Sleep disorders Seyed Kazem Malakouti, MD,Iran University of Medical Sciences

Seyed Kazem Malakouti, MD,Iran University of Medical Sciences

Sleep disorders


• Approximately 50% of community-dwelling elderly persons complain of some form of sleep difficulty


The most common sleep disorders in the elderly


• One central question raised by researchers in the field is whether

• these age-related changes represent a decrease in the need for sleep

• or a decrease in the ability to sleep. Although this question is still

• being debated and there is no clear consensus on whether there is

• a reduced need for sleep, there is clearly a reduced ability


Contributing factors with SDs


• Sleep-disordered breathing (SDB) is characterized by respiratory• events, including hypopneas (partial respiration) and/or apneas• (complete cessation of respiration), during sleep. These respiratory• events occur repeatedly over the course of the night with each respiratory• event lasting a minimum of 10 seconds. The number of apneas• per hour of sleep is called the apnea index (AI) and the number of apneas• and hypopneas per hour of sleep is called the apnea–hypopnea• index (AHI; also sometimes called the respiratory disturbance index• [RDI]). Clinical diagnosis of SDB is traditionally given when a• patient has an AHI of 10 to 15.• The cessations in breathing in SDB lead to repeated arousals from• sleep, as well as to reductions in blood oxygen levels over the course• of the night, which result in nighttime hypoxemia.



• Approximately 2% to 4% of middle-aged men and women (age 30

• to 60 years) have an AHI ≥ 5, compared to 32% to 81% of older• adults (age 60+ years). With increasing AHI, these percentages

are• slightly lower, with 19% to 62% of older adults having an AHI≥15• and up to 24% having an AHI ≥ 20. In addition, within the older• population, SDB is more common in men than in women and in• patients with hypertension, and may b


• Pathophysiology• There are three types of apneic events:

central, obstructive, and• mixed.


Presentation

• The cardinal symptoms of SDB are snoring and excessive daytime• sleepiness. It is often one or both of these two symptoms that• motivate the patient to seek evaluation and treatment of this sleep• disorder. Additional symptoms may include insomnia, nocturnal• confusion, and cognitive deficits, such as difficulty with

concentration• and memory.• Approximately 50% of regular snorers suffer from some degree• of SDB and snoring may be an early precursor to SDB


• snoring alone is associated with increased risk of ischemic heart disease

• and stroke.


• excessive daytime sleepiness• sleep fragmentation or repeated nighttime

awakenings• apneic events, and with the nocturnal hypoxia• unable to stay awake• cognitive deficits


SDB treatment

• Positive Airway Pressure• continuous positive airway pressure (CPAP• positive airway pressure (BiPAP), and auto-

CPAP



• Surgical Interventions• There are several different surgical approaches

for the treatment• of SDB, including (1) nasal reconstruction,

which corrects nasal• valve collapse, septal deviations, and turbinate

hypertrophy; (2) uvulopharynpalatoplasty



• (2) uvulopharynpalatoplasty• (UPPP), which corrects pharyngeal obstruction• by removal of pharyngeal tissue, including soft palate, uvula,• tonsillar pillars, and tonsillar tissue; (3) laser-assisted

uvulopharynpalatoplasty• (LAUP), which has the same standard procedure as• UPPP, but uses a laser to remove the pharyngeal tissue; (4) genioglossus• advancement, which corrects by the forward advancement of• the insertion of the tongue (usually in conjunction with UPPP or• LAUP); and (5) hyoid myotomy, which corrects hypopharyngeal• obstruction by suspending the hyoid bone to the superior edge of• the larynx (usually in conjunction with UPPP or LAUP).


• Oral Appliances• Oral devices are appropriate for the

management of milder forms• of obstructive sleep apnea and snoring. The

two most common oral• devices are the tongue-retaining device (TRD)

and the mandibular• advancement device (MAD



Diet and Lifestyle

• Obesity is a• common problem• Alcohol and certain medications, such as

sedative-hypnotics, narcotics,• and barbiturates, have a depressant effect on the

upper airway• musculature and may exacerbate SDB• Smoking• body position during


PERIODIC LIMB MOVEMENTS IN SLEEP/RESTLESS

LEGS SYNDROME


• Periodic limbmovements in sleep (PLMS) is characterized by clusters• of repeated leg (or sometimes arm) jerks that occur approximately• every 20 to 40 seconds over the course of the night. These clusters• of movements last on an average 0.5 to 5 seconds and cause

repeated• brief awakenings. The number of limb movements followed• by arousals per hour of sleep is called the periodic limb movement• index (PLMI). Clinical diagnosis of PLMS is typically given when a• patient has a PLMI >5.


• RLS is characterized• by dysesthesia in the legs, usually described by patients as “a

creeping• crawling sensation” or as “pins and needles,” which can only

be• relieved with vigorous movement. These sensations often

occur in• the evening or whenever the patient is in a restful, relaxed

state.• About 90% of patients with RLS also have PLMS, but only about• 20% of PLMS patients suffer from RLS.


• The prevalence of PLMS increases significantly with age and is estimated

• at 45%, compared to 5% to 6% in younger adults. Despite• this increase in prevalence, the severity of the condition

does not• worsen with age. The prevalence of RLS increases with

age as well.• There is no known gender difference in PLMS, however

RLS is twice• as common in older women than men.


• dysfunction• of the dopamine system.• iron homeostatic dysregulation• ferritin levels in• the cerebrospinal fluid are lower


• Patients with symptoms of RLS should be assessed for anemia, iron

• deficiency, uremia, and peripheral neuropathy prior to treatment.

• Polysomnography for PLMS



CIRCADIAN RHYTHMS SLEEP DISORDERS

• suprachiasmatic nucleus (SCN) in the anterior

• Hypothalamus


• core body temperature drops, melatonin

• secretions increase and individuals start feeling sleepy;


circadian rhythm lessentrained

• slow degeneration of• the SCN with age, (2) progressive reduction in

endogenous melatonin• secretion during the night, and (3) decreased

sensitivity to• external cues, or alternatively external cues

such as bright light may• be lacking or weak in older adults


• Healthy older adults receive on average• only 60 minutes of bright light a day (>2000 lux),

whereas elderly• demented patients living in the community receive on

average 30• minutes of bright light a day (>2000 lux• demented nursing• home patients receive on average no light >2000 lux

and only 10• minutes of bright light >1000 lux a day


• Another common circadian rhythm change in older age is the

• shifting, or advancing, of the sleep–wake cycle. This circadian

• rhythm disorder is called advanced sleep phase syndrome (ASPS),

• a condition in which the sleep–wake rhythm and the core body

• temperature rhythm are advanced, as compared to those of younger

• adults.


ADVANCE SLEEP

• Changes in the sleep–wake cycle are likely caused by changes in the

• core body temperature cycle, decreased light exposure, and environmental

• factors


ACTIGRAPH

• wear a wrist actigraph for 3–7 days


MANAGEMENT

• ASPS is not a medical disorder and does not necessarily need to be treated

• particularly bright-light therapy• exposure to bright light in the early morning

will strengthen and advance the rhythm• exposure to bright light in the late afternoon or

early evening will delay the rhythm• bright light for approximately 2 hours a day

during the late afternoon to early evening


• will also shift related rhythms such as core body temperature and endogenous melatonin.

• best source of bright light is sunlight, therefore patients should attempt to spend time outdoors in the late afternoon

• sunglasses should not be worn during this time


• “light box,” which provides a minimum of 2500 lux light exposure



RAPID EYE MOVEMENT SLEEP BEHAVIOR DISORDER


• an intermittent lack of skeletal muscle atonia that is typically present during REM sleep.

• RBD usually occurs during the second half of the night, when REM is more prevalent.

• Nighttime behaviors in RBD include vigorous and complex body movements and actions, such as walking, talking, and eating.


• RBD is associated with the intake of tricyclic antidepressants, fluoxetine, and monoamine oxidase inhibitors

• withdrawal from alcohol or sedatives• unable to recollect• may be violent and may harm the patient

and/or the patient’s bed partner.


• Clonazepam• tricyclic antidepressants, • Dopaminergic agents• melatonin


insomnia


• sleep onset insomnia • sleep maintenance insomnia (• early morning insomnia • the most common complaints in the elderly

are of – sleep maintenance insomnia – early morning insomnia.


Epidemiology

• The prevalence of insomnia is greater in older than younger adults, with a prevalence of 40% to 50%

• more insomnia complaints than men.


Etiology

• arthritis, cardiovascular disease, pulmonary• disease, chronic pain disorders• life changes, such as retirement and death of

loved ones• Depression and anxiety disorders• Polypharmacy




• stop all in-bed activities• go• to bed when feeling tired enough• stimulating or arousing activities prior to bedtime, such as• watching television, reading exciting books, or watching the alarm• Clock• cannot fall asleep within 20 minutes, they should• get out of bed• should wake• up and get out of bed at the same time everyday (• no longer than 30 minutes in the early• part of the day


• The 2005 NIH State-of-the-Science • (1) all antidepressants have potentially

significant adverse effects• (2) barbiturates and antipsychotic

medications• have significant risks• (3) there is no systematic evidence for efficacy

of antihistamines





BZD side effects

• changes in sleep architecture (i.e., reduction in• delta or deep sleep), morning hangover

effects, leading to excessive• daytime sleepiness, poor motor coordination,

and visuospatial• problems, which may be particularly

pronounced in the elderly.

Documents

Sleep disorders Seyed Kazem Malakouti, MD,Iran University of Medical Sciences