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Physio in the Ageing > Sleep & Ageing > Flashcards

Sleep & Ageing Flashcards

1
Q

How common are sleep problems in the elderly?

A

42% of 65 yo community-dwelling adults reported difficulty initiating or maintaining sleep

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2
Q

What is sleep?

A

A reversible behavioural state of perceptual disengagement from and unresponsiveness to the environment

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3
Q

Sleep is associated with changes in which physiological parameters?

A
  • EEG: Electroencephalogram (brain activity)
  • EOG: Electrooculogram (eye movements)
  • EMG: Electromyogram (muscle activity/tone)
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4
Q

What is polysomnogram?

A

Simultaneous recording of multiple physiological variables related to sleep, done during a lab-based sleep study

  • EEG
  • EOG
  • EMG (chin, leg, respiration)
  • ECG
  • Airflow
  • Respiratory effort (bands)
  • SpO2
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5
Q

What measures are taken during home sleep studies?

A
  • EEG
  • EOG
  • ECG
  • Position
  • Breathing movements (RIP)
  • Breathing (airflow)
  • O2 level (oximetry)
  • Leg movements (Pizeo-electric)
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6
Q

What are some of the sleep stage changes with age?

A
  • Decreased total sleep time
  • Increased sleep latency (time taken to fall asleep)
  • Decreased sleep efficiency
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7
Q

What evidence is there that sleep problems are related to associated health problems, not just the ageing process?

A
  • 2000 elderly subjects reported sleep difficulties on initial survey, 50% no longer had symptoms at 3 yr follow up, associated with improvements in health
  • Age related changes in sleep are only modest in those who are “optimally ageing”
  • Deterioration in sleep is observed with mental/medical illness & sleep apnea
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8
Q

What does optimal sleep quantity depend on?

A
  • Sleepiness
  • Mood alteration
  • Cognitive function
  • Immune function
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9
Q

What are the components of the two process model of sleep regulation (sleep-wake cycle)?

A
  • Homeostatic sleep drive
  • Circadian rhythm
  • Best when both are in sync
  • May also work out of sync (e.g. sleeping during the day after a big night out = homeostatic drive > circadian)
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10
Q

What is the circadian cycle?

A
  • Intrinsic biological rhythm
  • Associated with melatonin levels
  • Modulated by various factors
  • Main factor is light entering the eye
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11
Q

What physiological changes are associated with sleep during the circadian cycle?

A
  • Decreased temperature
  • Increased plasma growth hormone
  • Increased plasma cortisol
  • Decreased urinary potassium
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12
Q

How is the circadian cycle affected by age?

A
  • Decreased melatonin excretion in the elderly
  • Circadian cycle becomes weaker
  • BUT homeostatic drive still exists
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13
Q

How can age change sleep regulation?

A
  • Decreased melatonin levels due to deterioration in the suprachiasmatic nuclei
  • Decreased drive to sleep
  • Inconsistency of external cues (bright light exposure, irregular meal times, nocturia, decreased mobility/exercise)
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14
Q

What are the consequences of poor sleep in the elderly?

A
  • Increased risk of falls
  • Reduced QOL
  • Symptoms of anxiety & depression
  • Cognitive impairment
  • Deficits in attention, response times, STM & performance
  • Reduced survival
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15
Q

What are the most common sleep problems in the elderly?

A
  • Insomnia/poor sleep
  • Sleep Apnea
  • Restless Legs Syndrome/ Periodic Leg Movements
  • REM Behaviour Disorder
  • Circadian Rhythm Disorders
  • Hypersomnias
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16
Q

How is insomnia & poor sleep defined?

A
  • Subjective complaint of difficulties initiating and/or maintaining sleep, or non- restorative sleep
  • Duration 1 month
  • Results in daytime impairments e.g. mental/physical fatigue, sleep anticipatory anxiety & perceived neuropsychological deficits
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17
Q

What factors does the diathesis-stress-response model show contribute to insomnia?

A
  • Predisposing factors (familial light or disrupted sleepers, over-concern with well being, introspective & worrying disposition)
  • Precipitating factors (pain, occupational change, acute stress)
  • Perpetuating factors (excessive focus on sleep, increased time in bed while awake, daytime naps)
18
Q

How does the ratio of contributing factors to insomnia change over time?

A
  • Acute insomnia: Precipitating
  • Short-term insomnia: Precipitating > perpetuating
  • Chronic: Perpetuating > precipitating
19
Q

What are some of the additional causes of insomnia in the elderly?

A
  • Psychiatric illness
  • Psychosocial factors (loneliness, change of residence etc)
  • Behavioural or environmental factors
  • Primary sleep disorders
  • Medications
  • Medical disorders
20
Q

What is the relationship between sleep & chronic pain?

A
  • 88% of chronic pain patients report a sleep complaint
  • Patients report poor sleep coincides with onset of pain
  • Sleep deprivation lowers pain threshold
  • Poor sleep results in daytime consequences
  • Pre-sleep arousal is high in chronic pain (e.g. racing/intrusive thoughts, rapid HR, SOB, muscle tension)
21
Q

What factors perpetuate insomnia?

A
  • Excessive time in bed
  • Irregular timing of retiring/arising
  • Unpredictability of sleep
  • Worry over daytime deficits
  • Multiple bouts (naps, fragmentation) of sleep
  • Maladaptive conditioning
  • Increased caffeine consumption
  • Hypnotic & alcohol ingestion
22
Q

What are the treatments for insomnia?

A
  • Cognitive behavioural therapy techniques

- If insomnia continues, recommend investigation & treatment of a sleep disorder

23
Q

What does evidence show regarding cognitive behavioural therapy techniques for insomnia?

A
  • Treatment is comprehensive, long-term & likely to be onerous
  • CBT decreases sleep onset latency & improves pain severity
24
Q

What does CBT involve?

A
  • Stimulus control (bed is only used for sleep & sex, going to another room if unable to sleep >15mins, no daytime napping)
  • Sleep restriction (wake at the same time every day)
  • Sleep hygiene
  • Relaxation training
  • Cognitive therapy
25
Q

What does the cognitive therapy component of CBT involve?

A

Acknowledging the problem but taking the emphasis off sleep by strengthening their sense of control

Changing dysfunctional beliefs & attitudes about sleep e.g.

  • unrealistic expectations about sleep requirements
  • strong beliefs about the consequences of insomnia
  • worried about losing control and unpredictability of sleep
  • faulty beliefs about sleep promoting practices
  • perception that trying to sleep will help
26
Q

What advice can be given to a patient who is worried about not sleeping?

A
  • Do not worry if you do not sleep
  • You are not alone
  • Sleep should be automatic
  • Efforts to initiate sleep are counter productive
27
Q

What are some techniques to deal with a racing mind?

A
  • Allow time to unwind (1hr)
  • Putting the day to rest
  • Relaxation & imagery
  • Give up trying to sleep
28
Q

What advice can be given to promote sleep hygiene & relaxation?

A
  • Have a bedtime ritual
  • Use relaxation techniques
  • Do not use bed as a place to solve problems
  • Banish clocks from the bedroom
  • Exercise during the day (early in the day, not within 4 hours of sleep)
  • Do not eat large meals close to bedtime
  • Limit alcohol & caffeine consumption after 3pm
  • Keep the bedroom darkened
29
Q

What is OSA?

A
  • Pauses in respiration during sleep
  • Leads to haemodynamic changes (increase in BP, increased rates of arrhythmia, O2 desaturation)
  • Fragments sleep (frequent arousal, nocturia)
30
Q

How is OSA measured?

A
  • RDI: Respiratory disturbance index

- AHI: Apnea hypopnea index (number of respiratory events per hour of sleep)

31
Q

How is OSA severity graded?

A

AHI

  • <5/hr = normal
  • 5-14/hr = mild
  • 15-30/hr = mod
  • > 30/hr = severe
32
Q

What is the prevalence of OSA in the elderly?

A
  • 50% nursing home residents had RDI >20/hr
  • 81% 65-95yos had RDI >5/hr
  • BUT need to consider the difference between breathing abnormalities and patient symptoms (e.g. tiredness)
33
Q

Why is the airway more likely to obstruct as we age?

A
  • Soft palate gets longer
  • Pharyngeal fat pads increase in size
  • Bony structure around the pharyngeal structure changes
  • Response of the genioglosus muscle to negative pressure stimulation diminishes
34
Q

What are the potential health effects of OSA in the elderly?

A
  • Mortality
  • CV dysfunction
  • Cognitive impairment & dementia
  • Symptoms (e.g. sleepiness)
35
Q

What does evidence show regarding the relationship between OSA, age and mortality?

A
  • Increase in fatal & non-fatal CVS events in severe OSA with increasing age (mixed age data)
  • BUT no age-related increase in mortality when only looking at people aged 60-83yrs&raquo_space; people react differently at different times of the lifespan
36
Q

What are the patient reported symptoms of OSA?

A
  • Sleepiness
  • Concentration, memory and learning problems
  • Daytime fatigue/ reduced energy
  • Unrefreshing sleep
  • Nocturnal choking or gasping for breath
  • Nocturia and enuresis
  • Mood problems and depression
  • Decreased libido and erectile dysfunction
  • Recent weight gain
  • Dry mouth or throat in the morning
  • Morning headache
37
Q

What are the bed partner-reported symptoms of OSA?

A
  • Snoring
  • Witnessed apneas
  • Restless sleep
  • Irritability
38
Q

What are the risk factors for OSA?

A
  • Overweight & obesity
  • Neck circumference
  • Facial shape
  • Family history
  • Age & gender
39
Q

What are the treatment options for OSA?

A
  • Lifestyle changes (weight loss, PA, sedation, alcohol, smoking, sleep hygiene)
  • Positional therapy
  • Oropharyngeal exercises
  • Oral appliances
  • Provent
  • Surgery
  • CPAP/APAP
40
Q

What are the outcomes of CPAP for OSA?

A

Improved:

  • Subjective and objective sleepiness
  • Neurocognitive function
  • QOL measures
  • Cardiac function in heart failure
  • Insulin sensitivity

Reduced:

  • BP
  • Arrhythmia
41
Q

What is restless legs syndrome (RLS)?

A
  • Unpleasant sensations in the legs when in a relaxed & restful state therefore disrupting sleep
  • Patients report “creepy-crawly” leg sensations that are only relieved by moving the legs
  • Occurs in 10-20% of older adults (90% have PLMs)
42
Q

What is periodic leg movements syndrome (PLMS)?

A
  • Legs kick or jerk for between 0.5 and 5 seconds at 4-90% intervals during sleep
  • May be associate with insomnia or sleepiness
  • Prevalence increases with age & is ~45% in the elderly

Physio in the Ageing (10 decks)

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