Sleepy
>2/3 of OAs with multi-morbidity have sleep problems. What are 2 common sleep complaints?
1) Difficulty falling asleep
2) Nighttime awakening
3) Early morning awakening
4) Daytime sleepiness
True/False: subjective sleep issues are associated with worse health related quality of life in OAs?
TRUE. Insomnia also has been a predictor of death and NH placement and subjective and objective worse sleep has been a/w subsequent cognitive decline in OAs.
What are some validated sleep questionnaires?
Link to Epworth sleepiness scale, Pittsburgh sleep quality index
What sleep phase does periodic limb movement during sleep happen? REM or NREM?
Repetitive stereotypic leg movements during NREM. When a/w clinical sleep disturbance then called "PLMD". Need to establish Dx w/ polysomnography.
What are some physiologic changes to sleep with aging?
More non-REM sleep, higher percentage of lighter sleep stages (N1, N2) and less of deep sleep (N3). Less REM and earlier onset of REM. Advancement of circadian rhythms (bed earlier, wake earlier).
When would you consider polysomnography?
Name 3 risk factors for insomnia disorder
female gender, social isolation, low SES, multiple medications, psychiatric illness, chronic illnesses -- "comorbid insomnia", being a caregiver
RLS - uncontrollable urge to move legs at night, a/w uncomfortable and unpleasant sensation of the legs that worsens with inactivity and improves with movement. How can this present in dementia pts?
Rubbing or massaging of legs, increased motor activity (pacing, wandering), leg discomfort in the evening or with inactivity that improves with movement.
*Review meds! (antiemetics, antipsychotics, SSRIs, TCAs, diphenhydramine)
**Check for IDA!
How would you evaluate suspected sleep disordered breathing in a NH pt with significant mobility issues?
Portable in-home devices that combine oximetry, hr, respiratory effort, nasal airflow can be used but less sensitive, so negative studies should be evaluated with in-lab polysomnography.
What could you do for a pt with CSA who can't tolerate PAP?
Nighttime O2 supplementation can reduce apnea and O2 desaturation
Comment from Dr. Evans?: "Adaptive servo-ventilation is a form of ventilation that can normalize breathing patterns in CSA by giving expiratory PAP and dynamic adjustment of inspiratory pressure support and an automatic back up rate. ASV is contraindicated in eF <45% due to increased CV mortality."
Is this a setting that can be done on any CPAP machine? How common is it used?
Pharm tx of RLS?
Sx severe enough to affect quality of life -- dopaminergic agents: pramipexole or ropinirole 1-2h before bed. Maybe carbidopa-levodopa as QHS PRN? Gabapentin if can't tolerate dopamine agonists
FALSE. Less likely to be a/w neck circumference and obesity in OAs.
*Make sure to screen for alcohol use
What can help establish a circadian sleep rhythm disorder (sleep-wake cycle disturbance)?
Sleep log, or if unable to do a sleep log, consider wrist actigraphy.
Tx: advanced sleep phase my respond to evening bright light, delayed sleep phase to morning bright light and/or evening melatonin; can use melatonin or tasimelteon (melatonin agonist) for blind pts.
True/False: OAs w/dementia have less sleep disruption, sleep efficiency, and fragmentation than OAs w/o dementia.
FALSE.
*Cholinesterase inhibitors can exacerbate insomnia and cause viid dreams.
*Melatonin in this pop. has mixed results, but one large RCT did not show benefit. Bright light therapy may have beneficial effects, most prominent in severe dementia.
When to consider pharmacotherapy?
Transient sleep problems a/w acute stressor (bereavement), chronic insomnia not responsive to behavioral therapy, after discussing risks/benefits. Non-benzos are better tolerated in healthy OAs. Start at smallest dose, esp. for women.
What is the Choosing wisely recommendation for sleep issues in OAs?
What conditions can be a/w REM sleep behavior disorder?
PD, LBD, multisystem atrophy can be predated by RSLBD by years. Psych meds.
*Dx: Polysomnography. Tx: clonazepam :( melatonin, environmental safety.
What are some insomnia behavioral interventions (different from sleep hygiene) that are used for chronic insomnia?
Stricter than sleep hygiene. Stimulus control; sleep restriction; cognitive interventions; relaxation techniques; CBT (combination of above, most effective); bright light.
What are some non-benzo drugs approved for insomnia?
Non-benzo benzo receptor agonists (zolpidem); melatonin recepter agonists (ramelteon); orexin receptor antagonsit (suvorexant); sedating antidepressants (doxepin, mirtazapine, trazodone)