Insomnia Pearls in the Geriatric Population

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1 Insomnia Pearls in the Geriatric Population September 9, 2016 Stephanie Loegering, PharmD, CGP Clinical Pharmacist VA Medical Center Thank You MPhA Wi-fi Information: NETWORK: EC-CTR PASSWORD: westgate252 1

Understand Insomnia and how it impacts the geriatric population Understand risks associated with

2 Disclosure I have no actual or potential conflicts of interest associated with this presentation. Learning Objectives Upon successful completion of this activity, pharmacists should be able to: Understand Insomnia and how it impacts the geriatric population Understand risks associated with pharmacological treatment of insomnia in the geriatric population Identify first line treatments for insomnia 2

3 Case Study The patient is a 66-year-old male with a primary complaint of sleeplessness and sleepiness for approximately 8 months. Initially, he only had difficulty staying asleep 2-3 nights per week. However, over the past 5 months, sleep and daytime fatigue have increased in severity and frequency. He now wakes up at least 3 times per night at least 5 nights per week, and on most nights has difficulty falling asleep (takes her about 40 minutes to an hour). He has tried to maintain an active social and professional life. He heads his own consulting company. He notes increased irritability and lack of motivation. He has on occasion, taken over-the-counter medications. He notes an increase in his caffeine intake (4 cups of coffee and 1-3 diet colas per day Case Study PMH: hypertension, osteoarthritis, h/o depression in his 30s Medications: Atenolol, HCTZ, diphenhydramine for sleep SH: lives with his wife of 40 years and has 2 children and 2 grandchildren. He drinks 2 beers most days of the week and does not smoke. Review of Systems: He has stopped exercising secondary to fatigue and has recently gained almost 15 pounds. The additional weight has increased pain in his knees. PE: Mental, neurologic, and physical examination was within normal \ limits, with the exception of a body mass index of 31, BP: 135/92 mmhg HR: 68 Prevalence 30% of the general population 10-15% of adults experience chronic insomnia 20-30% of elderly adults 2005 NIH consensus conference and National Sleep Foundation 3

4 Pathophysiology Non-REM, REM sleep cycles every min. NREM stages 1-4 (1: lightest, 4: deepest) Stages 3-4 are slow wave sleep (SWS) and are most restorative (~20-25% of sleep time in adults) Older adults have less SWS and REM sleep The American Journal of Medicine (2006) Definition a disorder characterized by symptoms of difficulty with sleep initiation, sleep maintenance, or nonrestorative sleep associated with impairments in daily function or daytime stress DSM-IV-TR Definitions Initial (sleep-onset insomnia) Middle (Sleep maintenance insomnia) Late (Late insomnia) DSM IV-TR 4

5 Definitions Primary Sleep disordered breathing (SDB)/sleep apnea Restless leg syndrome (RLS)/periodic limb movement disorder (PLMD) Secondary Underlying medical or psychiatric disorder Acute < 4 weeks Chronic > 4 weeks Secondary Causes Psychiatric Illness Medications Behavioral/ Environmental Insomnia Medical Disorders Psychosocial Factors Primary Sleep disorders Consequences of Insomnia Diminished cognition Attention, Slowed response Increased risk of falls, fractures, car accidents Decreased memory Mis-diagnosed as dementia Psychiatric Disorders Anxiety Depression Reduced pain threshold 5

6 Consequences of Insomnia Insulin resistance Reduced quality of life Increased health care utilization Approach to Insomnia Identify that insomnia is a problem Sleep diary, sleep study Identify potential underlying causes for insomnia Treat underlying causes for insomnia Move sedating medications to bedtime Treatment Sleep apneas Continuous Positive Airway Pressure (CPAP) Limb movement disorders Associated w/ anemia iron supplements First line: dopaminergic agonists Ropinirole, pramipexole Second line Gabapentin, clonazepam 6

4-6hrs before bed Avoid excessive liquids 2-3hrs before bed Maintain a routine (sleep/wake times 7 days/week) Avoid

7 Treatment: Non-Pharmacological Stimulus Control Bedroom for sleep and sex only Go to bed only when sleepy Leave the bedroom if unable to sleep after 20 minutes Sleep Hygiene Regular exercise (at least 3-4 hrs before bed) Avoid tobacco, stimulants, etoh 4-6hrs before bed Avoid excessive liquids 2-3hrs before bed Maintain a routine (sleep/wake times 7 days/week) Avoid stimulation (screens) before bed Limit napping to 30 min and before 2pm Use gentle stretching, low-impact activities to improve quality 7

8 Treatment: Non-Pharmacological Cognitive Behavioral Therapy (psychologist) Identify dysfunctional beliefs and attitudes about sleep Sleep Restriction (paradoxical intention) Relaxation therapies Meditation, muscle relaxation activities Substance Use Disorder Treatment: Pharmacological PTSD/Anxiety Agents To Consider by Comorbidity No Comorbidities Depression Pain Gabapentin Prazosin Trazodone Mirtazapine Gabapentin Trazodone Mirtazapine Mirtazapine Trazodone Trazodone Mirtazapine Trazodone Temazepam Mirtazapine Melatonin Agonist Melatonin Agonist Zolpidem Melatonin Agonist Zolpidem Melatonin Agonist Melatonin Agonist Doxepin Doxepin Doxepin Doxepin Doxepin Amitriptyline Amitriptyline Amitriptyline Amitriptyline Amitriptyline Antihistamines Antihistamines Antihistamines Antihistamines Antihistamines Modified from the VA Academic Detailing Service Treatment: Pharmacological Medication Doses, Onset of Action, Half -life Class Agent Dose Geriatric Dose Onset Half-life Antidepressant Trazodone mg Start low 1-3hrs 7-8hrs Mirtazapine mg Start low unknown 20-40hrs Melatonin Agonist Ramelteon 8mg N/A 30min 1-3hrs Melatonin 1-10mg N/A 30min ~2hrs Anticonvulsant Gabapentin mg Start low Unknown 5-7hrs Benzodiazepine Temazepam* 15-30mg 7.5mg 30-60min hrs Lorazepam* 2-4mg 1-2mg 30 min 12hrs Modified from the VA Academic Detailing Service *Beers List 8

9 Treatment: Pharmacological Medication Doses, Onset of Action, Half -life Class Agent Dose Geriatric Dose Onset Half-life Non-Benzo Zolpidem IR* W: 5mg M: 5-10mg Zolpidem CR* Max 5mg Avoid >90d W: 6.25mg Max 6.25mg M: Avoid >90d mg 30min 30min 2.5hrs 2.8hrs Eszopiclone* 1-3mg 2mg Rapid(10min) 6hrs Zaleplon* 5-10mg Max 10mg 30min 1hr Antidepressants Doxepin 3-6mg Max: 6mg 30min 15hrs Amitriptyline* 10-25mg Caution Unknown 9-27hrs *Beers list Modified from the VA Academic Detailing Service New Medications Suvorexant (Belsomra ) - CIV MOA: blocks the binding of wake-promoting neuropeptides orexin A and orexin B to receptors OX 1 R and OX 2 R Dose: 10-20mg QHS (30 min before bed) Do NOT start at 20mg dose Decrease w/ CYP 3A4 inhibitors ADR: somnolence, sleep activities, impaired driving Benzodiazepines (lorazepam) Side Effects Z drugs (zolpidem, zaleplon) Antidepressants (Trazodone, Doxepin) Orexin Antagonists Morning Sedation Hypnagogic hallucinations Unsteady Gait, Falls /- Confusion /- Amnesia Dependence and Abuse + +/- - - Rebound Insomnia Respiratory Depression + +/- - - Orthostasis Anticholinergic /+ - Annu. Rev. Pharmacol. Toxicol,

10 Efficacy and Safety of Doxepin 1 mg, 3 mg, and 6 mg in Elderly Patients With Primary Insomnia: A Randomized, Double-Blind, Placebo-Controlled Crossover Study See PDF Martin Scharf, PhD; Roberta Rogowski, RN; Steven Hull, MD; Martin Cohn, MD; David Mayleben, PhD; Neil Feldman, MD; Larry Ereshefsky, PhD; Alan Lankford, PhD; and Thomas Roth, PhD Pharmacological Research Assessing the efficacy of melatonin to curtail benzodiazepine/z drug abuse Daniel P. Cardinalia, c, Diego A. Golombekb, c, Ruth E. Rosensteinb, c, Luis I. Bruscod, c, Daniel E. Vigoa, c A good Geriatrician takes away medications before adding new 10

11 Learning Objectives Upon successful completion of this activity, pharmacists should be able to: Understand Insomnia and how it impacts the geriatric population Understand risks associated with pharmacological treatment of insomnia in the geriatric population Identify first line treatments for insomnia Case Study XX is a 68-year-old male with a primary complaint of sleeplessness and sleepiness for approximately 8 months. Initially, he only had difficulty staying asleep 2-3 nights per week. However, over the past 5 months, sleep and daytime fatigue have increased in severity and frequency. He now wakes up at least 3 times per night at least 5 nights per week, and on most nights has difficulty falling asleep (takes her about 40 minutes to an hour). He has tried to maintain an active social and professional life. He heads his own consulting company. He notes increased irritability and lack of motivation. He has on occasion, taken over-the-counter medications. He notes an increase in her caffeine intake (4 cups of coffee and 1-3 diet colas in the evening) Case Study PMH: hypertension, osteoarthritis, h/o depression in his 30s Medications: Atenolol, HCTZ, diphenhydramine for sleep SH: lives with his wife of 40years and has 2 children and 2 grandchildren. He drinks 2 beers most days of the week and does not smoke. Review of Systems: He has stopped exercising secondary to fatigue and increase responsibilities at work and has recently gained almost 15 pounds. The additional weight has increased pain in his knees. PE: Mental, neurologic, and physical examination was within normal limits, with the exception of a body mass index of 31, BP: 135/92 mm Hg. 11

12 Test Question#1 True or False XX has chronic insomnia with primary problems with sleep onset and sleep maintenance Test Question #2 XX has the following underlying causes for insomnia A. Pain B. Excessive caffeine use C. Stress or anxiety D. All of the above E. Alcohol use Test Question #3 Which of the following recommendations would you give XX? A. Resume exercising to assist with pain and sleep B. Decrease caffeine and alcohol use C. Trial Advil PM instead of diphenhydramine to help with pain and sleep D. Assess for depression and consider Mirtazapine for sleep E. A, B, and D 12

13 Questions? Stephanie Loegering References American Psychiatric Association. (2013). Sleep-Wake Disorders In Diagnostic and Statistical Manual of Mental Disorders (5th ed.) Cardinali D, Golombek D, Rosenstein R, Brusco L, Vigo D. Assessing the efficacy of melatonin to curtail benzodiazepine/z drug abuse. Pharmacological Research 2016; 109: Chong Y, Fryar C, Gu Q. Prescription Sleep Aid Use Among Adults: Unites States NCHS Data Brief. 2013; 127 Clinical Pearls to Manage Chronic Insomnia. A Quick Reference Guide. VA Academic Detailing Service (2014) Expert Panel. American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. JAGS. 2015: 1-20 Hanlon JT, Semla TP, Schmader KE. Alterantive Medication sof rmedications in the Use of High Risk Medications in the Elderly and Potentially Harful Drug-Disease Interactions in the Elderly Quality Measures. JAGS Kamel, NS, Gammack JK. Insomnia in the Elderly: Cause, Approach, Treatment. The American Journal of Medicine 2006;119: Krishnan P, Hawranik P. Diagnosis and management of geriatric insomnia: A guide for nurse practitioners. JAANP. 2008; 20: Melton ST, Wood JM, Kirkwood CK. Eszopiclone for Insomnia. The Annals of Pharmacotherapy 2005; 39: Ramakrishnan R, Scheid D. Treatment Options for Insomnia. American Family Physician 2007;76: Scharf M, Rogowski R, Hull S. et.al. Efficacy and Safety of Doxepin 1mg, 3mg, and 6mg in Elderly Patients With Primary Insomnia: A Randomized, Double-Blind, Placebo-Controlled Crossover Study. J Clin Psychiatry. 2008; 69: Schatberg AF, DeBattista C. Hypnotics in Manual of Clinical Psychopharmacology Eighth Edition. American Psychiatric Publishing

INSOMNIA IN THE GERIATRIC POPULATION. Shannon Bush, MS4

INSOMNIA IN THE GERIATRIC POPULATION Shannon Bush, MS4 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