INSOMNIA IN ELDERLY

1
INSOMNIA IN ELDERLY

• ?????????????????????????????????? ???????????
• ??????????????????? ?????????????
• ?????????????????????

2
???????????????

• ???????????????????????????????????????????
  30-45 ????
• ??????????????? ? ???????????????
• ??????????????????????????????????????
• ??????????????????????? ?????????????????????????
  ???????????????

3
???????????????????????

• ?????
• Slow reaction time
• ??????????????
• ???????????

4
insomnia

• ?????????????
• ??????????????
• ???????????? ? ????
• ???????????????? ? ????????????, ???

5
???????????????????????

• ????????????????????????????? ???????????????????
  ??
• ????????
• 1) ??????????????????? ???????????????????
  ???????????????????????
• 2) ?????????????????????
• 3) ??????????? ??????????????????????
• 4) ?????????????????????? ????????????
  ?????????? ?
• 5) ????????????????????????? ????????????????????
  ?????????????????????????????????????

6
???????????????????????????

• ??????????????
• ??????????????????????????
• ????????????????????????
• ???????????????????
• ????????????????????????????????
  ?????????????????????????? ???????????????????????
  ???? ??????? ?????????????
• ?????????????????????????????????
• ?????????????????????????????????
• ?????????? ?????????? ?????????????????????

7
???????????????????????????????

• 1. ????????????
• 2. ?????????
• 3. ???????????
• 4. ?????????????????????
• 5. ?????????????????????????????????????????
  (primary sleep disorder)
• - Restless leg syndrome
• - Periodic limb movement disorder (PLMD)
  
• - Obstructive sleep apnea

8
???????????????????????????????

• 1. ???????????? ?????????????????? ???????????
  ??????????????? ???????????? ??????
  ????????????? (Adjustment disorders),
  ????????????????????????????
• 2. ????????? ?????????????????????????????????
  ???? ?????????? ? ???????? ??????
  ??????????????????? ?????????????????????
  ????????????? ????????????????????
  ????????????????

9
???????????????????????????????

• 3. ??????????? ????????????????????????????
• - Amphetamine / Methylphenidate
• - Pseudo ephedrine
• - Decongestants / Theophylline
• - Methyldopa, antihypertensive drug ??????
  reserpine clonidine
• - SSRI, eg. Fluoxetine, sertraline,
  venlafaxin , bupoprion
• - Cimetidine, alcohol, caffeine, thyroid
  hormone antineoplasties, ?????????

10

• 4. ????????????????????? ??????????????
  ?????????????????????????? ??????????????????????
  ??????? ????????????????? ????????????????????
  ???? ????????????????????????????????
  ??????????????????????????????????????????????????
  ????
• ?????????????????????????????????? ? ?? ?
  ?????????????????? ??????????????????????????????
  ?????????? ??????????????? ?????????????????????
  ??????????????????? ?????????????????????????????
  ?????????????? ???????????????? ????
  ????????????? ??????? ???????
  ????????????????? ????????????????????????????????
  ?????????????????????

11
???????????????

• Pseudoephedrine
• Decongestant
• Methyldopa
• ????????????????
• ?? Selective serotonin reuptake inhibitor (SSRI)
• Cimetidine

12
???????????????

• ??????????????
• Antineoplastics
• ????
• ??????????
• ???????????????? ? ???? ???? ?????? ????
  ???????????????

13
???????????????????????????????????????

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

14
?????????????????????????????????????

• ????????????????????????
• ??????????????????????????????
• ??????????????????????????
• ?????????????????????
• ??????????????? delirium
• ?????????????????????????

15
????????

• Cognitive Behavior Therapy (CBT)
• - ????????????????????????????????????????????????
  ??????? ??????????????? ??????????????????????????
  ???
• ??????????? ?????????? ???????????????????????
• ????????????????? ? ??????????????????????????????
  ???????????? ??? biofeedback ???????????
• ???????????????????????? ???????????????? ? REM
  ??? REM rebound ?????????????????????????

16
??????????????????????

• ??????????
• ????????????????????????????????????????????????
• ??????????????????????????????????????????????????
  ?
• ???????????????????????????????
  ???????????????????????????????????????????
• ??????????????????????????????? ?????????
• ?????????????????????????????????
• ????????????????????????

17
??????????????????????

• ??????????????????? ???? ?????????????????????????
  ??????????????????
• ????????????????????????????????????????????????
• ???????????????????? ? ???????????
• ?????????????????? ???? ???????
• ??????????????????????????? ? ????????????????????
  
• ?????????????? ???????????????????????????????????
  ??????????????

18
????????????????????????
??????????????

• ??????????????????? ?????????
  ???????????????????? ??????????? ??? rebound
  insomnia ???????????????????????????????
  ??????????????????????????????????????????????????
  ??????????????? ?????????????????????????????????
  ? ????????????????????????????????????????

19

• ???????????????????????????? ??????????
  ?????????????? ??????????? ????????
  ??????????????????????? ???????????????
  ?????????????????????????? ?????????????????

20
????????????????????????

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

21

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

22
(No Transcript)
23

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

24

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

25
???????????????????????????????????????

• ??????
• ?????
• 1. ??????????????????? sleep apnea
  ????????????? ??????????????????????????????
• 2. ?????????????????????????????????????????? ???
  ???? ????????????????????
• 3. ????????????????????????????
• ???????????????????????????????????????
  ???????????????????? ?????????????????????????????
  ??? ??????????????? ???????? ????????????????????
  ??? ??????????????????????????????????????????

26
Obstructive sleep apnea-hypopnea syndrome

• ??????
• ??????????????????????????????????????????????????
  ??????????????????????????????????? ? ??????????
  ??????????? ?????????? ?????????
  ????????????????? ????????? ?????????????????????
  ??? ???????
• ????????????????????? ? ???????? ??????????
  ????????? ????????

27
????????

• ???????????????? ?????????? ??????
  ???????????? ??????????????????????????
  ???????????????????? ?????????
  ???????????????? ???????????????

28
????????????????????????????????????????????

• Restless legs syndrome ???? RLS
• ????????????????????????????????? ??????? ????
  ??????????? ???????????? ? ???????????????????????
  ????????????????????????????????????????????????
  ??? ????????????????????????????
  ??????????????????????????????????????????????????
  
• ???????????????????????? RLS ???????? ??????
  ????????????????????????, Peripheral neuropathy,
  rheumatoid arthritis

29
????????

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

30
????????????????????????????????????????????

• Periodic limb movement disorder ???? PLMD
• ????????????????????????????? ????????????????????
  ??? ?????????????????????? ????????????????????
  ????????????????????????????? ????????????????
  ????????????????????? ????????????????????????????
  ????????????????? ?????????????????????????

31
????????

• ? ????????????? PLMD ???????????????????????
  RLS

32
????????

• ? ?????????????????????????????????????? 4
  ??????? ?????????????????? 3 ???
  ????????????????? 4 ???????????

33
REM behavior disorder (REM)

• ??????????????? REM sleep ????????? intermittent
  lack of skeletal muscle atonia

34
Delirium

• Usually acute and fluctuating
• Altered state of consciousness (reduced awareness
  of and ability to respond to the environment)
• Cognitive deficits in attention, concentration,
  thinking, memory, and goal-directed behavior are
  almost always present

35
Features of delirium

• May be accompanied by hallucination, illusion,
  emotional liability, alterations in the
  sleep-wake cycle, psychomotor slowing or
  hyperactivity
• Usually abrupt

36
????????????????

• ????????????????????????? ???????????????????????
  ????
• Cognitive ???????????
• ?????????????????????????? ? ?????????????????????
  ??? ? ?? ?
• ??????????????????????????????????????????????????
  ??????????????????????????????????????????????????
  ?????????????????????? ????????????????????????
  ????????? ?????????????????????????

37
What is Depression?

• Is a medical disorder that
• affects thoughts, feelings, physical
• health and behaviors.

38
???????????

• ????????????????????????????????????????, ???????
  ????????????????????? ????????????????
  ????????????????? ????????????????????????????????
  ?????????????????????? ??????????????????????????
  ??????????

39
Symptoms

• Depressed mood
• Markedly diminished interest in usual activities
• Significant increase/loss in appetite/weight
• Insomnia/hypersomnia
• Psychomotor agitation/retardation
• Fatigue or loss of energy
• Feelings of worthlessness or guilt
• Difficulty with thinking, concentrating, or
  making decisions
• Recurrent thoughts of death or suicide

40
???????????????????????????????????????

• ??????????? ???????????????????????
• ?????????????????????????????????
• ?????????
• ???????????????
• ??????????????????????????????? ? ??
• ???????????? ??????????????????????????
• ?????????????????
• ????????????? ??????
• ?????????????? ?
• ???????????????????????????????????????????

41
Signs and symptoms of depression in the elderly

• Recognizing depression in the elderly starts
  with knowing the signs and symptoms. Depression
  red flags include
• Sadness
• Fatigue
• Abandoning or losing interest in hobbies or other
  pleasurable pastimes
• Social withdrawal and isolation (reluctance to be
  with friends, engage in activities, or leave
  home)
• Weight loss loss of appetite

42
Signs and symptoms of depression in the elderly

• Sleep disturbances (difficulty falling asleep or
  staying asleep, oversleeping, or daytime
  sleepiness)
• Loss of self-worth (worries about being a burden,
  feelings of worthlessness, self-loathing)
• Increased use of alcohol or other drugs
• Fixation on death suicidal thoughts or attempts

43
Depression without sadness

• Older adults don't always fit the typical picture
  of depression. Many depressed seniors dont claim
  to feel sad at all. They may complain, instead,
  of low motivation, a lack of energy, or physical
  problems. In fact, physical complaints, such as
  arthritis pain or headaches that have gotten
  worse, are often the predominant symptom of
  depression in the elderly.
• Older adults with depression are also more likely
  to show symptoms of anxiety or irritability. They
  may constantly wring their hands, pace around the
  room, or fret obsessively about money, their
  health, or the state of the world

44
Depression Clues in Older Adults
Older adults who deny feeling sad or depressed
may still have major depression. Here are the
clues to look for

• Unexplained or aggravated aches and pains
• Hopelessness
• Helplessness
• Anxiety and worries
• Memory problems

• Loss of feeling of pleasure
• Slowed movement
• Irritability
• Lack of interest in personal care (skipping
  meals, forgetting medications, neglecting
  personal hygiene)

Adapted from American Academy of Family
Physicians
45
?????????????????????????????????????
(Schizophrenia)

• ????? 1 ????? ????????????????????? 2
  ???????????????? ?????????????????????????????????
  ???????????????????????? ???????????
• - ??????
• - ??????????
• - ???????????????????????? ???????????????
• - ????????????????????????? ???????????????
  catatonia
• - ???????????? (negative symptom) ???? ??????
  flat, alogia, avolition

46
?????????????????????????????????????
(Schizophrenia)

• ???????????????????? ????????????
  ??????????????????? ????????????????? ?
  ?????????????????????? ???? ?????
  ???????????????????????? ????????????????????????
  ???????
• ??????????????? ?????????????????????????????????
  ? 6 ????? ???? 6 ?????????????????????????????????
  ??????????? 1 ????? ??????????????????? 1
  (??????????????????????????????????????) ???? 1
  ???????????????? active phase
  ??????????????????????????????? ???????????????
  (prodrome) ????????????????????? (residual)

47

• ??????????????? 73 ?? ??????????????????????
  ???????????????????????????????? 7 ?????????
  ????????????????????????????????????? ??????????
  ??????????????????????? ?????????????????????????
  ?????? ?????????????? ?????????????????????
  ??????????????????????????? ??????????????????????
  ???? 3 ???? ????????????????????
  ?????????????????????????????

48

• ??????????? ???? 78 ?? ??????????????????????
  ???????????? ???????? ????? Dormicum ?? 15 ??
  ???????????????? ????????????? ??????????????
  ??????????????? ????????? ????????????????
  ??????????????

49

• ??????????????? 65 ?? ??????????????????
  ?????????? ????????????????????????????

50

• ??????????????? 60 ?? ?????????????????????????
  ?????????? ????? xanax ??? ????????? ????????
  ?????????

51
?????????????????????????????????????????????
??????????????????????????????????
????????????????????????
??????????????????????????????????????????????????
?
???????????????????????
???????? (gt 1 ?????)
?????????

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

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