Diagnosis and Treatment of Sleep Disorders in the Elderly

Subhash Bashyal, M.D.

George T. Grossberg, M.D.Samuel W. Fordyce Professor

Department of Neurology & PsychiatrySaint Louis University School of Medicine

Disclosures

Dr. Bashyal – None

Dr. Grossberg

Consultant – Baxter Bioscience; Bristol-Myers, Squibb; Forest Labs; Novartis; Lundbeck; Otsuka

Research Support: Baxter Bioscience; Janssen; Novartis; Pfizer; NIH

Safety Monitoring Committee - Merck

Epidemiology

13 % of US population are over 65 31% of elderly are in Nursing homes Study with adults >65 yrs. reported that 42 % had

difficulty staying or falling asleep, 23% to 34 % had symptoms of insomnia

Ref: Foley D, Ancoli-Israel S, Briz P, et al, J Psychosom Res 2004.

Importance of Sleep

Sleep impairment associated with decreased performance in psycho-motor tests, impaired memory and concentration, daytime sleepiness, fatigue and risk of falls

Sleep disordered breathing associated with increased risk of cognitive impairment

• Patients with depressive symptoms were up to 2.5 more likely to have insomnia or not feel rested

Ref: Yaffe K, Laffan AM, Harrison SL et al, JAMA 2011

Sleep changes in the Elderly

Problems with sleep initiation Decreased total sleep time Decrease in sleep efficiency Decrease in slow wave sleep Increase in sleep fragmentation

Ref: Neikrug AB, Ancoli-Israel S. Gerontology – Behavioral Sciences, 2010

Ref:, Kate Crowley, Neuropsychol Rev 2011

Factors affecting sleep

Medical illness - e.g., pain, sleep disorders (sleep –disorder breathing, restless leg syndrome, REM sleep behavior), infection, heart failure

Medications

Psychiatric illness – e.g., delirium, mood disorders, anxiety disorders

Ref: Desai AK, Grossberg GT, Psychiatry Consultation in Long-Term Care, John Hopkins Press 2010.

Factors affecting sleep (cont.)

Disruption in the circadian rhythm due to dementia or a lifetime of working evenings or nights

Environmental factors – e.g. inadequate exposure to light in the daytime, excessive exposure to light at night, excessive noise at night, uncomfortable bed, bedroom is too hot or too cold, sleep interrupted by the staff or by another resident

Factors affecting sleep (cont.)

Poor sleep hygiene or lifestyle factors

Change in one’s living situation

Multifactorial

Medications commonly affecting sleep

Psychiatric medications:

TCAs: Nortriptyline and protriptyline (more alerting)

SSRIs: Citalopram and Fluoxetine (more alerting) Venlafaxine and Bupropion are commonly

associated with sleep disturbance Anti psychotics: Aripiprazole often associated with

insomnia Stimulants

Beta blockers: Most commonly metoprolol and propranolol

Decongestants : pseudoephedrine, phenylpropanolamine

Anti biotics: Levofloxacin, Ciprofloxacin, Antivirals, amantadine

Asthma meds: Albuterol, theophylline Stimulants: Caffeine, Dextroamphetamine,

methylphenidate, methamphetamine

Medications:

Evaluation of insomnia

History: Sleep duration and quality, number of awakenings, initial vs. terminal insomnia.

Useful if sleep partner is also interviewed. Medication use, including over the counter and

herbal supplements Sleep diary (everyday for 1 to 2 weeks) Physical examination, lab tests, sleep study

J Am Geriatr Soc. 2009 May; 57(5): 761–789.

Evidence-Based Recommendations for the Assessment and Management of Sleep Disorders in Older Persons

Sleep Diary Daytime activities, naps, exercise, alcohol and

caffeine intake, meals, stress, tiredness Medication use Activities before bedtime and bedtime routine Wake up time Time to fall asleep, number of awakenings, total

time awake, quality of sleep, total sleep time

Other helpful questions

Do you have the urge to move your legs or experience uncomfortable sensations in your legs at night?

Do you get up to urinate at night? Does your partner tell you that you frequently

snore, stop breathing, or gasp for air at night? Do you usually doze off without planning, during the

day?

Interventions for the treatment of insomnia in long-term care residentsDietary

Restrict the intake of caffeine and chocolate, particularly in the evening.

Avoid a heavy meal late at nightRecommend a light snack (e.g. a glass of milk,

crackers) if nighttime awakenings are caused by hunger

Avoid fluid intake in the evening by residents with nocturia and encourage maximum bladder emptying before retiring

Ref: Desai AK, Grossberg GT, Psychiatry Consultation in Long-Term Care, John Hopkins Press 2010.

Interventions for the treatment of insomnia in long-term care residents (cont.)Environmental

Increase exposure to natural light in the daytimeIncrease exposure to indoor light in the daytime on

cloudy, rainy, and snowy daysRecommend bright-light therapyEnsure optimal room temperature and humidityReduce nighttime noise and nighttime exposure to

bright lightChange the room if conflict with a roommate or the

location of the room is an issue

Interventions for the treatment of insomnia in long-term care residents (cont.)Activity-oriented

Limit daytime napping to a short period in the morning or early afternoon

Limit the time spent in bed in the daytimeIncrease physical activity in the daytimeIncrease meaningful activity and socialization in the

daytimeEmploy a warm bath in the evening Avoid excessive stimulation and exercise after

dinnertime

Interventions for the treatment of insomnia in long-term care residents (cont.)Sleep hygiene

Recommend regular sleeping and waking times and a structured bedtime routine

Recommend calming bedtime rituals (e.g., soothing music, reading or listening to audio recordings of nonfiction books (such as spiritual and religious books)

Use one’s bed for sleep and sexual activity (rather than watching television, eating, or reading)

Interventions for the treatment of insomnia in long-term care residents (cont.)Staff-oriented

Educate and train staff regarding the evaluation and treatment of insomnia and other sleep disorders

Have staff mediate differences between roommates (e.g. one resident wanting to watch television late at night, disturbing the roommate who wants to go to sleep early)

Minimize staff interruptions of a resident’s sleepUse massage therapyUse aromatherapy

Interventions for the treatment of insomnia in long-term care residents (cont.)

Specific interventions for residents who are cognitively intact

Relaxation training

Cognitive behavior therapy

Stimulus control therapy

Sleep restriction therapy

Interventions for the treatment of insomnia in long-term care residents (cont.)Pharmacological

Restrict the use of alcohol and tobaccoPrescribe sedative hypnoticsPrescribe antidepressants with sedating properties to

treat insomnia in residents with depressionPrescribe atypical antipsychotics with sedating

properties to treat insomnia in residents with severe psychotic symptoms

Prescribe a pharmacological treatment for underlying medical conditions

Treatment of Insomnia Non pharmacological therapy Behavioral treatment: Sleep restriction, Stimulus

control, Relaxation therapy CBT: Uses a combination of above methods and

is the most effective. Effect more sustained compared to medication.

Bright light therapy

Ref: Wilson SJ, Nutt DJ, Alford C, et al. J Psychopharmacology 2010

Instructions for good sleep hygiene

Regular sleep/wake schedule Don't go to bed unless sleepy Decrease daytime naps (<30 mins, before 2 pm) Regular exercise (but not 3-5 hrs before bed) Exposure to natural light during the day Avoid heavy meals close to bedtime (< 3 hrs)

Sleep hygiene

Comfortable clothing to bed Use bed only for sleep and sex If unable to sleep, get out of bed and return only

when sleepy Keep bedroom quiet and dark Limit intake of liquids right before bedtime

Pharmacotherapy: FDA Approved medications for insomnia: Benzodiazepines (Short term treatment of insomnia) Flurazepam (Dalmane): Geriatric dose - 15 mg, half life 126-

158 hrs. Should not be used in older adults because of very long half-life.

Quazepam (Doral): Geriatric dose- 7.5 mg, half life 78 hrs. Should not be used in older adults because of very long half-life.

Benzodiazepines: Estazolam (ProSom Geriatric dose- 0.5-1 mg,

half life 10-24hrs.(Due to long half-life, residual CNS effects are likely.)

Temazepam (Restoril)Geriatric dose- 7.5-15 mg, half life 3.5-18.4 hrs.

Triazolam (Halcion)Geriatric dose -0.0625-0.25 mg, half life 1.7-5 hrs.(Poor choice due to very short half life and high incidence of CNS adverse reactions)

No short-term limitation for use Sleep onset and sleep maintenance Eszopiclone (Lunesta) :Geriatric dose- 1-2 mg, half life 9hrs.

Adverse Effects>10%: headache, unpleasant taste. Zolpidem ER (Ambien CR) :Geriatric dose- 6.25 mg, half life

1.9-7.3 hrs. Adverse Effects>10%: dizziness, headache, somnolence

Zolpidem (Ambien) :Geriatric dose-5 mg, half life 2.9-3.7 hrs. Adverse Effects>10%: dizziness, headache, somnolence.

Zaleplon (Sonata): Geriatric dose- 5 mg, half life 1 hrs.Adverse Effects: nausea (7%), myalgias (7%)

Nonbenzodiazepines

Melatonin Receptor Agonist

Onset – 14 days

No short-term limitation for use.

Sleep onset insomnia.

Ramelteon (Rozerem): Geriatric dose- 8 mg, half life 1-2.6

hrs. Adverse Effects: Headache (7%),Somnolence

(5%),Dizziness (5%).

Other medicationsAnti depressants : Trazodone/Desyrel

(hypotension, falls), TCAs(falls, disorientation), Mirtazepine/Remeron

Anti psychotics: Quetiapine/Seroquel, Olanzapine/Zyprexa (cardiovascular events, Sudden death)

Treatment of the comorbid conditons: Sleep apnea, Restless leg syndrome, Pain, Urinary issues.

Caution with use of sedatives

Minimum dose and for the shortest duration needed

Avoid sedative medications with anti cholinergic properties

If Obstructive Sleep Apnea is suspected, sedative hypnotics should be avoided

Increased risk of falls / disorientation Avoid long half-life drugs-hangover effect

Summary Importance of looking for sleep disorders in the

elderly Sleep hygiene Treatment of causative factors Treatment with a combination of CBT and

medications, offer the best results Benzodiazepine receptor agonist, and melatonin

receptor agonist safest for use in elderly