doron garfinkel, m.d. shoham geriatric medical center pardes – hana, israel head, geriatric...

DORON GARFINKEL, M.DDORON GARFINKEL, M.D..DORON GARFINKEL, M.DDORON GARFINKEL, M.D..

SHOHAM GERIATRIC MEDICAL CENTERSHOHAM GERIATRIC MEDICAL CENTER

PARDES – HANAPARDES – HANA , ,

ISRAELISRAEL

HEAD, GERIATRIC PALIATIVE DEPARTMENTHEAD, GERIATRIC PALIATIVE DEPARTMENT

SLEEP DISORDER IN THE ELDERLY -

EFFECT OF MELATONIN THERAPY

SLEEP DISORDER IN THE ELDERLY -

EFFECT OF MELATONIN THERAPY

Normal Sleep & Normal Aging:Our Internal Biological ClockNormal Sleep & Normal Aging:Our Internal Biological Clock

The biological clock resides in the brainThe biological clock resides in the brain It helps regulate when we feel sleepy It helps regulate when we feel sleepy

and when we are alertand when we are alert It works in tandem with light and dark, It works in tandem with light and dark,

and our body temperatureand our body temperature

and hormonesand hormones

M E L A T O N I N N ACETYL -5- METHOXYTRYPTAMINE


ITS SYNTHESIS & EXCRETION ARE REGULATED ITS SYNTHESIS & EXCRETION ARE REGULATED

BY ANBY AN ENDOGENOUS ENDOGENOUS CLOCK LOCATED IN CLOCK LOCATED IN

THE HYPOTHALAMUS THAT IS ENTRAINED THE HYPOTHALAMUS THAT IS ENTRAINED

TO THE EXTERNAL LIGHT - DARK CYCLETO THE EXTERNAL LIGHT - DARK CYCLE

ITS SYNTHESIS & EXCRETION ARE REGULATED ITS SYNTHESIS & EXCRETION ARE REGULATED

BY ANBY AN ENDOGENOUS ENDOGENOUS CLOCK LOCATED IN CLOCK LOCATED IN

THE HYPOTHALAMUS THAT IS ENTRAINED THE HYPOTHALAMUS THAT IS ENTRAINED

TO THE EXTERNAL LIGHT - DARK CYCLETO THE EXTERNAL LIGHT - DARK CYCLE

AN INDOLE-AMINE SECRETED IN RESPONSE AN INDOLE-AMINE SECRETED IN RESPONSE

TO DARKNESS FROM THE PINEAL GLANDTO DARKNESS FROM THE PINEAL GLAND

AN INDOLE-AMINE SECRETED IN RESPONSE AN INDOLE-AMINE SECRETED IN RESPONSE

TO DARKNESS FROM THE PINEAL GLANDTO DARKNESS FROM THE PINEAL GLAND

THE HORMONE INDUCES SLEEP THROUGH ITS SYNCHRONIZING EFFECT ON THE

INTERNAL BIOLOGICAL CLOCK EASILY CROSSES THE BLOOD BRAIN BARRIER (B. B. B.)

THE HORMONE INDUCES SLEEP THROUGH ITS SYNCHRONIZING EFFECT ON THE

INTERNAL BIOLOGICAL CLOCK EASILY CROSSES THE BLOOD BRAIN BARRIER (B. B. B.)



IS RAPIDLY METABOLIZED IN THE LIVER AND

OVER 85% ELIMINATED IN THE URINE

AS 6 SULPHATOXY - MELATONIN (6 - S - MT)

IS RAPIDLY METABOLIZED IN THE LIVER AND

OVER 85% ELIMINATED IN THE URINE

AS 6 SULPHATOXY - MELATONIN (6 - S - MT)

EFFECT OF AGE ON M E L A T O N I N

EFFECT OF AGE ON M E L A T O N I N

THERE IS AN AGE-RELATED CHANGE IN THERE IS AN AGE-RELATED CHANGE IN THE DAILY RHYTHM OF MELATONINTHE DAILY RHYTHM OF MELATONIN

SERUM MELATONIN CONCENTRATIONS SERUM MELATONIN CONCENTRATIONS DECREASE IN OLD AGEDECREASE IN OLD AGE

IN HEALTHY ELDERLY INSOMNIACS, 6-S MT IN HEALTHY ELDERLY INSOMNIACS, 6-S MT IS SIGNIFICANTLY LOWER AND ITS ONSET IS SIGNIFICANTLY LOWER AND ITS ONSET AND PEAK TIME ARE DELAYED - AND PEAK TIME ARE DELAYED - IN COMPARISON TO AGE MATCHED IN COMPARISON TO AGE MATCHED CONTROLS WITH NO SLEEP DISTURBANCESCONTROLS WITH NO SLEEP DISTURBANCES

URINARY 6 - SULPHATOXY MELATONIN (6- S- MT) EXCRETION

URINARY 6 - SULPHATOXY MELATONIN (6- S- MT) EXCRETION

0

5

10

15

6 -

S-

MT

(u

g)

18--21 21--24 00--03 03--06 06--09

COLLECTION INTERVAL (h)

ELDERS / ELDERS / PATIENTSPATIENTS

NORMALNORMAL

EXOGENOUS MELATONIN Therapeutic Effects

EXOGENOUS MELATONIN Therapeutic Effects

EXERTS SYNCHRONIZING EFFECTS ON CIRCADIAN EXERTS SYNCHRONIZING EFFECTS ON CIRCADIAN RHYTHMS - IT PHASE ADVANCES SLEEP OF RHYTHMS - IT PHASE ADVANCES SLEEP OF

PATIENTS SUFFERING FROM PATIENTS SUFFERING FROM

DELAYED SLEEP- PHASE SYNDROMEDELAYED SLEEP- PHASE SYNDROME CAN FACILITATE THE POST - FLIGHT ADAPTATION CAN FACILITATE THE POST - FLIGHT ADAPTATION

OF OF JET - LAGJET - LAG RESYNCHRONIZES THE SLEEP - WAKE CYCLERESYNCHRONIZES THE SLEEP - WAKE CYCLE

OF OF BLIND PEOPLEBLIND PEOPLE

EXOGENOUS MELATONIN Characteristics

EXOGENOUS MELATONIN Characteristics

IS NOT ASSOCIATED WITH SERIOUS SIDE EFFECTS

IS NOT ASSOCIATED WITH SERIOUS SIDE EFFECTS

IS SHORT LIVED IN HUMANS -

SERUM HALF LIFE IS ONLY 40-50 MINUTES

IS SHORT LIVED IN HUMANS -

SERUM HALF LIFE IS ONLY 40-50 MINUTES

CONTROLLED - RELEASE MELATONIN


ENABLES RESTORATION OF NORMAL SERUM ENABLES RESTORATION OF NORMAL SERUM MELATONIN CONCENTRATIONS BY CONTROLLED MELATONIN CONCENTRATIONS BY CONTROLLED DOSAGE AND TIMINGDOSAGE AND TIMING

ACHIEVES A PHARMACOKINETIC PROFILE SIMILAR ACHIEVES A PHARMACOKINETIC PROFILE SIMILAR TO THAT OF ENDOGENOUS MELATONIN TO THAT OF ENDOGENOUS MELATONIN SECRETED BY THE PINEAL GLANDSECRETED BY THE PINEAL GLAND

THE QUALITY OF SLEEP IS MUCH BETTER THAN THE QUALITY OF SLEEP IS MUCH BETTER THAN THAT ACHIEVED BY REGULAR , SHORT ACTING THAT ACHIEVED BY REGULAR , SHORT ACTING MELATONINMELATONIN

COMPLIANCE IS IMPROVED ESPECIALLY IN THE COMPLIANCE IS IMPROVED ESPECIALLY IN THE ELDERLYELDERLY

RESEARCH PROJECTSSTUDY DESIGN

RESEARCH PROJECTSSTUDY DESIGN

RANDOMIZED, PLACEBO CONTROLLED

DOUBLE - BLIND ± CROSSOVER DESIGN

SUBJECTS GIVEN EITHER 2mg OF


(CIRCADINTM, NEURIM PHARMACEUTICALS , ISRAEL)

OR A PLACEBO,

TWO HOURS BEFORE DESIRED BEDTIME ,

FOR THREE WEEKS - SEVERAL MONTHS

RANDOMIZED, PLACEBO CONTROLLED

DOUBLE - BLIND ± CROSSOVER DESIGN

SUBJECTS GIVEN EITHER 2mg OF


(CIRCADINTM, NEURIM PHARMACEUTICALS , ISRAEL)

OR A PLACEBO,

TWO HOURS BEFORE DESIRED BEDTIME ,

FOR THREE WEEKS - SEVERAL MONTHS

S U B J E C T SS U B J E C T S

ADULTS AND ELDERLY PEOPLE LIVING IN THE COMMUNITY WHO SUFFERED FROM SLEEP DISTURBANCES INITIALLY, PEOPLE LIVING IN MEDITERRANEAN TOWERS, A RESIDENTIAL CENTER FOR SENIOR CITIZENS IN ISRAEL THEN, PATIENTS SUFFERING FROM DIABETES MELLITUS, HEART DISEASE,

HYPERTENTION etc ± SLEEPING PILLS...

ADULTS AND ELDERLY PEOPLE LIVING IN THE COMMUNITY WHO SUFFERED FROM SLEEP DISTURBANCES INITIALLY, PEOPLE LIVING IN MEDITERRANEAN TOWERS, A RESIDENTIAL CENTER FOR SENIOR CITIZENS IN ISRAEL THEN, PATIENTS SUFFERING FROM DIABETES MELLITUS, HEART DISEASE,

HYPERTENTION etc ± SLEEPING PILLS...

RESEARCH PROJECTSTOOLS

RESEARCH PROJECTSTOOLS

A SLEEP QUESTIONNAIRE ASSESSMENT OF SLEEP QUALITY FOR

THREE CONSECUTIVE NIGHTS, BY WRIST ACTIGRAPHY WHILE SUBJECTS WERE SLEEPING AT HOME

MOTION RECORDING ANALYSED USING AN AUTOMATIC SCORING ALGORHYTHM

URINE COLLECTED AT 3 HOUR INTERVALS OVERNIGHT, URINARY 6-S MT ASSAYED BY R.I.A. OR ELISA

STUDY PROTOCOL STUDY PROTOCOL

RUN INRUN IN WASH WASH OUTOUT

1 WEEK 1 WEEK3 WEEKS 3 WEEKS

CR MELATONIN

CR MELATONIN CR MELATONINPLACEBOPLACEBO OR PLACEBOOR PLACEBO PLACEBO OR

PLACEBOPLACEBO

URINE COLLECTION A C T I G R A P H (3 NIGHTS))

PLC

PLC MEL0

10

20

30

40

Min

p < .088

LATENCY

EFFECTS OF CR MELATONIN ON SLEEP PARAMETERS IN ELDERLY PATIENTS




PLC

PLC MEL60

65

70

75

80

85

%

p < .001

EFFICIENCY

PLC

PLC

MEL

30

40

50

60

70

80

Min

p < .001

W.A.S.O.



IMPROVEMENT OF SLEEP QUALITY

IN ELDERLY PEOPLE BY

CONTROLLED- RELEASE MELATONIN


IN ELDERLY PEOPLE BY

CONTROLLED- RELEASE MELATONIN D. GARFINKEL, M. LAUDON, D. NOF, N. ZISAPEL

LANCET 1995; 346: 541 - 44

D. GARFINKEL, M. LAUDON, D. NOF, N. ZISAPEL

LANCET 1995; 346: 541 - 44

C O N C L U S I O N S C O N C L U S I O N S CONTROLLED - RELEASE MELATONIN

SIGNIFICANTLY IMPROVES SLEEP QUALITY IN ELDERLY INSOMNIACS

IN WHOM MELATONIN OUTPUT WAS IMPAIRED

MELATONIN REPLACEMENT THERAPY SHORTENS SLEEP LATENCY,

IMPROVES SLEEP EFFICIENCY AND DECREASES W.A.S.O.

MELATONIN REPLACEMENT THERAPY SHORTENS SLEEP LATENCY,

IMPROVES SLEEP EFFICIENCY AND DECREASES W.A.S.O.

CONTROLLED RELEASEM E L A T O N I N

CONTROLLED RELEASEM E L A T O N I N


IN DIABETIC PATIENTS

BY


IN DIABETIC PATIENTS

BY

Impaired nocturnal melatonin secretion in Non-dipper hypertensive patients

Impaired nocturnal melatonin secretion in Non-dipper hypertensive patients

Jonas M, Garfinkel D, Zisapel N, Laudon M, Grossman E

BLOOD PRESS 12 (1); 19-24, 2003.

Jonas M, Garfinkel D, Zisapel N, Laudon M, Grossman E

BLOOD PRESS 12 (1); 19-24, 2003.

BENZODIAZEPINESBENZODIAZEPINES

BENZODIAZEPINS ARE WIDELY USED IN BENZODIAZEPINS ARE WIDELY USED IN

THE ELDERLY POPULATION FOR THE THE ELDERLY POPULATION FOR THE

INITIATION OF SLEEP INITIATION OF SLEEP

VERY FREQUENTLY, COMPLAINTS ABOUT POOR SLEEP MAINTENANCE PERSIST

DESPITE BENZODIAZEPIN TREATMENT

VERY FREQUENTLY, COMPLAINTS ABOUT POOR SLEEP MAINTENANCE PERSIST

DESPITE BENZODIAZEPIN TREATMENT

WE REPORTED A DECREASED MELATONIN WE REPORTED A DECREASED MELATONIN OUTPUT IN ELDERLY PEOPLE SUFFERING FROM OUTPUT IN ELDERLY PEOPLE SUFFERING FROM INSOMNIA (Compared to Controls) INSOMNIA (Compared to Controls)

MELATONIN CAN IMPROVE SLEEP QUALITY IN MELATONIN CAN IMPROVE SLEEP QUALITY IN

MELATONIN - DEFICIENT ELDERLY PEOPLEMELATONIN - DEFICIENT ELDERLY PEOPLE

MELATONIN PRODUCTION CAN BE INHIBITED BY BENZODIAZEPINS !!!

MELATONIN PRODUCTION CAN BE !!! INHIBITED BY BENZODIAZEPINS

BENZODIAZEPINESBENZODIAZEPINES

0

25

50

75

100

O

DOSE REDUCTION - Period I DOSE REDUCTION - Period I

%%

11 22 33 44 55 66 WEEKSWEEKS

PLACEBOPLACEBO

MELATONINMELATONINGOAL

P < 0.05P < 0.05

FACILITATION OF BENZODIAZEPINE DISCONTINUATION BY

CONTROLLED-RELEASE MELATONIN

FACILITATION OF BENZODIAZEPINE DISCONTINUATION BY

CONTROLLED-RELEASE MELATONIN

FACILITATION OF BENZODIAZEPINE DISCONTINUATION BY C.R. MELATONINFACILITATION OF BENZODIAZEPINE

DISCONTINUATION BY C.R. MELATONIN

0

20

40

60

80

100

P = .05

MELATONINMELATONINPLACEBOPLACEBO

BENZODIAZEPINE DISCONTINUATION

%%

55 66 weekweek

0

25

50

75

100

O

BZD. DOSE REDUCTION VS SLEEP QUALITY BZD. DOSE REDUCTION VS SLEEP QUALITY

%%

11 22 33 44 55 66 WEEKSWEEKS

< < < M E L A T O N I N < < < < < < < M E L A T O N I N < < < <

7.5-7.5-

5.5-5.5-

6.5-6.5-

00

~11%~11%

FACILITATION OF BENZODIAZEPINE DISCONTINUATION BY C.R. MELATONINFACILITATION OF BENZODIAZEPINE

DISCONTINUATION BY C.R. MELATONIN

STILL ON BENZIDIAZEPINES - FAILURESTILL ON BENZIDIAZEPINES - FAILURE& STOPPED C. R. MELATONIN & STOPPED C. R. MELATONIN 22% 22%

FACILITATION OF BENZODIAZEPINE DISCONTINUATION BY C.R. MELATONIN

TWO YEARS AFTER TERMINATION OF THE STUDY

FACILITATION OF BENZODIAZEPINE DISCONTINUATION BY C.R. MELATONIN

TWO YEARS AFTER TERMINATION OF THE STUDY

BENZODIAZEPINE DOSE REDUCTION 78% STOPPED TAKING BZD 60% 0N C. R. MELATONIN 52% WITHOUT C. R. MELATONIN 8% REDUCED BZD DOSAGE 18% (Average 30% of Initial BZD Dose)

BENZODIAZEPINE DOSE REDUCTION 78% STOPPED TAKING BZD 60% 0N C. R. MELATONIN 52% WITHOUT C. R. MELATONIN 8% REDUCED BZD DOSAGE 18% (Average 30% of Initial BZD Dose)

CONCLUSIONS CONCLUSIONSCONTROLLED - RELEASE MELATONIN CONTROLLED - RELEASE MELATONIN

CAN FACILITATE BENZODIAZEPINE CAN FACILITATE BENZODIAZEPINE DISCONTINUATION OR ENABLES A DISCONTINUATION OR ENABLES A

SIGNIFICANT DOSE REDUCTION SIGNIFICANT DOSE REDUCTION

OF BENZODIAZEPINES, OF BENZODIAZEPINES,

WHILE MAINTAINING THE SAME OR BETTER WHILE MAINTAINING THE SAME OR BETTER SLEEP QUALITYSLEEP QUALITY

CONTROLLED - RELEASE MELATONIN CONTROLLED - RELEASE MELATONIN

CAN FACILITATE BENZODIAZEPINE CAN FACILITATE BENZODIAZEPINE DISCONTINUATION OR ENABLES A DISCONTINUATION OR ENABLES A

SIGNIFICANT DOSE REDUCTION SIGNIFICANT DOSE REDUCTION

OF BENZODIAZEPINES, OF BENZODIAZEPINES,

WHILE MAINTAINING THE SAME OR BETTER WHILE MAINTAINING THE SAME OR BETTER SLEEP QUALITYSLEEP QUALITY

D. GARFINKEL, N. ZISAPEL, J. WAINSTEIN, M. LAUDON,

Arch Int Med 159: 2456-60, 1999

D. GARFINKEL, N. ZISAPEL, J. WAINSTEIN, M. LAUDON,

Arch Int Med 159: 2456-60, 1999

FACILITATION OF BENZODIAZEPINE DISCONTINUATION BY MELATONIN :

A NEW CLINICAL APPROACH

FACILITATION OF BENZODIAZEPINE DISCONTINUATION BY MELATONIN :

A NEW CLINICAL APPROACH

שינה הפרעות בבתי אבות בקשישים

ובמחלקות סיעודיות

שינה הפרעות בבתי אבות בקשישים

ובמחלקות סיעודיות

הכנס הראשון לרפואה בגיל השלישי 2003 באפריל 28

הכנס הראשון לרפואה בגיל השלישי 2003 באפריל 28

ד"ר דורון גרפינקל מחלקה גריאטרית פליאטיבית

שהם -המרכז המשולב לרפואת הגיל השלישי פרדס חנה

ד"ר דורון גרפינקל מחלקה גריאטרית פליאטיבית

שהם -המרכז המשולב לרפואת הגיל השלישי פרדס חנה

SLEEP DISORDERS AND SLEEP SLEEP DISORDERS AND SLEEP FRAGMENTATION ARE VERY COMMON FRAGMENTATION ARE VERY COMMON

IN NURSING HOME RESIDENTS …IN NURSING HOME RESIDENTS …

APPROACH TO SLEEP DISORDERS IN THE NURSING HOME SETTING


Allesi CA & Schnelle JF. Sleep Med Rev 2000; 4(1): 45 - 56 (Review Article) Allesi CA & Schnelle JF. Sleep Med Rev 2000; 4(1): 45 - 56 (Review Article)

UNFORTUNATELY, THERE IS LITTLE DATA ON THE EFFECTIVENESS OF SLEEPING MEDICATIONS AND THE SPECIFIC MANAGEMENT OF SLEEP DISORDERS

IN THIS SETTING.

UNFORTUNATELY, THERE IS LITTLE DATA ON THE EFFECTIVENESS OF SLEEPING MEDICATIONS AND THE SPECIFIC MANAGEMENT OF SLEEP DISORDERS

IN THIS SETTING.

ACTIGRAPHY OF DEMENTED LONG TERM PATIENTS ACTIGRAPHY OF DEMENTED LONG TERM PATIENTS

SHOWED SLEEP EFFICIENCY SHOWED SLEEP EFFICIENCY OFOF 75%, 75%, A MEAN A MEAN

SLEEP ONSET SLEEP ONSET LATENCY OF ONE HOUR,LATENCY OF ONE HOUR, A MEAN A MEAN

W.A.S.O. OF MORE THAN TWO HOURSW.A.S.O. OF MORE THAN TWO HOURS, MORE THAN 13 , MORE THAN 13

HOURS WERE SPENT IN BEDHOURS WERE SPENT IN BED

Fetveit A, Bjorvatn B. Int J Geriatr Psychiatry 2002; 17: 604 - 9Fetveit A, Bjorvatn B. Int J Geriatr Psychiatry 2002; 17: 604 - 9

SLEEP DISTURBANCES AMONG NURSING HOME RESIDENTS

SLEEP DISTURBANCES AMONG NURSING HOME RESIDENTS

SLEEP DISTURBANCES WERE COMMON AMONG THE RESIDENTSSLEEP DISTURBANCES WERE COMMON AMONG THE RESIDENTS

THE MAIN CAUSES OF SLEEP THE MAIN CAUSES OF SLEEP DISTURBANCES IN BOTH SETTINGS WERE:DISTURBANCES IN BOTH SETTINGS WERE:

THE SLEEP OF OLDER PEOPLE IN HOSPITAL AND NURSING HOMES


Ersser & al. J Clin Nurs 1999; 8(4): 360 - 8 Ersser & al. J Clin Nurs 1999; 8(4): 360 - 8

NEEDING TO GO TO THE TOILET,

NOISE

PAIN

AND DISCOMFORT

A VARIETY OF FACTORS CONTRIBUTE TO THESE SLEEPING DIFFICULTIESA VARIETY OF FACTORS CONTRIBUTE TO THESE SLEEPING DIFFICULTIES

A VARIETY OF FACTORS CONTRIBUTE TO THESE SLEEPING DIFFICULTIESA VARIETY OF FACTORS CONTRIBUTE TO THESE SLEEPING DIFFICULTIES

AGE RELATED CHANGES IN SLEEP AGE RELATED CHANGES IN SLEEP THE HIGH PREVALENCE OF DEMENTIA, DEPRESSION,

MEDICAL ILLNESS AND MEDICATIONS THAT AFFECT SLEEP

THE HIGH PREVALENCE OF DEMENTIA, DEPRESSION,

MEDICAL ILLNESS AND MEDICATIONS THAT AFFECT SLEEP

RESPIRATORY DISTURBANCES OF SLEEP RESPIRATORY DISTURBANCES OF SLEEP

LIFESTYLE CHARACTERISTICS SUCH AS: INACTIVITY, LARGE AMOUNTS OF TIME SPENT IN BED,

LACK OF BRIGHT LIGHT EXPOSURE AND POOR SLEEP HYGIENE

AND THE DISRUPTIVE NIGHT-TIME NURSING HOME ENVIRONMENT

LIFESTYLE CHARACTERISTICS SUCH AS: INACTIVITY, LARGE AMOUNTS OF TIME SPENT IN BED,

LACK OF BRIGHT LIGHT EXPOSURE AND POOR SLEEP HYGIENE

AND THE DISRUPTIVE NIGHT-TIME NURSING HOME ENVIRONMENT



Allesi CA & Schnelle JF. Sleep Med Rev 2000; 4(1): 45 - 56 (Review Article) Allesi CA & Schnelle JF. Sleep Med Rev 2000; 4(1): 45 - 56 (Review Article)

THE IMPACT OF SEDATIVE-HYPNOTIC USE ON SLEEP SYMPTOM IN ELDERLY NURSING HOME RESIDENTSS


Monane M, Glynn RJ, Avorn J. Clin Pharmacol Ther 1996; 59(1): 83 Monane M, Glynn RJ, Avorn J. Clin Pharmacol Ther 1996; 59(1): 83

145 institutionalized elderly subjects, mean age 83.0 (range 65 - 105 years) in 12 nursing homes145 institutionalized elderly subjects, mean age 83.0 (range 65 - 105 years) in 12 nursing homes

At baseline: One or more sleep related complaints were present in 65% of the residents. No relationship was found between use of sedative - hypnotic agent and the presence or absence of sleep complaints.

AFTER 6 MONTHS OF FOLLOW UP: Improvement in functional status was significantly associated with improved sleep (p< 0.005).



CONCLUSIONS:CONCLUSIONS:

Monane M, Glynn RJ, Avorn J. Clin Pharmacol Ther 1996; 59(1): 83 Monane M, Glynn RJ, Avorn J. Clin Pharmacol Ther 1996; 59(1): 83

THERE WAS NO RELATIONSHIP BETWEEN DECREASED USE OF SEDATIVE - HYPNOTIC AGENTS AND WORSENED SLEEP, OR

BETWEEN THEIR INCREASED USE AND IMPROVED SLEEP REPORTS

NO DISCERNIBLE DIFFERENCE WAS FOUND IN QUALITY OF SLEEP AND WHETHER

PATIENTS FELT RESTED OR NOT,

BETWEEN THOSE

NO DISCERNIBLE DIFFERENCE WAS FOUND IN QUALITY OF SLEEP AND WHETHER

PATIENTS FELT RESTED OR NOT,

BETWEEN THOSE



Ersser & al. J Clin Nurs 1999; 8(4): 360 - 8 Ersser & al. J Clin Nurs 1999; 8(4): 360 - 8

PATIENTS ON HYPNOTIC MEDICATION PATIENTS ON HYPNOTIC MEDICATION

AND THOSE WHO WERE NOTAND THOSE WHO WERE NOT

AN INTERVENTION THAT COMBINES BOTH BEHAVIORAL AND ENVIRONMENTAL STRATEGIES AND THAT ADDRESSES

DAYTIME BEHAVIORAL FACTORS ASSOCIATED WITH POOR SLEEP (eg. Excessive time in bed)

The significant reduction in noise and light events … did not lead to significant improvement

in the day sleep and most night sleep measures

The significant reduction in noise and light events … did not lead to significant improvement

in the day sleep and most night sleep measures


WOULD POTENTIALLY BE MORE EFFECTIVE IN WOULD POTENTIALLY BE MORE EFFECTIVE IN IMPROVING THE NIGHT SLEEP & THE QUALITY OF LIFE IMPROVING THE NIGHT SLEEP & THE QUALITY OF LIFE

OF NURSING HOME RESIDENTSOF NURSING HOME RESIDENTS.

THE NURSING HOME AT NIGHT: EFFECT OF AN INTERVENTION ON NOISE,

LIGHT AND SLEEP

THE NURSING HOME AT NIGHT: EFFECT OF AN INTERVENTION ON NOISE,

LIGHT AND SLEEP

Sleep disturbances were studied as a mortality risk in 272 institutionalized elderly patients

Sleep disturbances were studied as a mortality risk in 272 institutionalized elderly patients

SLEEP PATTERNS AND MORTALITY AMONG ELDERLY PATIENTS IN A GERIATRIC HOSPITALSLEEP PATTERNS AND MORTALITY AMONG ELDERLY PATIENTS IN A GERIATRIC HOSPITAL

Manabe K & al. Gerontology 2000; 46(6): 318 - 22 Manabe K & al. Gerontology 2000; 46(6): 318 - 22

Mortality after two years was significantly higher in the nighttime insomnia, daytime sleepiness and sleep onset delay groups.

Mortality after two years was significantly higher in the nighttime insomnia, daytime sleepiness and sleep onset delay groups.

Sleep disturbances may be one of the symptoms indicating poor health

or functional deficits, and be an independent risk factor for survival.

Sleep disturbances may be one of the symptoms indicating poor health

or functional deficits, and be an independent risk factor for survival.

Chronic hypoxia due to alveolar hypoventilation and/or disturbance

in ventilation/perfusion ratio,

Chronic hypoxia due to alveolar hypoventilation and/or disturbance

in ventilation/perfusion ratio,

Nocturnal Respiratory DisturbancesNocturnal Respiratory Disturbances

INTRODUCTION INTRODUCTION ::

are usually the result of a variety of cardiopulmonary & neurological maladies whose prevalence is increasing with age.

are usually the result of a variety of cardiopulmonary & neurological maladies whose prevalence is increasing with age.

Sleep disturbances may aggravate hypoxia Sleep disturbances may aggravate hypoxia

and lead to increased mortality and morbidityand lead to increased mortality and morbidity

INTRODUCTION INTRODUCTION ::

Breathing problems in general & sleep apnea in particular, are both increasing with age and represent the main causes for clinically

significant, chronic night hypoxia

Breathing problems in general & sleep apnea in particular, are both increasing with age and represent the main causes for clinically

significant, chronic night hypoxia

Nocturnal Respiratory DisturbancesNocturnal Respiratory Disturbances

R E S U L T S R E S U L T S ::

Nocturnal Respiratory Disturbances in a Prolonged Care Geriatric InstitutionNocturnal Respiratory Disturbances in a Prolonged Care Geriatric Institution

RESPIRATORY DISTURBANCE INDEX (R D I)

R D I * No. PATIENTS

( % )Normal0 - 10

4 (8%)

Mild10 - 15

5 (10%)

Moderate15 - 25

27 ( 53%)

Severe > 25

15 (29%)

* RESPIRATORY DISTURBANCE INDEX : APNEA + HYPOPNEAAS A PORTION OF TOTAL SLEEP

CONCLUSIONS:CONCLUSIONS:IN SPITE OF NORMAL OR ONLY MILDLY IN SPITE OF NORMAL OR ONLY MILDLY

IMPAIRED RESULTS OF BOTH IMPAIRED RESULTS OF BOTH THE SUBJECTIVE SLEEP REPORTS AND THE SUBJECTIVE SLEEP REPORTS AND

ARTERIAL BLOOD GASES & SPIROMETRYARTERIAL BLOOD GASES & SPIROMETRY


A SIGNIFICANT NIGHT HYPOXIA ACCOMPANIED A SIGNIFICANT NIGHT HYPOXIA ACCOMPANIED WITH MANY PERIODS OF RESPIRATORY WITH MANY PERIODS OF RESPIRATORY

DISTURBANCES (APNEA / HYPOPNEA) WERE DISTURBANCES (APNEA / HYPOPNEA) WERE FOUND IN MOST OF THE SAME SUBJECTSFOUND IN MOST OF THE SAME SUBJECTS

Seleznev I, & al. Unpublished Data Seleznev I, & al. Unpublished Data


ALL SUBJECTS WITH SIGNIFICANT ALL SUBJECTS WITH SIGNIFICANT NOCTURNAL RESPIRATORY DISTUEBANCES NOCTURNAL RESPIRATORY DISTUEBANCES

WERE OFFERED THERAPY (CPAP) .. …WERE OFFERED THERAPY (CPAP) .. …

HOWEVER...HOWEVER...


ONLY 3 ELDERS AGREED TO TRY ONLY 3 ELDERS AGREED TO TRY THIS NON INVASIVE TREATMENT !THIS NON INVASIVE TREATMENT !


COHEN - MANSFIELD J, GARFINKEL D, LIPSON S.

Arch Gerontol & Geriatr 31: 65-76, 2000

COHEN - MANSFIELD J, GARFINKEL D, LIPSON S.

Arch Gerontol & Geriatr 31: 65-76, 2000

MELATONIN FOR TREATMMENT OF

SUNDOWNING

IN ELDERLY PERSONS WITH DEMENTIA

MELATONIN FOR TREATMMENT OF

SUNDOWNING

IN ELDERLY PERSONS WITH DEMENTIA


Determine the prevalence of hypoxia in

elderly people living in a nursing home

Find out whether this hypoxia was

influenced by the circadian rhythm

Look for correlations between apparent

maladies or clinical manifestations and

relevant laboratory respiratory findings.


OBJECTIVESOBJECTIVES::

.

.

.



Patients Patients ::

Elderly volunteers living in a nursing home at the Shoham Geriatric Center Pardes-Hana, Israel

Elderly volunteers living in a nursing home at the Shoham Geriatric Center Pardes-Hana, Israel

Exclusion criteria :Exclusion criteria :* Significant disability defined as Karnofski * Significant disability defined as Karnofski Performance Index < 50 Performance Index < 50 * Significant cognitive impairment MMSE score<18* Significant cognitive impairment MMSE score<18* Unstable medical conditions* Unstable medical conditions

.

Pulmonary function assessments were performed using Pulmonary function assessments were performed using bedside Spirometry in the evening before polysomnography bedside Spirometry in the evening before polysomnography Arterial blood gases were determined in the morning Arterial blood gases were determined in the morning following polysomnography.following polysomnography.


Methods Methods ::

These measurements were used to calculate several parameters, enabling a quantitative comprehensive evaluation

of sleep and breathing patterns

These measurements were used to calculate several parameters, enabling a quantitative comprehensive evaluation

of sleep and breathing patterns

Subjective assessment of the quality of sleep (a questionnaire)

Objective assessment of sleep quality was performed in all subjects in their own bed by 8 channel polysomnography

Subjective assessment of the quality of sleep (a questionnaire)

Objective assessment of sleep quality was performed in all subjects in their own bed by 8 channel polysomnography

87% of the subjects had PaO2 above 70 mmHg, 9% had values of 55 - 70 mmHg,

only 4% had a PaO2 below 55 mmHg.

87% of the subjects had PaO2 above 70 mmHg, 9% had values of 55 - 70 mmHg,

only 4% had a PaO2 below 55 mmHg.

The severity of dyspnea (according to the The severity of dyspnea (according to the NYHA Functional Classification) had a NYHA Functional Classification) had a

significant positive correlation with PaCOsignificant positive correlation with PaCO22 (p=0.034, (p=0.034, RR=0.306) and negative correlation =0.306) and negative correlation

with PaOwith PaO22 (p=0.015, (p=0.015, RR=0.348).=0.348).




99 patients met our criteria but only 51 99 patients met our criteria but only 51 volunteered to participate (14 men, 37 women) volunteered to participate (14 men, 37 women)

average age 82.1± 6.89 (range 70 to 95).average age 82.1± 6.89 (range 70 to 95).

36 patients had hypertension, 20 suffered from 36 patients had hypertension, 20 suffered from ischemic heart disease (7 also had CHF), 11 had ischemic heart disease (7 also had CHF), 11 had

COPD; Depression was diagnosed in 7, COPD; Depression was diagnosed in 7, diabetes mellitus in 6, previous CVA in 5 diabetes mellitus in 6, previous CVA in 5

hypothyroidism in one.hypothyroidism in one.




The subjective assessment of sleep quality according to the sleep questionnaire: 57% complained of severe sleep disorders27% had mildly-moderately disturbed sleep16% reported a good night sleep

No correlation was found between subjective sleep quality and nocturnal

oxygen saturation, PaO2 and PaCO2.

No correlation was found between subjective sleep quality and nocturnal

oxygen saturation, PaO2 and PaCO2.






Pulmonary Functions (FEV1)

SEVERITY *Number of

PatientsFEV1

Average ± SD

Normal 8 86.36 ± 6.48

Mild 24 69.56 ± 5.69

Moderate 11 50.85 ± 4.93

Severe 4 29.15 ± 8.71

* Normal > 80%, Mild 60 - 80%, Moderate 40 - 60%, Severe < 40% of the expected value Seleznev I, & al. Unpublished Data Seleznev I, & al. Unpublished Data



Extent of Nocturnal Apnea and Oxygen Desaturation

SEVERITY Apnea Index *

Periods of OxygenSaturation Bellow 90%

(% of Total Sleep Time ) **

Normal 26 (51%) 14 (27%)

Mild 23 (45%) 22 (43%)

Moderate – Severe 2 (4%) 15 (30%)

* Apnea Index : normal 0 - 5, mild 5 - 10, moderate to severe > 10** Saturation of Oxygen < 90% : normal = 0, mild < 10%, moderate - severe > 10% of Total Sleep Time

SLEEP DISORDERS

SHOULD BE HANDLED BY THE PHYSICIAN SHOULD BE HANDLED BY THE PHYSICIAN

IN THE SAME CLINICAL APPROACH AS THAT USED IN THE SAME CLINICAL APPROACH AS THAT USED FOR OTHER SYMPTOMS OR SIGNS:FOR OTHER SYMPTOMS OR SIGNS:

FIRST OF ALL,FIRST OF ALL,

DEFINE THE UNDERLYING CAUSE DEFINE THE UNDERLYING CAUSE

& MAKE THE CORRECT DIAGNOSIS& MAKE THE CORRECT DIAGNOSIS

APPROACH TO SLEEP DISORDERS

(IN THE NURSING HOME SETTING)

APPROACH TO SLEEP DISORDERS

(IN THE NURSING HOME SETTING)

Evaluating Causes of InsomniaEvaluating Causes of Insomnia

Situational factors that are major stressors such as a life Situational factors that are major stressors such as a life

trauma or an upcoming important eventtrauma or an upcoming important event

Environmental factors such as too much noise, temperature Environmental factors such as too much noise, temperature

that are too hot or too cold, or working a night shiftthat are too hot or too cold, or working a night shift

Factors related to medications, both prescription and Factors related to medications, both prescription and

nonprescription (i.e. CNS stimulants/ activating nonprescription (i.e. CNS stimulants/ activating

antidepressants)antidepressants)

Medical problems such as pain, endocrine, menopause, BPH, Medical problems such as pain, endocrine, menopause, BPH,

incontinence, CHF, PUD/GERD, COPD, allergic rhinitis, incontinence, CHF, PUD/GERD, COPD, allergic rhinitis,

seizure d/oseizure d/o

33 .A. PROVE IT: CHECK OVERNIGHT URINE FOR 6-STM B. CONSIDER A THERAPEUTIC TRIAL WITH 2mg OF

CONTROLLED - RELEASE MELATONIN . . .. . OR

11 . . RULE OUT AND TREAT SITUATIONS LEADING TO RULE OUT AND TREAT SITUATIONS LEADING TOSECONDARY SLEEP DISORDERS PARTICULARYSECONDARY SLEEP DISORDERS PARTICULARY SLEEP APNEA (PATIENT’S STORY, ANXIETYSLEEP APNEA (PATIENT’S STORY, ANXIETY , ,

DEPRESSION, PHYSICAL, IMAGING & LAB FINDINGSDEPRESSION, PHYSICAL, IMAGING & LAB FINDINGS.).)

11 . .RULE OUT AND TREAT SITUATIONS LEADING TO RULE OUT AND TREAT SITUATIONS LEADING TO SECONDARY SLEEP DISORDERS PARTICULARYSECONDARY SLEEP DISORDERS PARTICULARY SLEEP APNEA (PATIENT’S STORY, ANXIETYSLEEP APNEA (PATIENT’S STORY, ANXIETY , ,

DEPRESSION, PHYSICAL, IMAGING & LAB FINDINGSDEPRESSION, PHYSICAL, IMAGING & LAB FINDINGS.).) 2. NO APPARENT UNDERLYING CAUSE FOR. NO APPARENT UNDERLYING CAUSE FOR SLEEP SLEEP DISORDER andDISORDER and ADVANCED AGE - ADVANCED AGE -

CONSIDER A CONSIDER A PRIMARYPRIMARY MELATONIN DISORDER MELATONIN DISORDER

APPROACH TO SLEEP DISORDERS (IN THE NURSING HOME SETTING)

APPROACH TO SLEEP DISORDERS (IN THE NURSING HOME SETTING)

44 . .TRY A SLEEPING PILL… PREFERABLY NOT ATRY A SLEEPING PILL… PREFERABLY NOT A BENZODIAZEPINE AS THE FIRST CHOISEBENZODIAZEPINE AS THE FIRST CHOISE

doron garfinkel, m.d. shoham geriatric medical center pardes – hana, israel head, geriatric...

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