INSOMNIA IN THE GERIATRIC POPULATION. Shannon Bush, MS4
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1 INSOMNIA IN THE GERIATRIC POPULATION Shannon Bush, MS4
2 CHANGES IN SLEEP ARCHITECTURE 2 Reduction in slow wave sleep (stage 3 and 4) Increase in lighter stages of sleep (stage 1 and 2) Decrease in REM sleep Decrease in total sleep time Greater sleep fragmentation = more nighttime awakenings Changes in circadian rhythms 1 Decrease in melatonin, VIP and vasopressin-expressing neurons in the suprachiasmic nucleus Source: Sleep Problems in the Elderly, American Family Physician, 1999 May 1 4
3 TYPES OF INSOMNIA 1 Primary Insomnia: trouble initiating sleep, non-restful sleep that impairs daytime functioning Secondary Insomnia: Attributable to primary sleep disorder (OSA, RLS, etc), medical condition, psychiatric condition, medication, psychosocial factors
4 ASSESSING INSOMNIA 1 Low threshold for referral to polysomnography Screen for secondary causes 3 Medication Screen: B-Blockers, bronchodilators, steroids, decongestants, diuretics, etc. Sleep Diaries Record time into/out of bed, number/length of awakenings, sleep satisfaction + times of caffeine, exercise, alcohol Interview any bed partners Questionnaires Pittsburgh Sleep Quality Index Insomnia Severity Index
5 NONPHARMACOLOGIC INTERVENTIONS Behavioral Treatment (Sleep Hygiene) 2 Reduce time in bed Bed = Sleep Consistent wake times Eliminate/Reduce daytime naps Environmental changes Cognitive Behavioral Therapy Combinations of sleep hygiene, sleep restriction, stimulus control, and relaxation techniques to change maladaptive behaviors Sessions once weekly for 4-8 weeks Light Therapy 3
6 PHARMACOLOGIC INTERVENTIONS TO AVOID Benzodiazepines -> avoid in the elderly Increased half life in the elderly Rebound insomnia Associated with addiction, daytime sedation, dizziness and falls Non-Benzo Hypnotics-> avoid in elderly 5 Zolpidem (Ambien) Zaleplon (Sonata Eszopiclone (Lunesta)
7 PHARMACOLOGIC INTERVENTIONS 3 Ramelteon Melatonin M 1 and M 2 agonist Trazadone Non-tricyclic antidepressant with sedating properties Side Effects: Drowsiness, GI disturbance, headache, hypotension, agitation Suvorexant Orexin antagonist
8 NON-PRESCRIPTION INTERVENTIONS 3 Alcohol-> avoid Increases latency of sleep onset, decreases REM sleep initially then increases REM sleep rebound and causes early morning awakening Antihistamines-> avoid Associated with cognitive impairment, daytime drowsiness, anticholinergic effects Melatonin Needs more large-scale studies, but appears effective in circadian rhythm disturbances + improves sleep latency and quality, morning alertness, quality of life Appear safe, but unregulated
9 SUMMARY The geriatric population has intrinsic changes in sleep architecture Evaluate by ruling out causes of secondary insomnia + sleep diaries/questionnaires Best intervention: sleep hygiene + CBT Avoid: Benzos, non-benzo hypnotics, antihistamines, alcohol Consider: Light therapy, trazadone, Ramelteon Melatonin in the future
10 SOURCES 1. Wennerg, AM, Canham, SL, Smith, MT, Spira, AP. Optimizing Sleep in Older Adults: Treating Insomnia. Maturitas (2014). PubMed. Web. Accessed 21 Jan Cooke, JR, Ancoli-Israel, S. Normal and Abnormal Sleep in the Elderly. Handbook of Clinical Neurology. 98. (2012): PubMed. Web. Accessed 21 Jan Kamel, NS, Gammack, JK. : Insomnia in the Elderly: Cause, Approach, and Treatment. The American Journal of Medicine (2006): ScienceDirect. Web. Accessed 21 Jan Neubauer, DN. Sleep Problems in the Elderly. Amerian Family Physician (1999): AAFP. Web. Accessed 21 Jan American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults, Journal of the American Geriatrics Society (2015): Web. Accessed 21 Jan 2019
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