Sleep in the Elderly - Brown University · 2016. 5. 4. · Sleep Hygiene Education (cont’d) i....
Transcript of Sleep in the Elderly - Brown University · 2016. 5. 4. · Sleep Hygiene Education (cont’d) i....
Sleep in the Elderly
Richard P. Millman, MDJuly 15, 2009
Development of SleepDevelopment of Sleep
Roffwarg HP, Muzio JN and Dement WC. Science 1966.
Common Sleep Disorders in the Elderly
• Insomnia2. Circadian Rhythm Issues3. Restless Leg Syndrome4. Obstructive Sleep Apnea5. REM Sleep Behavior Disorder
Definition of Insomnia
Not a diagnosis, but a clinical problempresenting as one or more of the following:
n
Difficulty falling asleepn
Difficulty maintaining sleepn
Patient’s perception of poor sleep qualityResulting inn
Daytime sleepiness or fatiguen
Impaired function
Erman MK, Psychiatr Clin North Am. 1987;10:525-539Naylor MW, Aldrich Ms, In: Kryger MH, et al, eds. Principles and Practice of Sleep Medicine, 1994:413-417The Gallup Survey. Sleep in America. The Gallup Organization; 1991:1-50.
Ancoli-Israel1999
Prevalence of Insomnia* in theGeneral Adult PopulationPrevalence of Insomnia* in theGeneral Adult Population
10.2
17.716.8
9
11.7
10
0
5
10
15
20
Perc
ent
Ford1989
Ohayon1998
Ohayon2001
Ishigooka1999
Simon1997
*Insomnia = sleep disturbance every night for two weeks or more, or similarly stringent criteria.• Ford DE, Kamerow DB. JAMA. 1989;262:1479-1484.• Ohayon MM, et al. Compr Psychiatry. 1998;39:185-197.• Ohayon MM, Roth T. J Psychosom Res. 2001;51:745-755.• Ancoli-Israel S, Roth T. Sleep. 1999;22(suppl 2):S347-S353. • Ishigooka J, et al. Psychiatry Clin Neurosci. 1999;53:515-522.• Simon GE, VonKorff M. Am J Psychiatry. 1997;154:1417-1423.
Insomnia in Patients WithChronic Medical ConditionsInsomnia in Patients WithChronic Medical Conditions
0
10
20
30
40
50
60Pe
rcen
tage
of P
atie
nts
With
Inso
mni
a
Diabetes
MI
CHF
Angina
HipImpairment
BPH
ObstructiveAirway
Severe Insomnia†
Insomnia*
*Sleep disturbance “some” or “a good bit” of the time for four weeks.†Sleep disturbance “most” or “all” of the time for four weeks.MI = myocardial infarction; CHF = congestive heart failure; BPH = benign prostatic hyperplasia.Katz DA, McHorney CA. Arch Intern Med. 1998;158:1099-1107.
Chronic insomnia is associated with poorer
physical and emotional health
Sleep Disturbance Precedes the Onset of Depression
• Insomnia or difficulty sleeping under stress increased risk for depression later in life
- Johns Hopkins Precursors Study; Chang, 1997
• Insomnia predicted depression in elderly populations
- Dryman and Eaton, 1991; Livingston, 1993
• Precedes dysphoria, dissatisfaction, crying and irritability
- Perlis ML et al. J Affect Disord. 1997;42:209
Sleep Disturbance Precedes the Onset of Psychiatric Illness in General Adult Population
• Odds of developing depression during a year of insomnia - 39.8
• If insomnia resolved during the year - 1.6
Ford and Ford and KamerowKamerow.. JAMAJAMA. 1989;262:1479. 1989;262:1479--1484.1484.
Causes of Insomnia
PharmacologicAlcohol MAO inhibitorsAnticancer agents NicotineAntihypertensives SteroidsAutonomic agents TheophyllineCaffeine Thyroid preparationsCNS depressantsCNS stimulants
CNS - central nervous system; MAO - monoamine oxideAdapted from Erman MK. Hosp Proct. 1989, 23 (suppl 2):11: and Beaumont G. 1990
Diagnosing Insomnia: DifferentialDiagnosing Insomnia: DifferentialDiagnosisDiagnosis
Hauri PJ. Clin Chest Med. 1998;19:157-168.
Medical Etiologies
Cardiac diseasePulmonary diseasePain secondary to a medical condition (eg, cancer)Neurologic degenerativedisordersAllergies/asthmaRestless leg syndromeSleep apnea
Psychiatric Etiologies
Mood disordersAnxiety disordersSubstance abuse
disorders
Other Etiologies
Primary insomniaCircadian rhythm disorders
Types of Insomnia: DurationTransient Insomnia
Several daysShort-term Insomnia
< 3 weeks
Chronic Insomnia
> 3 weeks
1 week 2 weeks 3 weeks
NIH Consensus Conference. JAMA. 1984:251:2410-2414
CASE
“I wake up every hour to go to the bathroom.”
Sleep Hygiene Educationi Maintain a regular schedule for going to bed
and arisingi Avoid excessive time in bedi Avoid taking naps during the day and early eveningi Use the bed only for sleeping and sexual relationsi Do not watch the clock while in bedi Do something relaxing before bedtime
Zarcone VP, JR In: Kryger MH. Et al, eds. Principles and Practice of Sleep Medicine2nd ed. 1994 542-546 Becker et al. Postgrad Med 1993, 66-85
Sleep Hygiene Education (cont’d)iMake the bedroom as quiet and comfortable as
possibleiAvoid taking the troubles of the day to bediAvoid consumption of alcohol or caffeinated
beverages, especially within 6 hours of bedtimeiGet exercise, but early in the day (not within 2
hours of bedtime)
iAvoid going to bed hungry - eat a light snack in the evening if necessary
Zarcone VP, JR In: Kryger MH. Et al, eds. Principles and Practice of Sleep Medicine2nd ed. 1994 542-546 Becker et al. Postgrad Med 1993, 66-85
Increase Activity During the Daytime
Sleep Restriction
nRestrict time in bed (TIB) to actual sleep timen
Establish TIB based on sleep efficiency (SE) averaged over a 5 day period
n
Increased TIB by 15 minutes if average SE over 5 days >90% (85% for elderly); decrease if SE <85% (80% for elderly)
n
Be aware that daytime sleepiness is a potential side effect
Spielman AJ, et al. Psychiatr Clin North Am 1987;10:541-553Spielman AJ, et al. Sleep 1987;10:45-56.
Characteristics of the Ideal Hypnotic
No effect on memory
No respiratory depression
No interactionwith ethanol
No tolerance
No physicaldependence
IdealHypnotic
Rapidabsorption
No reboundinsomnia
No residualeffects
Mechanism otherthan generalCNS depression
Rapid sleep induction
Induction of physiologicalsleep pattern
Optimal half-life
No formationof activemetabolites
Barthollini G In: Sauvanet JP, et al, eds. Imidazopynidines in Sleep Disorders 1988: 1-9
NIH Statements About Agents Not Approved for Insomnia Treatment
• Dietary supplements/herbal remedies– Valerian: Limited evidence shows no benefit beyond placebo– No systematic evidence for efficacy; there are significant concerns about
risks• Antihistamines• Melatonin
– Little evidence exists for efficacy in the treatment of insomnia• Antipsychotics
– Studies demonstrating the usefulness…are lacking; use in chronic insomnia is not recommended
• Antidepressants– All antidepressants have potentially significant adverse effects, raising
concerns about the risk-benefit ratio.
Approved Pharmacologic Treatment Options for Insomnia
• BZDs– Estazolam– Flurazepam– Quazepam– Temazepam– Triazolam
• Non-BZD agents affecting GABA/BZD complex– Eszopiclone– Zaleplon– Zolpidem – Zolpidem CR
• MT receptor agonist– Ramelteon
GABA Reuptake
Usual Half-Life Range of BenzodiazepineTriazolam 1.5 - 5.5 hTemazepam 8 - 20.0 hEstazolam* 20 - 30.0 hQuazepam* 15 h + 35.0 hFlurazepam* 36 h +
FlurazepamQuazepam
Estazolam
Temazepam
Triazolam
O 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100Half-Life (h)
*Includes active metabolitesGreenblatt DJ, Shader RI, In: Meltzer HY, ed. Psychopharmacology: The Third GenerationThe Medical Letter. October 4, 1991;33(854): 91.
Table 9:1. Relative Risk of Hip Fracture
Long-acting Relative Short-acting RelativeBenzodiazepines Risk Benzodiazepines Risk
Chlordiazepoxide 2.3 Oxazepam 1.4Flurazepam 1.9 Lorazepam 1.0Diazepam 1.5 Triazolam 1.0Overall 1.7 Overall 1.1
Adapted from JAMA 1989;262:3303-3307
Effect of Drugs on Sleep Architecture
Polysomnographic Findings†
Barbiturates,Nonbarbiturates Benzodiazepines Zolpidem
♦
Stage 1 sleep♦
Stage 2 sleep♦
Stages 3 & 4 sleep ♦
REM sleepLatency *Time in *Number of cycles *
♦
Total sleep time /
† Clinical significance unknown* Not consistent among benzodiazepines
= No significant effects
Ashton H. In Cooper R, ed. Sleep London: Chapman & Hall Medical; 1994:175-211.
Hobbs WR, et al. In Hardman JG, et al. Eds. Goodman & Gilman’sThe Pharmacological Basis of Therapeutics, 9th ed., 1996:361-396
Bartholini G. In Sauvanet JP, et al. Eds. Imidazopyridines in Sleep Disorders. 1988:1-9.
Mariott L et al. J Clin Psychopharmacol 1989;9:9-14.I
Proposed Specificity of ActionDifferences in pharmacologic response between drugs may be due to drug selectivity for GABAA receptor subtypes
100
50
00.3 1 3 10 30 0.3 1 3 10 30
Res
pons
es (%
)
Animal Models
Hypnotic
Antico
nvuls
ant
Myorelaxant
Anticonvulsant
Myorel
axan
t
Hypnotic
Zolpidem (mg/kg) Triazolam (mg/kg)
Adapted from Sanger DJ, Zivkovic B. Psychopharmacology. 1966: 89:317-322
CASE
“I cannot fall asleep until 2 A.M. and I am always late forappointments.”
Delayed and Advanced Sleep Phase Syndromes
Diagnostic Criteria for RLS
• A desire to move the limbs usually associated with paresthesias or dysesthesias
• Motor restlessness during wakefulness• Symptoms are worse at rest and are
alleviated with activity • Symptoms are worse in the evening or night
International RLS study Group 1995
Pharmacological Treatment of RLS
Dopaminergic Agentslevodopa/carbidopapergolidepramipexoleropinirole
Opiodshydrocodonepropoxyphene