Self Treatment of Insomnia in the Elderly

Ashdin Tavaria M.D., Nalaka S. Gooneratne M.D., Clara Kwan M.D., Nirav Patel M.D., Lavanya Madhusudan, Kathy C. Richards, Ph.D. May 18, 2010

Acknowledgement

Supported by: – The Hartford Foundation – Penn Center of Excellence – National Institute of Health

Introduction

Sleep disorders are common in the elderly, with up to 57% of older adults complaining of difficulties with their sleep 1

Prevalence of Insomnia by Age

40

Male Female

30 20 10 0 15-24 25-34 35-44 45-54

Age Group

55-64 >65 -Ohayon, J Psychiat Res 1997

Introduction

Sleep disorders can be associated with an increased risk of – Driving accidents 2-4 – Cardiovascular mortality 5 – Falls 6 – Depression 7 – Cognitive deficits 8

Insomnia-associated Mortality

3 2.5

2 1.5

1 0.5

0 Nighttime insomnia Daytime sleepiness Early awakening Sleep-onset delay

Nursing home study of 272 patients 2 year follow-up Adjusted for ADLs, age, gender Manabe et al., Gerontology 2000

Insomnia-associated Cognitive Impairment: Results 4 3.5

3 2.5

2 1.5

1 0.5

0 Non depressed, Incident Insomnia Non depressed, Chronic Insomnia Depressed, no insomnia at f/u Depressed, Incident Insomnia Depressed, Chronic Insomnia EPESE dataset, 3 year follow-up, n=6,444 Adjusted for demographic and health factors Cricco et al., JAGS 2001

Introduction

Despite the significant prevalence of sleep disorders, many older adults do not seek evaluation or treatment of their sleep problems Instead engage in a number of self treatment activities 9, 10

Study Methods

Purpose of this study was to explore – Different types of self-treatment strategies – Determine their perceived efficacy

Study Methods

Cross-sectional survey study consisting of a mailed questionnaire Adults over the age of 65 recruited from the greater Philadelphia area Penn Partners in Healthy Living Program Data Base which is an elder outreach program affiliated with the University of Pennsylvania Health System

Results

A total of 242 study questionnaires were completed Average of 4.8 treatments used per study participant (SD 2.9, range 0-13) Correlation between the number of treatments attempted and the PSQI sleep quality score (r=0.37, p<0.0001) – Suggested that study participants who had worse sleep quality had attempted more sleep treatments.

Results

Bar graph showing the number of treatments used by subjects

Results

Activity Sleep Hygiene “Listened to radio, music or watched TV” “Read a book, newspaper, magazine” “Took a nap the next day” “Did not nap the next day” “Had a snack” “Drank other liquids (tea, coffee, milk, etc.)” “Drank a beer, wine or other alcohol” “Spoke to someone on the telephone” “Smoked a cigarette” Environment “Adjusted temperature of the room, adjusted blankets or clothing” “Went to a different room to sleep” “Wear ear plugs” Percent 66.4

56.2

44.0

35.0

34.1

32.6

13.0

8.2

4.2

47.0

15.6

1.4

Medications “Took a pain medicine”

Results

“Took an over-the-counter sleeping pill (Tylenol PM, etc.)” “Took a prescription sleeping pill (Valium, Ativan, Sonata, etc.)” Alternative Therapies “Did relaxation exercise, hypnosis, meditated” “Took a vitamins or herb” “Took melatonin” “Went for acupuncture treatment” Other “Had a hot bath or massage” “Went for a walk or exercised (jogging, swimming, etc.)” Percent 40.1

30.6

22.1

15.3

11.0

10.6

1.9

29.6

18.6

Efficacy of Different Types of Self-treatment Strategies

Value

Prescription sleeping medicine Change room Change room temperature Radio or TV Read Took medicine for pain Took a nap the next day OTC sleep med Spoke to someone Alcohol Bath/massage Value 0 0.5

1 1.5

2 2.5

3

Efficacy of Different Types of Self-treatment Strategies

Results

Prescription sleeping pills were felt to be the most effective treatment option (2.5) Ear plugs (1.0) were felt to be the least effective Prescription medications had a perceived efficacy that was significantly larger than the other methods (p-value = 0.0024)

Results

In our study, most commonly used interventions were watching TV or listening to the radio, or reading Pain medications were the most commonly used form of medication highlighting the impact of pain as a contributing factor to insomnia in the elderly Of particular concern, nearly half of all subjects who used alcohol or over-the-counter sleeping aids had not told this to their health care provider

Results

Women are more likely to engage in broad range of activities to improve their sleep when compared to men Caucasians tended to rely on pharmacotherapy while African Americans tended to use social tools

Discussion

Wide array of treatment options used by elders for the management of their insomnia High usage rates of several treatments highlights the importance of inquiring about the broad range of treatment choices made by older adults as they seek to address their sleep complaints

Discussion

Some elderly patients are trying up to 13 different treatments

Discussion

Response rate may be affected by participants may have become discouraged by the end and chosen not to fill out additional questionnaire Patients may have underreported negatively viewed activities or treatments such as alcohol, smoking, or even medications

Discussion

Self treatment can be dangerous Patients are unaware of the interplay between aging and physiology, chronic diseases and drugs Polypharmacy can result in adverse drug drug interactions which can lead to confusion, falls, and incontinence – Over-the-counter sleep aids

Discussion

As Healthcare providers we must be asking our patients about their sleep patterns If they are having disturbances we must ask what if any self-treatment activities they are engaging in

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