Sleep Disorders in the Elderly

Report
Sleep Disorders in the
Elderly
Matthew J. Beelen, M.D.
November 17th, 2010
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Why am I so tired all of the time?
I don’t have any energy…
I just can’t sleep well anymore…
My husband’s always falling asleep, he
doesn’t do anything anymore…
I wish I could just get some rest…
I don’t have any “get up and go…”
I just lie awake, I can’t get back to
sleep…
I think my memory is slipping…
Sound Familiar?
“A bodily disease which we look upon as
whole and entire within itself, may, after
all, be but a symptom of some ailment of
the spiritual part.”
-Nathaniel Hawthorne (1804-1864)
Objectives
Understand normal sleep physiology
and age-related changes
 Appropriately recognize and diagnose
sleep disorders
 Understand indications for formal sleep
studies
 Recommend appropriate treatment
measures
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Agenda
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Significance of sleep disorders
Physiology: Normal and Aging
Classifying sleep disorders
Sleep hygiene
Evaluation for sleep disorders
Insomnia
(Sleep-disordered breathing)
Other sleep disorders
Significance of Sleep Disorders
Survey of 9000 people > age 65
 No sleep complaints (12%)
 Difficulty initiating/maintaining (43%)
 Nocturnal waking (30%)
 Insomnia (29%)
 Chronic sleep difficulties (>50%)
 Daytime napping (25%)
 Trouble falling asleep (19%)
 Waking too early (19%)
 Waking without feeling rested (13%)
Ancoli-Israel S. JAGS 2005;53:S264-S271.
Significance of Sleep Disorders
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>50% of sedatives are used by people age > 65
In age 70-100, 19% of patients were taking a
sleep medicine (in one study)
Disturbed sleep is a strong predictor of ECF
placement, especially in patients with dementia
Mortality due to common conditions is 2 times
higher in elderly with sleep disorders than in those
without.
Daytime somnolence can interfere with activities
and function
Sleep disorders negatively impact quality of life
Sleep disorders can lead to depression and
cognitive impairment
Agenda
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Significance of sleep
disorders
Physiology: Normal and Aging
Classifying sleep disorders
Sleep hygiene
Evaluation for sleep disorders
Insomnia
Sleep-disordered breathing
Other sleep disorders
Normal Physiology - Basics
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Non-REM sleep
◦ Stage 1: very light, easy to arouse
◦ Stage 2: most of the night’s sleep
◦ Stage 3,4: slow wave, deeper sleep
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REM sleep
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EEG similar to stage 1
Low/absent muscle tone
Dreaming occurs here
Greatest cardiac and respiratory instability
Normal Physiology - Basics
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Sleep Architecture
◦ REM latency is about 90 minutes (wide
variation)
 Very short in narcolepsy
◦ REM normally occurs every 90 to 120
minutes
◦ More stage 3,4 in first half of night, more
REM 2nd half
◦ Brief awakenings (30 sec) common, not
usually remembered
◦ Brief arousals (3 sec) are normal
An 83-year-old woman who resides in a longterm care facility complains of chronic
insomnia. She is bedridden and is legally
blind secondary to diabetes mellitus. Which
of the following age related changes most
likely contributes to this patient’s sleep
disturbances?
A.
B.
C.
D.
E.
Reduction in total sleep time
Reduction in melatonin secretion
Reduction in stage 3 or 4 sleep
Increase in percentage of REM sleep
Breakdown of the segregation of sleep and
wakefulness
Age-Related Changes
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Non-REM
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REM
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Architecture
◦ Less slow wave sleep (stage 3 and 4), may
be entirely absent, easier to awaken
◦ Shorter REM latency
◦ Decreased REM percentage and duration
◦ Increased overall sleep latency
◦ More awakenings/arousals = less sleep
efficiency
◦ Less sleep in 24 hour period*
◦ Reduced sleep latency during day – harder
to stay awake
Espiritu JR. Clin Geriatr Med 2008;24:1-14.
Age-Related Changes
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Circadian cycle shifted earlier
◦ Decreased melatonin levels at night
◦ Decreased modulation of circadian rhythm
between day and night
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More naps during the day (1 hour)
◦ May have little impact on night-time sleep
◦ May enhance cognitive and psychomotor
performance due to increase total sleep
Espiritu JR. Clin Geriatr Med 2008;24:1-14.
Age Related Changes
Less physiologic flexibility with
schedule changes
 More comorbidities that can interfere
with sleep
 It is hard to know if sleep problems are
more common independent of other
conditions
 The ability to get restorative sleep gets
worse with age, the need for sleep
does not.
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Mechanisms Underlying Sleep Complaints
Vaz Fragoso CA. JAGS 2007;1853-1866.`
Precipitating Factors
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Declining Health Status
◦ Nocturia
◦ Pain (DJD, neuropathy)
◦ Cardiac Disease
 Angina, CHF, arrhythmia
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Pulmonary Disease
GER
Endocrine: thyroid, menopause, DM polyuria
CKD
Precipitating Factors
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Medications – impact sleep architecture
and sleep-disordered breathing
◦ CNS stimulants/depressants
◦ Diuretics, hypoglycemics
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Neuropsychological Impairments
◦ Depression, Anxiety
◦ Cognitive Impairment/Psychosis
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Primary Sleep Disorders
Perpetuating Factors Psychosocial
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Caregiving
◦ The work of caregiving
◦ Associated mental and physical health
problems
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Social Isolation
◦ Poorer sleep hygiene
◦ Decline in activity
Bereavement, Widowhood, Retirement
 Loss of zeitgebers* (physical, sensory)
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Agenda
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Significance of sleep disorders
Physiology: Normal and Aging
Classifying sleep disorders
Sleep hygiene
Evaluation for sleep disorders
Insomnia
Sleep-disordered breathing
Other sleep disorders
Classifying Sleep Disorders
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“Existing classifications differ, and many
terms remain inadequately defined, which
leads to diagnostic confusion. Historically,
insomnia has been classified according to
symptom type, symptom duration, and
underlying cause, but these classifications
have not been based on evidence of their
utility, and newer research suggests the
need for change.”
Krystal AD. JAGS 53:S258-S263, 2005.
Primary Sleep Disorders
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Primary Insomnia
◦ Sleep onset (Initial)
◦ Sleep maintenance (Middle)
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Sleep disordered breathing
◦ Obstructive sleep apnea
◦ Central sleep apnea
◦ Mixed sleep apnea
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Circadian rhythm disturbances
Primary Sleep Disorders
Restless Legs Syndrome
 Periodic Limb Movements of Sleep
 REM Sleep Behavior Disorder
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All primary disorders can be mixed
with other primary and with secondary
causes
Secondary Sleep Disorders
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Underlying conditions that should be
addressed first
Medical Illness – causing nocturnal
symptoms
Psychiatric Illness
Medications
Social/behavioral
Secondary Sleep Disorders
Psychophysiologic Insomnia
(stimulus/response)
 Adjustment Insomnia – recent stressor
 Inadequate Sleep Hygiene
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◦ Lack of schedule (retirement!)
◦ Sedentary or naps during daytime
◦ Voluntary sleep deprivation (doctors!)
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Mixed-type insomnia
A 67 y.o. woman asks you for sleeping pills.
She reports initial insomnia and restless
sleep with frequent awakenings. She is
retired and sedentary. Reads, watches TV
in bed, often naps despite caffeine intake
during the day. PE is WNL. Which is most
likely to help her sleep disturbance?
A.
B.
C.
D.
E.
Exposure to early morning daylight
Proper sleep habits
Sustained-release melatonin
Zolpidem
Referral for sleep study
Agenda
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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
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The bed is for sleeping (and sex) only
Increase activity, decrease naps
Avoid late meals
Avoid caffeine, ETOH, cigarettes
Environmental control (light, noise,
temp)
Decrease stress
Establish a routine
Agenda
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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
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Is there a sleep disorder (fatigue)?
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What is the nature of the problem?
◦ Or normal age-related change?
◦ False beliefs about sleep?
◦ Initial, middle, early awakening, EDS
Assess impact on daily life/function
Identify contributions from secondary
causes
 Look for clues of primary disorders
 Consider sleep diary and
partner/caregiver interview
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Polysomnography
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Formal Sleep Test – indications
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Diagnosis of sleep-disordered breathing
CPAP titration
Suspected narcolepsy
Suspected REM sleep movement disorder
Difficult to diagnose parasomnias (e.g. PLMS)
Not usually for:
 RLS
 Circadian rhythm disorders
 Primary insomnia
Agenda
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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 with initiation, maintenance,
duration, or quality of sleep that
results in the impairment of daytime
functioning, despite adequate
opportunity and circumstances for
sleep.
 Can lead to fatigue, mood disturbance,
interpersonal and job problems, and
reduced quality of life.
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From DSM-IV
Insomnia - Definitions
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Sleep latency usually > 30 minutes
Sleep efficiency < 85%
Transient: less than 1 week
Short-term: 1-4 weeks
Chronic: > 1 month
◦ May be perpetuated by worrying in bed or
unrealistic expectations of sleep duration
◦ More common in women, elderly, and
chronic disease (medical and psychiatric)
83 y.o. woman who has HTN and DJD
has 3 wk h/o difficulty falling asleep
and several awakenings per night.
Has symptoms related to
psychosocial stressors. You decide to
try short course hypnotic agent.
Which is most appropriate?
A.
B.
C.
D.
E.
Amitriptyline
Diphenhydramine
Melatonin
Triazolam
Zolpidem tartrate
Insomnia - Treatment
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Non-pharmacologic therapy
◦ Improvement in 70-80% of patients (though
some studies used psychologists)
◦ Stimulus control therapy – bed for sleeping
only, same wake time daily, 1 small nap only
◦ Sleep restriction therapy – reduce time in bed
to achieve 90% efficiency, gradually increase
(up to 6-7 hours)
◦ Relaxation therapy – biofeedback, imagery,
meditation, muscle relaxation
◦ Cognitive therapy – beliefs and attitudes
◦ Sleep hygiene education
Joshi S. Clin Geriatr Med 2008;24:107-119.
Insomnia - Medications
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Use lowest effective dose
Use intermittent dosing
Short term use (< 1 month if possible)
Gradual discontinuation (rebound)
Medications with shorter half lives are
preferred to prevent next-day sedation
Insomnia - Medications
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Short acting medications
◦ More improvement with sleep latency
◦ More withdrawal and dependence
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Long acting
◦ More improvement with sleep duration
◦ More next day symptoms (sedation,
cognitive impairment, falls)
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Most medications have not been
studied extensively in the elderly or
more than 6 months
Insomnia - Medications
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Benzodiazepines – GABA-A receptors
◦ Benefits: cheap, improve sleep latency, total
sleep time, number of awakenings, sleep
quality
◦ Disadvantages:
 More next day effects (drowsy, dizzy)
 More dependency/withdrawal
 More rebound symptoms
 More anterograde amnesia (especially with
shorter acting agents)
 Falls and hip fracture risk (long acting)
Tariq SH. Clin Geriatr Med 2008;24:93-105.
Insomnia - Medications
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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 half life (2.6 hours, 2.8 for “CR”)
 Better for sleep onset insomnia
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◦ Minimal impact on sleep architecture
“CR” not directly compared with
Ambien
 Can see rebound insomnia, mild next
day drowsiness, mild antergrade
amnesia
 “CR” approved for long term use
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Zaleplon (Sonata)
Ultrashort half-life (1 hour)
 Better for sleep onset insomnia
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◦ Can increase total sleep time and efficiency
Can be taken after a middle of night
awakening
 Rare rebound and next day effects
 Not approved for long term use
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◦ But reported to be safe for long term use in
elderly
Eszopiclone (Lunesta)
Medium half life (5-7 hours)
 Better for sleep maintenance insomnia
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◦ Increased total sleep time 49 min
Helps with sleep onset (27min)
 Few next day effects (but longer half
life suggest risk for next day effects in
elderly)
 Approved for long term use
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Sedative-Hypnotics Risk/Benefit
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Meta-analysis of 24 studies, > 2400 patients
older than age 60 treated with benzo’s or benzo
receptor agonists
◦ Benefits – compared to placebo (NNT = 13)
 Small improvement in sleep quality
 Sleep time increased (25 minutes)
 Decrease number of awakenings (0.63)
◦ Harms (NNH = 6)
 Cognitive impact (4.78 times more common)
 Psychomotor events (2.61 times as common)
 Daytime fatigue (3.82 times more common)
Glass et al. BMJ 2005;331:1153-1212.
Other Medications
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Ramelteon (Rozerem)
◦ Melatonin receptor agonist
 Small improvement in sleep onset (8 min)
 Improved total sleep time (12 min)
 Increase prolactin levels, few other side
effects.
 Not compared to other drugs or melatonin.
 Approved for chronic use.
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Sedating antihistamines – BEERS LIST
Other Medications
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Sedating Antidepressants
◦ Tricyclics: they help, but side effects
◦ Trazadone: helps, not as much as Ambien
◦ May improve SWS (stage 3 and 4)
◦ Remeron: increased sleep efficiency,
increases duration of slow wave sleep in
elderly
◦ These drugs are not well studied (or
approved) for insomnia in the elderly
◦ Best used for depression with insomnia
Other Medications - Melatonin
Levels correlate with circadian rhythm
 Deficiency is more common in elderly and
associated with insomnia
 Effects (0.1 to 10mg QHS)
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◦ 7.8 minute  latency in primary insomnia
◦ 38.8 minute  latency in delayed sleep phase
syndrome
◦ No impact on sleep efficiency
◦ Minimal side effects, if any
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Nutritional supplement – dosing?
Gooneratne NS. Clin Ger Med 2008;24:121-138.
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
◦ Hard for PCP’s to do cognitive therapy
◦ Medications not studied more than 6 months
◦ It is best to attempt education and nonpharmacologic therapy first, and continue even
if medications are used
Other Treaments for Insomnia
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Bright Light Therapy
◦ Light -> suprachiasmatic nucleus -> inhibits
production of melatonin by pineal gland
 Threshold between 200-400 lux (normal
indoor fluorescent light)
 Treatment uses 2000-10,000 lux
◦ Cochrane: no trials focused on elderly, but
benefit seen with younger patients
◦ Dosing, timing, duration, effectiveness not
established in the elderly
◦ Best evidence for SAD in younger people
Gammack JK. Clin Geriatr Med 2008;24:139-149.
66 year old man asks for Viagra. Has DM2,
HTN, CHF, obesity. Takes digoxin, lasix,
norvasc, insulin. ROS: +for ED, fatigue,
frequent daytime sleepiness. 5’10’’,
250#. BP 160/90, poorly alert. Wife
says he drinks 1-2 beers/night, snores
loudly, is sleepy during the day. Which
would be most beneficial:
A.
B.
C.
D.
E.
Avoid alcohol
CPAP
Methylphenidate
Oropharyngeal surgery
Viagra
Agenda
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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 present with daytime
somnolence
 Snoring: alone is not usually a problem
 Hypopnea
 Apnea – increased incidence in the
elderly, can be seen in 10-40%
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◦ Obstructive
◦ Central
◦ Mixed
Sleep-disordered Breathing
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Significance, Signs, and Symptoms
◦ Daytime somnolence, effect on function
◦ Decreased cognition, dementia may be
worse
◦ CHF, arrythmias, HTN, cor-pulmonale
◦ Polycythemia
◦ Nocturia
◦ Personality changes
◦ Morning headaches
◦ Decreased libido, impotence
◦ May increase mortality
Sleep-disordered Breathing
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Other Symptoms
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Snoring
Restless sleep
Choking/gasping during sleep
Witnessed apnea
Obstructive Sleep Apnea (OSA)
Definition: repetitive episodes of uper
airway obstruction with continued
movement of chest and abdominal
walls, leads to desaturations and
arousals.
 Risk factors: people with classic
symptoms and:
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Male
Large neck circumference (>18 inches)
Obesity
Crowding of oropharynx
OSA - Diagnosis
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Classic Symptoms and
Polysomnography
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EEG (at least 2 channel)
EMG (muscle activity – chin)
EOG (eye movements)
ECG
Respiratory airflow and effort
Oxygen saturation
Snoring intensity and body position
Reports an “Apnea-Hypopnea Index” - AHI
OSA - Stages
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Mild: sleepiness when sedentary, little
attention required, not daily, minor
impairment of function
◦ Mean sat >90 and min sat >85, AHI 6-20
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Moderate: daily sleepiness when
minimaly active and moderate
attention required (driving, meetings,
movies)
◦ Mean sat >90 and min >70, AHI 21-40
OSA - Stages
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Severe – daily sleepiness during tasks
that require significant attention
(driving, conversation, eating,
walking), marked impairment in
function
◦ Mean sat <90 or min <70, AHI > 40
OSA - Treatment
Unclear benefit to treating mild or
minimally symptomatic patients
 Treatment is likely to improve:
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HTN
CHF
Daytime function
Cognition and health-related quality of life
OSA - Treatment
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Weight loss, avoid supine position (tennis
balls)
Avoid sedating drugs
Prescription drugs not helpful
CPAP/BIPAP – Most efficacious
◦ Compliance issues
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Oral appliance – less effective, use for
mild cases or if CPAP not tolerated
Surgery – trach, uvuloplasty, bariatric
surgery – not first line, various
effectiveness
Central Sleep Apnea - CSA
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Definition – Periodic complete cessation of
airflow and respiratory effort, followed by
desaturations and arousals.
Related to chemoreceptors and CO2
physiology.
Hypercapneic – underlying hypoventilatory
disorders blunts chemoreceptor
responsiveness
Nonhypercapneic – underlying
hyperventilatory disorder causing periodic
hypocapnea which turns off respiratory
drive
CSA Associated Conditions
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Congestive heart failure
Prior Stroke and cerebrovascular
disease
Other neurologic disorders – ALS,
mucular dystrophy
Chronic renal failure
Hypothyroidism
Baseline CO2 retainers (COPD,
kyphoscoliosis)
CSA – Diagnosis and Treatment
Diagnosis – Polysomnography
 Treatment

◦ CPAP/BIPAP can help
◦ Nocturnal Oxygen can help (offsets
“overshoot”)
◦ Consult your local pulmonologist
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

A 66 y.o. man reports excessive daytime
sleepiness and an intense, irrisistable urge
to move about, especially in evening. He is
nervous, tense, irritable, has initial
insomnia. Wife notes he is restless during
night, moves legs abnormally. Which med
is most likely to be beneficial?
A.
B.
C.
D.
E.
Carbamazepine
Carbidopa-levodopa
Clonazepam
Clonidine
Iron supplementation
Other Sleep Disorders
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Restless Legs Syndrome
Periodic Limb Movements of Sleep
REM Sleep Behavior Disorder
Nocturnal Leg Cramps
Circadian Rhythm Disturbances
Restless Legs Syndrome (RLS)
Sensorimotor 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% prevalence, increased in the
elderly, more common in women
 Associated features

◦ FH positive in 60%
◦ PLMS in 80% (but 30% PLMS pts have RLS)

Diagnosis
◦ Classic symptoms
◦ Responds to trial of therapy
RLS – Associated Conditions

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Pregnancy
ESRD
Fe Deficiency
◦ Check ferritin, iron

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Parkinson’s
Radiculopathy
Neuropathy
Rheumatoid arthritis
DM
Depression/anxiety

Drugs can exacerbate
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◦
Sedating antihistamines
Metoclopramide
Calcium channel blockers
Neuroleptics
TCA’s
SSRI’s
Caffeine
Nicotine
ETOH
RLS – Treatment

Non-pharmacologic
◦ Avoid caffeine, ETOH,
associated medications
◦ Sleep hygiene
◦ Bedtime bath
◦ Mild exercise before
bedtime

Pharmacologic
see handout – most drugs
used off label
70-100% effective
RLS Treatment

Dopaminergics
◦ Requip/ropinirole and Mirapex/pramipexole–
only FDA approved meds)
◦ Use for daily or intermittent symptoms
◦ First line treatment (most studied)



Benzos – intermittent use, klonopin is best
choice
Opioids – daily or intermittent use
Neurontin – daily use, similar efficacy to
Requip (average dose 800mg)
◦ Neuropsychobiology 2003;48(2):82-6.

Magnesium, folate have “slight” evidence
Periodic Limb Movements of Sleep
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PLMS: Periodic episodes of repetitive
and highly stereotypc limb movements
during sleep
34-45% prevalence in the elderly,
increases with age
Associated with RLS, arousals, difficulty
achieving and maintaining sleep
Most are asymptomatic
Unclear significance
Associated conditions similar to RLS
PLMS – Diagnosis and Treatment

Diagnosis
◦ Clinical history and response to treatment
◦ Polysomnography can be used

Treatment
◦ Dopamine agonists
◦ Benzo’s – decrease arousals but not
movements
◦ Opioids
REM Sleep Behavior Disorder
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Lack of normally low muscle tone
during REM sleep
Cause unknown
Usually male, onset age 50-60
Act out dreams which can be violent
Vivid memory of dreams
Can diagnose with polysomnography
1/3 of Patients will develop Parkinson’s
Treat with benzo (klonopin 90%
effective)
Nocturnal Leg Cramps
Cause – not known
 Associated factors

◦ Meds (diuretics, nifedipine, beta agonists,
steroids, morphine, cimetidine, statins,
lithium)
◦ Conditions (uremia, DM, thyroid, electrolyte
d/o’s)

Diagnosis – history, check labs
Nocturnal Leg Cramps

Treatment
◦ Review associated factors
◦ Calf stretching exercises
◦ Quinine (200-300mg QHS)
 Evidence of moderate benefit
 Toxicity – careful in elderly, kidney/liver disease
◦ Digoxin interaction
◦ Hematologic (thrombocytopenia)
◦ Cinchonism
◦ Blindness, arrhythmias, death!
◦ Tonic Water…
◦ ? Dr. Gott – soap…
Circadian Rhythm Disturbance
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Advanced sleep phase syndrome
Neurologic control of rhythms is altered
Early to bed, early to rise
◦ Can interfere with societal norms
◦ Total sleep time and daytime function
usually not affected
Melatonin and light therapy are
theorized to help
 Reassure patients
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Summary
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Sleep problems are very common in
the elderly
Sleep problems have significant impact
on health and quality of life
Be as specific as possible in diagnosing
sleep disorders
Treatment should include all
contributing factors, and should include
counseling
Avoid a “pill for every symptom”
The way it used to be…

Chronic enlargement of the tonsils –
symptoms:
“As a result of the obstruction to nasal
respiration the patient snores during sleep.
The facial expression is somewhat dull, and
the mind is often as dull as the face betrays.
Aprosexia, or difficult attention, is a common
symptom.”
Eye, Ear, Nose, and Throat. A Manual for
Students and Practitioners. Lea Brothers
and Co. Philadelphia, PA. 1900.
References
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Salzman C. Pharmacologic treatment of disturbed sleep in the
elderly. Harv Rev Psychiatry 2008;16:271-278.
Glass J. et al. Sedative hypnotics in older people with insomnia:
meta-analysis of risks and benefits. BMJ 2005;331:1153-1212.
Vaz Fragoso CA et al. Sleep complaints in community-living older
persons: A multifactorial geriatric syndrome. JAGS
2007;55:1853-1866.
Ancoli-Israel S et al. Sleep disorders in the geriatric population:
Implications for health. Supplement to Geriatrics Dec. 2005. 115.
Butler JV et al. Nocturnal leg cramps in older people. Post Grad
Med J 2002;78:596-598.
Thorpy MJ. New paradigms in the treatment of restless legs
syndrome. Neurology 2005;64 (supp 3):S28-S33.
References
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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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Age-related sleep changes
Evaluation of sleep disturbances in older adults
The effect of chronic disorders on sleep in the elderly
Pharmacotherapy for insomnia
Nonpharmacologic therapy for insomnia
Complimentary and alternative medicine for sleep disturbances
in older adults
◦ Light therapy for insomnia in older adults
◦ Restless legs syndrome in older adults
65 y.o. woman, 5 mo. of difficulty falling/staying
asleep. Notes uncomfortable sensation in legs
removed in part by moving/rubbing legs.
Husband notes her kicking legs and moving arms
at night. Not falling asleep until 2 am, excessive
daytime fatigue, impacting function. Sertraline
started 4 weeks ago for mild depression. What
is most likely cause of her symptoms?
 A. Primary insomnia
 B. Major depressive disorder
 C. Anxiety disorder
 D. Restless legs syndrome
 E. Delayed sleep phase disorder

73 year old man with urinary urgency, nocturia x
3, has had urologic eval and medications given.
Symptoms improved from nocturia x 6 when
switched from terazosin to tolterodine. Also has
loud snoring and leg kicking at night which
distrubs wife. He is moderately obese and has
small prostate. PVR and urine are normal. Which
is the next most appropriate step?
 A. Switch from tolterodine to tamsulosin
 B. Refer for urologic eval
 C. Prescribe furosemide in late afternoon
 D. Refer to sleep clinic
 E. Prescribe finasteride

71 y.o. man has violent movement in sleep for
last 8 months (kicks, punches, yells 2-3 hours
after sleep onset). His wife says he snores
lightly occasionally and has nocturia x 1. He has
PD and MDD without recurrence. Only med is
mirapex. Speelp study confirms the movements
and shows no OSA. Best treatment?
 A. clonazepam
 B. Venlafaxine
 C. Ropinarole
 D. Trazodone
 E. Gabapentin
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72 y.o. man with mild dementia comes to
office saying he has had difficuly falling
and staying asleep for the last 4 months.
He has vivid dreams a few times per
month. Problems started after another
MD prescribed a new medication. Which
drug most likely caused his symptoms?
A. Buspirone
B. Trazodone
C. Donepezil
D. Melatonin
E. Ramelteon
82 y.o. man has EDS x 6 mo. Falls asleep during
day in late morning. Falls asleep easily at 8pm,
wakes up q2-3h at night. Social activities limited
by his need for naps. Has h/o CVA, MCI, HTN.
Wrist actigraphy testing shows 3 sleep periods
during 24 hour period with no dominant
nocturnal sleep period. Most likely diagnosis?
 A. Idiopathic hypersomnia
 B. Advanced sleep phase disorder
 C. Irregular sleep/wake rhythm disorder
 D. Sundowning
 E. REM sleep behavior disorder
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