INSOMNIA IN ELDERLY

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INSOMNIA IN ELDERLY

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  30-45 ????
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Sleep Cycles

• Sleep is divided into
• Rapid Eye Movement (REM) sleep
• Non-REM sleep
• Non-REM sleep is then divided into 4 stages
• Stage 1
• Stage 2
• Stage 3
• Stage 4

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Sleep Cycle
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• Initiation of Sleep Time to fall asleep
• - standard less than 30 minutes
• Sleep Efficiency Time sleeping / time in bed
• - standard Greater than 85

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Sleep Changes in the Elderly

• Takes longer to initiate sleep
• Increased time spent in lighter sleep  (Non-
• REM Stages 1 and 2)
• Less time spent in slow wave sleep (Non
• -REM Stages 3 and 4)
• Increased latency to REM sleep
• Experience frequent/early morning awakenings
• Reduced sleep efficiency/quality

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• Transient Insomnia symptoms present for less than
  one week
• Short Term Insomnia symptoms for 1-4 weeks
• Chronic Insomnia Symptoms present for more
  than one month

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Importance  of  Sleep 

• ? Active state that affects both physical and
  mental well-being
• ? Body  rest and energy restoration
• Infants   16-18 hours of sleep/day
• Teenagers 9 hours/day
• Adults  7-8 hours/day
• ? Prompted by brains natural cycles of activity 
  

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Sleep Stage Importance

• REM sleep is associated with dreaming
• 80-90 of subjects if awakened
• A person is actively paralyzed when dreaming
• Stage 3 4 sleep is where most brain and body
  restoration/rejuvenation occurs
• AKA delta sleep or slow wave sleep
• Brain repair and memory consolidation
• Important for full alertness the following day

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Insomnia resultant problems

• Reduction in motivation, energy or initiative
• Proneness for errors or accidents at work or
  while driving
• Tension, headaches or gastrointestinal symptoms
  in response to sleep loss
• Concerns or worries about sleep
• Secondary psychiatric problems

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Insomnia and ItsHealth Consequences

• Insomnia is associated with dementia,
• and may exacerbate cognitive deficits
• Nocturnal agitation
• Sundowning
• Daytime cognitive impairment
• Attention
• Concentration
• Memory

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Neurochemistry

• Several neurotransmitters have been implicated in
  inducing, preventing, or regulating sleep
• Norepinephrine, histamine, and acetylcholine
  promote wakefulness
• GABA promotes sedation and sleep
• Serotonin modulates movement thru sleep
  stages
• Melatonin promotes sleep induction in
  darkness
• Newly discovered Orexin or Hypocretin also
  modulate sleep cycles

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I

• 1. ???????????? ?????????????????? ???????????
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  ????????????? (Adjustment disorders),
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II

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• ?????????????????
• ???????????????? - Parkinson, dementia
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• ??????????????????????? ?????? gastrointestinal
  reflux ???????????????

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III

• ??????????? ????????????????????????????
• - Amphetamine / Methylphenidate
• - Pseudo ephedrine
• - Decongestants / Theophylline
• - Methyldopa, antihypertensive drug ??????
  resupine clonidine
• - SSRI, eg. Fluoxetine, sertraline,
  venlafaxin , bupoprion
• - Cimetidine, alcohol, caffeine, thyroid
  hormone antineoplasties, ?????????

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IV
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Assessing Insomnia in the Geriatric Patient

• Conduct physical examination
• Ask specific questions about sleep patterns 
• and complaints
• Obtain Comprehensive Medical History 
• Current Medications (diuretics, 
• benzodiazepines, stimulants, polypharmacy)
• Substance Use (alcohol, nicotine, caffeine)
• Sleep hygiene

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Cognitive Model of Insomnia
Sleep initiation problems
Acute insomnia
Life stress Problem solving Rumination and
worry
Physiologic arousal Cognitive arousal

insomnia
Sleep maintenance problem
Nonerstorative Sleep
Worry about sleep
Chronic insomnia
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Cognitive therapy
I

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CBT
II

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  ???????????? ??? biofeedback ???????????
• ???????????????????????? ???????????????? ? REM
  ??? REM rebound ?????????????????????????

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• ??????????????? 4 ??./??????
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• sleep efficiency ??????????????
  ?????????????????? ??????????? 85 ???????? 15
  ????
• ???????????? ??? efficiency gt 80 ?????????????
• 30 ????

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Combining PharmacologicTreatment with
CBTResearch Findings

• Pharmacologic treatment provides
• immediate benefit
• ? CBT takes longer to help, but the gains are
  maintained for up to 2 years later

CBT Cognitive Behavior Therapy.
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Pharmacologic Treatments

• FDA-approved drugs
• Benzodiazepine receptor agonists
• Melatonin receptor agonist
• Drugs used off-label (not FDA approved for
  insomnia)
• Sedating antidepressants
• Antipsychotics
• Self medication
• Alcohol
• H1 antihistamines (OTC sleep aids)
• Herbal remedies

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????????????????????????
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• ??????????????????? ?????????
  ???????????????????? ??????????? ??? rebound
  insomnia ???????????????????????????????
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• Benzodiazepines
• ?????????????????????? ?????????? short ????
  intermediate acting ???? lorazepam ???
  temazepam clonazepam ???? long half life
• ????? benzodiazepine ??? ? ???????????????
  visuospatial impairment
• cognitive impairment
• ??????????????????? dementia ????????
  ???????????????? benzodiazepine
  ???????????????????????????? ????????
  ??????????? hyperkinesias

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Sum Up Benzodiazepines

• Improve Intermediate/Long
• Sleep latency acting BZD
• Total sleep time Total sleep time
• Number of Major side effect
• awakenings Memory impairment
• Short acting BZD Abuse potential
• Good for sleep Hang over effects
• latency

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• Non-benzodiazepines hypnotics
• Zopidem
• ?????????????????? ?????????? ???????????????
  ??? rebound insomnia

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Trazodone (Desyrel)

• Non-tri-cyclic antidepressant inhibits seratonin 
  
• re-uptake
• T1/2 7-8 h
• Unlabeled use sedative/hypnotic
• 25-50 mg before bedtime max 75-150 mg/day
• Common SE somnolence, dizziness,lightheadedness
• Serious SE orthostatic hypotension, priapism, 
• arrhythmias, suicidal ideation

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• - Trazodone - ?????????????????????????? ???
  induction ???? aggravation of atrial ???
  ventricular arrhythmia ????????? ??????
  ??????????????????????????

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Diphenhydramine

• Mechanism of action
• Blockade of H1 receptors (basal forebrain,
  preoptic
• area of hypothalamus)
• Blockade of cholinergic, serotonergic,
  adrenergic
• receptors
• Dose 25-100 mg
• Elimination half-life 3.4-5.0 hours
• Common adverse events
• Sedation, dizziness, incoordination,
  nervousness,
• anticholinergic effects

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• ???????? ????????? Antihistamine - mental
  confusion, urinary retention, coustipation
  tolerance 1-2 ???????
• - Melatonin - large variation in formulation,
  purity ??? potency

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Ramelteon (Rozerem)
I

• Highly selective melatonin MT1 and MT2 
  receptor agonist
• Chronic insomnia in the elderly
• T1/2 1-2.6 h , 2-5 h
• 8 mg tablet before bedtime
• Rapid onset of action sleep onset

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Ramelteon (Rozerem)
II

• Do not administer with high fat meal
• Common SE headache, fatigue, dizziness
• SE ideation  Serious suicidal ideation, worsening
    of depression, complex sleep related  behavior
• Contraindications severe hepatic
  impairment, fluvoxamine 

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Herbal/Homeopathic Remedies

• Natural ZZZ
• Herbal blend
• Valerian root
• Inhibits reuptake of and stimulates the
  release of GABA in the CNS. (Commission
  E approved)
• Jujube seed
• Shown to calm, relax, reduce stress
• Passion flower
• Flavonoids play a role in binding to GABA
• Commission E approved
• L-Theanine
• Found in green tea
• Considered a relaxant
• Increases alpha brain waves

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• Restless legs syndrome ???? RLS
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???????????????????????????????????????????? (RLS)

• ???????????????????????? RLS ???????? ??????
  ????????????????????????, Peripheral neuropathy,
  rheumatoid arthritis

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????????

• Clonazepam, carbidopa/levodopa (simemet),
  pramipexole (sifrol) ??? opiates (oxycodone)

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PERIODIC LIMB MOVEMENTS IN SLEEP (PLMS)
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• Periodic limb movement disorder ???? PLMD
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• Incidence 45 ?????????????
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• ???????? ??????????? Restless leg syndrome

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Obstructive sleep apnea-hypopnea syndrome

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???????? (gt 1 ?????)
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• 1. ???? ??????????????????????
• ??????????????????????? (sleep hygiene)
• 3. ???????????????????? ???????????????????? 2
  ???????

??????????? ????????????????????
Primary sleep disorder ???? sleep apnea
syndrome, PLMD
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The End