1. Self Treatment of Insomnia in the Elderly Ashdin Tavaria M.D., Nalaka S. Gooneratne M.D., Clara Kwan M.D., Nirav Patel M.D., Lavanya Madhusudan, Kathy C. Richards, Ph.D. May 18, 2010

2. Acknowledgement Supported by: –The Hartford Foundation –Penn Center of Excellence –National Institute of Health

3. Introduction Sleep disorders are common in the elderly, with up to 57% of older adults complaining of difficulties with their sleep 1

4. Prevalence of Insomnia by Age -Ohayon, J Psychiat Res 1997

5. Introduction Sleep disorders can be associated with an increased risk of –Driving accidents 2-4 –Cardiovascular mortality 5 –Falls 6 –Depression 7 –Cognitive deficits 8

6. Insomnia-associated Mortality Nursing home study of 272 patients 2 year follow-up Adjusted for ADLs, age, gender Manabe et al., Gerontology 2000

7. Insomnia-associated Cognitive Impairment: Results EPESE dataset, 3 year follow-up, n=6,444 Adjusted for demographic and health factors Cricco et al., JAGS 2001

8. Introduction Despite the significant prevalence of sleep disorders, many older adults do not seek evaluation or treatment of their sleep problems Instead engage in a number of self- treatment activities 9, 10

9. Study Methods Purpose of this study was to explore –Different types of self-treatment strategies –Determine their perceived efficacy

10. Study Methods Cross-sectional survey study consisting of a mailed questionnaire Adults over the age of 65 recruited from the greater Philadelphia area Penn Partners in Healthy Living Program Data Base which is an elder outreach program affiliated with the University of Pennsylvania Health System

11. Results A total of 242 study questionnaires were completed Average of 4.8 treatments used per study participant (SD 2.9, range 0-13) Correlation between the number of treatments attempted and the PSQI sleep quality score (r=0.37, p<0.0001) –Suggested that study participants who had worse sleep quality had attempted more sleep treatments.

12. Results Bar graph showing the number of treatments used by subjects

13. ResultsActivityPercent Sleep Hygiene “Listened to radio, music or watched TV” 66.4 “Read a book, newspaper, magazine” 56.2 “Took a nap the next day” 44.0 “Did not nap the next day” 35.0 “Had a snack” 34.1 “Drank other liquids (tea, coffee, milk, etc.)” 32.6 “Drank a beer, wine or other alcohol” 13.0 “Spoke to someone on the telephone” 8.2 “Smoked a cigarette” 4.2 Environment “Adjusted temperature of the room, adjusted blankets or clothing” 47.0 “Went to a different room to sleep” 15.6 “Wear ear plugs” 1.4

14. Results MedicationsPercent “Took a pain medicine” 40.1 “Took an over-the-counter sleeping pill (Tylenol PM, etc.)” 30.6 “Took a prescription sleeping pill (Valium, Ativan, Sonata, etc.)” 22.1 Alternative Therapies “Did relaxation exercise, hypnosis, meditated” 15.3 “Took a vitamins or herb” 11.0 “Took melatonin” 10.6 “Went for acupuncture treatment” 1.9 Other “Had a hot bath or massage” 29.6 “Went for a walk or exercised (jogging, swimming, etc.)” 18.6

15. Efficacy of Different Types of Self-treatment Strategies

17. Results Prescription sleeping pills were felt to be the most effective treatment option (2.5) Ear plugs (1.0) were felt to be the least effective Prescription medications had a perceived efficacy that was significantly larger than the other methods (p-value = 0.0024)

18. Results In our study, most commonly used interventions were watching TV or listening to the radio, or reading Pain medications were the most commonly used form of medication highlighting the impact of pain as a contributing factor to insomnia in the elderly Of particular concern, nearly half of all subjects who used alcohol or over-the-counter sleeping aids had not told this to their health care provider

19. Results Women are more likely to engage in broad range of activities to improve their sleep when compared to men Caucasians tended to rely on pharmacotherapy while African Americans tended to use social tools

20. Discussion Wide array of treatment options used by elders for the management of their insomnia High usage rates of several treatments highlights the importance of inquiring about the broad range of treatment choices made by older adults as they seek to address their sleep complaints

21. Discussion Some elderly patients are trying up to 13 different treatments

22. Discussion Response rate may be affected by participants may have become discouraged by the end and chosen not to fill out additional questionnaire Patients may have underreported negatively viewed activities or treatments such as alcohol, smoking, or even medications

23. Discussion Self treatment can be dangerous Patients are unaware of the interplay between aging and physiology, chronic diseases and drugs Polypharmacy can result in adverse drug- drug interactions which can lead to confusion, falls, and incontinence –Over-the-counter sleep aids

24. Discussion As Healthcare providers we must be asking our patients about their sleep patterns If they are having disturbances we must ask what if any self-treatment activities they are engaging in

25. References