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MANAGEMENT OF INSOMNIA IN ELDERLY

Dr Jai Singh Yadav,* Dr Samiksha**

Assistant Professor,Deptt.of Psychiatry,*Psychologist**

*Department of psychiatry IMS BHU**S.L.N.M Hospital, Varanasi

 

Introduction

Insomnia is defined as difficulty in initiating or maintaining sleep. It is more commonly under diagnosed in the geriatric population.1 There are many factors associated with aging, such as retirement, health problems, death of spouse/family members, loss, grief, loneliness, anxiety, depression as well as changes in circadian rythym.2

Insomnia, affect the quality of life (including excessive daytime sedation, physical, psychological, cognitive problems affecting overall health of the patient4), Unfortunately, the number of medications increases with age, which in itself can lead to more morbidity,  side effects such as falls5. Cognitive impairment, financial stressors, and even sleep disturbances6 the biggest sleep problem in older people is a feeling of not getting enough sleep (Insomnia) or not being rested. Treating insomnia in the elderly can improve the overall health of the patient, but care must be taken when medications are used in the elderly.1Sleep disorders also are linked with premature death. Normal duration of sleep in elderly gradually decreases up 5 to 7 hours and it is basic requirement of body. The disturbances    of         sleep may related to pathological.3,4
More than one half of people older than 64 years who live at home and two thirds of people older than 64 years who reside in a long-term care facility are estimated to have some form of sleep disturbance. Older women are more likely to experience insomnia than older men. In a large epidemiological study of people older than 70 years, 35% of women reported moderate-to-severe insomnia, compared to only 13% of men.1

Primary insomnia

Primary insomnia is defined as sleeplessness that is not attributable to a medical, psychiatric or environmental cause.17 Treatment of primary insomnia in older patients should take into account the psychological changes in sleep associated with age, described in part 1 of this review. In most cases, the initial approach should be behavior modification.18

 

 Secondary insomnia

 Sleep disruption, is common among older people due to medical conditions that cause sleepiness are so frequent in this subpopulation. Pain related to musculoskeletal disorders, including arthritis, constitutes one of the most common causes of insomnia in this subpopulation. In addition to anti-inflammatory medication, bedtime acetaminophen often promotes more restful sleep. Nocturia is also a common cause of sleep loss (and therefore, daytime fatigue) in elderly patients. Nocturnal is a primary contributor to nocturnal falls and related hip fractures.14  When present, nocturia should prompt the search for sleep apnea, diabetes, prostatic disease (in men) and bladder prolapsed (in women), and appropriate treatment thereof. Gastrointestinal reflux that disturbs sleep should prompt dietary counseling and may require therapy, such as use of a proton pump inhibitor.

Insomnia may be the presenting complaint in older patients who have depression or early dementia. Depressed patients who have insomnia will often improve with antidepressant medication in doses appropriate for the older patient.15 since older patients are the greatest consumers of medications, a thorough drug history is important. Consider over-the-counter medications, as well; these often contain ingredients that interfere with sleep (e.g., caffeine). Whenever possible, medications that may interfere with sleep should be eliminated.

Treatments for sleep disorders include over-the-counter and prescription medications, behavioral treatments, relaxation techniques, sleep hygiene, sleep restriction, light therapy7, cognitive behavioral therapies3,8 , valerian, Tai Chi, yoga, meditation, acupuncture, and acupressure9

There are several effective non pharmacological treatment approaches in insomnia. Phototherapy is an interesting non pharmacological therapy for insomnia. As already described, older people often have a phase advance in their circadian rhythm that leads to earlier sleep onset and earlier, often nighttime, awakening. Evening light therapy appears to be a particularly effective treatment for early-morning insomnia from a phase-advanced circadian rhythm.19 Timed exposure to bright light has improved sleep (REM) sleep and slow-wave sleep in older people.20 Light therapy may be effective even when given earlier in the day: bright light exposure at lunchtime improved disturbed sleep in non demented residents of a geriatric facility.21 In patients with dementia, bright light therapy was also effective in reducing daytime sleep.22

Sleep hygiene reducing and limiting intake of caffeine, tobacco, avoiding alcohol and other stimulants to the early part of the day, maintain consistent life routine, including the sleep -wake schedule, mea times and exercise time, avoiding strenuous physical activity.

Stimulus control technique: Go to bed only when sleepy, use the bed only for sleep and avoid other activity in bed (sexual activity being the only exception), and avoid day time naps unless take them regularly.

 Sleep Restriction Therapy-This technique increases homeostatic sleep drive and consolidates sleep.  In this therapy reduced their time in bed to equal the amount of time they sleep as established by sleep diary.   

 Relaxation Techniques: Relaxation techniques have great utility in treating insomnia. Progressive muscle relaxation; involves tensing and relaxing a series of muscles. .These techniques provide a positive sleep promoting behavior and reduce the focus on insomnia. First few weeks, should be practice outside of bed time. Once mastered, these techniques are implemented as part of pre sleep ritual.

Cognitive Behavior Therapy: CBT was effective in reducing sleep latency, walking up, early morning awakening and increasing sleep efficiency (Morin, 1993). These therapies provide course introduction, sleep architecture, physiology, Stimulus control and restriction, hypnotic medication taper, case examples of patients with insomnia, and heightened physical and psychological arousal, relaxation techniques and the concept of scheduled worry time.        

Pharmacological Management:                                                                                                                                                                                      

 Benzodiazepines have been the most common hypnotics used by older patients. They can be divided roughly into 3 groups: long-acting, intermediate-acting and short-acting (Benzodiazepines suppress stages 3, 4 and REM sleep, and increase stage 2 sleep. Clinically, they decrease sleep latency and nocturnal awakenings. In general, when administering benzodiazepines to elderly patients, adhere to the familiar admonition, “Start low, go slow.” Begin with no more than half the maximal dose recommended for younger adult patients, titrate slowly, and prescribe the drug for short periods only. Because continued use can produce drug tolerance, dependence and the potential for withdrawal symptoms, encourage patients to limit their use to 2 or 3 nights per week. Use of benzodiazepines by geriatric patients has been associated with mobility problems and decreased ability to perform the activities of daily living.12 older patients taking these medications should be carefully monitored for daytime sedation and impaired motor coordination; they are at increased risk of falling, with resultant hip fracture.25Older patients who have been taking benzodiazepines long-term are more likely to experience postoperative confusion.27Because hypnotic agents, especially benzodiazepines, can contribute to upper-airway obstruction during sleep, avoid prescribing them for patients with known or suspected obstructive sleep apnea. The benefits of the drugs may not justify the increased risk in people over 60 years of age, especially if the patient has additional risk factors for adverse cognitive or psychomotor events (e.g., confusion, falls).

For sleep-onset insomnia, a short-acting agent such as triazolam or oxazepam may be effective. However, case reports of confusion, amnesia and behavior problems with triazolam have been reported.18 Long-acting benzodiazepines such as diazepam, flurazepam and chlordiazepoxide are not recommended for elderly patients. Clonazepam should rarely be used, because of its potency and long duration of action. New non-benzodiazepine agents are now becoming increasingly popular and have been shown to be effective in the short-term treatment of insomnia. Non-benzodiazepine drugs generally disrupt normal sleep architecture less than do benzodiazepines.28 Examples of non-benzodiazepine agents include zolpidem, zaleplon, zopiclone and eszopiclone.29,31 Amitriptyline is sometimes prescribed as a sleep inducer, particularly when there is a suggestion of underlying depression. Curtis and associates, 20 using criteria based on risk of adverse events, found amitriptyline to be one of the most commonly prescribed drugs that they concluded should be avoided for elderly patients. Trazadon role in the treatment of primary insomnia.33

The relative melatonin deficiency that accompanies aging may therefore contribute to insomnia. Promoted by some as a more “natural” sleep remedy, some studies22 have in fact shown melatonin administration to be modestly effective in improving sleep quality in elderly patients, However, Buscemi and coauthors,23,24 in their meta-analysis, concluded that melatonin, although safe, is of limited value in treating most primary or secondary sleep disorders. There was some evidence that short-term use of melatonin was useful in treating delayed sleep-phase syndrome,26  a disorder of sleep timing in which people are able to fall asleep only at late times, and then have difficulties waking up for morning activities.

References

1.       Subramanian S, Surani S. Sleep disorders in the elderly. Geriatrics. Dec 2007;62(12):10-32.

2.       Avidan AY. Sleep in the geriatric patient population. Semin Neurol. Mar 2005;25(1):52-63.

3.       Mahowald MW, Bornemann MA. Sleep Complaints in the geriatric patient. Minn Med. Oct 2007;90(10):45-7.

4.       Cole C, Richards K. Sleep disruption in older adults. Harmful and by no means inevitable, it should bi assessed for and treated. Am J Nurs. May 2007;107(5):40-9.

5.       Latimer Hill E, Cummings RG, Lewis R, Carrington S, Le Couteur DG. Sleep disturbance and falls in older people. J Ger A bio Sci Med. Jan 2007;62(1):62-6.

6.       Barry PJ, Gallagher P, Ryan C. Inappropriate prescribing in geriatric patient. Curr Psychiatry Rep. Feb 2008;10(1):37-43.

7.       Gammack JK. Light therapy for insomnia in older adults. Clin Geritr Med. Feb 2008;24(1):139-49.

8.       Rybarczyk B, Lopez M, Benson R, Alsten C, Stepanski E. Efficacy of two behavioral treatment progrmas for comorbid geriatric insomnia. Psychol Aging. Jun 2002; 17(2):288-98.

9.       Gooneratne NS. Complementary and alternative medicine for sleep disturbance in older adults. Clin Geriatr Med. Feb 2008;24(1):121-38.

10.    Byles JE, Mishra GD, Harris MA. The experience of insomnia among older women. Sleep. Aug 2005; 1:28(8):972-9.

11.    Mirsa S, Malow BA. Evaluation of sleep distubances in older adults. Clin Geriatr Med. Feb 2008;24(1):15-26.

12.    Ancoli-Israel S, Ayalon. Diagnosis and treatment of sleep disorders in older adults. Am J Geriatr Psychiatry. Feb 2006; 14(2):95-103.

13.     Wolkove N, Elkholy O, Baltzan M, et al. Sleep and aging: 1. Sleep disorders commonly found in older people. CMAJ2007; 176(9):1299-304.

14.    Stewart RB, Moore MT, May FE, et al. Nocturia: a risk factor for falls in the elderly. J Am Geriatr Soc1992; 40:1217-20.

15. Barkin RL, Schwer WA, Barkin SJ. Recognition and management of depression in primary care: a focus on the elderly: a pharmcotherapeutic overview of the selection process among the traditional and new antidepressants. Am J Ther2000; 7:205-26.

16. Mcgaffigan S, Bliwise DL. The treatment of sundowning: a selective review of pharmacological and nonpharmacological studies. Drugs Aging1997;10:10-7.

17. Silber MH. Clinical practice Chronic insomnia. N Engl J Med2005; 353:803-10. 6 Ringdahl EN, Pereira SL, Delzell JE Jr. Treatment of primary insomnia. J Am Board Fam Pract2004; 17:212-9.

18. Lack L, Wright H, Kemp K, et al. The treatment of early morning awakening insomnia with 2 evenings of bright light. Sleep2005; 28:616-23.

19. Campbell SS, Dawson D, Anderson MW. Alleviation of sleep maintenance insomnia with timed exposure to bright light. J Am Geriatr Soc1993; 41:829-36.

20. Fukuda N, Kobayashi R, Kohsaka M, et al. Effects of bright light at lunchtime on sleep in patients in a geriatric hospital II. Psychiatry Clin Neurosci2001; 55:291-3.

21. Fetveit A, Bjorvatn B. Bright-light treatment reduces actigraphic-measured daytime sleep in nursing home patients with dementia: a pilot study. Am J Geriatr Psychiatry2005; 13:420-3

22. Satlin A, Volicer L, Ross V, et al. Bright light treatment of behavioral and sleep disturbances in patients with Alzheimer’s disease. Am J Psychiatry1992; 149:1028-32.

23. Gray SL, lacroix AZ, Hanlon JT, et al. Benzodiazepine use and physical disabilityin community-dwelling older adults. J Am Geriatr Soc2006; 54: 224-30.

24. Cumming RG, Le Couteur DG. Benzodiazepines and risk of hip fractures in older people: a review of the evidence. CNS Drugs2003; 17: 825-37.

25. Nelson J, Chouinard G; Canadian Society for Clinical Pharmacology. Guidelines for the clinical use of benzodiazepines: pharmacokinetics, dependency, rebound and withdrawal. Can J Clin Pharmacol1999;6: 69-83.

26. Kudoh A, Takase H, Takahira Y, et al. Postoperative confusion increases in elderly long-term benzodiazepine users. Anesth Analg2004;99: 1674-8.

27   Sanger DJ. The pharmacology and mechanisms of action of new generation,non benzodiazepine hypnotic agents. CNS Drugs2004; 18 (Suppl 1):9-15 [discussion: 41, 43-5].

28. Cotroneo A, Gareri P, Lacava R, et al. Use of zolpidem in over 75-year-old patients with sleep disorders and comorbidities. Arch Gerontol Geriatr Suppl2004;(9):93-6.

29. Scharf M, Erman M, Rosenberg R, et al. A 2-week efficacy and safety study of eszoplicone in elderly patients with primary insomnia. Sleep2005; 28: 720-7.

30. Curtis LH, Ostbye T, Sendersky V, et al. Inappropriate prescribing for elderly Americans in a large outpatient population. Arch Intern Med2004; 164: 1621-5.

31. James SP, Mendelson WB. The use of trazodone as a hypnotic: a critical review. J Clin Psychiatry2004; 65: 752-5.

32   Olde Rikkert MG, Rigaud AS. Melatonin in elderly patients with insomnia: a systematic review. Z Gerontol Geriatr2001;34: 491-7.

33. Buscemi N, Vandermeer B, Hooton N, et al. The efficacy and safety of exogenousmelatonin for primary sleep disorders: a meta-analysis. J Gen Intern Med2005; 20: 1151-8.

34. Buscemi N, Vandermeer B, Hooton N, et al. Efficacy and safety of exogenousmelatonin for secondary sleep disorders and sleep disorders accompanying sleep restriction: meta-analysis. BMJ2006; 332: 385-93.