Professional Documents
Culture Documents
Elderly
Matthew J. Beelen, M.D.
November 17th, 2010
Sound Familiar?
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Objectives
Understand
Agenda
Significance of sleep disorders
Physiology: Normal and Aging
Classifying sleep disorders
Sleep hygiene
Evaluation for sleep disorders
Insomnia
(Sleep-disordered breathing)
Other sleep disorders
Agenda
Significance
of sleep disorders
Physiology: Normal and Aging
Classifying sleep disorders
Sleep hygiene
Evaluation for sleep disorders
Insomnia
Sleep-disordered breathing
Other sleep disorders
sleep
REM
sleep
Architecture
Age-Related Changes
Non-REM
REM
Architecture
Age-Related Changes
Circadian
Precipitating Factors
Declining
Health Status
Nocturia
Pain (DJD, neuropathy)
Cardiac Disease
Angina, CHF, arrhythmia
Pulmonary Disease
GER
Endocrine: thyroid, menopause, DM polyuria
CKD
Precipitating Factors
Medications
Neuropsychological
Impairments
Depression, Anxiety
Cognitive Impairment/Psychosis
Primary
Sleep Disorders
Isolation
Widowhood, Retirement
Loss of zeitgebers* (physical, sensory)
Agenda
Significance of sleep disorders
Physiology: Normal and Aging
Classifying sleep disorders
Sleep hygiene
Evaluation for sleep disorders
Insomnia
Sleep-disordered breathing
Other sleep disorders
Insomnia
disordered breathing
rhythm disturbances
Legs Syndrome
Periodic Limb Movements of Sleep
REM Sleep Behavior Disorder
All
Insomnia
(stimulus/response)
Adjustment Insomnia recent stressor
Inadequate Sleep Hygiene
Lack of schedule (retirement!)
Sedentary or naps during daytime
Voluntary sleep deprivation (doctors!)
Mixed-type
insomnia
Agenda
Significance
of sleep
disorders
Normal physiology
Age related changes
Classifying sleep disorders
Sleep hygiene
Evaluation for sleep disorders
Insomnia
Sleep-disordered breathing
Other sleep disorders
Sleep Hygiene
The
Agenda
Significance of sleep disorders
Physiology: Normal and Aging
Classifying sleep disorders
Sleep hygiene
Evaluation for sleep disorders
Insomnia
Sleep-disordered breathing
Other sleep disorders
Evaluation - History
Is
What
causes
Look for clues of primary disorders
Consider sleep diary and
partner/caregiver interview
Polysomnography
Formal
Agenda
Significance
of sleep
disorders
Physiology: Normal and
Aging
Classifying sleep disorders
Sleep hygiene
Evaluation for sleep
disorders
Insomnia
Sleep-disordered breathing
Other sleep disorders
Insomnia - Definition
Difficulty
Insomnia - Definitions
Sleep latency usually > 30 minutes
Sleep efficiency < 85%
Transient: less than 1 week
Short-term: 1-4 weeks
Chronic: > 1 month
Amitriptyline
Diphenhydramine
Melatonin
Triazolam
Zolpidem tartrate
Insomnia - Treatment
Non-pharmacologic
therapy
Insomnia - Medications
Use
Insomnia - Medications
Short
acting medications
Long
acting
Most
Insomnia - Medications
Benzodiazepines
GABA-A receptors
Insomnia - Medications
Benzodiazepine
receptor agonists
Advantages
more specific targeting of GABA receptors in
the brain so less side effects
Disadvantages
Not well studied in the elderly (use lower
starting doses)
Not compared against each other
More expensive ($65-100 per month)
Dependence/withdrawal still occur
Still can increase risk of falls and fractures
Zolpidem (Ambien)
Short
Zaleplon (Sonata)
Ultrashort
half-life (1 hour)
Better for sleep onset insomnia
Can increase total sleep time and efficiency
Can
Eszopiclone (Lunesta)
Medium
Sedative-Hypnotics Risk/Benefit
Meta-analysis
Other Medications
Ramelteon
(Rozerem)
Sedating
Other Medications
Sedating
Antidepressants
supplement dosing?
Drugs vs No Drugs
Unclear if cognitive behavioral therapy or
medication therapy is better
Both help
Medications may work more quickly
CBT may have more lasting benefit
Light Therapy
Avoid alcohol
CPAP
Methylphenidate
Oropharyngeal surgery
Viagra
Agenda
Significance of sleep disorders
Normal physiology
Age related changes
Classifying sleep disorders
Sleep hygiene
Evaluation for sleep disorders
Insomnia
Sleep-disordered breathing
Other sleep disorders
Sleep-disordered Breathing
Usually
Sleep-disordered Breathing
Significance,
Sleep-disordered Breathing
Other
Symptoms
Snoring
Restless sleep
Choking/gasping during sleep
Witnessed apnea
Male
Large neck circumference (>18 inches)
Obesity
Crowding of oropharynx
OSA - Diagnosis
Classic
Symptoms and
Polysomnography
OSA - Stages
Mild:
Moderate:
OSA - Stages
Severe
OSA - Treatment
Unclear
HTN
CHF
Daytime function
Cognition and health-related quality of life
OSA - Treatment
Weight
balls)
Avoid sedating drugs
Prescription drugs not helpful
CPAP/BIPAP Most efficacious
Compliance issues
Oral
heart failure
Prior Stroke and cerebrovascular
disease
Other neurologic disorders ALS,
mucular dystrophy
Chronic renal failure
Hypothyroidism
Baseline CO2 retainers (COPD,
kyphoscoliosis)
Polysomnography
Treatment
Agenda
Significance
of sleep disorders
Normal physiology
Age related changes
Classifying sleep disorders
Sleep hygiene
Evaluation for sleep disorders
Insomnia
Sleep-disordered breathing
Other sleep disorders
Carbamazepine
Carbidopa-levodopa
Clonazepam
Clonidine
Iron supplementation
Legs Syndrome
Periodic Limb Movements of Sleep
REM Sleep Behavior Disorder
Nocturnal Leg Cramps
Circadian Rhythm Disturbances
neurologic condition,
possibly caused by abnormal iron
metabolism and dopaminergic
dysfunction unclear
Compelling urge to move limbs
(legs>arms)
Worse at rest
Worse at night
May have dysesthesia or pain
Relieved with movement
Disrupts sleep, alertness, daytime function,
QOL
RLS Facts
5-15%
Classic symptoms
Responds to trial of therapy
Pregnancy
ESRD
Fe
Deficiency
arthritis
DM
Depression/anxiety
can exacerbate
Sedating antihistamines
Metoclopramide
Calcium channel blockers
Neuroleptics
TCAs
SSRIs
Caffeine
Nicotine
ETOH
RLS Treatment
Non-pharmacologic
Pharmacologic
RLS Treatment
Dopaminergics
Benzos
choice
Opioids daily or intermittent use
Neurontin daily use, similar efficacy to
Requip (average dose 800mg)
Neuropsychobiology 2003;48(2):82-6.
Magnesium,
Dopamine agonists
Benzos decrease arousals but not
movements
Opioids
not known
Associated factors
Meds (diuretics, nifedipine, beta agonists,
steroids, morphine, cimetidine, statins,
lithium)
Conditions (uremia, DM, thyroid, electrolyte
d/os)
Melatonin
Summary
Sleep
References
References
Silber MH. Chronic insomnia. NEJM 2005;353:803-810.
Ancoli-Israel S et al. Prevalence and comorbidity of insomnia
and effect on functioning in elderly populations. JAGS
2005;53:S264-S271.
Clinics in Geriatric Medicine 2/08: Sleep in elderly adults.
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