Sleep Issues & the Older Adult

1. Sleep Issues & the Older Adult Jerusalem Walker, BA, RN, BSN Nursing 707

2. Appreciate the significance of sleep issues for the older adult • Understand the pathophysiology and symptoms of sleep problems in older adults • Identify two assessment instruments for older adult sleep problems • Identify principles of non-pharmacological interventions Learning Objectives

3. Sleep problems in older adults: • May make underlying illnesses worse • Are associated with increased risk of HTN, depression, cardiovascular disease, and stroke • May alter mood and behavior, especially for the cognitively impaired • Increase risk of accidental injury (e.g., falls) • Negatively impact quality of life • Are often ignored by care providers (Bloom et al., 2009; Crowley, 2011; McEnany, 2011) Problem & significance

4. Approximately ½ of older adults report sleep difficulties • More common in women than men • 35% of women over 70 vs. 13% of men report moderate to severe insomnia • 2/3 of residents of long-term care facilities over age 64 have some form of sleep disturbance (Gentili, 2012) epidemiology

5. Alterations in regulation of circadian sleep-wake cycle • Decrease in sleep efficiency • Progressive decrease in total sleep time after age 50 • More frequent nocturnal awakenings, increased time spent awake after sleep onset • Decrease in slow wave sleep • Decrease in REM sleep • Earlier morning awakenings (Crowley, 2011; McEnany, 2011) Age-related changes

6. Primary sleep disorders • Sleep disordered breathing (e.g., obstructive sleep apnea) • Periodic limb movements during sleep • Restless legs syndrome • Secondary sleep disorders • Medical illnesses • Chronic pain • Psychiatric conditions • Drug-related • Psychosocial factors • Combination of these factors and age-related changes (Crowley, 2011; Gentili, 2012; McEnany, 2011) Causes of sleep disturbances Sleep disorders may be primary or caused by another problem, condition, or situation

7. Excessive daytime sleepiness • Fatigue • Impaired memory • Confusion • Stupor • Attention deficits and learning problems • Irritability and mood changes • Decreased healing • Weight gain Symptoms (Bloom et al., 2009; Crowley, 2011; McEnaney, 2011; Petit, Azad, Byszewski, Sarazan, & Power, 2003)

8. Normal sleep routine, including bedtime and waking time • Difficulty falling asleep • Number of nighttime awakenings • Difficulty falling back asleep after waking up • Snoring, or kicking or thrashing about • Nocturia • Daytime sleepiness • Number of naps during the day and duration • Dozing off unintentionally during the day • Sleep required to function well and feel alert • Current medications, including sleep medicines • Alcohol and food intake prior to bedtime (Bloom et al., 2009; Crowley, 2011; McEnaney, 2011) Assessment Questions

9. Polysomnography (sleep study) Comprehensive, multi-parametric recording of changes occurring during sleep • Actigraphy Device which is worn around the wrist or ankle which records movement: valid and reliable for assessing sleep duration • Pittsburgh Sleep Quality Index Self-report instrument which asks questions about sleep habits experienced on the majority of days for the past month (Buysse, Reynolds, Monk, Berman, & Kupfer, 1989; Petit et al, 2003; “Polysomnography,” 2012) Formal assessment tools

10. Regular time for sleeping and waking up • Avoid naps longer than 20 minutes • Avoid caffeine in the afternoon • No TV, radio, or reading in bed • Avoid excessive alcohol intake, especially before bedtime • Eat a light evening meal; light snack before bed if needed • Get up and do a quiet activity if unable to sleep for 30 minutes • Exercise daily, but avoid aerobic activity within 4 hours of bedtime • Light therapy, massage, relaxation techniques lifestyle modifications (Bloom et al., 2009; Crowley, 2011; McEnaney, 2011; Petit, 2003)

11. Identify underlying cause (e.g., anxiety, chronic pain) and treat with appropriate agents • Medications are second-line therapy after nonpharmacologic treatment has proven ineffective • Prescribe benzodiazepines with great caution; pay attention to half-life , liver metabolism and abuse liability • Polypharmacy increases the risk of drug interactions and side effects • Educate patients and monitor closely for adverse effects • Risk of use of antihistamines, antidepressants, antipsychotics, and anticonvulsants outweigh the benefits • Use of short-term medication therapy with behavioral modification may be more effective than either alone Medication Considerations (Bloom et al., 2009; Crowley, 2011; McEnaney, 2011; Petit, 2003)

12. References • Bloom, H. G., Ahmed, I., Alessi, C. A., Ancoli-Israel, S., Buysse, D. J., Kryger, M. H., Phillips, B. A., et al. (2009). Evidence-based recommendations for the assessment and management of sleep disorders in older persons. Journal of the American Geriatrics Society, 57(5), 761–789. • Buysse, D. J., Reynolds, C. F., Monk, T. H., Berman, S. R., & Kupfer, D. J. (1989). The Pittsburgh Sleep Quality Index: A new instrument for psychiatric practice and research. Psychiatry Research, 28(2), 193–213. • Crowley, K. (2011). Sleep and sleep disorders in older adults. Neuropsychology Review, 21(1), 41–53. doi:10.1007/s11065-010-9154-6 • Gentili, A. (2012). Geriatric sleep disorder. Retrieved October 20, 2012, from http://emedicine.medscape.com/article/292498-overview#a0104 • McEnany, G. P. (2011). Normal and disordered sleep late in life. Geropsychiatric And Mental Health Nursing (2nd ed., pp. 367–394). Jones & Bartlett Learning. • Petit, L., Azad, N., Byszewski, A., Sarazan, F. F.-A., & Power, B. (2003). Non‐pharmacological management of primary and secondary insomnia among older people: review of assessment tools and treatments. Age and Ageing, 32(1), 19–25. doi:10.1093/ageing/32.1.19 • Polysomnography. (2012, October 20).Wikipedia, the free encyclopedia. Retrieved from http://en.wikipedia.org/w/index.php?title=Polysomnography&oldid=513037384