הפרעות שינה ב ג י ל ה מ ב ו ג ר הפרעות שינה ב ג י ל ה מ ב ו ג ר דר' דורון גרפינקל מנהל מחלקה גריאטרית - פליאטיבית שהם – המרכז המשולב לרפואת הגיל השלישי, פרדס חנה.

Sleep is Essential to Our Overall Health and Well-Being Key to our health, performance, safety and quality of life As essential a component as good nutrition and exercise to optimal health Essential to our ability to perform both cognitive and physical tasks, engage fully in life and function in an effective, safe and productive way

Sleep and Aging How does sleep change as we age? Do we need less sleep as we get older? Can a person expect to experience more sleep problems or have a sleep disorder as they advance in age? As we age, how does sleep affect our overall health, medical conditions and general well being? What can we do to get good sleep? As our aging population increases, so do their concerns and experiences with sleep problems and disorders. Along with the body and brain changes that occur as we age, sleep also changes as part of the normal aging process. Many older people want to know how much sleep they need, how to sleep better and the signs and symptoms of sleep disorders. This program will address these questions as well as some of the common myths about sleep and aging. It will cover basic sleep physiology, sleep patterns, habits and quality of sleep along with the sleep changes that occur in the normal aging process. In addition, it discusses the association of sleep with health and disease, the importance of sleep to the lives of aging persons and provides an overview of the sleep disorders that become more prevalent as we age. Lastly, it provides some practical tips that help address sleep problems, when to seek help and how to get a good night’s sleep.

Specific Problems - Snoring Partial blockage of airway causing abnormal breathing & sleep disruptions 90 million in the US; 37 million experience on a regular basis Males Those who are overweight and with large neck size most at risk Loud snoring can be a symptom of sleep apnea Snoring is a breathing noise that occurs during sleep and can be very disruptive to you or your bed partner. While breathing in, the air passage between the upper soft palate and the throat or base of the tongue opens and closes. As muscles relax, there is a partial obstruction to the air passage - the area colored orange in the diagram - causing the tissues to vibrate and make the snoring noise. This abnormal breathing that causes sleep disruptions affects approximately 90 million American adults; 37 million on a regular basis. Persons most at risk are males and those who are overweight. It often increases with age.  Loud snoring is particularly serious as it can be a symptom of sleep apnea and can be associated with high blood pressure and other health problems.

Specific Problems - Sleep Apnea Increases as we age: affecting 4% and 2% of middle-aged men and women and close to 27% and 19% of older men and women Characterized by pauses or gaps in breathing due to an obstruction of the airway RESPIRATORY SLEEP DISORDERS Sleep apnea is a serious sleep disorders that is most often diagnosed at a sleep center by an overnight sleep study. It becomes increasingly prevalent as we age, affecting 18 million Americans. It is more common in men, affecting 4% of middle-aged men and 2% of middle-aged women. Older men and women may even experience more episodes of apnea. Persons with sleep apnea experience an obstruction in the airway at the back of the throat during sleep. This is a breathing abnormality that occurs during sleep, and in general, such breathing problems increase with age. In sleep apnea, air is blocked, breathing pauses—sometimes for longer than 60 seconds—and oxygen levels drop. This event alerts the brain, causing an arousal and breathing resumes. Snoring often accompanies such events. As many as 20-60 of these events can occur in an hour, causing multiple sleep disruptions throughout the night, poor sleep and eventual daytime sleepiness.  

Specific Problems - Sleep Apnea (continued) Signs and Symptoms Loud, regular snoring Large neck size Obesity Associated with major medical conditions Most common treatment CPAP For younger and middle-aged adults, having a large neck size and being overweight puts you at risk for apnea. If you experience snoring on a regular basis and it can be heard from another room, this is a sign that you might have sleep apnea and it should be discussed with your doctor. The incidence of sleep apnea increases with age. Because apnea can vary in severity, its treatment varies accordingly. However, untreated apnea puts a person at risk for cardiovascular disease, headaches and depression. The most common and effective treatment for sleep apnea is the use of a CPAP (continuous positive airway pressure) mask, like the one shown above, that forces air through the pathway and allows the person to breath and sleep well. Staying off one’s back while sleeping and the use of a special dental appliance may also be helpful. In addition, behavioral changes such as losing weight and avoiding alcohol, nicotine and sleeping medications can contribute to a reduction in the number of apneic events. RESPIRATORY SLEEP DISORDERS

Restless Legs Syndrome - RLS Unpleasant/uncomfortable feelings in the legs during rest, evening... creeping, crawling, tingling, aching... Urge to move, improves by moving Any age, increases with age Sleeping problems Causes (imbalance of dopamin?) Both restless legs syndrome (RLS) and periodic limb movement disorder (PLMD) are neurological movement disorders that are bothersome and characterized by an irresistible urge to move the limbs. In RLS, unpleasant, tingling, creeping or pulling feelings occurring mostly in the legs, are worse in the evening and make it difficult to fall asleep. Its prevalence increases with age and about 12 million people experience RLS symptoms. About 80% of people with RLS also have PLMS and experience involuntary jerking of the legs and, sometimes, arms during sleep, making it difficult to get a continuous night of sleep. One study found that approximately 45% of older persons have at least a mild form of PLMS. Many people with these disorders also report insomnia and daytime sleepiness. Treatment of RLS and PLMD involves prescription medications, often with dopaminergic agents or agonists. Treatment may also include iron, vitamin or folate therapy, and developing good health and sleep habits including avoidance of alcohol and nicotine, regular exercise and establishing a regular sleep-wake schedule. In the older adult, it is important to watch for side effects as well as interactions with other drugs.

Periodic Limb Movement Disorder (PLMD) Neurological movement disorders /nighttime leg twitching / myoclonus Involuntary jerking of legs > arms during sleep (periodic, flex/extend), without being aware... If severe, may also occur while awake Not all patients with PLMD have RLS BUT most patients with RLS have PLMD Both restless legs syndrome (RLS) and periodic limb movement disorder (PLMD) are neurological movement disorders that are bothersome and characterized by an irresistible urge to move the limbs. In RLS, unpleasant, tingling, creeping or pulling feelings occurring mostly in the legs, are worse in the evening and make it difficult to fall asleep. Its prevalence increases with age and about 12 million people experience RLS symptoms. About 80% of people with RLS also have PLMS and experience involuntary jerking of the legs and, sometimes, arms during sleep, making it difficult to get a continuous night of sleep. One study found that approximately 45% of older persons have at least a mild form of PLMS. Many people with these disorders also report insomnia and daytime sleepiness. Treatment of RLS and PLMD involves prescription medications, often with dopaminergic agents or agonists. Treatment may also include iron, vitamin or folate therapy, and developing good health and sleep habits including avoidance of alcohol and nicotine, regular exercise and establishing a regular sleep-wake schedule. In the older adult, it is important to watch for side effects as well as interactions with other drugs.

Primary RLS Overall prevalence: 3-15% Mean age of onset: 34 +/- 20 years Highly variable course Primary (idiopathic) RLS make up majority of cases; majority are hereditary

Secondary RLS Iron deficiency (5% of patients with RLS have iron deficiency; 25-30% of patients with iron deficiency anemia have RLS) Renal failure Pregnancy Parkinson’s Disease Neuropathy Medications may aggravate: antihistamines, TCAs, SSRIs, DA receptor LITHIUM, CAFFEIN,

RLS / PLMS - Treatment Medications: Healthy lifestyle – baths, massages, warm packs, meditation – yoga EXERCISE Avoid alcohol, tobacco, caffein Sleep hygiene Medications: Dopaminergic, Opioids, muscle relaxants & sleep medications (clonex), Gabapentin

Specific Problems - Insomnia A perception or complaint of inadequate or poor sleep Difficulty falling asleep Frequent awakenings Waking too early and having difficulty falling back to sleep Waking unrefreshed A highly prevalent condition affecting as many as 48% of older persons Next day consequences

Sleep Disturbances in the Elderly Prevalence of Insomnia by age group* : Age 18-34 – 14% Age 35-49 – 15% Age 50-64 – 20% Age 65-79 – 25% *Mellinger GD et al. Arch Gen Psychiatry 1985;42:225-232.

Sleep Problems/Disorders Prevalent Among Older Persons SYMPTOMS OF SLEEP PROBLEMS BY AGE Symptoms: a few nights a week or more 55-64 65-74 75-84 Insomnia 49% 46% 50% Snoring 41% 28% 22% Sleep Apnea 9% 6% 7% Restless Legs Syndrome (RLS) 15% 17% 21% This list represents the most common sleep disorders that are prevalent as we age.

SLEEP DISORDERS IN THE ELDERLY POINTS FOR CONSIDERATION SLEEP DISORDERS IN THE ELDERLY SLEEP DISTURBANCES IN NURSING HOMES & GERIATRIC WARDS NOCTURNAL RESPIRATORY DISTURBANCES THE ROLE OF MELATONIN IN SLEEP THE ROLE OF HYPNOTICS (SLEEPING PILLS) THE RATIONAL DIAGNOSTIC & THERAPEUTIC APPROACH

Sleep and Aging Well The information in this publication was independently developed by the National Sleep Foundation. © 2003 National Sleep Foundation

The Sleep Cycle in Adults Awake 1 2 Stages REM REM REM REM REM 3 Sleep occurs in stages. There are 4 stages of NREM or Non-Rapid Eye Movement sleep and one stage of REM or Rapid-Eye Movement sleep. NREM Stage 1 sleep is the onset of sleep with Stages 2, 3 and 4 becoming progressively deeper. REM sleep, also known as dream sleep, first occurs about 90 minutes after sleep onset. The eyes dart back and forth during REM sleep, thus, the name rapid eye movement sleep. Brain waves, which can be measured by an overnight sleep study, alter during each stage. Most of the deep sleep occurs in the first third of the night and most of the REM sleep is experienced in the last third of the night. All stages of sleep are important. Sleeping throughout these stages is important because this is when tissue growth and repair occur, energy is restored, and learning or memory is consolidated. 4 0 1 2 3 4 5 6 7 8 Hours in Sleep

Normal Sleep and Aging: Less Deep Sleep As we age, our brain waves change and we tend to experience less deep sleep. Less time is spent in stages 3 and 4 while there may be longer periods of stage 1 and 2 sleep. In fact, stage 1 sleep can increase as much as 8-15%. Most studies also demonstrate an overall decline in REM sleep. The change in sleep architecture that occurs is associated with the aging process, but the disruptions in sleep are likely due to the impact of medical or psychiatric conditions.

The ability to get continuous and consolidated sleep may become more difficult as we age

Health and Environment Affect Our Sleep With age, we become more sensitive to: Hormonal Changes Physiological Conditions Environmental Conditions Light Noise Temperature

SLEEP DISTURBANCES IN THE ELDERLY A MAJOR CLINICAL & SOCIAL PROBLEM

SLEEP DISORDERS IN THE ELDERLY WITH AGE, THE INCIDENCE OF SLEEP DISORDERS INCREASES & THE QUALITY OF SLEEP DECREASES HEALTHY ELDRLY INDIVIDUALS: TAKE LONGER TIME TO FALL ASLEEP ( LATENCY) HAVE DECREASED TOTAL SLEEP TIME and DECREASED “SLOW WAVE” SLEEP HAVE INCREASED FREQUENCY & DURATION OF ARAUSALS DURING SLEEP (W.A.S.O.) HAVE AN INCREASED INCIDENCE OF DAYTIME SLEEPINESS

Normal Sleep and Normal Aging: Sleep Efficiency Changes with age (% Time in Bed Sleeping) Sleep Efficiency As a result of all of these physiological, hormonal, and environmental changes, older persons tend to sleep less efficiently. While they may be in bed 8 hours, at 55 years of age and older, both men and women may be in actual sleep for just 7 hours or less. Frequent disruptions or poor sleep robs the older person of the continuous sleep necessary to experience the deeper stages of sleep and reap their benefits. Age Men Women

SLEEP DISORDERS IN THE ELDERLY MANY ELDERLY PEOPLE WHO REPORT ON SUBJECTIVE DIFFICULTIES TO FALL ASLEEP AND MANY AWAKENINGS, MAY BE FOUND TO HAVE NORMAL LATENCY AND W.A.S.O. ON THE OTHER HAND, SOME ELDERS WHO REPORT A “GOOD NIGHT SLEEP”, ARE FOUND TO HAVE SEVERE SLEEP DISTURBANCES WHEN OBJECTIVELY ASSESSED BY ACTIGRAPHY A POINT OF CRUCIAL IMPORTANCE IN RESPIRATORY SLEEP DISORDERS

THE “BAD SIDE” OF AGING: AGE-RELATED DISEASES & DISFUNCTIONS ATHEROSCLEROSIS C A N C E R D E M E N T I A D E P R E S S I O N (ANXIETY) IMPAIRED IMMUNITY INCONTINENCE OSTEOPOROSIS & OSTEOARTHROSIS THE BAD SIDE OF D R U G S DIABETES MELLITUS , F A L L S (#) CATARACT, GLAUCOMA, AMD, HEARING LOSS, PROSTATIC HYPERTROPHY, PARKINSON’S DISEASE G.I. PROBLEMS, SKIN PROBLEMS

SLEEP DISORDERS IN THE ELDERLY P O S S I B L E C A U S E S 1. SECONDARY TO THE INCREASED INCIDENCE OF DISEASES ASSOCIATED WITH PAIN, DYSPNEA, NOCTURIA, G. I. DISCOMFORT ETC. 2. SECONDARY TO THE INCREASED CONSUMPTION OF DRUGS: SPECIFIC ADVERSE EFFECTS ON SLEEP, OR NONSPECIFIC (PALPITATIONS, NAUSEA, URINATION, PRURITUS ETC.) 3. A PRIMARY ENDOGENOUS AGE - RELATED SLEEP DISORDER ( MELATONIN ?)

Medications Can Also Cause Sleep Problems

The Use of Alcohol, Caffeine and Nicotine Impacts on Sleep Although alcohol, especially close to bedtime, has been known to facilitate sleep, when it wears off, it tends to cause fragmented sleep. Both alcohol and caffeine have been associated with insomnia. Caffeine, as an ingredient in coffee, tea, soda and chocolate as well as in some bottled water, and nicotine are both stimulants and both have a negative effect on our ability to get a good night’s sleep. Caffeine affects each person differently, but can affect sleep when taken anytime after lunch. Nicotine, like alcohol, has its greatest effect during withdrawal, causing sleep disruptions. Some people who use tobacco also experience more nightmares and one recent study indicates that nicotine can disturb the brain’s ability to regulate breathing during sleep. When taken too close to bedtime or in the middle of the night, nicotine makes it difficult to fall asleep.

Examples of ‘Legal’ Drugs That Cause Insomnia Alcohol Decongestants CNS stimulants Stimulating antidepressants Beta-blockers Diuretics Thyroid hormones Bronchodilators Nicotine Calcium channel blockers Caffeine Corticosteriods CNS Depressants Quinidine Anticonvulsants Antiparkinsonian agents

Summary: Sleep Changes Sleep during the night changes with age: Less deep sleep / more lighter sleep More difficulty maintaining sleep due to arousals & awakenings Sleep is less efficient and more fragmented The internal biological clock shifts to earlier bed and wake times Older persons experience a higher prevalence of medical conditions and take more medications that are associated with sleep problems/disorder

Summary: Consequences of Sleep Changes Tendency to stay in bed longer to get a sufficient amount of sleep results in worse sleep More likely to take more naps to meet sleep need - may result in worse sleep Inadequate or poor sleep results in daytime sleepiness and fatigue Ability to function well, enjoy life and overall quality of life is affected

Consequences of Poor Sleep in older adults Difficulty sustaining attention & slowed response time Decreased ability to accomplish daily tasks Impairments in memory & concentration Increased consumption of healthcare resources higher incidence of symptoms related to depression and anxiety Increased risk of falls Shorter survival Increased institutionalization rate Inability to enjoy social relationships Decreased QOL Increased incidence of cognitive decline Increased incidence of pain Ancoli-Israel s, Cook JR. J Am Geriatr Soc 2005;53 (suppl):S264-S271

APPROACH TO SLEEP DISORDERS (IN THE NURSING HOME SETTING) SHOULD BE HANDLED BY THE PHYSICIAN IN THE SAME CLINICAL APPROACH AS THAT USED FOR OTHER SYMPTOMS OR SIGNS: FIRST OF ALL, DEFINE THE UNDERLYING CAUSE & MAKE THE CORRECT DIAGNOSIS

Evaluating Causes of Insomnia Situational factors that are major stressors such as a life trauma or an upcoming important event Environmental factors such as too much noise, temperature that are too hot or too cold, or working a night shift Factors related to medications, both prescription and nonprescription (i.e. CNS stimulants/ activating antidepressants) Medical problems such as pain, endocrine, menopause, BPH, incontinence, CHF, PUD/GERD, COPD, allergic rhinitis, seizure d/o

APPROACH TO SLEEP DISORDERS (IN THE NURSING HOME SETTING) 1. RULE OUT AND TREAT SITUATIONS LEADING TO SECONDARY SLEEP DISORDERS PARTICULARY SLEEP APNEA (PATIENT’S STORY, ANXIETY, DEPRESSION, PHYSICAL, IMAGING & LAB FINDINGS). 2. NO APPARENT UNDERLYING CAUSE FOR SLEEP DISORDER and ADVANCED AGE - CONSIDER A PRIMARY MELATONIN DISORDER 3. A. PROVE IT: CHECK OVERNIGHT URINE FOR 6-STM B. CONSIDER A THERAPEUTIC TRIAL WITH 2mg OF CONTROLLED - RELEASE MELATONIN . . .. . OR 4. TRY A SLEEPING PILL… PREFERABLY NOT A BENZODIAZEPINE AS THE FIRST CHOISE

How To Enhance Your Sleep: Practical Tips for Good Sleep Establish a regular schedule with consistent bed and wake times Maintain a relaxing bedtime routine Create a sleep-promoting environment that is comfortable, quiet, dark and preferably cool In order to promote and maintain sleep sufficient for good health, the following tips are recommended for a healthy sleep lifestyle: Establishing a regular sleep schedule helps keep you in sync with your natural circadian clock and makes it easier to fall asleep and maintain sleep throughout the night. Close to bedtime, prepare with the same relaxing ritual every night. This should not include alerting activities, but rather doing something that is enjoyable like listening to the radio, reading or taking a hot bath. If you want to delay or make your bedtime later, expose yourself to brighter light in the early evening or engage in a participatory activity. Your bedroom should be sleep promoting. Older people are more sensitive to noise, light and temperature, so keep the sleep environment quiet, dark and preferably cool so that it is comfortable.

Sleep Tips (continued) Limit fluids and don’t eat too much close to bedtime Avoid caffeine, nicotine and alcohol too close to bedtime and even after lunch Exercise, but not within 3 hours before bedtime Limit fluid and eat healthy snacks before bed or you will need to make frequent trips to the bathroom. Eating too much leads to discomfort and possibly heartburn. Eating too little can leave you with hunger pangs. Practice good health habits for good sleep by avoiding caffeine, nicotine and alcohol, especially close to bedtime. Exercise, in general, can be sleep-promoting. However, it should not be done 3–6 hours before bedtime. Your body needs time to cool down and relax.

If You Have Difficulty Sleeping Limit time in bed Use your bed only for sleep and satisfying sex Avoid watching the clock Limit naps Don’t spend too much time in bed. The longer you stay in bed, the more disturbed sleep becomes. You should be in bed about 30 minutes longer than you want to sleep and only use your bed for sleep or sex. For example, if you want to sleep 8 hours, do not spend more than 8.5 hours in bed. If you have difficulty sleeping, either at the beginning of the night and within 15 minutes of going to bed, or if you wake in the middle of the night and can not sleep, get out of bed and go into another room. Do something relaxing until you feel sleepy again, but try not to make the environment too bright. Bright light tells your body it is time to wake up. Then, return to your bed when you feel sleepy. Opening your eyes to look at the clock forces you to wake up. In addition, if you focus on the clock when you cannot sleep, you may become anxious when looking at the time. If this happens, it is sometimes best to remove the clock. Naps can be helpful for daytime functioning, but they can also decrease the need for nighttime sleep. Taking a nap, especially close to bedtime, will decrease your drive to sleep and may make it difficult to fall asleep. Also, you may not need as much sleep during the night. Naps may be helpful before going on a trip when you need to drive for long stretches or if you are changing time zones. When taken appropriately, they can contribute to improved performance. If you need to nap, limit it to 20-30 minutes early in the afternoon to avoid going in to deeper stages of sleep, making it more difficult to become alert following a nap.

Keep a Sleep Diary to Identify Your Sleep Habits and Patterns If you find you have difficulty sleeping and/or have some of the signs of a sleep disorder, be sure to talk to your doctor. It is very helpful to complete a sleep diary for at least 10 days so that you can document your sleep habits, schedules, relevant health habits and any sleep problems you are having. This can then be taken to your medical appointment for discussion with your doctor. Most sleep problems are manageable and treatable. Sleep plays a vital role in your health. Addressing any symptoms of sleep difficulties with your doctor not only impacts on your health, but can also affect other medical conditions.

SLEEP WELL !