Sleep Disorders in the Elderly

Calvin Damanik

Significance of Sleep Disorders

Survey of 9000 people > age 65 No sleep complaints (12%) Difficulty initiating/maintaining (43%) Nocturnal waking (30%) Insomnia (29%) Chronic sleep difficulties (>50%) Daytime napping (25%) Trouble falling asleep (19%) Waking too early (19%) Waking without feeling rested (13%)
Ancoli-Israel S. JAGS 2005;53:S264-S271.

Significance of Sleep Disorders

>50% of sedatives are used by people age > 65 In age 70-100, 19% of patients were taking a sleep medicine (in one study) Disturbed sleep is a strong predictor of ECF placement, especially in patients with dementia Mortality due to common conditions is 2 times higher in elderly with sleep disorders than in those without. Daytime somnolence can interfere with activities and function Sleep disorders negatively impact quality of life Sleep disorders can lead to depression and cognitive impairment

Normal Physiology - Basics

Non-REM sleep
Stage 1: very light, easy to arouse Stage 2: most of the nights sleep Stage 3,4: slow wave, deeper sleep

REM sleep
EEG similar to stage 1 Low/absent muscle tone Dreaming occurs here Greatest cardiac and respiratory instability

Normal Physiology - Basics

Sleep Architecture
REM latency is about 90 minutes (wide variation)
Very short in narcolepsy

REM normally occurs every 90 to 120 minutes More stage 3,4 in first half of night, more REM 2nd half Brief awakenings (30 sec) common, not usually remembered Brief arousals (3 sec) are normal

Age-Related Changes
Non-REM REM
Less slow wave sleep (stage 3 and 4), may be entirely absent, easier to awaken Shorter REM latency Decreased REM percentage and duration Increased overall sleep latency More awakenings/arousals = less sleep efficiency Less sleep in 24 hour period* Reduced sleep latency during day harder to stay awake

Architecture

Espiritu JR. Clin Geriatr Med 2008;24:1-14.

Age-Related Changes
Circadian cycle shifted earlier
Decreased melatonin levels at night Decreased modulation of circadian rhythm between day and night

More naps during the day (1 hour)

May have little impact on night-time sleep May enhance cognitive and psychomotor performance due to increase total sleep
Espiritu JR. Clin Geriatr Med 2008;24:1-14.

Age Related Changes

Less physiologic flexibility with schedule changes More comorbidities that can interfere with sleep It is hard to know if sleep problems are more common independent of other conditions The ability to get restorative sleep gets worse with age, the need for sleep does not.

Mechanisms Underlying Sleep Complaints

Vaz Fragoso CA. JAGS 2007;1853-1866.`

Precipitating Factors
Declining Health Status
Nocturia Pain (DJD, neuropathy) Cardiac Disease
Angina, CHF, arrhythmia

Pulmonary Disease GER Endocrine: thyroid, menopause, DM polyuria CKD

Precipitating Factors
Medications impact sleep architecture and sleep-disordered breathing
CNS stimulants/depressants Diuretics, hypoglycemics

Neuropsychological Impairments
Depression, Anxiety Cognitive Impairment/Psychosis

Primary Sleep Disorders

Perpetuating Factors - Psychosocial

Caregiving
The work of caregiving Associated mental and physical health problems

Social Isolation
Poorer sleep hygiene Decline in activity

Bereavement, Widowhood, Retirement Loss of zeitgebers* (physical, sensory)

Primary Sleep Disorders

Primary Insomnia
Sleep onset (Initial) Sleep maintenance (Middle)

Sleep disordered breathing

Obstructive sleep apnea Central sleep apnea Mixed sleep apnea

Circadian rhythm disturbances

Primary Sleep Disorders

Restless Legs Syndrome Periodic Limb Movements of Sleep REM Sleep Behavior Disorder All primary disorders can be mixed with other primary and with secondary causes

Secondary Sleep Disorders

Underlying conditions that should be addressed first Medical Illness causing nocturnal symptoms Psychiatric Illness Medications Social/behavioral

Secondary Sleep Disorders

Psychophysiologic Insomnia (stimulus/response) Adjustment Insomnia recent stressor Inadequate Sleep Hygiene
Lack of schedule (retirement!) Sedentary or naps during daytime Voluntary sleep deprivation (doctors!)

Mixed-type insomnia

Sleep Hygiene
The bed is for sleeping (and sex) only Increase activity, decrease naps Avoid late meals Avoid caffeine, ETOH, cigarettes Environmental control (light, noise, temp) Decrease stress Establish a routine

Insomnia - Definition
Difficulty with initiation, maintenance, duration, or quality of sleep that results in the impairment of daytime functioning, despite adequate opportunity and circumstances for sleep. Can lead to fatigue, mood disturbance, interpersonal and job problems, and reduced quality of life.
From DSM-IV

Insomnia - Definitions
Sleep latency usually > 30 minutes Sleep efficiency < 85% Transient: less than 1 week Short-term: 1-4 weeks Chronic: > 1 month
May be perpetuated by worrying in bed or unrealistic expectations of sleep duration More common in women, elderly, and chronic disease (medical and psychiatric)

Insomnia - Treatment
Non-pharmacologic therapy
Improvement in 70-80% of patients (though some studies used psychologists) Stimulus control therapy bed for sleeping only, same wake time daily, 1 small nap only Sleep restriction therapy reduce time in bed to achieve 90% efficiency, gradually increase (up to 6-7 hours) Relaxation therapy biofeedback, imagery, meditation, muscle relaxation Cognitive therapy beliefs and attitudes Sleep hygiene education

Joshi S. Clin Geriatr Med 2008;24:107-119.

Insomnia - Medications
Use lowest effective dose Use intermittent dosing Short term use (< 1 month if possible) Gradual discontinuation (rebound) Medications with shorter half lives are preferred to prevent next-day sedation

Insomnia - Medications
Short acting medications
More improvement with sleep latency More withdrawal and dependence

Long acting
More improvement with sleep duration More next day symptoms (sedation, cognitive impairment, falls)

Most medications have not been studied extensively in the elderly or more than 6 months

Insomnia - Medications
Benzodiazepines GABA-A receptors
Benefits: cheap, improve sleep latency, total sleep time, number of awakenings, sleep quality Disadvantages:
More next day effects (drowsy, dizzy) More dependency/withdrawal More rebound symptoms More anterograde amnesia (especially with shorter acting agents) Falls and hip fracture risk (long acting)
Tariq SH. Clin Geriatr Med 2008;24:93-105.

Insomnia - Medications
Benzodiazepine receptor agonists
Advantages
more specific targeting of GABA receptors in the brain so less side effects

Disadvantages
Not well studied in the elderly (use lower starting doses) Not compared against each other More expensive ($65-100 per month) Dependence/withdrawal still occur Still can increase risk of falls and fractures

Drugs vs No Drugs
Unclear if cognitive behavioral therapy or medication therapy is better
Both help Medications may work more quickly CBT may have more lasting benefit

Hard for PCPs to do cognitive therapy Medications not studied more than 6 months It is best to attempt education and non-pharmacologic therapy first, and continue even if medications are used

Other Treaments for Insomnia

Bright Light Therapy
Light -> suprachiasmatic nucleus -> inhibits production of melatonin by pineal gland
Threshold between 200-400 lux (normal indoor fluorescent light) Treatment uses 2000-10,000 lux

Cochrane: no trials focused on elderly, but benefit seen with younger patients Dosing, timing, duration, effectiveness not established in the elderly Best evidence for SAD in younger people

Gammack JK. Clin Geriatr Med 2008;24:139-149.

Sleep-disordered Breathing
Usually present with daytime somnolence Snoring: alone is not usually a problem Hypopnea Apnea increased incidence in the elderly, can be seen in 10-40%
Obstructive Central Mixed

Sleep-disordered Breathing
Significance, Signs, and Symptoms
Daytime somnolence, effect on function Decreased cognition, dementia may be worse CHF, arrythmias, HTN, cor-pulmonale Polycythemia Nocturia Personality changes Morning headaches Decreased libido, impotence May increase mortality

Sleep-disordered Breathing
Other Symptoms
Snoring Restless sleep Choking/gasping during sleep Witnessed apnea

Obstructive Sleep Apnea (OSA)

Definition: repetitive episodes of uper airway obstruction with continued movement of chest and abdominal walls, leads to desaturations and arousals. Risk factors: people with classic symptoms and:
Male Large neck circumference (>18 inches) Obesity Crowding of oropharynx

OSA - Diagnosis
Classic Symptoms and Polysomnography
EEG (at least 2 channel) EMG (muscle activity chin) EOG (eye movements) ECG Respiratory airflow and effort Oxygen saturation Snoring intensity and body position Reports an Apnea-Hypopnea Index - AHI

OSA - Stages
Mild: sleepiness when sedentary, little attention required, not daily, minor impairment of function
Mean sat >90 and min sat >85, AHI 6-20

Moderate: daily sleepiness when minimaly active and moderate attention required (driving, meetings, movies)
Mean sat >90 and min >70, AHI 21-40

OSA - Stages
Severe daily sleepiness during tasks that require significant attention (driving, conversation, eating, walking), marked impairment in function
Mean sat <90 or min <70, AHI > 40

OSA - Treatment
Unclear benefit to treating mild or minimally symptomatic patients Treatment is likely to improve:
HTN CHF Daytime function Cognition and health-related quality of life

OSA - Treatment
Weight loss, avoid supine position (tennis balls) Avoid sedating drugs Prescription drugs not helpful CPAP/BIPAP Most efficacious
Compliance issues

Oral appliance less effective, use for mild cases or if CPAP not tolerated Surgery trach, uvuloplasty, bariatric surgery not first line, various effectiveness

Central Sleep Apnea - CSA

Definition Periodic complete cessation of airflow and respiratory effort, followed by desaturations and arousals. Related to chemoreceptors and CO2 physiology. Hypercapneic underlying hypoventilatory disorders blunts chemoreceptor responsiveness Nonhypercapneic underlying hyperventilatory disorder causing periodic hypocapnea which turns off respiratory drive

CSA Associated Conditions

Congestive heart failure Prior Stroke and cerebrovascular disease Other neurologic disorders ALS, mucular dystrophy Chronic renal failure Hypothyroidism Baseline CO2 retainers (COPD, kyphoscoliosis)

CSA Diagnosis and Treatment

Diagnosis Polysomnography Treatment
CPAP/BIPAP can help Nocturnal Oxygen can help (offsets overshoot) Consult your local pulmonologist

Other Sleep Disorders

Restless Legs Syndrome Periodic Limb Movements of Sleep REM Sleep Behavior Disorder Nocturnal Leg Cramps Circadian Rhythm Disturbances

Restless Legs Syndrome (RLS)

Sensorimotor neurologic condition, possibly caused by abnormal iron metabolism and dopaminergic dysfunction unclear Compelling urge to move limbs (legs>arms)

Worse at rest Worse at night May have dysesthesia or pain Relieved with movement Disrupts sleep, alertness, daytime function, QOL

RLS Facts
5-15% prevalence, increased in the elderly, more common in women Associated features
FH positive in 60% PLMS in 80% (but 30% PLMS pts have RLS)

Diagnosis
Classic symptoms Responds to trial of therapy

RLS Associated Conditions

Pregnancy ESRD Fe Deficiency
Check ferritin, iron

Drugs can exacerbate

Sedating antihistamines Metoclopramide Calcium channel blockers Neuroleptics TCAs SSRIs Caffeine Nicotine ETOH

Parkinsons Radiculopathy Neuropathy Rheumatoid arthritis DM Depression/anxiety

RLS Treatment
Non-pharmacologic
Avoid caffeine, ETOH, associated medications Sleep hygiene Bedtime bath Mild exercise before bedtime

Pharmacologic
see handout most drugs used off label 70-100% effective

RLS Treatment
Dopaminergics
Requip/ropinirole and Mirapex/pramipexole only FDA approved meds) Use for daily or intermittent symptoms First line treatment (most studied)

Benzos intermittent use, klonopin is best choice Opioids daily or intermittent use Neurontin daily use, similar efficacy to Requip (average dose 800mg)
Neuropsychobiology 2003;48(2):82-6.

Magnesium, folate have slight evidence

Periodic Limb Movements of Sleep

PLMS: Periodic episodes of repetitive and highly stereotypc limb movements during sleep 34-45% prevalence in the elderly, increases with age Associated with RLS, arousals, difficulty achieving and maintaining sleep Most are asymptomatic Unclear significance Associated conditions similar to RLS

PLMS Diagnosis and Treatment

Diagnosis
Clinical history and response to treatment Polysomnography can be used

Treatment
Dopamine agonists Benzos decrease arousals but not movements Opioids

REM Sleep Behavior Disorder

Lack of normally low muscle tone during REM sleep Cause unknown Usually male, onset age 50-60 Act out dreams which can be violent Vivid memory of dreams Can diagnose with polysomnography 1/3 of Patients will develop Parkinsons Treat with benzo (klonopin 90% effective)

Nocturnal Leg Cramps

Cause not known Associated factors
Meds (diuretics, nifedipine, beta agonists, steroids, morphine, cimetidine, statins, lithium) Conditions (uremia, DM, thyroid, electrolyte d/os)

Diagnosis history, check labs

Nocturnal Leg Cramps

Treatment
Review associated factors Calf stretching exercises Quinine (200-300mg QHS)
Evidence of moderate benefit Toxicity careful in elderly, kidney/liver disease
Digoxin interaction Hematologic (thrombocytopenia) Blindness, arrhythmias, death!