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Sleep Disorders in Long-Term Care. Thomas Magnuson, M.D. Assistant Professor Division of Geriatric Psychiatry UNMC. To Get Your Nursing CEUs. After this program go to www.unmc.edu/nursing/mk . Your program ID number for the July 12 th program is 10CE028. Instructions are on the website.

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sleep disorders in long term care

Sleep Disorders in Long-Term Care

Thomas Magnuson, M.D.

Assistant Professor

Division of Geriatric Psychiatry

UNMC

to get your nursing ceus
To Get Your Nursing CEUs
  • After this program go to www.unmc.edu/nursing/mk.
  • Your program ID number for the July 12th program is 10CE028.
  • Instructions are on the website.
  • **All questions about continuing education credit and payment can be directed towards the College of Nursing at UNMC.**

Heidi KaschkeProgram Associate, Continuing Nursing Education402-559-7487hkaschke@unmc.edu

objectives
Objectives
  • Discuss the causes of sleep disruption in long-term care
  • Identify non-pharmacologic interventions possible to remedy sleep disruption
  • Assess pharmacologic interventions for sleep disruption
impact
Impact
  • Significant problem
    • Many residents with sleep problems
      • 50% of the elderly have sleep problems
      • 65% in Los Angeles area ALFs
    • Effect
      • Cognition
      • Physical health
      • Mood
      • Quality of life
      • Staff morale
well elderly
Well Elderly
  • Spend more time in bed to get the same amount of sleep
    • Total sleep time only mildly decreased from when younger
  • Increase in nighttime awakenings and daytime napping
    • Earlier bedtimes
    • Increased time to fall asleep
    • More easily aroused by sound
  • Daytime sleepiness not part of normal aging
long term care
Long-Term Care
  • More often self-report sleep problems
    • More severe self-report
  • Asleep at all hours, even mealtimes
    • Wake and sleep fragmentation
      • Wakefullness interrupted by brief sleep
      • Leads to extreme sleep-wake disruption
  • Distributed across the entire day
    • Rarely awake or asleep for hours
effects of poor sleep
Effects of Poor Sleep
  • Variety of problems
    • Irritability
    • Poor concentration
    • Decreased memory
    • Lessened reaction time
    • Poorer performance on tasks
  • Community dwelling elderly
    • More falls
    • Increased mortality
slide8
Case
  • 78-year-old demented female
    • Up at night, loud and disruptive
    • Sleeps much of the day
    • No activities
  • CAD, HTN, depression, hypothyroidism, h/o breast cancer, arthritis, GERD, constipation, incontinence
    • ASA, APAP, sertraline, synthroid, esomeprazole, metoprolol, furosemide, senna, MOM, oxybutynin, donepezil, memantine, hydrocodone/APAP
first questions
First Questions
  • How much are they sleeping?
    • Usually no one really knows
      • Up at night…sleeping pill
      • Up in the day…stimulant
    • Shifts need to talk to each other
    • Sleep is poorly documented
  • When are they sleeping?
    • Daytime?
    • Nighttime?
    • Both?
first intervention
First Intervention
  • Sleep chart
    • Daily
      • Every hour, on the hour
      • Not 4:01, just 4:00
    • 24 hours a day
      • For a week
    • Good general idea
      • Usually is around 9-11 hours a day
causes
Causes
  • Primary sleep disorders
  • Medical conditions
  • Psychiatric disorders
  • Medications/polypharmacy
  • Circadian rhythm problems
  • Environment
    • Noise and light at night
    • Low daytime light
  • Behavioral
    • Physical inactivity
    • More time in bed
primary sleep disorders
Primary Sleep Disorders
  • Sleep disordered breathing (SDB)
  • Restless Leg Syndrome (RLS)
  • Periodic Limb Movement Disorder (PLMD)
  • REM sleep behavior disorder (RBD)
sleep disordered breathing sdb
Sleep Disordered Breathing (SDB)
  • Airflow interrupted
    • Obesity common cause
  • Apnea/hypopnea
    • 10 second episodes
    • 15 times an hour
  • Low oxygen to brain
    • Disrupts sleep
  • LTC residents
    • 50-66% have at least mild SDB
  • Treatment is CPAP
    • Air forces airway open
restless leg syndrome rls
Restless Leg Syndrome (RLS)
  • Uncomfortable feeling in legs
    • Relieved by moving legs
  • Worse later in the day
    • Falling asleep is hard
  • Symptoms come on and worsen with age
    • Possible cause of motor restlessness and wandering
  • Treatment
    • ropinerole (Requip) and pramipexole (Mirapex)
periodic limb movement disorder plmd
Periodic Limb Movement Disorder (PLMD)
  • Legs kick, jerk during nighttime sleep
    • Easier to identify if one has asleep partner
    • Causes sleep fragmentation
  • Treatment
    • Much as RLS
    • ropinerole (Requip)
    • pramipexole (Mirapex)
rem sleep behavior disorder rbd
REM Sleep Behavior Disorder (RBD)
  • Usually CNS motor is paralyzed in REM
    • Except for breathing
  • Act out dreams
    • Prominent in older men, certain dementias
    • Safety is an issue
  • Treatment
    • clonazepam (Klonopin)
    • Secure the environment
slide17
Case
  • Workup
    • Sleep chart
      • Broken up
        • Averages 9.4 hours a day
        • Range 4-13 hours a day
    • Lab, medical tests
      • Oxygen saturation unremarkable
      • TSH normal
      • CBC, BMP normal
medications
Medications
  • Near bedtime
    • Lung medications/bronchodilators
      • caffeine, albuterol
    • Stimulants
      • methylphenidate (Ritalin)
  • Daytime sedation
    • Antihistamines
      • promethazine (Phenergan)
    • Anticholinergics
      • diphenhydramine (Benedryl)
    • Sedating antidepressants
      • nortriptyline, mirtazapine (Remeron) less than 30mg/d
medical conditions
Medical Conditions
  • Common
    • Pain
    • Parasthesias
    • Nighttime cough
    • Dyspnea
    • GERD
    • Incontinence or frequent nighttime urination
    • Neurodegenerative disorders
      • Parkinson’s disease, e.g.
dementia
Dementia
  • Common sleep problems
    • More sleep disruption
    • Lower sleep efficiency
    • More light sleep
    • Less deep sleep
    • Less REM
    • Sundowning
circadian rhythm
Circadian Rhythm
  • Body’s pattern of sleep/wake
    • Elderly
    • Blunted in amplitude
      • Less time in each sleep/wake cycle
    • Shifted in time
      • More daytime somnolence, nighttime awakenings
    • Less stable in LTC than in the community
    • May correlate with degree of dementia
    • Decreases survival in LTC
circadian rhythm22
Circadian Rhythm
  • Exerts much influence on the timing of sleep
    • Weak CR or reset CR may strongly influence sleep problems
  • How to try and fix
    • Exposure to bright light in the daytime
      • Regular scheduled exposure
    • Physical activity less important than light
    • Bright in the day, dark at night
slide23
Case
  • Medical conditions
    • GERD
      • Well controlled, no evidence of nighttime heartburn
      • No food for an hour before bedtime
    • Pain
      • No complaints on routine APAP
      • Signs of worsened pain not present
    • Incontinence
      • Oblivious at night
      • Toileting right before bedtime
slide24
Case
  • Medical conditions
    • Mood
      • Stable symptoms
    • Hypothyroidism
      • TSH normal
    • Primary sleep disorders
      • Oxygenation normal
      • No noted movements awake or asleep that resemble RLS or PLMD
      • No odd or unusual nighttime behavior
    • Dementia
      • Pattern of sleep problem sounds familiar
slide25
Case
  • Medications
    • hydrocodone/APAP (Vicodin)
      • Pain controlled well on APAP
      • Not used in awhile
    • sertraline (Zoloft)
      • Not a sedating antidepressant
      • Could give at nighttime
    • oxybutynin (Ditropan)
      • Anticholinergic, antihistaminergic
      • Can choose a less concerning agent
    • L-thyroxine (Synthroid)
      • Only if underused
night in ltc
Night in LTC
  • Many sleep problems in the environment
    • Shared rooms
    • Frequent noise and light interruptions
      • Extended, nightly basis
      • Most noise caused by workers
        • Doing personal cares
    • Room level light
      • Suppresses melatonin
      • Disrupts sleep
      • Changes CR
treatment
Treatment
  • Nonpharmacologic
    • Timed light exposure
      • More alert right after exposure
    • More active in the day
      • Mixed results
    • Lower noise and light levels
      • Hard to change the environment
treatment28
Treatment
  • Mixed approach
    • Daytime light exposure
    • Increased physical activity
    • Bedtime routine
    • Less time in bed
    • Minimize nighttime disruption
  • Results
    • Lessened daytime sedation
    • More social energy
    • More physically active
    • Hard to change nighttime noise and light levels
treatment29
Treatment
  • Pharmacologic treatment
    • Hypnotics
      • zolpidem (Ambien)
      • zaleplon (Sonata)
      • ramelteon (Rozerem)
    • Adverse events
      • Dizziness
      • Drowsiness
      • Falls
    • Not efficacious
      • Don’t give to someone sleeping 13 hours a day
    • Psychological dependence
treatment30
Treatment
  • Pharmacologic
    • Benzodiazepines
      • alprazolam (Xanax)
      • lorazepam (Ativan)
      • clonazepam (Klonopin)
    • Adverse events
      • Falls
      • Confusion
      • Sedation
      • Dependency
treatment31
Treatment
  • Pharmacologic
    • Sedating antidepressants
      • Tricyclics
        • Nortriptyline
        • Amitriptyline
    • Trazodone
    • Mirtazapine
  • Adverse events
    • Daytime sedation
    • Falls, orthostasis
    • Confusion, bladder retention, constipation, tachycardia
treatment32
Treatment
  • Melatonin
    • Hormone
    • Mixed results
  • Bad idea
    • Antipsychotics
    • Alcohol
    • Caffeine
    • Exercise prior to bedtime
slide33
Case
  • No noisy roommate
  • No routine awakenings
  • Environment is noisy
  • Often sitting in chair near front door
  • Falls asleep in her room
  • Rarely goes outside
slide34
Case
  • Likely dementia related
    • Timed light therapy
    • Take outdoors to sit in the sun
    • Discontinue prn narcotic
    • Changed oxybutynin
    • Allowed timed naps to limit time in bed
    • Made rigid bedtime routine
    • Dark at night, bright in the daytime
    • No sleeping pill
objectives35
Objectives
  • Discuss causes of sleep disruption in long-term care
  • Identify non-pharmacologic interventions possible to remedy sleep disruption
  • Assess pharmacologic interventions for sleep disruption