Understanding Sleep Problems in Older Adults

 
Sleep Problems
 
Alfred Fisher MD PhD
Professor and Chief
Division of Geriatrics, Gerontology, and
Palliative Medicine
Department of Internal Medicine
University of Nebraska Medical Center
 
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Sleep problems are common in older adults,
particularly those with comorbid medical
conditions and psychiatric illness
 
Risk Factors for Sleep Disturbance:
Chronic illness
Multiple medical problems
Mood disturbance
Less physical activity
Physical disability
 
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Primary sleep disorders that increase with age:
Sleep-related breathing disorders (eg, sleep apnea)
Restless legs syndrome
Circadian rhythm sleep disorders
 
Insomnia is more common in women than in men at
all ages
 
Self-reported sleeping difficulties are more common
in older African Americans, particularly women and
in those with depression and chronic illness
 
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Screening Questions:
Is the person satisfied with his or her sleep?
Does sleep or fatigue interfere with daytime activities?
Does the bed partner or others complain of unusual
behavior during sleep, such as snoring, interrupted
breathing, or leg movements?
 
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Patient sleep log can be helpful
-Supplement with information from bed partner, others,
and/or validated sleep questionnaire
Focused physical exam ― guided by evidence from
the history
Conduct mental status testing – with a focus on
memory and mood problems, particularly
depression
Lab testing ― guided by findings of the history and
physical exam
 
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Polysomnography is indicated if primary sleep
disorder is suspected:
Sleep apnea
Narcolepsy
Periodic limb movement disorder
Violent or other unusual behaviors during sleep
Other sleep symptoms that do not respond to treatment
In-home portable monitoring ― screens for sleep
apnea
 
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Depression and anxiety are common psychiatric
problems that are associated with insomnia
Treatment of depression may improve the sleep
abnormalities
Lack of attention to sleep complaints in older depressed
adults can make depression less likely to respond to
treatment
Caregiving can be associated with sleep difficulties
Sleep disorders in older adults are associated with
increased suicide risk
Can be secondary to medical conditions or medications
 
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Medications/agents that can contribute to
insomnia, particularly if taken near bedtime:
Agents that increase urination (eg, diuretics)
Stimulating agents (eg, caffeine, sympathomimetics,
bronchodilators, activating psychiatric medications)
Agents that can cause nightmares and impair sleep
Antidepressants
Antiparkinsonian agents
Antihypertensives (eg, propranolol)
Cholinesterase inhibitors
 
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Do not start an older patient with persistent sleep
complaints on a sedative-hypnotic agent without careful
clinical assessment to identify the cause of the
complaints
If the history and physical exam do not suggest a
serious underlying cause, mild symptoms may respond
to simple sleep hygiene
Chronic insomnia generally does not respond to simple
sleep hygiene, and requires behavioral treatment, such
as cognitive behavioral therapy for insomnia (CBT-I)
Patients should be educated that daytime napping will
decrease nighttime sleep
 
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Characterized by an uncontrollable urge to move the
legs, usually with an unpleasant sensation in the legs,
that worsens with inactivity, generally at night, and
improves with movement
Diagnosis is made based on the patient’s description of
the symptoms
Symptoms occur while the person is awake and can also
involve the arms
Prevalence increases with age
Can be associated with iron deficiency – can check
ferritin level to assess
 
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Medications can also aggravate or induce RLS:
Antiemetics
Antipsychotics
SSRIs
Tricyclic Antidepressants
Diphenydramine
These medications should be addressed in patients with
new or worsening RLS
 
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Treat RLS if symptoms are severe or if quality of life
is impacted
A dopaminergic agent is generally the initial agent
of choice for older patients
Evening dose of a dopamine agonist (eg,
pramipexole or ropinirole) is commonly used for
patients with frequent (eg, nightly) symptoms of RLS
Gabapentin is an alternative for those who cannot
tolerate a dopamine agonist
 
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Sleep issues are common in older individuals and can
be evaluated in a step-wise manner
Insomnia can respond well to non-pharmacologic
interventions including improved sleep hygiene and/or
CBT-I
Restless legs is associated with iron deficiency and can
respond to dopamine agonists or gabapentin
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Sleep problems are common among older adults, especially those with chronic illnesses and mood disturbances. Primary sleep disorders that increase with age include sleep-related breathing disorders and restless legs syndrome. Changes in sleep patterns with aging involve decreases in total sleep time and sleep efficiency, while daytime napping may increase. Evaluation of sleep involves screening questions and office assessments, including sleep logs and mental status testing. It's essential to address sleep issues in older individuals to improve their quality of life.


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  1. Sleep Problems Alfred Fisher MD PhD Professor and Chief Division of Geriatrics, Gerontology, and Palliative Medicine Department of Internal Medicine University of Nebraska Medical Center

  2. SLEEP PROBLEMS IN OLDER PEOPLE Sleep problems are common in older adults, particularly those with comorbid medical conditions and psychiatric illness Risk Factors for Sleep Disturbance: Chronic illness Multiple medical problems Mood disturbance Less physical activity Physical disability

  3. SLEEP PROBLEMS IN OLDER PEOPLE Primary sleep disorders that increase with age: Sleep-related breathing disorders (eg, sleep apnea) Restless legs syndrome Circadian rhythm sleep disorders Insomnia is more common in women than in men at all ages Self-reported sleeping difficulties are more common in older African Americans, particularly women and in those with depression and chronic illness

  4. CHANGES IN SLEEP WITH AGING Sleep Characteristic Age-Related Change Total sleep time Decrease Sleep latency (time to fall asleep) Sleep efficiency (time asleep over time in bed) Daytime napping Increase or no change Decrease Increase Stages N1 and N2 Increase Slow-wave sleep (Stage N3) Percent rapid eye movement (REM) Wake after sleep onset Decrease Decrease Increase

  5. EVALUATION OF SLEEP Screening Questions: Is the person satisfied with his or her sleep? Does sleep or fatigue interfere with daytime activities? Does the bed partner or others complain of unusual behavior during sleep, such as snoring, interrupted breathing, or leg movements?

  6. OFFICE EVALUATION OF SLEEP Patient sleep log can be helpful -Supplement with information from bed partner, others, and/or validated sleep questionnaire Focused physical exam guided by evidence from the history Conduct mental status testing with a focus on memory and mood problems, particularly depression Lab testing guided by findings of the history and physical exam

  7. OBJECTIVE EVALUATION OF SLEEP Polysomnography is indicated if primary sleep disorder is suspected: Sleep apnea Narcolepsy Periodic limb movement disorder Violent or other unusual behaviors during sleep Other sleep symptoms that do not respond to treatment In-home portable monitoring screens for sleep apnea

  8. INSOMNIA Depression and anxiety are common psychiatric problems that are associated with insomnia Treatment of depression may improve the sleep abnormalities Lack of attention to sleep complaints in older depressed adults can make depression less likely to respond to treatment Caregiving can be associated with sleep difficulties Sleep disorders in older adults are associated with increased suicide risk Can be secondary to medical conditions or medications

  9. MEDICATIONS ASSOCIATED WITH INSOMNIA Medications/agents that can contribute to insomnia, particularly if taken near bedtime: Agents that increase urination (eg, diuretics) Stimulating agents (eg, caffeine, sympathomimetics, bronchodilators, activating psychiatric medications) Agents that can cause nightmares and impair sleep Antidepressants Antiparkinsonian agents Antihypertensives (eg, propranolol) Cholinesterase inhibitors

  10. MANAGEMENT OF INSOMNIA Do not start an older patient with persistent sleep complaints on a sedative-hypnotic agent without careful clinical assessment to identify the cause of the complaints If the history and physical exam do not suggest a serious underlying cause, mild symptoms may respond to simple sleep hygiene Chronic insomnia generally does not respond to simple sleep hygiene, and requires behavioral treatment, such as cognitive behavioral therapy for insomnia (CBT-I) Patients should be educated that daytime napping will decrease nighttime sleep

  11. WHAT IS INCLUDED IN CBT-I? Intervention Goal Description Stimulus control To recondition maladaptive sleep-related behaviors Patient is told to go to bed only when sleepy, not use the bed for eating or watching TV, get out of bed if unable to fall asleep, return to bed only when sleepy, get up at the same time each morning, not take naps during the day Sleep restriction To improve sleep efficiency (time asleep divided by time in bed) by causing sleep deprivation Patient first collects a 1- to 2-week sleep diary to determine average total daily sleep time, then stays in bed only that duration plus ~ 15 minutes, gets up at same time each morning, takes no naps in the daytime, gradually increases time allowed in bed as sleep efficiency improves

  12. WHAT IS INCLUDED IN CBT-I? Intervention Goal Description Cognitive interventions To change misunderstandings and false beliefs regarding sleep Identify patient s dysfunctional beliefs and attitudes about sleep; educate patient to change these false beliefs and attitudes, including normal changes in sleep with increased age and changes that are pathologic Relaxation techniques To recognize and relieve tension and anxiety Teach patient to tense and relax each muscle group. Electromyographic biofeedback: give patient feedback regarding muscle tension and teach techniques to relieve it. Teach meditation or imagery techniques to relieve racing thoughts or anxiety.

  13. RESTLESS LEGS SYNDROME Characterized by an uncontrollable urge to move the legs, usually with an unpleasant sensation in the legs, that worsens with inactivity, generally at night, and improves with movement Diagnosis is made based on the patient s description of the symptoms Symptoms occur while the person is awake and can also involve the arms Prevalence increases with age Can be associated with iron deficiency can check ferritin level to assess

  14. RESTLESS LEGS SYNDROME Medications can also aggravate or induce RLS: Antiemetics Antipsychotics SSRIs Tricyclic Antidepressants Diphenydramine These medications should be addressed in patients with new or worsening RLS

  15. TREATMENT OF RESTLESS LEGS SYNDROME Treat RLS if symptoms are severe or if quality of life is impacted A dopaminergic agent is generally the initial agent of choice for older patients Evening dose of a dopamine agonist (eg, pramipexole or ropinirole) is commonly used for patients with frequent (eg, nightly) symptoms of RLS Gabapentin is an alternative for those who cannot tolerate a dopamine agonist

  16. SUMMARY Sleep issues are common in older individuals and can be evaluated in a step-wise manner Insomnia can respond well to non-pharmacologic interventions including improved sleep hygiene and/or CBT-I Restless legs is associated with iron deficiency and can respond to dopamine agonists or gabapentin

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