Sleep in Older Adults - SUNY Downstate Medical Center

Sleep in Older Adults Mirnova Cede, MD 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. 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. Sleep in America 4/10 Americans describe themselves as great sleepers. 43% of Americans report rarely or never getting a good nights sleep. 95% of Americans utilize an electronic device one hour prior to sleep. Sleepfoundation .org Changes in Sleep In the population 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 hrs Kripke et la. 2002

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. Variable Women Men Lack of Sleep 24% 19%

Difficulty Initiating Sleep 26% 17% Difficulty Maintaining Sleep 35% 28% Early Morning Awakening 24% 19% Sleepfoundation .org, Sleep in America Poll 2001, Hale et al. 2009 Selected Groups Other vulnerable groups:

Hispanics and Blacks: poor sleep hygiene higher 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, Parkinsons disease, stroke and incontinence. Occupational: Night shift and rotating shift workers., 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. 2012

Outcomes of Poor Sleep Short term Hazards: Excessive daytime sleepiness Mood: 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 leptin Immune: 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. 2011 Outcomes of Poor Sleep Long term hazards: Obesity DM II Hypercholesterolemia

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. 2010 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%. Delta waves. 25% REM sleep is characterized by eye movement, increased respiration rate, increased brain activity and

dreaming. Normal Changes with Aging Increased awakenings and arousals Decreased REM sleep Decreased slow wave sleep Increased stage shifts Fewer cycles Reduced sleep efficiency Circadian control of sleep

Circadian rhythm mediated by the CLOCK system in the suprachiasmatic nucleus (SCN) in the hypothalamus The 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 2007 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 2013 Insomnia Definition:

Prolonged sleep latency, difficulties in maintaining sleep, early morning awakening and/or the experience of nonrestorative 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 men higher in older adults Bastien et al. 2011 Bastien 2011 Insomnia 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. Gellis et al. 2009, Wolkove et al. 2010 Insomnia

Exercise: Light Therapy: Promotes both sleep onset and sleep consolidation Elderly benefit from even minimal exercise Also benefits cardiovascular status, bone density, joints and balance Moderately bright light (1000 lux) or more improves subjective alertness, mood, and sleep quality Morning 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. 2010 Insomnia Cognitive Behavioral Therapy: Cognitive principles of insomnia Treatment 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 2011 Insomnia Pharmacotherapy: Melatonin

Melatonin 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. 2014 Insomnia Benzodiazepines: No adverse effects on COPD and SDA May develop tolerance, may experience withdrawal( including seizures Short term use associated with sedation, poor recall, psychomotor slowing. Longer term use associated with Alzheimers disease Bastien et al 2011, , Pomara et al 1998, Pomara et al. 2015, Gage et al. 2014 Insomnia Non Benzo Benzodiazepine Receptor Agonists

GABAa complex, higher affinity for alpha 1 Zolpidem:5mg, 10mg Zaleplon: 5mg, 10 mg Eszopiclone: 1mg -3mg Less tolerance and rebound Amnestic parasomnias Equivocal 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 Sleep apnea Apnea: cessation of breathing >10 sec Obstrucitve: if effort Central: wiithout effort Hypopnea: reduction in breathing ( 50% of airflow +O2 desaturations) AHI: Apnea + Hypopnea Index Obstructive Sleep Apnea/Hypopnea Syndrome:

AHI=5 or more respiratory event per hour of sleep AHI=15 or more moderate toe severe sleep apnea. Sleep Apnea Evaluation Clinical history: snoring, excessive daytime sleepiness, witnessed apneas, weight gain, impotence Physical findings: BMI >30, Hypertension, Neck Circumference >=17 in Polysomnography: AHI >5 1/3 elderly patients have AHI >5 Morbidity and Mortality increased with increasing AHI

Treatment: 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. 2008 Sleep Apnea Prevalence: men 14%, women 5% Untreated: Car Accidents/ Work Accidents Cardiovascular disease

Hypertension Diabetes Metabolic Syndrome Andrews et al 2004, Jean Louis et al 2008 Periodic Limb Movement Disorder Sleep disorder where the person moves limbs involuntarily during sleep. Associated with Restless leg syndrome Half 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. 2008 Restless Leg Syndrome Disorder of dysethesia in legs which often occurs when the person is inactive which includes nighttime Prevalence 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. 2008 PLMD/RLS Associated conditions: ESRD Neuropathies and myelopathies Pregnancy Anemia (iron deficiency) Chronic renal failure

Folate / B12 deficiency Medications (tricyclics, SSRIs, caffeine) Obesity Hypothyroidism PLMD/RLS Treatment: Nonpharmacologic Mental alerting actions Avoidance of certain meds: ie. Antidepressants, antipsychotics, antihistamines and alcohol, nicotine, caffeine Exercise Pneumatic 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. 2008 REM Sleep Behavior Disorder (RBD) Diagnostic Criteria

Presence of REM sleep without atonia Atleast 1 of the following: Absence of epileptiform activity, not another sleep disorders Strongly associated with neurodegenerative illnesses like PD or LBD, MSA Sleep related injurious behavior Abnormal REM sleep behaviors on PSG. 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 2013 REM Sleep Behavior Disorder (RBD) Treatment Reduce injury, remove hazards No FDA approved treatments First line pharmacotherapy: Melatonin 3mg to 15mg qhs

Clonazepam 0.25to 2mg qhs Or both Coeytaux et al 2013 Dementia Sleep changes in Alzheimers Dementia include: Reduction in fast sleep spindles Deterioration of rest/ activity cycle in moderate dementia Multiple 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. 2006 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 program Bright light therapy in the evening may ameliorate sleep-wake cycle disturbance Pharmacological: 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. 2004 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 Diet Sleep environment Any recent trauma or stressors Case Review of systems: SOB, chest pain, claudication Medications (diuretics, stimulants) Past medical history: metabolic syndrome, ESRD, Parkinsons, Dementia Consider sleep study if high risk First line treatment if insomnia First line treatment if dementia Thank you Questions? [email protected]

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