Sleep in Older Adults Mirnova Ceïde, MD - PowerPoint Presentation

Slide1

Sleep in Older Adults

Mirnova Ceïde, MD Assistant Professor of Psychiatry and MedicineAlbert Einstein College of Medicine/ Montefiore Medical CenterApril 6, 2015Slide2

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.Slide3

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

.orgSlide4

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

hrsSlide5

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%Slide6

Selected Groups

Other vulnerable groups:Hispanics and Blacks: poor sleep hygienehigher 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. 2012Slide7

Outcomes of Poor Sleep

Short term Hazards: Excessive daytime sleepinessMood: 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

leptinImmune: 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. 2011Slide8

Outcomes of Poor Sleep

Long term hazards:ObesityDM IIHypercholesterolemia

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. 2010Slide9

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%.

D

elta waves

.

25% REM

sleep

is characterized by eye movement, increased respiration

rate,

increased brain

activity and dreaming. Slide10

Normal Changes with Aging

Increased awakenings and arousalsDecreased REM sleep

Decreased

slow wave sleep

Increased stage shiftsFewer “cycles

”

Reduced sleep

efficiencySlide11

Circadian control of sleep

Circadian rhythm mediated by the CLOCK system in the suprachiasmatic nucleus (SCN) in the hypothalamusThe 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 2007Slide12

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 2013Slide13

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 menhigher in older adults

Bastien

et al. 2011Slide14

Bastien

2011Slide15

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. Slide16

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 qualityMorning 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. 2010Slide17

Insomnia

Cognitive Behavioral Therapy:Cognitive principles of insomniaTreatment 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 2011Slide18

Insomnia

Pharmacotherapy:MelatoninMelatonin 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. 2014Slide19

Insomnia

Benzodiazepines:No adverse effects on COPD and SDAMay 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. 2014Slide20

Non

Benzo Benzodiazepine Receptor AgonistsGABAa complex, higher affinity for alpha 1 Zolpidem:5mg, 10mgZaleplon: 5mg, 10 mg

Eszopiclone: 1mg -3mg

Less tolerance and rebound

Amnestic parasomniasEquivocal 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

InsomniaSlide21

Sleep apnea

Apnea: cessation of breathing >10 secObstrucitve: if effortCentral: wiithout

effort

Hypopnea: reduction in breathing ( 50% of airflow +O2 desaturations)

AHI: Apnea + Hypopnea IndexObstructive Sleep Apnea/Hypopnea Syndrome:

AHI=5 or more respiratory event per hour of sleep

AHI=15 or more moderate toe severe sleep apnea.Slide22

Sleep Apnea

EvaluationClinical history: snoring, excessive daytime sleepiness, witnessed apneas, weight gain, impotencePhysical findings: BMI >30, Hypertension, Neck Circumference >=17 in

Polysomnography: AHI

>

51/3 elderly patients have AHI >5Morbidity and Mortality increased with increasing AHITreatment: 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. 2008Slide23

Sleep Apnea

Prevalence: men 14%, women 5%Untreated:Car Accidents/ Work AccidentsCardiovascular disease

Hypertension

Diabetes

Metabolic SyndromeAndrews et al 2004, Jean Louis et al 2008 Slide24

Periodic Limb Movement Disorder

Sleep disorder where the person moves limbs involuntarily during sleep.Associated with Restless leg syndromeHalf 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. 2008Slide25

Restless Leg Syndrome

Disorder of dysethesia in legs which often occurs when the person is inactive which includes nighttimePrevalence 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. 2008Slide26

PLMD/RLS

Associated conditions:ESRDNeuropathies and myelopathies

Pregnancy

Anemia (iron deficiency)

Chronic renal failureFolate / B12 deficiencyMedications (

tricyclics

, SSRI’s, caffeine)

Obesity

Hypothyroidism

 Slide27

PLMD/RLS

Treatment:NonpharmacologicMental alerting actions

Avoidance of certain meds:

ie

. Antidepressants, antipsychotics, antihistamines and alcohol, nicotine, caffeineExercisePneumatic 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. 2008Slide28

REM Sleep Behavior Disorder (RBD)

Diagnostic CriteriaPresence 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 2013Slide29

REM Sleep Behavior Disorder (RBD)

TreatmentReduce injury, remove hazardsNo FDA approved treatments

First line pharmacotherapy:

Melatonin 3mg to 15mg

qhsClonazepam 0.25to 2mg qhs

Or both

Coeytaux

et al 2013Slide30

Dementia

Sleep changes in Alzheimer’s Dementia include:Reduction in fast sleep spindlesDeterioration of rest/ activity cycle in moderate dementiaMultiple 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. 2006Slide31

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

programBright light therapy in the evening may ameliorate sleep-wake cycle disturbancePharmacological:

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. 2004Slide32

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

DietSleep environment

Any recent trauma or stressorsSlide33

Case

Review of systems: SOB, chest pain, claudicationMedications (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 dementiaSlide34

Thank you

Questions?mceide@montefiore.org