AGSF Cindy Khamphaphanh PharmD Candidate Chad Kawakami PharmD BCPS CDE August 9 2017 OBJECTIVES To understand Agerelated changes in sleep Causes of sleep problems Officebased evaluation of sleep ID: 627973
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Slide1
Insomnia
Winnie Suen, MD, MSc, AGSFCindy Khamphaphanh Pharm.D. CandidateChad Kawakami, PharmD, BCPS, CDEAugust 9, 2017Slide2
OBJECTIVES
To understandAge-related changes in sleepCauses of sleep problemsOffice-based evaluation of sleep
Sleep problem treatment options
2Slide3
How is insomnia defined?
DSM-5Difficulty in initiating or maintaining sleep or waking up too early, which is associated with daytime impairment (such as fatigue, poor concentration, daytime sleepiness, or concerns about sleep)
Sleep
problems must occur at least 3 times per week and (to meet chronic insomnia), must be present for 3 months. Slide4
Mr. Chen
66 year old man, recently retired engineer (6 months), mentions at the end of his appointment, that he is “up all night”, tired during the day, spends much of his time “resting.” It interferes with the couples
‘
social
activities.
He saw a TV ad for a new sleeping pill and would like it to be prescribed to him.
11Slide5
What would you like to ask him next to figure out why he is not able to sleep? Slide6
Key History Questions
DIAGNOSISAre you satisfied with your sleep? Does sleep or fatigue interfere with daytime activities? Do others complain about unusual behaviors during sleep? (snoring, interrupted breathing, leg movements)
Record- estimated amount of sleep, number of awakenings, time of morning awakening, when they got up, any symptoms at night, any medications or agents taken for sleep, time spent napping during the day
7Slide7
His Sleep Routine
Wine with dinnerDozes watching TV, gets into bed at 10pmLies awake for 2-3 hoursAwakens at 4pm to urinate and can’t go back to sleep
Get up 6am and
“
rests
”
on couch after breakfast
Exercises in
evening
Rests on couch before dinner.
Does not drink coffee or tea
Denies leg discomfort, morning headaches
…
H
e
has some difficulty falling asleep in the past, but never this bad.
12Slide8
Per his wife
Snores lightlyHasn’t stopped breathingDoes not kick legs during sleepNo major personality changes, but overall more
“
quiet
”
and withdrawn.
13Slide9
History & Physical
PMHHTNGERDDepression
L knee arthritis
MEDICATIONS
Atenolol 100 mg qd
Clonidine 0.2 mg bid
Lisinopril 20 mg qd
Ranitidine 75 mg qd
Zoloft 50 mg po qd
Tylenol 650mg po q6h prn
14Slide10
Key Physical Exam Areas
Informed by the history takingPainful joints- examine jointsNocturia- examine cardiac, renal, prostate, or for diabetesPoor memory- assess mood and memory issuesSlide11
History & Physical
14EXAM: BP 130/75 P 80 Weight 140 lb Ht 5’4”
Alert, able to answer questions and carry on conversation without falling asleep.
Rest of exam unremarkable except GDS=7/15.Slide12
Do you need to do any other investigations? Slide13
Key laboratory testing
Guided by history and examPolysomnography- when suspect sleep apnea (central, obstructive), narcolepsy or REM sleep behavior disorderIn lab is gold standardPortable devices combining oximetry with HR, RR, nasal airflow may be promising (negative finding >> in lab)
OSA common in older adults- morning HA, personality changes, poor memory, confusion, irritability
Wrist activity monitors- estimate sleep vs wakefulness based on wrist movement
Diagnosis of circadian rhythm sleep disorderSlide14
Basic Science: Normal Sleep Physiology
DEEP SLEEP
DREAM
3Slide15
Common changes with age
Trouble falling asleep= lower sleep efficiency
Less deep sleep
Early awakening
More daytime naps
Early bedtime
4Slide16
Primary Sleep Disorders
Non-REM
-PLMS
(polysomnography; dopamine agonist)
-RLS
(Iron,
dopamine angonist)
Sleep
Apnea
Eval at Sleep lab
CPAP
5-20%
6Slide17
What could be possible causes of his insomnia? Slide18
Insomnia
MedicalPsychiatricNeurologicEnvironment/ Diet
5Slide19
Assessment/Plan
A/P MedicationsCoughArthritis
E
xercise in evening
Alcohol at night
Exacerbated by depression and lifestyle changes in the context of recent retirement.
15Slide20
What would you advise as next steps for treatment? Slide21
Plan
#1 Improve Sleep hygieneMaintain regular rising and bed time
Do
not go to bed unless sleepy
Decrease
or eliminate naps, unless necessary rest period
Exercise
daily but not immediately before bedtime
Do
not use bed for reading or watching TV
Relax
mentally before going to sleep; do not use bedtime as worry time
If
hungry, have a light snack, but avoid heavy meals at
bedtime
Limit
or eliminate alcohol, caffeine, and nicotine, especially before bedtime
15Slide22
Plan
#1 Improve Sleep hygieneWind down before bedtime and maintain a routine period of preparation for bed
Control
nighttime environment with comfortable temperature, quiet, darkness
Try
a familiar noise (fan, white noise)
Wear
comfortable bed clothing
If
unable to fall asleep in 30 minutes, get out of bed, perform soothing activity like listening to soft music, light reading
Get
adequate exposure to sunlight or bring light during the day
15Slide23
Plan
#2 Remove offending medicine agents15Slide24
Plan
#3 Nonpharmacologic Interventions to Improve SleepSleep restrictionCognitive interventions
Relaxation
techniques
progressive
muscle relaxation
Cognitive behavioral therapy
combines s
t
imulus
control, sleep restrictions, cognitive interventions, with or without relaxation techniques; usually includes sleep hygiene
15Slide25
Plan
#4 Pharmacologic therapySlide26
Pharmacologic Treatment of Insomnia in the ElderlyCindy Khamphaphanh Pharm.D. Candidate
Chad Kawakami Pharm.D., BCPS, CDEUniversity of Hawai’i at HiloThe Daniel K. Inouye College of PharmacySlide27
Approach to Pharmacologic Treatment
1. Determine the underlying cause of insomniaMedical conditions (treat these appropriately first)Medication related 2. Treat on a short-term basis together with non-pharmacologic interventions3. When starting a medication, “Start low and go slow.”4. Monitor for side effectsSlide28
Medications Contributing to Insomnia
Antidepressants - SSRI, SNRI, MAOICardiovascular - alpha agonists/antagonists, beta-blockers, diureticsDecongestants - phenylephrine, pseudoephedrineNarcotic analgesics - codeine, oxycodonePulmonary - albuterol, ipratropium, theophyllineStimulants - amphetamine derivatives, caffeine, methylphenidate, modafinilOthersAntineoplastic agentsCorticosteroidsNicotinePhenytoinThyroid supplementsEtOHSlide29
Pharmacologic Treatment: Overview
First Line for Insomnia (Non-Geriatric): Hypnotic sedativesSleep-onset insomniaShorter-acting agents (e.g. zolpidem, zaleplon, triazolam)More rebound and withdrawal symptoms with discontinuationSleep-maintenance insomniaLonger-acting agents (e.g temazepam, eszopiclone)More daytime carryoverAmerican Geriatrics Society recommends AGAINST the use of hypnotics as first line in older adultsSlide30
Sleep Medications: Geriatrics Approach
MelatoninMelatonin Receptor Agonist RameltonAntidepressantsNon-Benzodiazepines (Short-acting)EszopicloneZolpidemZaleplonBenzodiazepines (Intermediate-acting)TemazepamLorazepam (insomnia d/t anxiety or stress)EstazolamSuvorexantSlide31
Sleep Medications: Melatonin
MelatoninRX: prolonged release (Circadian)2mg two hrs before bed improved sleep and alertness in patients >55yoOTC: short acting dietary supplementLittle to no effect (no clinically meaningful benefit)Headache, back pain, nasopharyngitis, arthralgiaDo not use in hepatic impairment, autoimmune disease, LAPP lactase deficiency or glucose-galactose malabsorptionSlide32
Sleep Medications: Melatonin Receptor Agonist
Ramelteon (Rozerem) Consider in patients w/ hx of substance abuse disorder who prefer not to use scheduled drugContraindicated w/ fluvoxamineNo significant rebound insomnia or withdrawalAvoid taking immediaely after meal d/t delayed onsetSlide33
Sleep Medications: Antidepressants
Antidepressants: Recommended after treatment failures or when comorbid depression presentTrazodone Moderate orthostatic effects (administer with food)Effective for insomnia w/ or w/o depressionHeadache, dizziness, nausea, priapismMirtazapineIncreased appetite, weight gain, headache, dizzinessEffective for insomnia w/ depressionDoxepin (FDA approved)Sinequan 25 mg - 75 mg (antidepressant – do not use) vs. Silenor 3 - 6 mg at bedtime (insomnia)Silenor has the same sedation profile as Sinequan
minus the toxicity
Little rebound
insomnia
No specific preferred agentSlide34
Sleep Medications: Non-BZD Hypnotic Sedatives
Zolpidem (Ambien, Ambien CR)Tab, ER, sublingual, oral sprayNo rebound insomnia when abruptly discontinuedAvoid taking immediately after meal d/t delayed onsetZaleplon (Sonata)No withdrawal symptoms, daytime anxiety, sedation, or psychomotor impairmentAvoid taking immediately after meal d/t delayed onsetRebound insomnia more likely w/ higher dosesEszopiclone (Lunesta)Metallic aftertaste and headacheAvoid with high-fat meal d/t delayed onset
Non-BZD compared to BZD appear to be equally effective
CNS depression w/ sedative but no anxiolytic
effects
Beer’s Criteria
–
Increase risk for fallsSlide35
Sleep Medications: BZD Hypnotic Sedatives
Temazepam*LorazepamEstazolamTriazolamAvoid in elderly: Increased risk of fallsPsychomotor impairment Cause CNS depression with sedative and anxiolytic effectsRisk of withdrawal and toleranceSlide36
Sleep Medications: Novel Drugs
Suvorexant (Belsomra)Novel orexin receptor antagonist - block binding of orexin neuropeptides to receptors suppressing wake drive.Usual dose: 10mg - 30 mins before bedtime; may increase to max 20mgDue to less side effects, consider in elderly before hypnoticsMost common side effect is mild-to-moderate daytime somnolenceNo withdrawal or rebound insomnia when abruptly discontinuedNo dosage adjustment for renal impairment and mild - moderate hepatic impairmentAvoid taking immediately after meal d/t delayed onset