Sleep & Ageing Flashcards
How common are sleep problems in the elderly?
42% of 65 yo community-dwelling adults reported difficulty initiating or maintaining sleep
What is sleep?
A reversible behavioural state of perceptual disengagement from and unresponsiveness to the environment
Sleep is associated with changes in which physiological parameters?
- EEG: Electroencephalogram (brain activity)
- EOG: Electrooculogram (eye movements)
- EMG: Electromyogram (muscle activity/tone)
What is polysomnogram?
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
What measures are taken during home sleep studies?
- EEG
- EOG
- ECG
- Position
- Breathing movements (RIP)
- Breathing (airflow)
- O2 level (oximetry)
- Leg movements (Pizeo-electric)
What are some of the sleep stage changes with age?
- Decreased total sleep time
- Increased sleep latency (time taken to fall asleep)
- Decreased sleep efficiency
What evidence is there that sleep problems are related to associated health problems, not just the ageing process?
- 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
What does optimal sleep quantity depend on?
- Sleepiness
- Mood alteration
- Cognitive function
- Immune function
What are the components of the two process model of sleep regulation (sleep-wake cycle)?
- 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)
What is the circadian cycle?
- Intrinsic biological rhythm
- Associated with melatonin levels
- Modulated by various factors
- Main factor is light entering the eye
What physiological changes are associated with sleep during the circadian cycle?
- Decreased temperature
- Increased plasma growth hormone
- Increased plasma cortisol
- Decreased urinary potassium
How is the circadian cycle affected by age?
- Decreased melatonin excretion in the elderly
- Circadian cycle becomes weaker
- BUT homeostatic drive still exists
How can age change sleep regulation?
- 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)
What are the consequences of poor sleep in the elderly?
- Increased risk of falls
- Reduced QOL
- Symptoms of anxiety & depression
- Cognitive impairment
- Deficits in attention, response times, STM & performance
- Reduced survival
What are the most common sleep problems in the elderly?
- Insomnia/poor sleep
- Sleep Apnea
- Restless Legs Syndrome/ Periodic Leg Movements
- REM Behaviour Disorder
- Circadian Rhythm Disorders
- Hypersomnias
How is insomnia & poor sleep defined?
- 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
What factors does the diathesis-stress-response model show contribute to insomnia?
- 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)
How does the ratio of contributing factors to insomnia change over time?
- Acute insomnia: Precipitating
- Short-term insomnia: Precipitating > perpetuating
- Chronic: Perpetuating > precipitating
What are some of the additional causes of insomnia in the elderly?
- Psychiatric illness
- Psychosocial factors (loneliness, change of residence etc)
- Behavioural or environmental factors
- Primary sleep disorders
- Medications
- Medical disorders
What is the relationship between sleep & chronic pain?
- 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)
What factors perpetuate insomnia?
- 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
What are the treatments for insomnia?
- Cognitive behavioural therapy techniques
- If insomnia continues, recommend investigation & treatment of a sleep disorder
What does evidence show regarding cognitive behavioural therapy techniques for insomnia?
- Treatment is comprehensive, long-term & likely to be onerous
- CBT decreases sleep onset latency & improves pain severity
What does CBT involve?
- 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
What does the cognitive therapy component of CBT involve?
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
What advice can be given to a patient who is worried about not sleeping?
- Do not worry if you do not sleep
- You are not alone
- Sleep should be automatic
- Efforts to initiate sleep are counter productive
What are some techniques to deal with a racing mind?
- Allow time to unwind (1hr)
- Putting the day to rest
- Relaxation & imagery
- Give up trying to sleep
What advice can be given to promote sleep hygiene & relaxation?
- 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
What is OSA?
- Pauses in respiration during sleep
- Leads to haemodynamic changes (increase in BP, increased rates of arrhythmia, O2 desaturation)
- Fragments sleep (frequent arousal, nocturia)
How is OSA measured?
- RDI: Respiratory disturbance index
- AHI: Apnea hypopnea index (number of respiratory events per hour of sleep)
How is OSA severity graded?
AHI
- <5/hr = normal
- 5-14/hr = mild
- 15-30/hr = mod
- > 30/hr = severe
What is the prevalence of OSA in the elderly?
- 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)
Why is the airway more likely to obstruct as we age?
- 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
What are the potential health effects of OSA in the elderly?
- Mortality
- CV dysfunction
- Cognitive impairment & dementia
- Symptoms (e.g. sleepiness)
What does evidence show regarding the relationship between OSA, age and mortality?
- 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»_space; people react differently at different times of the lifespan
What are the patient reported symptoms of OSA?
- 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
What are the bed partner-reported symptoms of OSA?
- Snoring
- Witnessed apneas
- Restless sleep
- Irritability
What are the risk factors for OSA?
- Overweight & obesity
- Neck circumference
- Facial shape
- Family history
- Age & gender
What are the treatment options for OSA?
- Lifestyle changes (weight loss, PA, sedation, alcohol, smoking, sleep hygiene)
- Positional therapy
- Oropharyngeal exercises
- Oral appliances
- Provent
- Surgery
- CPAP/APAP
What are the outcomes of CPAP for OSA?
Improved:
- Subjective and objective sleepiness
- Neurocognitive function
- QOL measures
- Cardiac function in heart failure
- Insulin sensitivity
Reduced:
- BP
- Arrhythmia
What is restless legs syndrome (RLS)?
- 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)
What is periodic leg movements syndrome (PLMS)?
- 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
