1. Sleep Disorders in the Elderly Module 2
Brenda K. Keller, MD
Assistant Professor
Geriatrics & Gerontology
University of Nebraska Medical Center
This is Brenda Keller from the Section of Geriatrics and Gerontology. Our process will be for you to complete a series of 3 modules and questions on sleep disorders in the elderly. If you have not completed the first module, please do so at this time and then return to this module. Module 2 will review non-pharmacological treatment of insomnia. These modules will utilize power point with voice overlay. Each module will be followed by case-based questions with answers that will explain the right and wrong responses. Then you will have the option to continue with the next module or take a break at that time. The learner is recommended to complete a module before disengaging. When the module and questions are completed click on “Mark Reviewed on the main page of the minifellowship to indicate your completion.

2. Module 2 Non-pharmacological Management
Sleep hygiene
Stimulus control
Sleep restriction
Cognitive therapy
Paradoxical intention
Several non-pharmacological techniques have been proposed to treat insomnia in the elderly. In this module we will review sleep hygiene, stimulus control, sleep restriction, cognitive therapy and paradoxical intention.
McCall JAGS July 2005-Vol 53, No. 7 pS272-S277

3. Effectiveness of Non-pharmacological Treatment of Insomnia
Improve symptoms of insomnia in 70-80% of patients with primary insomnia
Effects last at least 6 months after treatment completed
Non-pharmacological treatment has been found to improve symptoms in 70-80% of patients with primary insomnia. These effects tend to be long lasting, with studies showing retained effectiveness for 6 months after the treatment is completed.

4. Non-pharmacological Management
Sleep hygiene
Education about health and environmental practices that affect sleep
This strategy is used in conjunction with other techniques to improve sleep
Sleep hygiene is education about health and environmental practices that effect sleep. This strategy is used in conjunction with other techniques to improve sleep. A Sleep Hygiene Tips page is available for your use on the main page of this module.

5. Sleep Hygiene Health Factors Environmental Factors Diet Exercise Light
Substance abuse
Environmental Factors
Light
Noise
Room temperature
Mattress
Many factors affect sleep, both heath related factors and environmental factors. Knowledge about these factors can overcome sleeping problems in many cases. Diet can affect sleep in a variety of ways. Heavy meals within a few hours of bedtime can contribute to acid reflux. For some people caffeine, even in small amounts early in the day, can affect sleep hours later. Others find that avoiding caffeine 6 hours before bedtime is enough to help sleep. An exercise program of brisk walking or low impact aerobics 30 minutes 4 times a week has been associated with improved sleep quality for older adults with moderate insomnia. It is best to not exercise within 4 hours of sleep time. Substance use and abuse is also associated with sleep problems. Although alcohol has sedative properties, and may speed the beginning of sleep, it actually increases the number of awakenings. Having a nice, quiet, comfortable, darkened room may be all that is needed to induce sleep for some people with insomnia. Bright lights, noises, and uncomfortable mattress in a room that is too hot or too cold can make sleep impossible. Correcting these environmental factors is far less expensive and safer than prescribing a pill.

6. Non-pharmacological Management
Stimulus control
Reinforces temporal and environmental cues for sleep onset
Go to bed when sleepy
Use the bed only for sleep
Bedtime routines
Regular morning rise time
Avoid napping
Stimulus control reinforces the temporal and environmental cues for sleep onset. The patient should go to bed only when sleepy. The bed is to be used only for sleep, not for watching TV, reading, eating, etc. Cultivating pre-bedtime routines, such as warm milk, emptying the bladder and not going to bed hungry is helpful. The patient should arise at a regular time each morning, regardless of when they went to bed and napping should be avoided.

7. Non-pharmacological Management
Sleep restriction
Decrease amount of time in bed to increase sleep efficiency
Only allowed time in bed is usually spent asleep
Increase by 15 minutes per night
Wake time constant, bedtime adjusted
Allows short afternoon naps
The rationale for sleep restriction is to decrease the amount of time in bed to increase the sleep efficiency. The only allowed time in bed is usually spent asleep. The maximum sleep restriction is 5 hours per night. The time in bed is then increased by 15 minutes per night. Like stimulus control, the wake up time is constant, however with sleep restriction, the bedtime is adjusted per protocol. Sleep restriction does allow for short afternoon naps.

8. Non-pharmacological Management
Cognitive therapy
Involves identifying dysfunctional beliefs and attitudes about sleep and replaces them with adaptive substitutes.
Helps minimize anticipatory anxiety and arousal
Cognitive therapy involves identifying dysfunctional beliefs and attitudes about sleep and replaces them with adaptive substitutes. This helps to minimize anticipatory anxiety and arousal.

9. Non-pharmacological Management
Paradoxical intention
Based on premise that performance
anxiety inhibits sleep onset
Involves persuading a patient to engage in the feared behavior of staying awake
If pt stops trying to fall asleep and genuinely attempts to stay awake, sleep may come more easily
The paradoxical intention method of sleep management is based on the premise that performance anxiety inhibits sleep onset. It involves convincing the patient to engage in the feared behavior of staying awake. The theory is that if the patient stops trying to fall asleep and genuinely attempts to stay awake, sleep may come more easily.

10. Summary
We have reviewed several effective non-pharmacological approaches to the treatment of insomnia. You may now precede to your case questions in regard to non-pharmacological treatment of insomnia. To complete the question for credit, close out this module, click on question 2, answer the question and review the answer. After you complete the questions, you may begin the next module or take a break. It is recommended that you complete a module before disengaging. When the modules and questions are completed, click on “Mark Reviewed” on the main page of the Minifellowship to indicate your completion.

11. Critiques from the Geriatric Review Syllabus. AGS 2002 New York, NY.
Post-test Question 1
A 67-year-old woman asks you to prescribe sleeping pills for her. She reports initial insomnia and restless sleep with frequent awakenings. The patient is retired and leads a sedentary life style. She frequently reads or watches television in bed and often naps, despite caffeine intake throughout the day. Physical examination is unremarkable. Which of the following is most likely to ameliorate this patient’s sleep disturbance?
A. Exposure to early morning daylight
B. Proper sleep habits
C. Sustained-release melatonin
D. Zolpidem
E. Referral for polysomnography
Used with permission from: Murphy JB, et. Al. Case Based Geriatrics Review: 500 Questions and
Critiques from the Geriatric Review Syllabus. AGS 2002 New York, NY.

12. Correct Answer: B. Proper sleep habits
Poor sleep habits may be the most common cause of sleep problems in older adults. Irregular sleep–wake patterns, related to the life style in this patient, can undermine the ability of the circadian system to effectively provide sleepiness and wakefulness at appropriate times. Caffeine intake in the afternoon can have alerting effects for many hours, thus impairing nighttime sleep. Excessive wake time in bed may cause increased arousal that is reinforced nightly. Other factors (eg, medical illness, medications, psychiatric disorders, and primary sleep disorders) also should be considered. However, proper sleep habits should be implemented. These include regularity of sleep and wake times; avoidance of excessive time in bed; relaxing bedtime routine; daily activity and exercise; avoidance of caffeine, alcohol, and nicotine in the afternoon and evening; and elimination of loud noise, excessive light, and uncomfortable room temperature. Even if poor sleep habits are not responsible for insomnia, their elimination minimizes any perpetuating influence.

13. Use of a short-acting hypnotic agent is not an appropriate first step in the management of simple insomnia. Hypnotics should be used only in limited circumstances, following evaluation of the patient’s symptoms and in the context of proper sleep habits. Similarly, melatonin has not definitively been shown to benefit age-related sleep-maintenance insomnia. Exposure to early morning light can be useful for delayed or advanced sleep-phase syndrome or jet lag. Polysomnography can be useful for evaluating chronic insomnia or for suspicion of primary sleep disorders, such as sleep apnea, periodic limb movement disorder, or rapid eye movement (REM)–behavior disorder, but referral to a sleep specialist is not warranted for this patient.

14. Post–test 2
A 75-year-old man on no medications has awakened frequently during the night for the past year. He is not tired during the day, and has no symptoms associated with awakening What is the best next step?
A. Education on age-related changes in sleep patterns
B. Referral to a sleep laboratory
C. Diazepam 5 mg at bedtime
D. Diphenhydramine 25 mg at bedtime
E. Lorazepam 0.25 mg at bedtime

15. Correct Answer: A. Education on age-related changes in sleep patterns
Problems with sleep are common in otherwise healthy older persons. With normal aging, time spent in stages 3 and 4 sleep, the deeper levels of sleep, decreases, and time spent in stages 1 and 2, the lighter periods of sleep, increases. These shifts account for the frequent awakenings of older persons. However, there are other causes of sleep disturbance, such as pain, anxiety, or urinary urgency, that should be evaluated before it is assumed that the patient’s sleep changes are associated with normal aging. In cases of short-term insomnia (eg, acute grief, change in residence), appropriate treatment may include a low dose of a benzodiazepine taken every other night for 1 to 2 weeks. Short- and intermediate-acting benzodiazepines such as lorazepam, oxazepam, and temazepam are most appropriate.

16. You as
Long-acting agents such as flurazepam and diazepam, which have active metabolites, are not recommended. For an older patient with difficulty sleeping, absence of daytime sleepiness, and no associated stresses or medications, the most likely cause is normal changes of aging. The most appropriate management of this 75-year-old man is to educate him about age-related changes in sleep patterns. No pharmacologic intervention is needed. Diphenhydramine is a weak sedative-hypnotic that is associated with multiple anticholinergic side effects and should not be used in older persons. Referral to a sleep laboratory is indicated for patients with evidence of sleep apnea or unexplained secondary causes of insomnia. End