1. DORON GARFINKEL, M.D. SHOHAM GERIATRIC MEDICAL CENTER PARDES – HANA, ISRAEL HEAD, GERIATRIC PALIATIVE DEPARTMENT SLEEP DISORDER IN THE ELDERLY - EFFECT OF MELATONIN THERAPY

2. Normal Sleep & Normal Aging: Our Internal Biological Clock  The biological clock resides in the brain  It helps regulate when we feel sleepy and when we are alert  It works in tandem with light and dark, and our body temperature and hormones and hormones

3. M E L A T O N I N N ACETYL -5- METHOXYTRYPTAMINE ITS SYNTHESIS & EXCRETION ARE REGULATED BY AN ENDOGENOUS CLOCK LOCATED IN THE HYPOTHALAMUS THAT IS ENTRAINED ITS SYNTHESIS & EXCRETION ARE REGULATED BY AN ENDOGENOUS CLOCK LOCATED IN THE HYPOTHALAMUS THAT IS ENTRAINED TO THE EXTERNAL LIGHT - DARK CYCLE TO THE EXTERNAL LIGHT - DARK CYCLE ITS SYNTHESIS & EXCRETION ARE REGULATED BY AN ENDOGENOUS CLOCK LOCATED IN THE HYPOTHALAMUS THAT IS ENTRAINED ITS SYNTHESIS & EXCRETION ARE REGULATED BY AN ENDOGENOUS CLOCK LOCATED IN THE HYPOTHALAMUS THAT IS ENTRAINED TO THE EXTERNAL LIGHT - DARK CYCLE TO THE EXTERNAL LIGHT - DARK CYCLE AN INDOLE-AMINE SECRETED IN RESPONSE TO DARKNESS FROM THE PINEAL GLAND TO DARKNESS FROM THE PINEAL GLAND AN INDOLE-AMINE SECRETED IN RESPONSE TO DARKNESS FROM THE PINEAL GLAND TO DARKNESS FROM THE PINEAL GLAND

4. THE HORMONE INDUCES SLEEP THROUGH ITS SYNCHRONIZING EFFECT ON THE INTERNAL BIOLOGICAL CLOCK EASILY CROSSES THE BLOOD BRAIN BARRIER (B. B. B.) THE HORMONE INDUCES SLEEP THROUGH ITS SYNCHRONIZING EFFECT ON THE INTERNAL BIOLOGICAL CLOCK EASILY CROSSES THE BLOOD BRAIN BARRIER (B. B. B.) M E L A T O N I N N ACETYL -5- METHOXYTRYPTAMINE IS RAPIDLY METABOLIZED IN THE LIVER AND OVER 85% ELIMINATED IN THE URINE AS 6 SULPHATOXY - MELATONIN (6 - S - MT) IS RAPIDLY METABOLIZED IN THE LIVER AND OVER 85% ELIMINATED IN THE URINE AS 6 SULPHATOXY - MELATONIN (6 - S - MT)

5. EFFECT OF AGE ON M E L A T O N I N  THERE IS AN AGE-RELATED CHANGE IN THE DAILY RHYTHM OF MELATONIN Z SERUM MELATONIN CONCENTRATIONS DECREASE IN OLD AGE Z IN HEALTHY ELDERLY INSOMNIACS, 6-S MT IS SIGNIFICANTLY LOWER AND ITS ONSET AND PEAK TIME ARE DELAYED - IN COMPARISON TO AGE MATCHED CONTROLS WITH NO SLEEP DISTURBANCES

6. URINARY 6 - SULPHATOXY MELATONIN (6- S- MT) EXCRETION ELDERS / PATIENTS NORMAL

7. EXOGENOUS MELATONIN Therapeutic Effects EXERTS SYNCHRONIZING EFFECTS ON CIRCADIAN RHYTHMS - IT PHASE ADVANCES SLEEP OF PATIENTS SUFFERING FROM PATIENTS SUFFERING FROM DELAYED SLEEP- PHASE SYNDROME DELAYED SLEEP- PHASE SYNDROME CAN FACILITATE THE POST - FLIGHT ADAPTATION CAN FACILITATE THE POST - FLIGHT ADAPTATION OF JET - LAG OF JET - LAG RESYNCHRONIZES THE SLEEP - WAKE CYCLE RESYNCHRONIZES THE SLEEP - WAKE CYCLE OF BLIND PEOPLE OF BLIND PEOPLE

8. EXOGENOUS MELATONIN Characteristics IS NOT ASSOCIATED WITH SERIOUS SIDE EFFECTS IS NOT ASSOCIATED WITH SERIOUS SIDE EFFECTS IS SHORT LIVED IN HUMANS - SERUM HALF LIFE IS ONLY 40-50 MINUTES IS SHORT LIVED IN HUMANS - SERUM HALF LIFE IS ONLY 40-50 MINUTES

9. CONTROLLED - RELEASE MELATONIN ENABLES RESTORATION OF NORMAL SERUM MELATONIN CONCENTRATIONS BY CONTROLLED DOSAGE AND TIMING ENABLES RESTORATION OF NORMAL SERUM MELATONIN CONCENTRATIONS BY CONTROLLED DOSAGE AND TIMING ACHIEVES A PHARMACOKINETIC PROFILE SIMILAR TO THAT OF ENDOGENOUS MELATONIN SECRETED BY THE PINEAL GLAND ACHIEVES A PHARMACOKINETIC PROFILE SIMILAR TO THAT OF ENDOGENOUS MELATONIN SECRETED BY THE PINEAL GLAND THE QUALITY OF SLEEP IS MUCH BETTER THAN THAT ACHIEVED BY REGULAR, SHORT ACTING MELATONIN THE QUALITY OF SLEEP IS MUCH BETTER THAN THAT ACHIEVED BY REGULAR, SHORT ACTING MELATONIN COMPLIANCE IS IMPROVED ESPECIALLY IN THE ELDERLY COMPLIANCE IS IMPROVED ESPECIALLY IN THE ELDERLY

10. RESEARCH PROJECTS STUDY DESIGN RANDOMIZED, PLACEBO CONTROLLED DOUBLE - BLIND ± CROSSOVER DESIGN SUBJECTS GIVEN EITHER 2 mg OF CONTROLLED - RELEASE MELATONIN (CIRCADIN TM, NEURIM PHARMACEUTICALS, ISRAEL) OR A PLACEBO, TWO HOURS BEFORE DESIRED BEDTIME, FOR THREE WEEKS - SEVERAL MONTHS RANDOMIZED, PLACEBO CONTROLLED DOUBLE - BLIND ± CROSSOVER DESIGN SUBJECTS GIVEN EITHER 2 mg OF CONTROLLED - RELEASE MELATONIN (CIRCADIN TM, NEURIM PHARMACEUTICALS, ISRAEL) OR A PLACEBO, TWO HOURS BEFORE DESIRED BEDTIME, FOR THREE WEEKS - SEVERAL MONTHS

11. S U B J E C T S   ADULTS AND ELDERLY PEOPLE LIVING IN THE COMMUNITY WHO SUFFERED FROM SLEEP DISTURBANCES   INITIALLY, PEOPLE LIVING IN MEDITERRANEAN TOWERS, A RESIDENTIAL CENTER FOR SENIOR CITIZENS IN ISRAEL   THEN, PATIENTS SUFFERING FROM DIABETES MELLITUS, HEART DISEASE, HYPERTENTION etc ± SLEEPING PILLS...   ADULTS AND ELDERLY PEOPLE LIVING IN THE COMMUNITY WHO SUFFERED FROM SLEEP DISTURBANCES   INITIALLY, PEOPLE LIVING IN MEDITERRANEAN TOWERS, A RESIDENTIAL CENTER FOR SENIOR CITIZENS IN ISRAEL   THEN, PATIENTS SUFFERING FROM DIABETES MELLITUS, HEART DISEASE, HYPERTENTION etc ± SLEEPING PILLS...

12. RESEARCH PROJECTS TOOLS   A SLEEP QUESTIONNAIRE   ASSESSMENT OF SLEEP QUALITY FOR THREE CONSECUTIVE NIGHTS, BY WRIST ACTIGRAPHY WHILE SUBJECTS WERE SLEEPING AT HOME   MOTION RECORDING ANALYSED USING AN AUTOMATIC SCORING ALGORHYTHM   URINE COLLECTED AT 3 HOUR INTERVALS OVERNIGHT, URINARY 6-S MT ASSAYED BY R.I.A. OR ELISA

13. STUDY PROTOCOL RUN IN RUN IN WASH OUT 1 WEEK 3 WEEKS CR MELATONIN CR MELATONIN PLACEBO OR PLACEBO OR PLACEBO PLACEB‎O OR PLACEBO URINE COLLECTION A C T I G R A P H ) (3 NIGHTS)

14. EFFECTS OF CR MELATONIN ON SLEEP PARAMETERS IN ELDERLY PATIENTS

17. IMPROVEMENT OF SLEEP QUALITY IN ELDERLY PEOPLE BY CONTROLLED- RELEASE MELATONIN IMPROVEMENT OF SLEEP QUALITY IN ELDERLY PEOPLE BY CONTROLLED- RELEASE MELATONIN D. GARFINKEL, M. LAUDON, D. NOF, N. ZISAPEL LANCET 1995; 346: 541 - 44

18. C O N C L U S I O N S C O N C L U S I O N S CONTROLLED - RELEASE MELATONIN SIGNIFICANTLY IMPROVES SLEEP QUALITY IN ELDERLY INSOMNIACS IN WHOM MELATONIN OUTPUT WAS IMPAIRED MELATONIN REPLACEMENT THERAPY SHORTENS SLEEP LATENCY, IMPROVES SLEEP EFFICIENCY AND DECREASES W.A.S.O.

19. CONTROLLED RELEASE M E L A T O N I N IMPROVEMENT OF SLEEP QUALITY IN DIABETIC PATIENTS BY IMPROVEMENT OF SLEEP QUALITY IN DIABETIC PATIENTS BY

20. Impaired nocturnal melatonin secretion in Non-dipper hypertensive patients Jonas M, Garfinkel D, Zisapel N, Laudon M, Grossman E BLOOD PRESS 12 (1); 19-24, 2003.

21. BENZODIAZEPINES BENZODIAZEPINS ARE WIDELY USED IN THE ELDERLY POPULATION FOR THE INITIATION OF SLEEP BENZODIAZEPINS ARE WIDELY USED IN THE ELDERLY POPULATION FOR THE INITIATION OF SLEEP VERY FREQUENTLY, COMPLAINTS ABOUT POOR SLEEP MAINTENANCE PERSIST DESPITE BENZODIAZEPIN TREATMENT

22. WE REPORTED A DECREASED MELATONIN OUTPUT IN ELDERLY PEOPLE SUFFERING FROM INSOMNIA (Compared to Controls) MELATONIN CAN IMPROVE SLEEP QUALITY IN MELATONIN CAN IMPROVE SLEEP QUALITY IN MELATONIN - DEFICIENT ELDERLY PEOPLE MELATONIN PRODUCTION CAN BE INHIBITED BY BENZODIAZEPINS !!! MELATONIN PRODUCTION CAN BE INHIBITED BY BENZODIAZEPINS !!! BENZODIAZEPINES

23. DOSE REDUCTION - Period I % % 1 1 2 2 3 3 4 4 5 5 6 6 WEEKS PLACEBO MELATONIN GOAL P < 0.05 FACILITATION OF BENZODIAZEPINE DISCONTINUATION BY CONTROLLED-RELEASE MELATONIN

24. FACILITATION OF BENZODIAZEPINE DISCONTINUATION BY C.R. MELATONIN MELATONIN PLACEBO BENZODIAZEPINE DISCONTINUATION % 56 week

25. BZD. DOSE REDUCTION V S SLEEP QUALITY % % 1 1 2 2 3 3 4 4 5 5 6 6 WEEKS < < < M E L A T O N I N < < < < 7.5- 5.5- 6.5- 0 0 ~11% FACILITATION OF BENZODIAZEPINE DISCONTINUATION BY C.R. MELATONIN

26. STILL ON BENZIDIAZEPINES - FAILURE & STOPPED C. R. MELATONIN 22% FACILITATION OF BENZODIAZEPINE DISCONTINUATION BY C.R. MELATONIN TWO YEARS AFTER TERMINATION OF THE STUDY BENZODIAZEPINE DOSE REDUCTION 78% STOPPED TAKING BZD 60% 0N C. R. MELATONIN 52% WITHOUT C. R. MELATONIN 8% REDUCED BZD DOSAGE 18% (Average 30% of Initial BZD Dose) BENZODIAZEPINE DOSE REDUCTION 78% STOPPED TAKING BZD 60% 0N C. R. MELATONIN 52% WITHOUT C. R. MELATONIN 8% REDUCED BZD DOSAGE 18% (Average 30% of Initial BZD Dose)

27. CONCLUSIONS CONTROLLED - RELEASE MELATONIN CAN FACILITATE BENZODIAZEPINE DISCONTINUATION OR ENABLES A SIGNIFICANT DOSE REDUCTION OF BENZODIAZEPINES, WHILE MAINTAINING THE SAME OR BETTER SLEEP QUALITY WHILE MAINTAINING THE SAME OR BETTER SLEEP QUALITY CONTROLLED - RELEASE MELATONIN CAN FACILITATE BENZODIAZEPINE DISCONTINUATION OR ENABLES A SIGNIFICANT DOSE REDUCTION OF BENZODIAZEPINES, WHILE MAINTAINING THE SAME OR BETTER SLEEP QUALITY WHILE MAINTAINING THE SAME OR BETTER SLEEP QUALITY

28. D. GARFINKEL, N. ZISAPEL, J. WAINSTEIN, M. LAUDON, Arch Int Med 159: 2456-60, 1999 D. GARFINKEL, N. ZISAPEL, J. WAINSTEIN, M. LAUDON, Arch Int Med 159: 2456-60, 1999 FACILITATION OF BENZODIAZEPINE DISCONTINUATION BY MELATONIN : A NEW CLINICAL APPROACH

29. הפרעות שינה בקשישים בבתי אבות ובמחלקות סיעודיות הכנס הראשון לרפואה בגיל השלישי 28 באפריל 2003 הכנס הראשון לרפואה בגיל השלישי 28 באפריל 2003 ד"ר דורון גרפינקל מחלקה גריאטרית פליאטיבית שהם -המרכז המשולב לרפואת הגיל השלישי פרדס חנה ד"ר דורון גרפינקל מחלקה גריאטרית פליאטיבית שהם -המרכז המשולב לרפואת הגיל השלישי פרדס חנה

30. SLEEP DISORDERS AND SLEEP FRAGMENTATION ARE VERY COMMON IN NURSING HOME RESIDENTS … APPROACH TO SLEEP DISORDERS IN THE NURSING HOME SETTING Allesi CA & Schnelle JF. Sleep Med Rev 2000; 4(1): 45 - 56 (Review Article) UNFORTUNATELY, THERE IS LITTLE DATA ON THE EFFECTIVENESS OF SLEEPING MEDICATIONS AND THE SPECIFIC MANAGEMENT OF SLEEP DISORDERS IN THIS SETTING. UNFORTUNATELY, THERE IS LITTLE DATA ON THE EFFECTIVENESS OF SLEEPING MEDICATIONS AND THE SPECIFIC MANAGEMENT OF SLEEP DISORDERS IN THIS SETTING.

31. ACTIGRAPHY OF DEMENTED LONG TERM PATIENTS SHOWED SLEEP EFFICIENCY OF 75%, A MEAN SLEEP ONSET LATENCY OF ONE HOUR, A MEAN W.A.S.O. OF MORE THAN TWO HOURS, MORE THAN 13 HOURS WERE SPENT IN BED ACTIGRAPHY OF DEMENTED LONG TERM PATIENTS SHOWED SLEEP EFFICIENCY OF 75%, A MEAN SLEEP ONSET LATENCY OF ONE HOUR, A MEAN W.A.S.O. OF MORE THAN TWO HOURS, MORE THAN 13 HOURS WERE SPENT IN BED Fetveit A, Bjorvatn B. Int J Geriatr Psychiatry 2002; 17: 604 - 9 SLEEP DISTURBANCES AMONG NURSING HOME RESIDENTS SLEEP DISTURBANCES WERE COMMON AMONG THE RESIDENTS

32. THE MAIN CAUSES OF SLEEP DISTURBANCES IN BOTH SETTINGS WERE: THE SLEEP OF OLDER PEOPLE IN HOSPITAL AND NURSING HOMES Ersser & al. J Clin Nurs 1999; 8(4): 360 - 8 NEEDING TO GO TO THE TOILET, NOISE PAIN AND DISCOMFORT

33. A VARIETY OF FACTORS CONTRIBUTE TO THESE SLEEPING DIFFICULTIES A VARIETY OF FACTORS CONTRIBUTE TO THESE SLEEPING DIFFICULTIES   AGE RELATED CHANGES IN SLEEP   THE HIGH PREVALENCE OF DEMENTIA, DEPRESSION, MEDICAL ILLNESS AND MEDICATIONS THAT AFFECT SLEEP   THE HIGH PREVALENCE OF DEMENTIA, DEPRESSION, MEDICAL ILLNESS AND MEDICATIONS THAT AFFECT SLEEP   RESPIRATORY DISTURBANCES OF SLEEP   LIFESTYLE CHARACTERISTICS SUCH AS: INACTIVITY, LARGE AMOUNTS OF TIME SPENT IN BED, LACK OF BRIGHT LIGHT EXPOSURE AND POOR SLEEP HYGIENE AND THE DISRUPTIVE NIGHT-TIME NURSING HOME ENVIRONMENT   LIFESTYLE CHARACTERISTICS SUCH AS: INACTIVITY, LARGE AMOUNTS OF TIME SPENT IN BED, LACK OF BRIGHT LIGHT EXPOSURE AND POOR SLEEP HYGIENE AND THE DISRUPTIVE NIGHT-TIME NURSING HOME ENVIRONMENT APPROACH TO SLEEP DISORDERS IN THE NURSING HOME SETTING Allesi CA & Schnelle JF. Sleep Med Rev 2000; 4(1): 45 - 56 (Review Article)

34. THE IMPACT OF SEDATIVE-HYPNOTIC USE ON SLEEP SYMPTOM IN ELDERLY NURSING HOME RESIDENTSS Monane M, Glynn RJ, Avorn J. Clin Pharmacol Ther 1996; 59(1): 83 145 institutionalized elderly subjects, mean age 83.0 (range 65 - 105 years) in 12 nursing homes At baseline: One or more sleep related complaints were present in 65% of the residents. No relationship was found between use of sedative - hypnotic agent and the presence or absence of sleep complaints. AFTER 6 MONTHS OF FOLLOW UP: Improvement in functional status was significantly associated with improved sleep (p< 0.005).

35. THE IMPACT OF SEDATIVE-HYPNOTIC USE ON SLEEP SYMPTOM IN ELDERLY NURSING HOME RESIDENTSS CONCLUSIONS: Monane M, Glynn RJ, Avorn J. Clin Pharmacol Ther 1996; 59(1): 83 THERE WAS NO RELATIONSHIP BETWEEN DECREASED USE OF SEDATIVE - HYPNOTIC AGENTS AND WORSENED SLEEP, OR BETWEEN THEIR INCREASED USE AND IMPROVED SLEEP REPORTS

36. NO DISCERNIBLE DIFFERENCE WAS FOUND IN QUALITY OF SLEEP AND WHETHER PATIENTS FELT RESTED OR NOT, BETWEEN THOSE NO DISCERNIBLE DIFFERENCE WAS FOUND IN QUALITY OF SLEEP AND WHETHER PATIENTS FELT RESTED OR NOT, BETWEEN THOSE THE SLEEP OF OLDER PEOPLE IN HOSPITAL AND NURSING HOMES Ersser & al. J Clin Nurs 1999; 8(4): 360 - 8 PATIENTS ON HYPNOTIC MEDICATION AND THOSE WHO WERE NOT

37. AN AN INTERVENTION THAT COMBINES BOTH BEHAVIORAL AND ENVIRONMENTAL STRATEGIES AND THAT ADDRESSES DAYTIME BEHAVIORAL FACTORS ASSOCIATED WITH POOR SLEEP ( eg. Excessive time in bed ) The significant reduction in noise and light events … did not lead to significant improvement in the day sleep and most night sleep measures CONCLUSIONS: WOULD POTENTIALLY BE MORE EFFECTIVE IN IMPROVING THE NIGHT SLEEP & THE QUALITY OF LIFE OF NURSING HOME RESIDENTS RESIDENTS. THE NURSING HOME AT NIGHT: EFFECT OF AN INTERVENTION ON NOISE, LIGHT AND SLEEP

38. Sleep disturbances were studied as a mortality risk in 272 institutionalized elderly patients SLEEP PATTERNS AND MORTALITY AMONG ELDERLY PATIENTS IN A GERIATRIC HOSPITAL Manabe K & al. Gerontology 2000; 46(6): 318 - 22 Mortality after two years was significantly higher in the nighttime insomnia, daytime sleepiness and sleep onset delay groups. Sleep disturbances may be one of the symptoms indicating poor health or functional deficits, and be an independent risk factor for survival.

39. Chronic hypoxia due to alveolar hypoventilation and/or disturbance in ventilation/perfusion ratio, Nocturnal Respiratory Disturbances INTRODUCTION : are usually the result of a variety of cardiopulmonary & neurological maladies whose prevalence is increasing with age.

40. Sleep disturbances may aggravate hypoxia and lead to increased mortality and morbidity INTRODUCTION : Breathing problems in general & sleep apnea in particular, are both increasing with age and represent the main causes for clinically significant, chronic night hypoxia Nocturnal Respiratory Disturbances

41. R E S U L T S : Nocturnal Respiratory Disturbances in a Prolonged Care Geriatric Institution

42. CONCLUSIONS: IN SPITE OF NORMAL OR ONLY MILDLY IMPAIRED RESULTS OF BOTH THE SUBJECTIVE SLEEP REPORTS AND ARTERIAL BLOOD GASES & SPIROMETRY Nocturnal Respiratory Disturbances in a Prolonged Care Geriatric Institution A SIGNIFICANT NIGHT HYPOXIA ACCOMPANIED WITH MANY PERIODS OF RESPIRATORY DISTURBANCES (APNEA / HYPOPNEA) WERE FOUND IN MOST OF THE SAME SUBJECTS Seleznev I, & al. Unpublished Data

43. CONCLUSIONS: ALL SUBJECTS WITH SIGNIFICANT NOCTURNAL RESPIRATORY DISTUEBANCES WERE OFFERED THERAPY (CPAP).. … HOWEVER... Nocturnal Respiratory Disturbances in a Prolonged Care Geriatric Institution ONLY 3 ELDERS AGREED TO TRY THIS NON INVASIVE TREATMENT ! Seleznev I, & al. Unpublished Data

44. COHEN - MANSFIELD J, GARFINKEL D, LIPSON S. Arch Gerontol & Geriatr 31: 65-76, 2000 COHEN - MANSFIELD J, GARFINKEL D, LIPSON S. Arch Gerontol & Geriatr 31: 65-76, 2000 MELATONIN FOR TREATMMENT OF SUNDOWNING IN ELDERLY PERSONS WITH DEMENTIA

45. Seleznev I, & al. Unpublished Data Determine the prevalence of hypoxia in elderly people living in a nursing home Find out whether this hypoxia was influenced by the circadian rhythm Look for correlations between apparent maladies or clinical manifestations and relevant laboratory respiratory findings. Nocturnal Respiratory Disturbances in a Prolonged Care Geriatric Institution OBJECTIVES: .. .. ..

46. Seleznev I, & al. Unpublished Data Nocturnal Respiratory Disturbances in a Prolonged Care Geriatric Institution Patients : Elderly volunteers living in a nursing home at the Shoham Geriatric Center Pardes-Hana, Israel Exclusion criteria : * Significant disability defined as Karnofski Performance Index < 50 * Significant cognitive impairment MMSE score<18 * Unstable medical conditions

47. ..   Pulmonary function assessments were performed using bedside Spirometry in the evening before polysomnography  Arterial  Arterial blood gases were determined in the morning following polysomnography. Nocturnal Respiratory Disturbances in a Prolonged Care Geriatric Institution Methods : These measurements were used to calculate several parameters, enabling a quantitative comprehensive evaluation of sleep and breathing patterns k k Subjective assessment of the quality of sleep (a questionnaire) k k Objective assessment of sleep quality was performed in all subjects in their own bed by 8 channel polysomnography k k Subjective assessment of the quality of sleep (a questionnaire) k k Objective assessment of sleep quality was performed in all subjects in their own bed by 8 channel polysomnography

48. 87% of the subjects had PaO 2 above 70 mmHg, 9% had values of 55 - 70 mmHg, only 4% had a PaO 2 below 55 mmHg. The severity of dyspnea (according to the NYHA Functional Classification) had a significant positive correlation with PaCO 2 (p=0.034, R =0.306) R =0.306) and negative correlation with PaO 2 PaO 2 (p=0.015, R =0.348). R E S U L T S : Nocturnal Respiratory Disturbances in a Prolonged Care Geriatric Institution Seleznev I, & al. Unpublished Data

49. 99 patients met our criteria but only 51 volunteered to participate (14 men, 37 women) average age 82.1± 6.89 (range 70 to 95). 36 patients had hypertension, 20 suffered from ischemic heart disease (7 also had CHF), 11 had COPD; Depression was diagnosed in 7, diabetes mellitus in 6, previous CVA in 5 hypothyroidism in one. R E S U L T S : Nocturnal Respiratory Disturbances in a Prolonged Care Geriatric Institution Seleznev I, & al. Unpublished Data

50. The subjective assessment of sleep quality according to the sleep questionnaire: 57% complained of severe sleep disorders 27% had mildly-moderately disturbed sleep 16% reported a good night sleep No correlation was found between subjective sleep quality and nocturnal oxygen saturation, PaO 2 and PaCO 2. R E S U L T S : Nocturnal Respiratory Disturbances in a Prolonged Care Geriatric Institution Seleznev I, & al. Unpublished Data

51. R E S U L T S : Nocturnal Respiratory Disturbances in a Prolonged Care Geriatric Institution Seleznev I, & al. Unpublished Data

52. R E S U L T S : Nocturnal Respiratory Disturbances in a Prolonged Care Geriatric Institution

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

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

55. 3 3. A. PROVE IT: CHECK OVERNIGHT URINE FOR 6-STM B. CONSIDER A THERAPEUTIC TRIAL WITH 2mg OF CONTROLLED - RELEASE MELATONIN..... OR 1. RULE OUT AND TREAT SITUATIONS LEADING TO SECONDARY SLEEP DISORDERS PARTICULARY SLEEP APNEA (PATIENT’S STORY, ANXIETY, DEPRESSION, PHYSICAL, IMAGING & LAB FINDINGS). 1. RULE OUT AND TREAT SITUATIONS LEADING TO SECONDARY SLEEP DISORDERS PARTICULARY SLEEP APNEA (PATIENT’S STORY, ANXIETY, DEPRESSION, PHYSICAL, IMAGING & LAB FINDINGS).. NO APPARENT UNDERLYING CAUSE FOR SLEEP 2. NO APPARENT UNDERLYING CAUSE FOR SLEEP DISORDER and ADVANCED AGE - DISORDER and ADVANCED AGE - CONSIDER A PRIMARY MELATONIN DISORDER CONSIDER A PRIMARY MELATONIN DISORDER APPROACH TO SLEEP DISORDERS (IN THE NURSING HOME SETTING ) 4. TRY A SLEEPING PILL… PREFERABLY NOT A BENZODIAZEPINE AS THE FIRST CHOISE BENZODIAZEPINE AS THE FIRST CHOISE