1. Diagnosis and Treatment of Sleep Disorders in the Elderly Subhash Bashyal, M.D. George T. Grossberg, M.D. Samuel W. Fordyce Professor Department of Neurology & Psychiatry Saint Louis University School of Medicine

2. Disclosures Dr. Bashyal – None Dr. Grossberg Consultant – Baxter Bioscience; Bristol-Myers, Squibb; Forest Labs; Novartis; Lundbeck; Otsuka Research Support: Baxter Bioscience; Janssen; Novartis; Pfizer; NIH Safety Monitoring Committee - Merck

3. Epidemiology 13 % of US population are over 65 31% of elderly are in Nursing homes Study with adults >65 yrs. reported that 42 % had difficulty staying or falling asleep, 23% to 34 % had symptoms of insomnia Ref: Foley D, Ancoli-Israel S, Briz P, et al, J Psychosom Res 2004.

4. Importance of Sleep Sleep impairment associated with decreased performance in psycho-motor tests, impaired memory and concentration, daytime sleepiness, fatigue and risk of falls Sleep disordered breathing associated with increased risk of cognitive impairment Patients with depressive symptoms were up to 2.5 more likely to have insomnia or not feel rested Ref: Yaffe K, Laffan AM, Harrison SL et al, JAMA 2011

5. Sleep changes in the Elderly Problems with sleep initiation Decreased total sleep time Decrease in sleep efficiency Decrease in slow wave sleep Increase in sleep fragmentation Ref: Neikrug AB, Ancoli-Israel S. Gerontology – Behavioral Sciences, 2010

6. Ref:, Kate Crowley, Neuropsychol Rev 2011

7. Factors affecting sleep Medical illness - e.g., pain, sleep disorders (sleep –disorder breathing, restless leg syndrome, REM sleep behavior), infection, heart failure Medications Psychiatric illness – e.g., delirium, mood disorders, anxiety disorders Ref: Desai AK, Grossberg GT, Psychiatry Consultation in Long-Term Care, John Hopkins Press 2010.

8. Factors affecting sleep (cont.) Disruption in the circadian rhythm due to dementia or a lifetime of working evenings or nights Environmental factors – e.g. inadequate exposure to light in the daytime, excessive exposure to light at night, excessive noise at night, uncomfortable bed, bedroom is too hot or too cold, sleep interrupted by the staff or by another resident

9. Factors affecting sleep (cont.) Poor sleep hygiene or lifestyle factors Change in one’s living situation Multifactorial

10. Medications commonly affecting sleep Psychiatric medications: TCAs: Nortriptyline and protriptyline (more alerting) SSRIs: Citalopram and Fluoxetine (more alerting) Venlafaxine and Bupropion are commonly associated with sleep disturbance Anti psychotics: Aripiprazole often associated with insomnia Stimulants

11. Beta blockers: Most commonly metoprolol and propranolol Decongestants : pseudoephedrine, phenylpropanolamine Anti biotics: Levofloxacin, Ciprofloxacin, Antivirals, amantadine Asthma meds: Albuterol, theophylline Stimulants: Caffeine, Dextroamphetamine, methylphenidate, methamphetamine Medications:

12. Evaluation of insomnia History: Sleep duration and quality, number of awakenings, initial vs. terminal insomnia. Useful if sleep partner is also interviewed. Medication use, including over the counter and herbal supplements Sleep diary (everyday for 1 to 2 weeks) Physical examination, lab tests, sleep study

13. J Am Geriatr Soc. 2009 May; 57(5): 761–78 9. Evidence-Based Recommendations for the Assessment and Management of Sleep Disorders in Older Persons

14. Sleep Diary Daytime activities, naps, exercise, alcohol and caffeine intake, meals, stress, tiredness Medication use Activities before bedtime and bedtime routine Wake up time Time to fall asleep, number of awakenings, total time awake, quality of sleep, total sleep time

15. Other helpful questions Do you have the urge to move your legs or experience uncomfortable sensations in your legs at night? Do you get up to urinate at night? Does your partner tell you that you frequently snore, stop breathing, or gasp for air at night? Do you usually doze off without planning, during the day?

16. Interventions for the treatment of insomnia in long-term care residents Dietary Restrict the intake of caffeine and chocolate, particularly in the evening. Avoid a heavy meal late at night Recommend a light snack (e.g. a glass of milk, crackers) if nighttime awakenings are caused by hunger Avoid fluid intake in the evening by residents with nocturia and encourage maximum bladder emptying before retiring Ref: Desai AK, Grossberg GT, Psychiatry Consultation in Long-Term Care, John Hopkins Press 2010.

17. Interventions for the treatment of insomnia in long-term care residents (cont.) Environmental Increase exposure to natural light in the daytime Increase exposure to indoor light in the daytime on cloudy, rainy, and snowy days Recommend bright-light therapy Ensure optimal room temperature and humidity Reduce nighttime noise and nighttime exposure to bright light Change the room if conflict with a roommate or the location of the room is an issue

18. Interventions for the treatment of insomnia in long-term care residents (cont.) Activity-oriented Limit daytime napping to a short period in the morning or early afternoon Limit the time spent in bed in the daytime Increase physical activity in the daytime Increase meaningful activity and socialization in the daytime Employ a warm bath in the evening Avoid excessive stimulation and exercise after dinnertime

19. Interventions for the treatment of insomnia in long-term care residents (cont.) Sleep hygiene Recommend regular sleeping and waking times and a structured bedtime routine Recommend calming bedtime rituals (e.g., soothing music, reading or listening to audio recordings of nonfiction books (such as spiritual and religious books) Use one’s bed for sleep and sexual activity (rather than watching television, eating, or reading)

20. Interventions for the treatment of insomnia in long-term care residents (cont.) Staff-oriented Educate and train staff regarding the evaluation and treatment of insomnia and other sleep disorders Have staff mediate differences between roommates (e.g. one resident wanting to watch television late at night, disturbing the roommate who wants to go to sleep early) Minimize staff interruptions of a resident’s sleep Use massage therapy Use aromatherapy

21. Interventions for the treatment of insomnia in long-term care residents (cont.) Specific interventions for residents who are cognitively intact Relaxation training Cognitive behavior therapy Stimulus control therapy Sleep restriction therapy

22. Interventions for the treatment of insomnia in long-term care residents (cont.) Pharmacological Restrict the use of alcohol and tobacco Prescribe sedative hypnotics Prescribe antidepressants with sedating properties to treat insomnia in residents with depression Prescribe atypical antipsychotics with sedating properties to treat insomnia in residents with severe psychotic symptoms Prescribe a pharmacological treatment for underlying medical conditions

23. Treatment of Insomnia Non pharmacological therapy Behavioral treatment: Sleep restriction, Stimulus control, Relaxation therapy CBT: Uses a combination of above methods and is the most effective. Effect more sustained compared to medication. Bright light therapy Ref: Wilson SJ, Nutt DJ, Alford C, et al. J Psychopharmacology 2010

24. Instructions for good sleep hygiene Regular sleep/wake schedule Don't go to bed unless sleepy Decrease daytime naps (<30 mins, before 2 pm) Regular exercise (but not 3-5 hrs before bed) Exposure to natural light during the day Avoid heavy meals close to bedtime (< 3 hrs)

25. Sleep hygiene Comfortable clothing to bed Use bed only for sleep and sex If unable to sleep, get out of bed and return only when sleepy Keep bedroom quiet and dark Limit intake of liquids right before bedtime

26. Pharmacotherapy: FDA Approved medications for insomnia: FDA Approved medications for insomnia: Benzodiazepines (Short term treatment of insomnia) Flurazepam (Dalmane): Geriatric dose - 15 mg, half life 126- 158 hrs. Should not be used in older adults because of very long half-life. Quazepam (Doral): Geriatric dose- 7.5 mg, half life 78 hrs. Should not be used in older adults because of very long half- life.

27. Benzodiazepines: Estazolam (ProSomGeriatric dose- 0.5-1 mg, half life 10-24hrs.(Due to long half-life, residual CNS effects are likely.) Temazepam (Restoril)Geriatric dose- 7.5-15 mg, half life 3.5-18.4 hrs. Triazolam (Halcion)Geriatric dose -0.0625-0.25 mg, half life 1.7-5 hrs.(Poor choice due to very short half life and high incidence of CNS adverse reactions)

28. No short-term limitation for use Sleep onset and sleep maintenance Eszopiclone (Lunesta) :Geriatric dose- 1-2 mg, half life 9hrs. Adverse Effects>10%: headache, unpleasant taste. Zolpidem ER (Ambien CR) :Geriatric dose- 6.25 mg, half life 1.9-7.3hrs. Adverse Effects>10%: dizziness, headache, somnolence Zolpidem (Ambien) :Geriatric dose-5 mg, half life 2.9-3.7 hrs. Adverse Effects>10%: dizziness, headache, somnolence. Zaleplon (Sonata): Geriatric dose- 5 mg, half life 1 hrs. Adverse Effects: nausea (7%), myalgias (7%) Nonbenzodiazepines

29. Melatonin Receptor Agonist Onset – 14 days No short-term limitation for use. Sleep onset insomnia. Ramelteon (Rozerem): Geriatric dose- 8 mg, half life 1-2.6 hrs. Adverse Effects: Headache (7%),Somnolence (5%),Dizziness (5%).

30. Other medications Anti depressants : Trazodone/Desyrel (hypotension, falls), TCAs(falls, disorientation), Mirtazepine/Remeron Anti psychotics: Quetiapine/Seroquel, Olanzapine/Zyprexa (cardiovascular events, Sudden death) Treatment of the comorbid conditons: Sleep apnea, Restless leg syndrome, Pain, Urinary issues.

31. Caution with use of sedatives Minimum dose and for the shortest duration needed Avoid sedative medications with anti cholinergic properties If Obstructive Sleep Apnea is suspected, sedative hypnotics should be avoided Increased risk of falls / disorientation Avoid long half-life drugs-hangover effect

32. Summary Importance of looking for sleep disorders in the elderly Sleep hygiene Treatment of causative factors Treatment with a combination of CBT and medications, offer the best results Benzodiazepine receptor agonist, and melatonin receptor agonist safest for use in elderly