Transcript Module 2 - 217.5 KB

Sleep Disorders in the Elderly
Module 2
Brenda K. Keller, MD
Assistant Professor
Geriatrics & Gerontology
University of Nebraska Medical Center
Module 2
•
•
•
•
•
Non-pharmacological
Management
Sleep hygiene
Stimulus control
Sleep restriction
Cognitive therapy
Paradoxical intention
McCall JAGS July 2005-Vol 53, No. 7 pS272-S277
Effectiveness of Nonpharmacological Treatment of
Insomnia
• Improve symptoms of insomnia in 70-80%
of patients with primary insomnia
• Effects last at least 6 months after
treatment completed
Non-pharmacological
Management
• Sleep hygiene
– Education about health and environmental
practices that affect sleep
• This strategy is used in conjunction with
other techniques to improve sleep
Sleep Hygiene
• Health Factors
– Diet
– Exercise
– Substance abuse
• Environmental
Factors
–
–
–
–
Light
Noise
Room temperature
Mattress
Non-pharmacological
Management
• Stimulus control
– Reinforces temporal and environmental cues
for sleep onset
– Go to bed when sleepy
– Use the bed only for sleep
– Bedtime routines
– Regular morning rise time
– Avoid napping
Non-pharmacological
Management
• Sleep restriction
– Decrease amount of time in bed to increase
sleep efficiency
– Only allowed time in bed is usually spent
asleep
– Increase by 15 minutes per night
– Wake time constant, bedtime adjusted
– Allows short afternoon naps
Non-pharmacological
Management
• Cognitive therapy
– Involves identifying dysfunctional beliefs and
attitudes about sleep and replaces them with
adaptive substitutes.
– Helps minimize anticipatory anxiety and
arousal
Non-pharmacological
Management
• Paradoxical intention
– Based on premise that performance
anxiety inhibits sleep onset
– Involves persuading a patient to engage in the
feared behavior of staying awake
– If pt stops trying to fall asleep and genuinely
attempts to stay awake, sleep may come
more easily
Summary
Post-test Question 1
• A 67-year-old woman asks you to prescribe sleeping pills
for her. She reports initial insomnia and restless sleep
with frequent awakenings. The patient is retired and
leads a sedentary life style. She frequently reads or
watches television in bed and often naps, despite
caffeine intake throughout the day. Physical examination
is unremarkable. Which of the following is most likely to
ameliorate this patient’s sleep disturbance?
A. Exposure to early morning daylight
B. Proper sleep habits
C. Sustained-release melatonin
D. Zolpidem
E. Referral for polysomnography
Used with permission from: Murphy JB, et. Al. Case Based Geriatrics Review: 500 Questions and
Critiques from the Geriatric Review Syllabus. AGS 2002 New York, NY.
Correct Answer: B. Proper sleep habits
• Poor sleep habits may be the most common cause of sleep
problems in older adults. Irregular sleep–wake patterns, related to
the life style in this patient, can undermine the ability of the circadian
system to effectively provide sleepiness and wakefulness at
appropriate times. Caffeine intake in the afternoon can have alerting
effects for many hours, thus impairing nighttime sleep. Excessive
wake time in bed may cause increased arousal that is reinforced
nightly. Other factors (eg, medical illness, medications, psychiatric
disorders, and primary sleep disorders) also should be considered.
However, proper sleep habits should be implemented. These include
regularity of sleep and wake times; avoidance of excessive time in
bed; relaxing bedtime routine; daily activity and exercise; avoidance
of caffeine, alcohol, and nicotine in the afternoon and evening; and
elimination of loud noise, excessive light, and uncomfortable room
temperature. Even if poor sleep habits are not responsible for
insomnia, their elimination minimizes any perpetuating influence.
• Use of a short-acting hypnotic agent is not an
appropriate first step in the management of
simple insomnia. Hypnotics should be used only
in limited circumstances, following evaluation of
the patient’s symptoms and in the context of
proper sleep habits. Similarly, melatonin has not
definitively been shown to benefit age-related
sleep-maintenance insomnia. Exposure to early
morning light can be useful for delayed or
advanced sleep-phase syndrome or jet lag.
Polysomnography can be useful for evaluating
chronic insomnia or for suspicion of primary
sleep disorders, such as sleep apnea, periodic
limb movement disorder, or rapid eye movement
(REM)–behavior disorder, but referral to a sleep
specialist is not warranted for this patient.
Post–test 2
A 75-year-old man on no medications has
awakened frequently during the night for the
past year. He is not tired during the day, and has
no symptoms associated with awakening.
What is the best next step?
A. Education on age-related changes in sleep
patterns
B. Referral to a sleep laboratory
C. Diazepam 5 mg at bedtime
D. Diphenhydramine 25 mg at bedtime
E. Lorazepam 0.25 mg at bedtime
Correct Answer: A. Education on age-related
changes in sleep patterns
• Problems with sleep are common in otherwise healthy
older persons. With normal aging, time spent in stages 3
and 4 sleep, the deeper levels of sleep, decreases, and
time spent in stages 1 and 2, the lighter periods of sleep,
increases. These shifts account for the frequent
awakenings of older persons. However, there are other
causes of sleep disturbance, such as pain, anxiety, or
urinary urgency, that should be evaluated before it is
assumed that the patient’s sleep changes are associated
with normal aging. In cases of short-term insomnia (eg,
acute grief, change in residence), appropriate treatment
may include a low dose of a benzodiazepine taken every
other night for 1 to 2 weeks. Short- and intermediateacting benzodiazepines such as lorazepam, oxazepam,
and temazepam are most appropriate.
• Long-acting agents such as flurazepam and diazepam,
which have active metabolites, are not recommended.
For an older patient with difficulty sleeping, absence of
daytime sleepiness, and no associated stresses or
medications, the most likely cause is normal changes of
aging. The most appropriate management of this 75year-old man is to educate him about age-related
changes in sleep patterns. No pharmacologic
intervention is needed. Diphenhydramine is a weak
sedative-hypnotic that is associated with multiple
anticholinergic side effects and should not be used in
older persons. Referral to a sleep laboratory is indicated
for patients with evidence of sleep apnea or unexplained
secondary causes of insomnia. End
You as