Transcript Sleep Disorders in Long

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