Sleep Problems Flashcards
do elderly people have an increased or decreased sleep latency?
increased
latency=time to fall asleep
when should we consider polysomnography in an elderly patient? (5)
if primary sleep disorder is suspected:
1) sleep apnea
2) narcolepsy
3) periodic limb movement disorder
4) violent or unusual behaviors during sleep
5) other sleep sx that don’t respond to tx
what can be used in the home to screen for sleep apnea?
in-home portable monitoring
what can we give our patient to use that provides an estimate for sleep vs. wakefulness throughout the night?
wrist-activity monitor
helpful in nursing home setting to identify circadian rhythm disorders
what are the 3 diagnostic criteria for insomnia?
1) difficulty falling asleep, staying asleep, waking too early, or sleep that is non-restorative or poor in quality
2) adequate opportunity and circumstances for sleeping
3) daytime impairment related to the sleep complaint, such as fatigue, poor attention, mood disturbance, daytime sleepiness
______ is a common cause of sleep problems
depression
treating depression may improve sleep abnormalities
what are a few common medical problems that can contribute to sleep difficulties?
1) pain from arthritis
2) paresthesias
3) cough
4) dyspnea (cardiac, pulm dz)
5) GERD
_____ can lead to sleep difficulties because of increased frequency of urinatino
diuretics
what are 3 drug classes that can induce nightmares and impair sleep in the elderly?
1) antidepressants
2) antiparkinson agents
3) anti-HTN (propranolol)
what is alcohol abuse’s effect on sleep?
lighter sleep of shorter duration
can worsen sleep apnea
what is the term for the sleep disorder with episodes of cessation of breathing without associated respiratory effort?
central sleep apnea
the ______ pattern of sleep apnea has a crescendo-decrescendo pattern of breathing
cheynes-stokes
what are common causes of central sleep apnea? what should initial treatment focus on?
opioid use, stroke, heart failure, or other conditions
initial TX should focus on management of heart failure, if present
______ sleep apnea is characterized by a complete or partial (hyponea) upper airway obstruction during sleep, with evidence of respiratory effort during the events
obstructive sleep apnea
what will your OSA patient complain of throughout the day?
daytime sleepiness morning headache personality change poor memory, confusion irritability
what might the person with OSA’s bed partner report in their partner during the night?
loud snoring ,cessation of breathing, choking during sleep
what are 2 important predictors of OSA?
high BMI and large neck circumference
others: alcoholism, male gender, dementia
what should we do to confirm DX if we suspect OSA? what is the main treatment?
sleep lab for evaluation
main tx = positive airway pressure
repetitive, stereotypic leg movements that occur during sleep is known as what?
restless leg syndrome
does restless leg syndrome occur during REM sleep or non-REM sleep?
non-REM sleep
diagnosis of periodic limb movement disorder requires what?
polysomnography
what is the name of the disorder characterized by an urge to move the legs, usually accompanied by an unpleasant sensation in the legs that occurs with inactivity?
restless leg syndrome
when are symptoms worst for restless leg syndrome? when are they best?
worst = night best = with movement
can restless leg syndrome involve the arms?
yes
how do we diagnose restless leg syndrome?
clinically
does not require polysomnography
what disorder do most patients with restless leg syndrome also have?
periodic limb movement syndrome
how do we treat restless leg syndrome?
dopaminergic agent is initial agent of choice
what is the difference between a delayed sleep phase and an advanced sleep phase?
delayed = fall asleep late, awaken late
advanced = fall asleep early, awaken early (common in old people)
problems with delays or advanced sleep phases may respond to what?
appropriately timed bright light
what is the name of the disorder characterized by excessive motor activities during sleep and a pathologic absence of the normal muscle atonia during REM sleep?
REM sleep behavior disorder
what underlying disorder is REM sleep behavior disorder often linked with?
neurodegenerative disorders
what are presenting symptoms of REM sleep behavior disorder?
vigorous sleep behaviors associated with vivid dreams
might result in injury to patient or bed partner
what is the first step when working up REM sleep behavior disorder?
review meds!
TCA, MAOIs, fluoxetine, venlafaxine, cholinesterase inhibitors may be at fault
what is needed to confirm DX of REM sleep behavior disorder?
polysomnography
what are the 4 treatment option for REM sleep behavior disorder?
1) if drug induced – discontinue
2) clonazepam – adverse effects a concern in older patients
3) melatonin
4) environmental safety interventions
people with dementia are more likely to have a higher percentage of sleep in stage ____ and decreases in stage ___ and ____
more sleep in stage 1
less sleep in stage 3 and 4
true or false, people with dementia are more likely to sleep during the day and have nighttime wakefulness?
true
what minor fix can help improve sleep quality in a patient with dementia?
give their cholinesterase inhibitors IN THE MORNING (they exacerbate insomnia and cause vivid dreams)
should we use sedatives or hypnotics in our patients with dementia?
no; they have not been adequately tested in this population
what non-pharmacologic treatment can we use for dementia patient’s with sleep difficulties?
bright light therapy
patient just moved into a nursing home and can’t stand the sleep-disruptive environment. what are some non-pharm treatments we can give her?
1) daytime bright light exposure
2) change medication times; allow patient to sleep in
3) back rub, warm drink, relaxation tape
which drug class should we use when treating a patient’s sleep difficulties, benzodiazepines or antihistamines (like diphenhydramine)?
use benzos
do NOT use antihistamines
patients in the hospital on ______ are at high risk for sleep-related breathing disorders
opioids
if your patients history and PE do not suggest a serious underlying cause of their sleeplessness, where should you start?
improved sleep hygiene
what is the first line treatment for chronic insomnia?
cognitive behavioral therapy
combine with sleep restriction, stimulus control and cognitive therapy, +/- relaxation techniques
generally, we want to try our best to avoid sleep medications. why?
increased risk of falls
are short or intermediate acting agents used for problems INITIATING sleep? what is the main side effect with these?
short acting agents for initiating sleep
more rebound and withdrawal syndromes after discontinuation
are short or intermediate acting agents used for problems MAINTAINING sleep? what is the main side effect with these?
intermediate acting
more daytime carry over
studies have shown that chronic ______ use increases morbidity and mortality
benzodiazepines
does chronic use of benzodiazepines exacerbate sleep problems?
yes
how can we help eliminate the need for benzos in our patient who requires more intense therapy for their insomnia?
1) decrease dose by half for 2 weeks prior to full withdrawal; may need to taper more slowly
2) add replacement tablet (tylenol PM or melatonin) after tapering off benzo
3) refer to CBT
there is evidence for usefulness of _______ in circadian rhythm disturbances
melatonin
what 3 non-prescription sleep products are not generally recommended for sleep?
1) sedating antihistamines (like benadryl – anticholinergic SE)
2) alcohol (messes up sleep later in night)
3) valerian (herbal, little effectiveness)
