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 ID: 753468
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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