Sleep and Aging– A Lecture

Barbara Phillips, MD

Overview

•Normal sleep

•Sleep and aging

•Insomnia and aging

•Sleep-disordered breathing and aging

•Restless Legs Syndrome and Periodic Limb Movement Disorder (RLS / PLMD)

•Education about sleep and aging

•Ethical issues

•Summary

Normal Sleep

•Average human need is 8.3 hours

•Normal sleep latency: 10 minutes

•Normal sleep structure

–5% stage 1

–50% stage 2

–15-25% stages 3 and 4 (slow wave sleep)

–25% REM

•Napping occurs at the beginning and the end of life (in our culture)

Sleep Changes with Age

•Increased awakenings and arousals

•Decreased REM sleep

•(Probably) decreased SWS

•Increased stage shifts

•Fewer “cycles”

•Reduced sleep efficiency

•Phase advancement

Effects of Sleep Disturbance

•Impaired vigilance

•Impaired memory

•Increased upper airway collapsibility

•Impaired mood

•Decreased respiratory drive

Insomnia in the Elderly

•About 1/2 of elderly have insomnia

•Women are twice as likely to have insomnia

•Annual incidence rate is 5%

•Risk factors for insomnia in the elderly

–Depression

–Respiratory symptoms

–Disability

–Fair to poor perceived health

–Widowhood

Treatment of Insomnia in Aging

•Behavioral / nonpharmacologic

•Pharmacologic

•Why treat?

–Quality of life

–Caretaker sleep loss may result in nursing home placement

Behavioral Treatment of Insomnia

•Sleep hygiene

•Exercise

•Bright light

•Evaluation of medications

•Napping?

•Nocturnal activities hour

Sleep Hygiene

•Regular schedule, especially rise time

•Avoid stimulants, alcohol, caffeine

•Set aside a worry time

•Keep sleeping room cool, dark, quiet

•Use bed only for sleep and sex

Exercise

•Exercise promotes both sleep onset and sleep consolidation in all groups

•Specific studies in the elderly have shown benefits with very minimal exercise

•Exercise confers additional benefits on bones, joints, balance

Bright Light

•Moderately bright light (1000 lux) or more improves subjective alertness, mood, and sleep quality

•Morning bright light promotes sleep onset

Napping?

•Napping is associated with increased mortality (Foley)

•Napping is associated with

–Lower diastolic blood pressure

–Improved mood

–Decreased subjective sleepiness

–Improved performance (Tamaki)

Pharmacologic Treatment of Insomnia

•Melatonin

•Antihistamines, antidepressants, antipsychotics

•Hypnotics

Melatonin

•Melatonin levels may decline with aging

•Melatonin levels are lower in elderly insomniacs than aged matched controls

•Some studies have shown improvement in sleep quality with melatonin

•Melatonin is not FDA approved and is

Antihistamines, Antipsychotics, and Antidepressants

•Less effective in promoting sleep than are hypnotics

•No safer than hypnotics

–Trazodonecauses orthostatic hypotension, priapism, daytime somnolence

–SSRI’sinduce / worsen Restless Legs Syndrome

–Antidepressants / hypnotics have comparable fall rates

•May cause daytime hangover

•Should probably be used for primary indication, not for sleep

Hypnotic Use in Geriatric Insomnia

•Non-institutionalized seniors:

12% M, 9% F

•Hospitalized veterans: 11%

•Institutionalized seniors: 34%

(benzodiazepines)

Benzodiazepines in the Elderly

•Probably no increased risk of falls

•No adverse effects on COPD and SDB

•Probably cognitive dysfunction

•Tolerance

New Hypnotics

•Zolpidemand Zaleplon

–Nonbenzodiazepines

–Act on GABA receptors

•Safety profile

–No rebound or tolerance

–Normal sleep structure

•Studies in elderly

–No excess risk of falls or respiratory depression

–No cognitive dysfunction

Insomnia and Pain:

Treatment in the Elderly

Compassion

vs.

Pharmacologic Calvinism?

Sleep-Disordered Breathing in the Elderly

Sleep Apnea: A Primer I

•Apnea: cessation in breathing > 10 sec

–Obstructive if there is effort

–Central if effort is absent

•Hypopnea: reduction in breathing

•AHI: Apnea+HypopneaIndex

•Obstructive Sleep Apnea Hypopnea

Syndrome: 5 or more respiratory

event / hr of sleep

Sleep Apnea: A Primer II

Obstructive Apnea

•Clinical history: snoring, sleepiness, witnessed apneas, weight gain, impotence

•Physical findings: obesity, hypertension, big neck, crowded airway

Age and Apnea

Obstructive Sleep-Disordered Breathing Peaks in Mid-life

•Survivorship

•Obesity peaks in middle age

•Central sleep apnea doesn’t “count”

Sleep Apnea in the Elderly

•Less oxygen desaturation

•Less morbidity

•Less mortality

•Less severe

What isSleep Apnea in the Elderly??

•1/3 of seniors have AHI > 5

•AI > 20 does not predict mortality in aged

•Morbidity and mortality increase with increasing AHI

Suggested “Cut Points”

•AHI alone is not enough!

•AHI > 10 with sequelae?

•AHI > 20 -30?

When to Treat Sleep Apnea in the Elderly?

•Hypertension

•Cognitive dysfunction

•Nocturia

•High levels of sleep-disordered breathing

How to Treat Sleep Apnea in the Elderly

•CPAP is treatment of choice

•Oral appliances may fit over dentures

•Surgery has less favorable outcome in those over 50

•Body position may make a difference

•Weight loss and smoking cessation are mandatory, if applicable!

Restless Legs Syndrome (RLS) and Periodic Limb Movement Disorder (PLMD)

•RLS is a

symptom

•PLMS is an

EMG finding

•RLS and PLMS frequently overlap

•Neither is necessary nor sufficient to make the diagnosis of the other

Restless Legs Syndrome (RLS)

•Uncomfortable leg sensations

•Worse at night

•Worse with inactivity / relieved with activity

•Associated motor hyperactivity

Periodic Limb Movement Disorder (PLMD)

•Stereotypic, repetitive movements of the legs (or arms)

•During sleep / inactivity

•Every 20-40 seconds

•May be associated with arousals from sleep

•Occur in minimum clusters of 4

Patient Complaints with RLS

•Sleep disturbances

•Difficulty falling asleep and staying asleep

•Need to walk around (“nightwalkers”)

•Daytime sleepiness

Associated Conditions

•Neuropathies, myelopathies, and radiculopathies

•Pregnancy

•Anemia (iron deficiency)

•Chronic renal failure

•Folate/ B12 deficiency

•Medications (tricyclics, SSRI’s, caffeine)

•Obesity

•Hypothyroidism

Restless Legs Syndrome (RLS) and Periodic Limb Movement Disorder (PLMD)-Rx

•Check ferritin, replace if level is < 45

•Consider calcium and magnesium

•Consider renal failure and diabetes

•Encourage exercise

•Validate and support

•Dopamine agonists

–Carbidopa/ Levodopa, Pergolide, Pramipexole

•Anticonvulsants

–Gabapentin, Carbamazepine

•Benzodiazepines

–Clonazepam, Temazepam

•Opioids

–Oxycodone, Methadone

Restless Legs Syndrome (RLS) and Periodic Limb Movement Disorder (PLMD)-Rx

Sleep History and Physical for Geriatricians

•Witnessed apneas

•Accidents due to sleepiness

•Cognitive dysfunction

•Nocturia

•Restless, crawly leg sensations

•Difficulty falling asleep / staying asleep

•Napping / schedule

•Obesity (BMI > 30, neck > 17 / 16 )

•Hypertension

Training Opportunities

•Health professionals need to be taught to ASK about sleep complaints

•Minimal curriculum: sleep structure / function, insomnia, SDB, RLS

•Clinicians know little about sleep’s structure, function, and changes with age

Ethical Issues in Sleep and Aging

•Allocation of resources –is it “worth it”to treat mild sleep apnea?

•Hypertension results from OSAHS

•Cognitive deficits result from OSAHS

•Physical restraints of patients with RLS

•Hypnotic use for geriatric insomnia