sleep in older adults mirnova ceïde, md assistant professor of psychiatry and medicine albert...
TRANSCRIPT
Sleep in Older Adults
Mirnova Ceïde, MD Assistant Professor of Psychiatry and Medicine
Albert Einstein College of Medicine/ Montefiore Medical Center
April 6, 2015
Learning Objectives
• Describe the prevalence of sleep disorders in the population.
• Describe the effects of factors such as age, race/ethnicity, medical and mental illnesses on sleep.
• Illustrate normal sleep changes which occur in aging.
• Discuss diagnosis and treatment of common disorders in the elderly.
Sleep in America
• 4/10 Americans describe themselves as “great sleepers.”
• 43% of American’s report rarely or never getting a good night’s sleep.
• 95% of Americans utilize an electronic device one hour prior to sleep.
Sleepfoundation .org
Changes in Sleep In the population
Kripke et la. 2002
Population Estimates of Sleep Duration
Kripke et al. 1979 8 hrs
Sleep Habit Gallup Poll 1979 8hrs
Schoenborn et al. 1986 7.5 hrs
Sleep Habit Gallup Poll 1995 7 hrs
Sleep in America Poll 1998 6.6 hrs
Jean-Louis et al. 1999 6.5 hrs
Sleep in America Poll 2008 6.5 hrs
Selected Groups
• Certain groups have been identified as vulnerable to poor sleep:• Older adults : higher prevalence of insomnia and medical
comorbidities.• Gender: Women are more likely to report insomnia
symptoms.
Sleepfoundation .org, Sleep in America Poll 2001, Hale et al. 2009
Variable Women Men
Lack of Sleep 24% 19%
Difficulty Initiating Sleep 26% 17%
Difficulty Maintaining Sleep
35% 28%
Early Morning Awakening 24% 19%
Selected Groups• Other vulnerable groups:
• Hispanics and Blacks: • poor sleep hygiene• higher prevalence of sleep symptoms• higher prevalence of sleep apnea• less adherent to sleep study referrals
• Psychiatric illness particularly mood disorders, dementia, substance abuse.
• Medical illness: particularly GERD, pulmonary, metabolic syndrome, Parkinson’s disease, stroke and incontinence.
• Occupational: Night shift and rotating shift workers.
Sleepfoundation..org, Baldwin et al. 2010, Hayes 2009, Jean Louis et al. 2008, Nunes et al. 2008, Loredo et al 2010. Ruiter et al. 2011,
Ohayon et al. 2010,, Ceide et al. 2012
Outcomes of Poor Sleep• Short term Hazards:
• Excessive daytime sleepiness• Mood: depressive symptoms, relapse of chronic
psychiatric illness• Nutrition: snacking, consumption of energy dense
food, delayed gastric emptying• Metabolic: increased postprandial glucose and
decrease metabolic rate, increased ghrelin and decreased leptin
• Immune: increased cytokines such as IL-6• Vascular: endothelial dysfunction
Chaput et al. 2010, Buxton et al 2012, Heffner er al. 2012, Taheri et al. 2004, Kim et al. 2011
Outcomes of Poor Sleep• Long term hazards:
• Obesity• DM II• Hypercholesterolemia• Hypertension• Mortality (in the elderly)
Kohatsu et al. 2012, Zizi et al. 2012, Knutson et al. 2009, Kripke et al. 2002, Gangwisch et al 2008, Vgontzas et al.
2010
Stages of Sleep• 5% Stage 1 is the beginning of the sleep cycle, and is a
relatively light stage of sleep. Slow theta waves• 50% Stage 2 is the second stage of sleep; body temp
decrease and breathing rate slows. Sleep spindles and K complexes.
• 15-25% Stage 3 and 4 or NREM is a transitional period between light sleep and a very deep sleep; blood pressure dips by 10%. Delta waves.
• 25% REM sleep is characterized by eye movement, increased respiration rate, increased brain activity and dreaming.
Normal Changes with Aging
• Increased awakenings and arousals• Decreased REM sleep• Decreased slow wave sleep• Increased stage shifts• Fewer “cycles”• Reduced sleep efficiency
Circadian control of sleep
• Circadian rhythm mediated by the CLOCK system in the suprachiasmatic nucleus (SCN) in the hypothalamus
• The SCN releases amino acids in response to light via retinal projections.
• Changes are mediated by NO and Glutamate• SCN CLOCK system regulates transcription of nuclear
glucocorticoid receptors in the brain and peripheral tissues.
Ding et al 1994, Kino et al 2007
Normal Changes with Aging
• Age is associated with decreased electrical, hormonal and gene – expression activity of SCN cells.
• Decrease in pineal gland function and decreased circulating melatonin.
• Gender specific changes in post menopausal women.• Women experience a more significant decline in melatonin
• Decreased photoreception due to pupillary miosis and impaired crystalline lens light transmission.
• Impaired pineal innervation/interconnection between the SCN and the pineal gland.
• SCN degeneration.• Phase advancement Costa et al 2013
Insomnia• Definition:
• Prolonged sleep latency, difficulties in maintaining sleep, early morning awakening and/or the experience of non-restorative sleep.
• Cause marked distress or significant impairment.• Subtypes include: psychophysiological, sleep- state
misperception, and idiopathic insomnia
• Prevalence:10 to 30 %: • 2:1 ratio women to men• higher in older adults
Bastien et al. 2011
Bastien 2011
Insomnia
Gellis et al. 2009, Wolkove et al. 2010
Fundamentals of Good Sleep Hygiene
What to do What not to do
-Use your bed for sleep and sexual activities
-In general, refrain from napping and going to sleep too early (phase advance syndrome)
-Make the quality of your sleep a priority
-Before bedtime avoid heavy eating, consumption of caffeine or alcohol, smoking, exercise
-Develop and maintain bedtime “rituals” that make going to sleep familiar
-While you try to fall asleep, avoid thinking of life issues, problem solving, etc.
Insomnia
• Exercise:• Promotes both sleep onset and sleep consolidation • Elderly benefit from even minimal exercise• Also benefits cardiovascular status, bone density, joints and balance
• Light Therapy:• Moderately bright light (1000 lux) or more improves subjective
alertness, mood, and sleep quality• Morning bright light promotes normal sleep in phase delay• Evening bright light promotes sleep in phase advance• Bright light resynchronizes circadian rhythm
• Napping:• Lower diastolic blood pressure, Improves mood, Decreases subjective
sleepiness, Improved performance• Also associated with increased mortality Wolkove et al. 2010
Insomnia• Cognitive Behavioral Therapy:
• Cognitive principles of insomnia• Treatment targets include:
• Unrealistic sleep expectations• Misconceptions about the causes of insomnia• Distorted perception of insomnia consequences• Faulty beliefs about sleep promoting practices• Other sleep disturbing thoughts
• Efficacy: • In RCT, CBT and CBT/Med are better than meds alone.• Improved attitudes and beliefs about sleep are associated with
better sleep at 24 months.
Belanger et al. 2006, Bluestein et al. 2011, Morin et al 2011
Insomnia• Pharmacotherapy:
• Melatonin• Melatonin levels decline with age • Lower in elderly insomniacs than age matched controls• Some studies show improvement in sleep quality• Not FDA improved, studies have looks as doses from 3mg to 6mg.
• Melatonin Receptor Agonist • Ramelteon; prolonged-release melatonin, agomelatine and tasimelteon• FDA approved sleep onset insomnia, with studies specifically in the
elderly• Half life 1-2.5 hrs• Clinical dose 8mg• No tolerance in 12 months studies, no withdrawal symptoms• Adverse effects: somnolence, fatigue, dizziness, nausea
Raehrs et a l 2012, Bastien et al 2011, Laudon et al. 2014
Insomnia• Benzodiazepines:
• No adverse effects on COPD and SDA• May develop tolerance, may experience
withdrawal( including seizures• Short term use associated with sedation, poor recall,
psychomotor slowing.• Longer term use associated with Alzheimer’s disease
Bastien et al 2011, , Pomara et al 1998, Pomara et al. 2015, Gage et al. 2014
• Non Benzo Benzodiazepine Receptor Agonists• GABAa complex, higher affinity for alpha 1 • Zolpidem:5mg, 10mg• Zaleplon: 5mg, 10 mg• Eszopiclone: 1mg -3mg• Less tolerance and rebound• Amnestic parasomnias• Equivocal risk for falls compared to insomnia
• Antidepressants:• Mirtazapine, Trazodone, Doxepine• Orthostatic Hypotension• Anticholinergic, Antihistamine side effects• Equivalent fall risks
Roehrs et al 2012, Bastien et al 2011
Insomnia
Sleep apnea
• Apnea: cessation of breathing >10 sec• Obstrucitve: if effort• Central: wiithout effort
• Hypopnea: reduction in breathing ( 50% of airflow +O2 desaturations)
• AHI: Apnea + Hypopnea Index• Obstructive Sleep Apnea/Hypopnea Syndrome:
• AHI=5 or more respiratory event per hour of sleep• AHI=15 or more moderate toe severe sleep apnea.
Sleep Apnea• Evaluation
• Clinical history: snoring, excessive daytime sleepiness, witnessed apneas, weight gain, impotence
• Physical findings: BMI >30, Hypertension, Neck Circumference >=17 in
• Polysomnography: AHI >5• 1/3 elderly patients have AHI >5• Morbidity and Mortality increased with increasing AHI
• Treatment: CPAP• Surgery is less favorable over the age of 50 years old• Weight loss and smoking cessation are mandatory• Compliance may be problematic
Jean Louis et al. 2008
Sleep Apnea• Prevalence: men 14%, women 5%• Untreated:
• Car Accidents/ Work Accidents• Cardiovascular disease• Hypertension• Diabetes• Metabolic Syndrome
Andrews et al 2004, Jean Louis et al 2008
Periodic Limb Movement Disorder
• Sleep disorder where the person moves limbs involuntarily during sleep.
• Associated with Restless leg syndrome• Half of people with ESRD
• Diagnosed on PSG: • 3 periods of atleast 30 movements during the night, lasting
a few minutes to an hour or more, followed by partial arousal and awakening.
Ancoli-Israel et al. 2008
Restless Leg Syndrome• Disorder of dysethesia in legs which often occurs when
the person is inactive which includes nighttime
• Prevalence increases with age, about 45%.• More common in women.• 50% of patients with ESRD
• Diagnosis: • NIH criteria: an urge to move limbs with or without
sensations, improvement with activity, worsening at rest, worsening in the evening or night.
Ancoli-Israel et al. 2008
PLMD/RLS• Associated conditions:
• ESRD• Neuropathies and myelopathies• Pregnancy• Anemia (iron deficiency)• Chronic renal failure• Folate / B12 deficiency• Medications (tricyclics, SSRI’s, caffeine)• Obesity• Hypothyroidism
•
PLMD/RLS• Treatment:
• Nonpharmacologic• Mental alerting actions• Avoidance of certain meds: ie. Antidepressants, antipsychotics,
antihistamines and alcohol, nicotine, caffeine• Exercise• Pneumatic compression, heating pads• Daily HD for uremic patients
• Pharmacologic• Dopamine agonist : pramipexole, ropinirole• Gabapentin• Opioids: particularly methadone• Benzodiazepine: diazepam• Anticonvulsants: carbamazepine Einollahi et al. 2014, Ancoli-Israel et al.
2008
REM Sleep Behavior Disorder (RBD)
• Diagnostic Criteria• Presence of REM sleep without atonia• Atleast 1 of the following:
• Sleep related injurious behavior• Abnormal REM sleep behaviors on PSG.
• Absence of epileptiform activity, not another sleep disorders
• Strongly associated with neurodegenerative illnesses like PD or LBD, MSA• 40-80% of people with RBD develop PD in 5 to 15 years.
• Prevalence: most common in males over 50 years old.• General population 0.5%• People 70-89 years old 8.9% Coeytaux et al 2013
REM Sleep Behavior Disorder (RBD)
• Treatment• Reduce injury, remove hazards• No FDA approved treatments• First line pharmacotherapy:
• Melatonin 3mg to 15mg qhs• Clonazepam 0.25to 2mg qhs• Or both
Coeytaux et al 2013
Dementia• Sleep changes in Alzheimer’s Dementia include:
• Reduction in fast sleep spindles• Deterioration of rest/ activity cycle in moderate dementia• Multiple night time awakening• Frequent daytime napping• May have increased overall sleep in more severe dementia
Rauchs et al 2008, Gehrman et al 2005, Fetveit et al. 2006
Dementia• Sleep disturbance is one of the main causes for institutionalization of people with
dementia.• Often comorbid with other neuropsychiatric symptoms.• Nonpharmacological:
• Increase activity during the day to improve the rest/activity cycle.• Exercise, HHA, day program
• Bright light therapy in the evening may ameliorate sleep-wake cycle disturbance
• Pharmacological: • Melatonin: decease sundowning and may slow cognitive decline.• Antidepressants, if accompanied by depressive symptoms• Hypnotics such as non benzo benzodiazepine receptor agonist or rarely
benzodiazepines.• Monitor for fall risk and delirium• Antipsychotics may be used if accompanied by psychotic symptoms and
agitation.• Avoid anticholinergic agents.
Lin et al 2013, Wolkove et al. 2010, Hatfield et al. 2004
Case• 60 years old divorced Black woman reporting poor sleep
and depressed mood.• Description of symptoms; onset, sleep maintenance or
early morning awakens.• Get collateral from a partner.• Clarify mood symptoms and any psychiatric history. Ask
about mania• Sleep hygiene• Diet• Sleep environment• Any recent trauma or stressors
Case• Review of systems: SOB, chest pain, claudication• Medications (diuretics, stimulants)• Past medical history: metabolic syndrome, ESRD,
Parkinson’s, Dementia• Consider sleep study if high risk• First line treatment if insomnia• First line treatment if dementia
