Test 2 Flashcards
Sleep difficulties are common in older adults – one of most common complaints to their primary care providers.
Complaints associated with poor sleep…daytime fatigue, difficulty concentrating, low energy, depressed mood and problems with relationships.
Disordered sleep
Complaint is often ignored when older people complain about it in the doctor’s office as there are so many other issues to manage.
Sleeping pills common – benzodiazepines
Lack of sleep can profoundly affect quality of life and health- increases chance of accidents, falls, cognitive decline, diabetes, and higher rates of mortality.
In older people, it is an independent predictor of suicide.
Disordered sleep
Borbley(1982)
Two Process Model –
1) homeostatic process driven by sleep debt and need for sleep (different from fatigue with lethargy, low energy and anergia); and
2) circadian rhythm where light triggers wakefulness and darkness triggers melatonin, in a rhythm of peaks and valleys. Hormones (like melatonin) and neurotransmitters control circadian cycle and regulate timing of sleep.
Physiology of sleep
Five stages of ____:
Stage 1 – transition, drifting to sleep,
Stage 2 – light sleep,
Stage 3 &4 – progressively deeper and more restorative where pulse, respirations and metabolism slow, and
Stage 5 – REM vital signs similar to wakeful, where dreams occur, large muscle paralysis, inactivity.
With aging, the stage that tends to shorten the most is the REM stage (important for learning and memory).
sleep
Sleep initiation relies heavily on sleepiness, reflected in a high homeostatic drive or sleep debt, while sleep maintenance relies on a low circadian drive.
Napping reduces homeostatic drive or sleep debt.
Phase-advanced sleep pattern refers to the enactment of sleep too early in the day – going to sleep too early for the circadian day.
Phase-delayed sleep pattern refers to difficulty in getting to sleep and difficulty in getting up in the morning.
Physiology of sleep
Sleep is less efficient however sleep requirements remain unchanged
After the age of 50 sleep declines by 27 minutes per decade
Increase in frequent nocturnal awakening
A progressive decline in deeper states of sleep
More frequent and longer nighttime awakenings and
An overall reduction in REM sleep
Common changes in sleep patterns
psychological issues – anxiety, depression, bipolar disorders, dementia, delirium, psychosis or unrealistic sleep expectations.
Pain
Shortness of breath
GERD, constipation, diarrhea
Narcolepsy
Behavioral issues such as daytime napping, smoking, heavy meals near bedtime, inactivity
Environmental issues- watching TV in bed, noise, excessive light, bedding
Stimulant medications such as caffeine, nicotine, decongestants/antihistamines
Steroid medications
Common sleep disorders elderly
Antidepressants such as Wellbutrin, SSRI’s, Effexor
Alcohol (tends to cause waking during night)
Obstructive Sleep Apnea – age dependent, male dominant, obese – snore, apnea, heart rate, BP, muscle contraction of chest, abdomen, diaphragm
Restless Leg Syndrome – uncomfortable sensations in lower legs, attempt to relieve during sleep by moving legs or rising and walking. Associated with kidney failure, iron deficiency, vitamin deficiencies(e.g. magnesium), certain meds (e.g. SSRI’s), genetic.
Common sleep disorders elderly
Full medical work-up. Medical hx, medications, substance use, physical examination, labs (thyroid, iron, etc.).
Routine sleep patterns, normal bedtime, rising time
Habits before bed – food, drink, medications….
Bedtime activities once in bed
Nocturnal awakenings
Quality of sleep – scale 1-10
Daytime sleepiness
Daytime napping
Environment at hours of sleep – light, noise, temp
Symptoms at hour of sleep – pain, anxiety, fear, SOB
Sleep diary very helpful
Assessment of sleep
Sleep hx – define sleep problem: not being able to fall asleep (sleep latency), stay asleep (sleep efficiency), early morning awakening, not feeling refreshed, assess onset and clinical course, evaluate patterns, question partner, determine presence of other sleep disorders, obtain family history.
Assessment of sleep disorders
Understand potential sources of sleep problems and address the issues; correct dx –> correct intervention.
Focus on proper sleep hygiene and address sleep expectations…. Educate regarding sleep physiology.
Therapeutic interventions
Behavioural Interventions
Sleep hygiene
Sleep restriction
Cognitive-Behavioural Therapy for Insomnia
Relaxation Techniques
Complementary Therapies
Exercise
Light Therapy (see research article posted on Moodle)
Massage Therapy
Dietary Supplements
Therapeutic interventions
Medication management should supplement not replace behavioural interventions and other therapy.
Start with low doses, titrate slowly, watch for drug-drug interactions and side effects, use for short periods (up to 10 days) and discontinue.
Medications include antidepressants, nonbenzodiazepine hypnotics (e.g. zopiclone). Histamine receptors and benzodiazepines generally should be avoided for older adults. Melatonin not recommended for people with dementia.
When discontinuing sedative-hypnotic medications remember – physiological withdrawal and taper off, replace with sleep hygiene and address expectations.
Pharmacology interventions
Delirium - a syndrome of disturbed consciousness, attention, cognition, and perception; a complex interaction between medical conditions, cognitive functioning, and behaviour.
Delirium is life-threatening and can lead to permanent cognitive damage.
For many older adults it is the first indicator of a newly emerged underlying physical illness.
