

Older Adults.

REFERENCES:

1. DON’T USE ANTIMICROBIALS TO TREAT BACTERIURIA IN OLDER ADULTS UNLESS SPECIFIC

URINARY TRACT SYMPTOMS ARE PRESENT

1. Tal, S., et al., Profile and prognosis of febrile elderly patients with bacteremic urinary tract infection. J

Infect, 2005. 50(4): p. 296-305.

2. Caterino, J.M., et al., Age, nursing home residence, and presentation of urinary tract infection in U.S.

emergency departments, 2001-2008. Acad Emerg Med, 2012. 19(10): p. 1173-80.

3. Ishay, A., I. Lavi, and R. Luboshitzky, Prevalence and risk factors for asymptomatic bacteriuria in

women with Type 2 diabetes mellitus. Diabet Med, 2006. 23(2): p. 185-8.

4. Mims, A.D., et al., Clinically inapparent (asymptomatic) bacteriuria in ambulatory elderly men:

epidemiological, clinical, and microbiological findings. J Am Geriatr Soc, 1990. 38(11): p. 1209-14.

5. Nicolle, L.E., Asymptomatic bacteriuria in the elderly. Infect Dis Clin North Am, 1997. 11(3): p. 647-62.

6. Woodford, H.J. and J. George, Diagnosis and management of urinary tract infection in hospitalized older

people. J Am Geriatr Soc, 2009. 57(1): p. 107-14.

7. Nicolle, L.E., et al., Infectious Diseases Society of America guidelines for the diagnosis and treatment of

asymptomatic bacteriuria in adults. Clin Infect Dis, 2005. 40(5): p. 643-54.

8. Abrutyn, E., et al., Does asymptomatic bacteriuria predict mortality and does antimicrobial treatment

reduce mortality in elderly ambulatory women? Ann Intern Med, 1994. 120(10): p. 827-33.

9. Sanchez, G.V., et al., In vitro antimicrobial resistance of urinary Escherichia coli isolates among U.S.

outpatients from 2000 to 2010. Antimicrob Agents Chemother, 2012. 56(4): p. 2181-3.

10. Barkham, T.M., F.C. Martin, and S.J. Eykyn, Delay in the diagnosis of bacteraemic urinary tract

infection in elderly patients. Age Ageing, 1996. 25(2): p. 130-2.

11. Boscia, J.A., et al., Lack of association between bacteriuria and symptoms in the elderly. Am J Med,

1986. 81(6): p. 979-82.

12. Arinzon, Z., et al., Clinical presentation of urinary tract infection (UTI) differs with aging in women.

Arch Gerontol Geriatr, 2012. 55(1): p. 145-7

45

13. Balogun, S.A. and J.T. Philbrick, Delirium, a Symptom of UTI in the Elderly: Fact or Fable?

A Systematic Review. Can Geriatr J, 2014. 17(1): p. 22-6.

14. Nicolle, L.E., Urinary tract infection in long-term-care facility residents. Clin Infect Dis, 2000. 31(3):

p. 757-61.

2. DON’T USE BENZODIAZEPINES OR OTHER SEDATIVE HYPNOTICS IN OLDER ADULTS AS

FIRST LINE CHOICE FOR INSOMNIA, AGITATION OR DELIRIUM

1. Glass J, Lanctot KL, Herrmann N, Sproule BA, Busto UE. Sedative hypnotics in older people with

insomnia: meta-analysis of risks and benefits. BMJ 2005; 331 (7526): 1169.

2. Allain H, Bentue-Ferrer D, Polard E, et al. Postural instability and consequent falls and hip fractures

associated with the use of hypnotics in the elderly. Drugs Aging 2005; 22:749-65.

3. Wang PS, Bohn RL, Glynn RJ, et al. Zolpidem use and hip fractures in older people. J Am Geriatr Soc

2001; 49: 1685-90.

4. Finkle WD, Der JS, Greenland S, et al. Risk of fractures requiring hospitalization after an initial

prescription of zolpidem, alprazolam, lorazepam, or diazepam in older adults. J Am Geriatr Soc 2011;

59(10): 1883-90.

5. Recalls and alerts: Sublinox (zolpidem tartrate) – association with complex sleep behaviours - for

health professionals. Ottawa (ON): Health Canada; 2011. Available: http://www.hc-sc.gc.ca/dhp-

mps/medeff/bulletin/carn-bcei_v22n2-eng.php# (accessed 16 October 2015).

6. American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older

adults. J Am Geriatr Soc 2012; 60: 616-31.

7. Zisberg A, Shadmi E, Sinoff G, et al. Hospitalization as a turning point for sleep medication use in older

adults. Drugs Aging 2012; 29:565-76.

8. McMillan JM, Aitken E, Holroyd-Leduc JM. Management of insomnia and long-term use of sedative

hypnotic drugs in older patients. CMAJ 2013; 185(17): 1499-1505.

9. Gray SL, Anderson ML, Dublin S, et al. Cumulative use of strong anticholinergics and incident dementia.

JAMA Int Med 2015; 175(3): 401-7.

10. Nguyen MH, Kruse A. A randomized controlled trial of tai chi for balance, sleep quality and cognitive

performance in elderly Vietnamese. Clin Interv Aging 2012; 7:185-90.

11. Chen MC, Liu HE, Huang HY. The effect of a simple traditional exercise programme (Baduanjin

exercise) on sleep quality of older adults: a randomized controlled trial. Int J Nurs Stud 2012: 49:265-73.

12. McCurry SM, LaFazia DM, Pike KC, et al. Development and evaluation of a sleep education program for

older adults with dementia living in adult family homes. Am J Geriatr Psychiatry 2012; 20: 494-504.

3. DON’T RECOMMEND PERCUTANEOUS FEEDING TUBES IN PATIENTS WITH ADVANCED

DEMENTIA; INSTEAD OFFER ORAL FEEDING

1. A new way of looking at the impact of dementia in Canada. Alzheimer Society of Canada, 2012.

2. Mitchell SL, Teno JM, Kiely DK, et al. The clinical course of advanced dementia. N Engl J

Med 2009;361:1529-38.

46

3. Sampson EL, Candy B, Jones L. Enteral tube feeding for older people with advanced

dementia. Cochrane Database Syst Rev 2009; (2):CD007209.

4. Garrow D, Pride P, Moran W, et al. Feeding alternatives in patients with dementia: examining

the evidence. Clin Gastroenterol Hepatol 2007;5:1372-8.

5. American Geriatrics Society Ethics Committee and Clinical Practice and Models of Care

Committee. American Geriatrics Society Feeding tubes in advanced dementia position

statement. J Am Geriatr Soc 2014;62:1590-3.

6. Gillick MR. Rethinking the role of tube feeding in patients with advanced dementia. N Engl J

Med 2000;342:206-10.

7. Arcand M. End-of-life issues in advanced dementia: Part 2: Management of poor nutritional intake,

dehydration, and pneumonia. Canadian Family Physician 2015;61(4):337-41.

8. Kuo S, Rhodes R, Mitchell S, et al. Natural history of feeding-tube use in nursing home

residents with advanced dementia. J Am Med Dir Assoc 2009;10:264-70.

9. Hanson LC, Carey TS, Caprio AJ, et al. Improving decision-making for feeding options in

advanced dementia: a randomized, controlled trial. J Am Geriatr Soc 2011;59:2009-16.

4. DON’T USE ANTIPSYCHOTICS AS FIRST CHOICE TO TREAT BEHAVIOURAL AND

PSYCHOLOGICAL SYMPTOMS OF DEMENTIA (BPSD)

1. Canadian Psychiatric Association. Psychiatry: Thirteen Things Physicians and Patients Should Question.

http://www.choosingwiselycanada.org/recommendations/psychiatry/

2. Canadian Geriatrics Society. Geriatrics: Five Things Physicians and Patients Should Question.

http://www.choosingwiselycanada.org/recommendations/geriatrics/

3. American Psychiatric Association. Five Things Physicians and Patients Should Question.

http://www.choosingwisely.org/societies/american-psychiatric-association/

4. American Geriatrics Society. Ten Things Physicians and Patients Should Question.

http://www.choosingwisely.org/societies/american-geriatrics-society/

5. AMDA – The Society for Post-Acute and Long-Term Care Medicine. Ten Things Physicians and Patients

Should Question. http://www.choosingwisely.org/societies/amda-the-society-for-post-acute-and-long-

term-care-medicine/

6. Nowrangi MA, Lyketsos CG, Rosenberg PB. Principles and management of neuropsychiatric symptoms in

Alzheimer’s dementia. Alz Res Ther. 7:12, 2015.

7. Herrmann N, Lanctot KL. Pharmacologic management of neuropsychiatric symptoms of Alzheimer

disease. Can J Psychiatry 52:630, 2007.

8. Schneider LS, Dagerman KS, Insel P: Risk of death with atypical antipsychotic drug treatment for

dementia: meta-analysis of placebo-controlled trials. JAMA 294: 1934, 2005.

9. Jackson JW, Schneeweiss S, vanderWeele TJ, Blacker D. Quantifying the role of adverse events in the

mortality difference between first and second generation antipsychotics in older adults: systematic review

and meta-analysis. PLOS One 9:e105376, 2014.

47

10. Gallagher D, Herrmann N. Agitation and aggression in Alzheimer’s disease; an update on

pharmacological and psychosocial approaches to care. Neurodegener Dis Manag 5:77, 2015.

11. Valiyeva E, Herrmann N, Rochon PA, Gill S, Anderson GM. Effect of regulatory warnings on

antipsychotic prescription rates among elderly patients with dementia: a population-based time-series

ananlysis. CMAJ 179:438, 2008.

5. AVOID USING MEDICATIONS KNOWN TO CAUSE HYPOGLYCEMIA TO ACHIEVE HEMOGLOBIN

A1C <7.5% IN MANY ADULTS AGE 65 AND OLDER; MODERATE CONTROL IS GENERALLY BETTER

1. Kirkman MS, Briscoe VJ, Clark N, Florez H, Haas LB and Halter JB. Diabetes in older adults: a consensus

report. JAGS 2012; 60: 2342-56.

2. Emergency department visit rates for hypoglycemia as first listed diagnosis per 1,000 diabetic adults

aged 18 years or older by age, United States, 2006-2009.

http://www.cdc.gov/diabetes/statistics/hypoglycemia/fig5byage.htm Assessed October 2, 2015.

3. Munshi MN, Segal AR, Suhl E, Staum E, Desrochers L and Sternthal A. Frequent hypoglycemia among

elderly patients with poor glycemic control. Arch Int Med 2001; 171(4): 362-4.

4. Gerstein HC, Miller ME, Byington RP, Goff DC, Bigger JT and Buse JB. Effects of intensive glucose

lowering in type 2 diabetes. N Engl J Med 2008; 358: 2545-59.

5. Duckworth W, Abraira C, Moritz T, Reda D, Emanuele N and Reaven PD. Glucose control and vascular

complications in veterans with type 2 diabetes. N Engl J Med 2009; 360: 129-39.

6. Patel A, MacMahon S, Chalmers J, Neal B, Billot L and Woodward M. Intensive blood glucose control and

vascular outcomes in patients with type 2 diabetes. N Engl J Med 2008; 358(24): 2560-72.

7. Currie Cj, Peters JR, Tynan A, Evans M, Heine RJ and Bracco OL. Survival as a function of Hb(A1c) in

people with type 2 diabetes: a retrospective cohort study. Lancet 2010; 375(9713): 481-9.

8. Brown AF, Mangione CM, Saliba D and Sarkisian CA. California Healthcare Foundation/American

Geriatrics Society panel on improving care for elders with diabetes. J Amer Geriatr Soc 2003; 51(Suppl.

Guidelines): S265-S280.

9. Meneilly GS, Knip A and Tesseier D. Canadian Diabetes Association 2013 Clinical Practice Guidelines for

the prevention and management of diabetes in Canada: Diabetes in the elderly. Can J Diabetes 2013;

37(suppl 1): S184-S190. http://guidelines.diabetes.ca/browse/chapter37

10. Trimble LA, Sundberg S, Markham L, et al. Value of the clock drawing test to predict problems with

insulin skills in older adults. Can J Diabetes 2005; 29:102-104.

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