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| July 2015 | Archive |
Insomnia, a Common Concern
To think like a geriatrician, begin with the analysis of age vs illness. With a full understanding of sleep in the elderly, use this to determine which patients need additional evaluation. What is the influence of aging on sleep quality and what is the implication of this effect on quality of life and patients’ ability to function? As a starting point in evaluation strategies, have patients use a sleep diary to create a detailed understanding of the issue. Remind them to be sure to include input from the bed partner if applicable. Become familiar with the disease states that cause or contribute to sleep disturbance. As a function of the treatment plan, develop a comprehensive body of recommendations that include remedies and/or strategies to relieve the condition and involve no increase in patient risk. In view of the large number of older adults who voice complaints and concerns about sleep, it’s easy to assume that the blame lies with the aging process. However, evidence fails to support this,1,2 and, in fact, shows that “disturbed sleep is rare in healthy older adults.”1 Key Facts About Sleep in the ElderlyThe amount of sleep we need does not change. As with younger adults, most adults need about seven to nine hours of sleep per night. Ask patients about their sleep requirements during their 30s, and the requirement should remain about the same. Recognize that it can take longer to fall asleep. With aging, there is a decrease in the deep sleep phase along with more awakenings. The circadian rhythm changes with aging, and modifies sleep patterns so that awakening occurs earlier. Perhaps this contributed to Benjamin Franklin’s adage, “Early to bed, early to rise …” But none of these changes is enough to create problems for a patient. If a patient complains about sleep disturbance, recognize that it’s unlikely due to aging alone but rather more likely due to other conditions that may require attention. Chronic sleep disturbance is known to be a risk for a number of serious conditions including worsening mood,1,3 cognitive ability,1,4 and falls.1,5 In a study by Perlis et al, elderly subjects with persistent insomnia, particularly women, were at greater risk for the development of depression.1,3 When compared with matched controls, aged patients with sleep difficulties have slower reaction times and suffer from more cognitive dysfunction such as impaired memory.1,4 Evaluating Sleep ConcernsOlder adults who feel they are not getting enough sleep and cannot function normally for a period lasting more than two to three weeks are high risk and need a full evaluation. A detailed history is critical. Consider requesting patients and/or their bed partner to keep a sleep diary for one or two weeks to develop a picture of sleep habits and schedules. Often the diary can help reveal patterns and point toward the need for additional testing or adopting behavioral/environmental changes that may eliminate the problem. The most common sleep disorders among older adults include insomnia, sleep-disordered breathing such as snoring or sleep apnea, and movement disorders such as restless leg syndrome and periodic limb movements of sleep. Insomnia is the inability to fall asleep or to remain asleep throughout the night. Sleep-disordered breathing is the name for what had previously been simply called snoring. It is caused by a partial blockage of the airway passage from the nose and mouth to the lungs. The blockage causes the tissues in these areas to vibrate, leading to the noise produced when someone snores. Sleep apnea, a more serious disease related to snoring, causes a person to stop breathing for 10 or more seconds multiple times per night, creating frequent awakenings throughout the night. For patients whose symptoms suggest these disorders, referral to a sleep lab or a neurologist is appropriate. Movement disorders involve two disturbances that may disrupt sleep: restless leg syndrome and periodic limb movement. Restless leg syndrome affects more than 20% of people aged 80 and older. Restless leg syndrome is characterized by uncomfortable feelings in the legs such as tingling, crawling, or the feeling of pins and needles. Periodic limb movement is a condition in which an individual kicks or jerks one or both legs many times during sleep. Consultation with a neurologist is often best for diagnostic and therapeutic recommendations. Regardless of the cause of a patient’s disturbed sleep, provide him or her with patient education materials covering the basics of sleep hygiene. Sleep disturbance is often multifactorial, and these nonpharmacologic strategies can be additionally beneficial. Suggestions to Improve Patients’ Ability to Sleep
Final ThoughtFor sleep management strategies, you’ll generally want to avoid using most of the available sleep agents, both over-the-counter products and prescription medications. One reason to pay attention to your patients’ complaints about sleep is that if not addressed, patients may visit the local pharmacy and reach for a “nighttime medication.” The most common over-the-counter sleep aid contains Benadryl, which is an anticholinergic agent known to cause cognitive dysfunction in the elderly. Preferably you could advise a trial of long-acting melatonin, which has been shown to be effective in the elderly.6 If additional pharmacologic remedies are needed, I would advise trials of trazadone (50 to 100 mg at bedtime) or mirtazapine (7.5 mg or 15 mg at bedtime), and would avoid if at all possible the sedative hypnotics that are included in the Beers Criteria and thus considered high risk for potential benefit. So next time you hear a patient grumble about poor sleep, think like a geriatrician and address this common complaint.7 — Rosemary Laird, MD, MHSA, AGSF, is a geriatrician, executive medical director of senior services for Florida Hospital at Winter Park, and past president of the Florida Geriatrics Society. She is a coauthor of Take Your Oxygen First: Protecting Your Health and Happiness While Caring for a Loved One With Memory Loss. References
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