Insomnia in Older Adults Part I: Assessment

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1 abstract DRUGS &AGING Part I: Assessment Insomnia is very common among older adults and may have serious consequences.the assessment of insomnia can be challenging, given the number of possible causes and the fact that insomnia is often not a presenting complaint. Inquiring about patients sleep and performing a thorough evaluation of any concerns will allow a rational and targeted approach to treatment. Key words: insomnia, sleep, older adults, aging, diagnosis Amit Morris, BSc, School of Medicine, Queen's University, Kingston, ON; Department of Psychiatry, Sleep and Alertness Clinic, Toronto Western Hospital, University of Toronto, Toronto, ON. Colin M. Shapiro, MBBCh, PhD, FRCP(C), Department of Psychiatry, Sleep and Alertness Clinic, Toronto Western Hospital, University of Toronto, Toronto, ON. Introduction Insomnia is defined as difficulty falling or staying asleep, or unrestorative sleep. It is often a symptom of another problem but may occur as a primary disorder. Chronic insomnia is extremely common among older adults. Multiple factors contribute to this prevalence, including agerelated changes in sleep, increased medical comorbidity, medication effects, psychiatric and neurologic disorders, other sleep disorders, and psychosocial factors. Although chronic insomnia is associated with serious clinical consequences and decreased quality and quantity of life, it is often underappreciated, underdiagnosed, and undertreated. This article reviews the prevalence, consequences, and etiology of chronic insomnia in older adults and suggests an approach to the assessment of insomnia in a primary care setting. The second article in this two-part series will address the treatment of insomnia. Prevalence of Insomnia Among Older Adults The prevalence of sleep complaints increases with age, with more than half of adults above age 65 reporting regular problems. 1 Difficulty staying asleep is the most frequent complaint; early morning awakening with difficulty getting back to sleep and difficulty falling asleep are also common. 2 The incidence of insomnia among older adults has been observed to be 5% per year 3 and is more frequently reported by women than men. 4 In keeping with their high rate of sleep problems, older adults use a disproportionate amount of hypnotic medications and much of this use is chronic. One illustrative study found that 15% of individuals 65 years and over used hypnotic drugs; nearly one-third continued to use them four years later. More than three-quarters of the individuals who continued to use hypnotics did so often or all the time. 5 Consequences of Insomnia The seriousness of sleep problems is often underestimated. Indeed, insomnia carries significant associated morbidity. It is associated with decreased quality of life and increased utilization of health care resources, as reviewed by Benca. 6 Older individuals with insomnia experience a subjective sense of poorer health, which may improve with resolution of the sleep problem. 3 Many chronic physical ailments progress more rapidly if the patient has sleep difficulties. 7 Memory, attention, mood, and performance problems can result from insomnia and may be mistaken for dementia. Daytime sleepiness resulting from insomnia can lead to decreased attention and responsiveness, with an increased risk of falls, injuries, and motor vehicle accidents. 8,9 Insomnia is a risk factor for subsequent development of depression. 10 Sleep problems also strain caregivers and have been cited as one of the most important factors in the decision to admit an older person to a nursing home. 11 A 1994 study 50 GERIATRICS & AGING July/August 2004 Volume 7, Number 7

Figure 1: Sleep Architecture Changes in Older Adults With aging, stage 1 sleep increases and stage 3 and 4 decrease. Nighttime awakenings occur more frequently.

2 Figure 1: Sleep Architecture Changes in Older Adults With aging, stage 1 sleep increases and stage 3 and 4 decrease. Nighttime awakenings occur more frequently. Suprachiasmatic nucleus ("the biological clock") Optic chiasm Pituitary gland Pineal gland production site of melatonin Awake REM Sleep Stages Young Adult Awake REM Sleep Stages Older Adult 51

3 Table 1: Medications that can Induce Insomnia Cardiovascular Antidepressants Gastrointestinal Irritants Beta-Blockers Phenelzine ASA, anti-inflammatories Diuretics Tranylcypromine Antibiotics Calcium channel blockers Imipramine Cancer chemotherapeutics Respiratory Trimipramine Other Decongestants Amoxapine Antipsychotics Beta-2 agonists Fluoxetine Glucocorticoids Theophylline Fluvoxamine Thyroid hormone Paroxetine Sertraline Moclobemide Venlafaxine Buproprion estimated the overall financial cost of insomnia in the US to be $30 to 35 billion annually (1994 dollars). 12 Etiology There are multiple potential causes of insomnia in older adults, including agerelated sleep changes, medical conditions, substances, psychiatric and neuropsychiatric disorders, other sleep disorders, and psychosocial factors. Sleep-wake patterns and sleep architecture change with aging, making it difficult to define normal sleep in an older person. Compared with younger adults, total sleep as well as sleep efficiency the percent of in-bed time spent asleep both decrease in the older patient, while nightime awakenings increase. The lightest stage of sleep stage 1 increases in amount, while the most restorative sleep stages 3 and 4 decreases (Figure 1). 13 Together, these changes predispose to lighter, more fragmented, and less restorative sleep. Furthermore, growth hormone release during sleep invariably Phenytoin Baclofen Oxycodone Donepezil Pergolide Selegiline All stimulants Sources: Information from Kennedy et al., 1998; Shapiro et al.,1994; and Ancoli-Israel, declines with aging, and melatonin declines in some older patients. These hormonal changes have been referred to as endopause, 14 and treatment of a melatonin deficiency may be relevant in some patients (to be addressed in part II of this series). Many medical conditions can disturb sleep, including pain from any source (e.g., arthritis, headache), dyspnea (e.g., in chronic obstructive pulmonary disease), thyroid disease, diabetes, benign prostatic hyperplasia, urinary tract infection, and nocturia. Cardiac ischemia may disrupt sleep without producing prominent angina; the ischemia may itself result from sleep apnea and associated increases in sympathetic tone. 15 Conditions aggravated by lying down (e.g., gastroesophageal reflux, congestive heart failure with paroxysmal nocturnal dyspnea) and those with nocturnal exacerbations (e.g., asthma) are particularly notable causes. 16 Medications that predispose to insomnia include commonly used antidepressants, respiratory medications, cardiovascular medications, and glucocorticoids (Table 1). Altering doses or timing of administration may improve sleep. 8 Caffeine and nicotine are well known to impair sleep. Alcohol, often used a hypnotic substitute, does decrease time to fall asleep but increases sleep fragmentation and decreases quality 19 ; it can also precipitate sleep apnea. Withdrawal from very short-acting benzodiazepine hypnotics may result in rebound insomnia acutely. Withdrawal of treatment effects overnight for example, in a patient with Parkinson s disease taking levodopa five times daily between 7a.m. and 7p.m. can also result in sleep disruption. Physicians need to consider patients 24-hour need for medications and not think of patients lives in terms of daytime hours only. Psychiatric conditions such as mood and anxiety disorders are prevalent in the older population and may cause insomnia. Depression and insomnia are particularly closely associated: depression is a common cause of insomnia; insomnia is a risk factor for the subsequent development of depression; and increasing age is a risk factor for both. 10 Any evaluation of sleep difficulties in older adults therefore should include a mood assessment. Alzheimer s disease is associated with significant fragmentation of sleep and disruption of sleep architecture. 13 This disruption is likely a result of degeneration of neurons involved in generating circadian rhythmicity and sleep. 20 As mentioned, sleep disturbances play an important role in the decision to opt for institutionalization. Nocturnal agitation or sundowning may also be a result of disruption of circadian rhythms. Increasing daytime light exposure and ensuring social activity as well as mild exercise may improve entrainment to a regular day/night rhythm and improve sleep quality. 8 Attention to environmental factors, including decreasing noise levels, may be of additional benefit. Parkinson s disease can result in insomnia due to immobility, stiffness, pain, or nocturia, or as a side effect of therapy with levodopa GERIATRICS & AGING July/August 2004 Volume 7, Number 7

4 Table 2: History Questions for Insomnia Screening Questions Do you have any difficulty falling or staying asleep at night? Do you feel sleepy or have trouble staying awake during the day? Evaluate the Sleep Complaint Establish the time course: How and when did the sleeping difficulty start? Is it intermittent or continous? Characterize the Sleep Complaint: What time do you go to bed? By how much does this vary night to night? What time is lights out? How long does it take you to fall asleep? Do you wake up at night? How often? How long does it take to get back to sleep? Are you aware of what wakes you up? (Pain, need to urinate, shortness of breath, etc.) What time do you wake up for good? What time do you get out of bed? How much do these vary? How have you been dealing with the sleep problem to this point? Non-prescription sedatives? Alcohol? Daytime Functioning: Do you feel sleepy, tired, or fatigued during the day, so that you d like to take a nap? Do you take naps during the day? When, where, and for how long? How do you feel after a nap? Do you nod off during the day? In what situations? Have you ever endangered yourself (e.g., driving)? Can you resist the urge to sleep? Has your memory or concentration changed? Your mood? Evaluate Contributing Problems Sleep hygiene and relaxation: What do you do to prepare for sleep? Do worrisome thoughts interfere with your relaxation before sleep? Do you worry that you won t get enough sleep? Is your sleeping environment free of noise and other disturbances? How much exercise do you get during the day? Substances: What medications including non-prescription and herbal medications do you take? Do you use caffeine, nicotine, or alcohol? When and how much? Medical Causes: Take a medical history and review of systems Do you have any physical symptoms that keep you from falling asleep? That wake you up? (Pain, shortness of breath, etc.) Do you have any unusual or uncomfortable sensations in your legs before going to sleep? Psychiatric Causes: Take a psychiatric history How do you feel emotionally during the day? Are you able to enjoy things? Do you have periods where you feel very anxious? For the Bed Partner: Does your partner stop breathing at night? Does he/she snore, gasp or make choking sounds? (Sleep apnea) Do your partner s legs kick or jerk during the night? (Periodic limb movements) Has your partner s mood or emotional state changed recently? What do you think is the cause of your partner s sleep difficulty? Source: Adapted from Shapiro and Steingart, with permission from SERDI. 53

5 Table 3: Physical Examination for Insomnia Examination Rationale Vital signs Head Neck Cardiovascular Respiratory Musculoskeletal Neurologic Source: Information from Doghramji, Hypertension is associated with obstructive sleep apnea, and respiratory disorders can cause insomnia. Look for impediments to airflow, such as overbite, large or abnormal tonsils, tongue, soft palate, or uvula. Note the size of the airway in the pharynx. Inspect the nose for obstruction. Thyroid enlargement can signal hyper- or hypothyroidism; hyperthyroidism can lead to increased sympathetic outflow and insomnia; decreased growth hormone with hypothyroidism leads to poor-quality sleep (decreased slow-wave sleep) and daytime sleepiness. 25 Examine for signs of congestive heart failure (CHF) e.g., S3, crackles, elevated jugular venous pressure, ankle edema. Look for respiratory disorders or causes of dyspnea e.g., asthma, COPD, CHF. Examine for signs of arthritis, neck/back, or other pain. Look for signs of Parkinson s disease (tremor, rigidity); a mini-mental status exam may elicit signs of dementing illness. Sleep-associated disorders of limb movement or breathing may result in insomnia. Restless leg syndrome (RLS), periodic limb movements in sleep (PLMS), and sleep apnea are very common in older adults. In RLS, pre-sleep leg discomfort and an associated urge to move the legs can result in difficulty getting to sleep. This condition is more common with age and may be associated with the use of antidepressant medications. PLMS involves leg kicks every seconds during the night. Sleep apnea involves repeated cessation of breathing, and increases dramatically in women after menopause. Bed partners may notice kicking with the former condition and apneic events or prominent snoring with the latter. Both PLMS and sleep apnea result in repeated arousals, unrefreshing sleep, and daytime sleepiness. Complaints of difficulty maintaining sleep are not common, as the arousals are not usually recalled. Insomnia may also be a primary disorder, without another disorder as its apparent cause. For example, poor bedtime habits or an unconducive environment may impair sleep ability. Insomnia of any cause may become a conditioned response to the sleep environment and so be perpetuated beyond the duration of an initial precipitant referred to as psychophysiologic insomnia. Other psychosocial factors such as lack of exercise, isolation, loneliness, bereavement, and fear of death in sleep can contribute to difficulty sleeping in aging adults. 16 As well, changes in circadian rhythms can disrupt sleep. With aging, the sleep-wake cycle commonly shifts to earlier hours. This can result in awakening around 3 or 4a.m. with inability to return to sleep as well as sleepiness at 7 or 8p.m. 8 While an advanced sleep phase still allows for an adequate amount of sleep, individuals may stay awake until a time they feel is more socially acceptable. They are nonetheless woken by the shifted circadian rhythm in the early hours of the morning; the result is less sleep and daytime sleepiness. Strategies similar to those discussed for improving entrainment in Alzheimer s disease may be beneficial in this situation. 16 Approach to Insomnia in an Older Adult History It has been observed that only 5% of people with insomnia visit a physician specifically to discuss their sleep complaint, while approximately one quarter bring it up during the course of a visit for another purpose, and the majority never mention it at all. 22 Because of the consequences of insomnia on health and quality of life, as well as the potential for successful intervention, physicians should ask all of their older patients about sleep and sleepiness. Suggested screening questions are given in Table 2. If a complaint of insomnia is established, the history must be thorough, given the number of possible causes and the importance of directing treatment at any identifiable underlying causes. Questions should cover patterns of time in bed, sleep, awakening, and daytime function. Medical, psychiatric, and substance histories should be sought. Interviewing a bed partner, if the patient has one, can be helpful for identifying conditions such as sleep apnea and PLMS. Suggested questions are presented in Table 2. Sleep Diary Having the patient complete a daily sleep diary spanning two or more weeks may be helpful. Besides sleep and awakening times and daytime functioning, the diary should include the timing and amount of any medication, caffeine, and alcohol use. Physical An outline for a brief physical examination is given in Table 3. Labwork Labwork should include a complete blood count, chemistry profile, and thyroid stimulating hormone. 24 Vitamin B12 and folate levels should be assessed, as low levels can cause RLS. Treatment Treatment should address any underlying conditions identified. The treatment of primary insomnia involves environmental 54 GERIATRICS & AGING July/August 2004 Volume 7, Number 7

6 and behavioural strategies and the judicious use of medication if necessary; these will be discussed in the second article of this two-part series. Even when a cause is found, behavioural and pharmacologic treatment of the insomnia may provide additional benefit. When to Refer to a Sleep Specialist It has been suggested that the patient should be referred to a sleep specialist when there is a suspicion of obstructive sleep apnea or a primary sleep disorder, or when the insomnia is refractory to behavioural and pharmacological treatment. 24 While this is classical, treatment will differ based on the results of a sleep study, and it is therefore increasingly common to seek expert help earlier. All patients with excessive daytime sleepiness should be formally assessed. Summary Insomnia in an older adult is a common problem and a diagnostic challenge. It can have many causes and clinically significant consequences. Detailed evaluation including a thorough history is necessary to try to identify a cause and to allow for directed treatment. 15. Czeisler CA, Winkelman JW, Richardson GS. Sleep disorders. In: Braunwald E, Fauci AS, Kasper DL, et al., editors. Harrison's principles of internal medicine, 15th ed. Toronto: McGraw-Hill, Moller HJ, Barbera J, Kayumov L, et al. Psychiatric aspects of late-life insomnia. Sleep Medicine Reviews 2004;8: Kennedy SH, Parikh SV, Shapiro CM. Defeating depression. Thornhill: Joli Joco, Shapiro CM, MacFarlane JG, Hussain MR. Conquering insomnia: an illustrated guide to understanding sleep and a manual for overcoming sleep disruption. Hamilton: Empowering Press, Gillin JG, Drummond SP. Medication and substance abuse. In: Kryger MH, Roth T, Dement W, editors. Principles and practice of sleep medicine, 3rd ed. Philadelphia: Saunders, 2000: Sloan EP, Flint AJ, Shapiro CM. Keeping pace with circadian rhythm problems in the elderly. Canadian J Diagnosis 1993;11: Razmy A, Shapiro CM. Interactions of sleep and Parkinson's disease. Semin Clin Neuropsychiatry 2000;5: Dement WC. The proper use of sleeping pills in the primary care setting. J Clin Psychiatry 1992;53(Suppl.):S50 S Shapiro CM, Steingart A. Fifty-one questions for the elderly insomniac and why. In: Sleep disorders and insomnia in the elderly. Facts and research in gerontology, Vol. 7. New York: Springer, 1993: Doghramji PP. Detection of insomnia in primary care. J Clin Psychiatry 2001;62 (Suppl. 10):S18 S Shapiro CM. Growth hormone-sleep interaction: a review. Research Communications in Physiology, Psychiatry and Behavior 1981;6: Kales A, Kales JD. Sleep disorders: recent finding in the diagnosis and treatment of disturbed sleep. NEJM 1974;290: No competing financial interests declared. References 1. Ancoli-Israel S. Sleep problems in older adults: putting myths to bed. Geriatrics 1997;52: Shochat T, Ancoli-Israel S. Sleep and sleep disorders. In: Cassel CK, Leipzig RM, Cohen HJ, et al. Geriatric medicine: an evidence based approach, 4th ed. New York: Springer Verlag, 2003: Foley DJ, Monjan A, Simonsick EM, et al. Incidence and remission of insomnia among elderly adults: an epidemiologic study of 6800 persons over three years. Sleep 1999;22(Suppl. 2):S366 S Foley DJ, Monjan AA, Brown SL, et al. Sleep complaints among elderly persons: an epidemiologic study of three communities. Sleep 1995;18: Morgan K, Clarke D. Longitudinal trends in late-life insomnia: implications for prescribing. Age and Ageing 1997;26: Benca RM. Consequences of insomnia and its therapies. J Clin Psychiatry 2001;62(Suppl. 10):S33 S Devins GM, Edworthy SM, Paul LC, et al. Restless sleep, illness intrusiveness and depressive symptoms in three chronic illness conditions: rheumatoid arthritis, end-stage renal disease and multiple sclerosis. J Psychosom Res 1993;37: Ancoli-Israel S. Insomnia in the elderly: a review for the primary care practitioner. Sleep 2000;23(Suppl. 1):S23 S Roth T, Ancoli-Israel S. Daytime consequences and correlates of insomnia in the United States: results of the 1991 national sleep foundation survey II. Sleep 1999;22(Suppl. 2):S354 S Buysse DJ. Insomnia, depression and aging. Geriatrics 2004;59: Sanford JR. Tolerance of debility in elderly dependents by supporters at home: its significance for hospital practice. BMJ 1975;3: Chilcott LA, Shapiro CM. The socioeconomic impact of insomnia: an overview. Pharmacoeconomics 1996;10(Suppl. 1):S1 S Bliwise DL. Sleep in normal aging and dementia [review]. Sleep 1993;16: Shin K, Shapiro C. Menopause, sex hormones and sleep. Bipolar disorders 2003;5:

Insomnia. Learning Objectives. Disclosure 6/7/11. Research funding: NIH, Respironics, Embla Consulting: Elsevier

Insomnia. Learning Objectives. Disclosure 6/7/11. Research funding: NIH, Respironics, Embla Consulting: Elsevier Insomnia Teofilo Lee-Chiong MD Professor of Medicine National Jewish Health University of Colorado Denver School of Medicine Learning Objectives Learn about the causes of transient and chronic Learn how