PHYSICAL EXERCISE FOR SLEEP PROBLEMS WITH THE ELDERLY

Transcription

1 What s the evidence? PHYSICAL EXERCISE FOR SLEEP PROBLEMS WITH THE ELDERLY Dr Paul Montgomery, Centre for Evidence-Based Intervention

2 Drawbacks of hypnotic medications Controversial for long-term use because of potential risk of tolerance and dependency (NIH 1990) Older people more likely to be affected by daytime residual effects (Prinz 1990; Morgan 1988) May increase likelihood of developing sleep apnoea (Kripke 1983) Associated with increased mortality (Kripke 1998)

3 Non-Drug Treatments Investigated Cognitive-behavioural therapy (CBT) Montgomery 2003 Bright light therapy Montgomery 2002 Some evidence of effectiveness No studies identified Physical exercise Montgomery 2002 This review

4 Traditional theories for exercise & sleep Thermoregulation Body restoration Energy conservation

5 More recent hypotheses Anti-anxiety & antidepressant effects on sleep E.g., two RCTs found significant effects of exercise on depression with older people (Singh et al 2001; Mather et al 2002) Raising levels of adenosine Modifying circadian rhythm

6 Common exercise types for elderly Resistance training (e.g., light weights) Traditional cardio (e.g., brisk walking) Aerobic (e.g., tai chi)

7 Systematic Review Cochrane Collaboration Montgomery P, Dennis JA Physical exercise for sleep problems in adults aged 60+. Cochrane Database of Systematic Reviews

8 Review Criteria Design: Randomized controlled trials Intervention: Exercise programs for older adults Population: > 60 years of age Screened to exclude those with dementia or depression

9 Sleep Problems Primary Insomnia Difficulties initiating and maintaining sleep Sleep efficiency Delayed or advanced sleep phase problems Parasomnias Impaired daytime functioning

10 High-Quality Evidence Randomized controlled trials

11 Review Results 1 study included in 2002 review: King AC, Oman RF, Brassington GS, Bliwise DL, Haskell WL. Moderate-intensity exercise and self-rated quality of sleep in older adults. JAMA 1997; 277(1): Post-2002 Additions Li F, Fisher KJ, Harmer P, Irbe D, Tearse RG, Weimer C Tai Chi and Self-Rated Quality of Sleep and Daytime Sleepiness in Older Adults: A Randomized Controlled Trial. Journal of the American Geriatrics Society 52:

12 Brisk Walking King et al 1997

13 King et al 1997 RCT Sample (n=48) Mean age: 62 Location: USA Intervention (n=24) Moderate-intensity community-based exercise training (low impact aerobics; brisk walking) 4 x min per wk for 16 wks Control (n=24) No intervention waitlist

14 Results: King et al Significant positive effects compared to control on: Sleep quality Sleep onset latency (9 min less per night than control) Sleep duration (48 min more per night than comparison)

15 Sleep Onset Latency, minutes Exercise Control P =.007 Baseline Posttest King et al 1997

16 Sleep Duration, hours Exercise Control P =.047 Baseline Posttest King et al 1997

17 Tai Chi Li et al 2004

18 Li et al 2004 RCT Sample (n=118) Mean age: 75 Location: USA Intervention (n=62) tai chi emphasizing movement coordination and regulated breathing 3 x 1hr per wk for 24 wks Control (n=56) Low-impact exercise (seated exercise with controlled breathing, stretching, relaxation) 3 x 1hr per wk for 24 wks

19 Results: Li et al Significant positive effects compared to low-intensity exercise on: Sleep quality Sleep onset latency (18 min less per night than comparison) Sleep duration (48 min more per night than comparison) Sleep efficiency Sleep disturbances

20 Intervention drawbacks Moderate intensity exercise may be unsuitable for many older people

21 High-Quality Evidence Other non-drug interventions

22 Soft Music Lai et al 2006

23 Lai et al 2006 RCT 1 study identified (non-systematic review) Sample: 60 (30 intervention, 30 no-treatment control) Mean age: 67; Location: Taiwan Intervention: 45 min sedative music tapes at bedtime for 3 wks Significant positive effects on: Sleep quality Sleep duration Sleep efficiency Sleep onset latency Daytime dysfunction

24 Lower-Quality Evidence Quasi-experimental and crossover studies

25 Warm Baths Passive body heating, e.g., via immersion to neck in C water for 30 min Crossover study suggests could increase slow wave (deep sleep) in healthy female elderly with insomnia (Liao 2002) Elderly reports of better sleep and quicker falling asleep (n=30) (Kanda et al 1999)

26 Herbal Agents & Teas Review by Shimazaki et al 2007: Very little evidence aside from small studies with subjective measurements Unclear whether agents pose risks in long-term care due to potential drug interactions

27 Conclusions

28 Physical exercise Very little evidence Durable effects of interventions unknown Promising results from King et al 1997 & Li et al 2004 for physical exercise Underlying mechanisms of tai chi for impact on sleep unclear (enhanced feeling of wellbeing via relaxation techniques and smooth movements and modification of circadian rhythm suspected) Li et al findings suggests tai chi more effective than lowintensity exercise Further research justifiable, particularly considering negative consequences of pharmacological treatments

29 Other non-drug interventions Again, very limited evidence Promising results from Lai et al 2006 study on soft music, but only 1 study Especially little known about efficacy of warm bathing and herbal agents for elderly sleep problems Further randomized controlled trials needed

30 References

31 References Borkovec TD Insomnia. Journal of Consulting and Clinical Psychology 50: Health NIo The Treatment of Sleep Disorders of Older People. NIH Consensus Statement pp Kanda K, Tochihara Y, Ohnaka T Bathing before sleep in the young and in the elderly. European Journal of Applied Physiology and Occupational Physiology 80:71-5 Kripke DF Why we need a tax on sleeping pills. Southern Medical Journal 76:632-6 Kripke DF, Klauber MR, Wingard DL, Fell RL, Assmus JD, Garfinkel L Mortality hazard associated with prescription hypnotics. Biological Psychiatry 43 Lai HL, Good M Music improves sleep quality in older adults. Journal of Advanced Nursing 53: Liao W-C Effects of passive body heating on body temperature and sleep regulation in the elderly: a systematic review. International Journal of Nursing Studies 39:803-10

32 References (continued) Mellinger GD, Balter MB, Uhlenhuth EH Insomnia and its treatment. Archives of General Psychiatry 42 Morgan K, Dallosso H, Ebrahim S, Arie T, Fentem PH Prevalence, frequency, and duration of hypnotic drug use among elderly living at home. BMJ 26:601-2 Morin CM, Gramling SE Sleep patterns and aging: comparison of older adults with and without insomnia complaints. Psychology and Aging 4:290-4 Prinz P, Vitiello M, Raskind M, Thorpy M Geriatrics: sleep disorders and aging. New England Journal of Medicine 323:520-6 Shimazaki M, Martin JL Do Herbal Agents Have a Place in the Treatment of Sleep Problems in Long-Term Care? Journal of the American Medical Directors Association 8: Simon G, Von Korff M Prevalence, burden and treatment of insomnia in primary care. American Journal of Psychiatry 154: Singh NA, Clements KM, Singh MAF The Efficacy of Exercise as a Long-term Antidepressant in Elderly Subjects. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences 56:M497-M504 Stepnowsky Jr CJ, Ancoli-Israel S Sleep and its disorders in seniors. Sleep Med Clin 3:281-93