Sleep Issues & the Older Adult Jerusalem Walker, BA, RN, BSN Nursing 707

Appreciate the significance of sleep issues for the older adult Understand the pathophysiology and symptoms of sleep problems in older adults Identify two assessment instruments for older adult sleep problems Identify principles of non- pharmacological interventions LEARNING OBJECTIVES

Sleep problems in older adults: May make underlying illnesses worse Are associated with increased risk of HTN, depression, cardiovascular disease, and stroke May alter mood and behavior, especially for the cognitively impaired Increase risk of accidental injury (e.g., falls) Negatively impact quality of life Are often ignored by care providers (Bloom et al., 2009; Crowley, 2011; McEnany, 2011) PROBLEM & SIGNIFICANCE

Approximately ½ of older adults report sleep difficulties More common in women than men 35% of women over 70 vs. 13% of men report moderate to severe insomnia 2/3 of residents of long-term care facilities over age 64 have some form of sleep disturbance (Gentili, 2012) EPIDEMIOLOGY

Alterations in regulation of circadian sleep-wake cycle Decrease in sleep efficiency Progressive decrease in total sleep time after age 50 More frequent nocturnal awakenings, increased time spent awake after sleep onset Decrease in slow wave sleep Decrease in REM sleep Earlier morning awakenings (Crowley, 2011; McEnany, 2011) AGE-RELATED CHANGES

Primary sleep disorders – Sleep disordered breathing (e.g., obstructive sleep apnea) – Periodic limb movements during sleep – Restless legs syndrome Secondary sleep disorders – Medical illnesses – Chronic pain – Psychiatric conditions – Drug-related – Psychosocial factors Combination of these factors and age-related changes (Crowley, 2011; Gentili, 2012; McEnany, 2011) CAUSES OF SLEEP DISTURBANCES Sleep disorders may be primary or caused by another problem, condition, or situation

Excessive daytime sleepiness Fatigue Impaired memory Confusion Stupor Attention deficits and learning problems Irritability and mood changes Decreased healing Weight gain SYMPTOMS (Bloom et al., 2009; Crowley, 2011; McEnaney, 2011; Petit, Azad, Byszewski, Sarazan, & Power, 2003)

1.Normal sleep routine, including bedtime and waking time 2.Difficulty falling asleep 3.Number of nighttime awakenings 4.Difficulty falling back asleep after waking up 5.Snoring, or kicking or thrashing about 6.Nocturia 7.Daytime sleepiness 8.Number of naps during the day and duration 9.Dozing off unintentionally during the day 10.Sleep required to function well and feel alert 11.Current medications, including sleep medicines 12.Alcohol and food intake prior to bedtime (Bloom et al., 2009; Crowley, 2011; McEnaney, 2011) ASSESSMENT QUESTIONS

Polysomnography (sleep study) Comprehensive, multi-parametric recording of changes occurring during sleep Actigraphy Device which is worn around the wrist or ankle which records movement: valid and reliable for assessing sleep duration Pittsburgh Sleep Quality Index Self-report instrument which asks questions about sleep habits experienced on the majority of days for the past month (Buysse, Reynolds, Monk, Berman, & Kupfer, 1989; Petit et al, 2003; “Polysomnography,” 2012) FORMAL ASSESSMENT TOOLS

Regular time for sleeping and waking up Avoid naps longer than 20 minutes Avoid caffeine in the afternoon No TV, radio, or reading in bed Avoid excessive alcohol intake, especially before bedtime Eat a light evening meal; light snack before bed if needed Get up and do a quiet activity if unable to sleep for 30 minutes Exercise daily, but avoid aerobic activity within 4 hours of bedtime Light therapy, massage, relaxation techniques LIFESTYLE MODIFICATIONS (Bloom et al., 2009; Crowley, 2011; McEnaney, 2011; Petit, 2003)

Identify underlying cause (e.g., anxiety, chronic pain) and treat with appropriate agents Medications are second-line therapy after nonpharmacologic treatment has proven ineffective Prescribe benzodiazepines with great caution; pay attention to half-life, liver metabolism and abuse liability Polypharmacy increases the risk of drug interactions and side effects Educate patients and monitor closely for adverse effects Risk of use of antihistamines, antidepressants, antipsychotics, and anticonvulsants outweigh the benefits Use of short-term medication therapy with behavioral modification may be more effective than either alone MEDICATION CONSIDERATIONS (Bloom et al., 2009; Crowley, 2011; McEnaney, 2011; Petit, 2003)

References Bloom, H. G., Ahmed, I., Alessi, C. A., Ancoli-Israel, S., Buysse, D. J., Kryger, M. H., Phillips, B. A., et al. (2009). Evidence-based recommendations for the assessment and management of sleep disorders in older persons. Journal of the American Geriatrics Society, 57(5), 761–789. Buysse, D. J., Reynolds, C. F., Monk, T. H., Berman, S. R., & Kupfer, D. J. (1989). The Pittsburgh Sleep Quality Index: A new instrument for psychiatric practice and research. Psychiatry Research, 28(2), 193–213. Crowley, K. (2011). Sleep and sleep disorders in older adults. Neuropsychology Review, 21(1), 41–53. doi: /s Gentili, A. (2012). Geriatric sleep disorder. Retrieved October 20, 2012, from McEnany, G. P. (2011). Normal and disordered sleep late in life. Geropsychiatric And Mental Health Nursing (2nd ed., pp. 367–394). Jones & Bartlett Learning. Petit, L., Azad, N., Byszewski, A., Sarazan, F. F.-A., & Power, B. (2003). Non‐pharmacological management of primary and secondary insomnia among older people: review of assessment tools and treatments. Age and Ageing, 32(1), 19–25. doi: /ageing/ Polysomnography. (2012, October 20).Wikipedia, the free encyclopedia. Retrieved from