This page has moved. Click here to view.
I. Introduction
- 12%-15% of all people have experienced serious sleep problems
- Not all sleep problems are insomnia
- The elderly receive almost 40% of all sedative-hypnotic prescriptions
- Several classifications of sleep disorders exist
II. Classification of Sleep Disorders
- Primary Sleep Disorder: sleep disorder is the primary or only manifestation of the problem
- Secondary Sleep Disorder: sleep disturbance is pan of a larger symptom complex
- Parasomnias: involve activities that would be more or less normal if performed during wakefulness, but are performed during sleep
III. Classification of Sleep Disorders
- Disorders of initiation and maintenance of sleep (DIMS)
- Disorders of excessive sleep (DOES)
- Disorders of the sleep-wake cycle
- Parasomnias
IV. Methods Used to Investigate Sleep Disorders
- Interviews
- Sleep diaries
- Questionnaires
- Polygraphy
- Visual observation
V. Survey Data of Sleep in the Elderly
- Increased time in bed
- Increased nocturnal awakening
- Decreased total sleep time
- Increased sleep onset latency
- Dissatisfaction with their sleep
- Daytime fatigue
- More frequent napping
VI. History of Sleep
- Previously thought to be a uniform state
- 1935: EEG changes noted (Loom/s)
- 1953: REM stage noted (Aserinsky & Kleitman)
- 1955: REM linked to dreaming (Dement & Kleitman)
VII. Sleep Stages-- NREM: orthodox sleep; the "S-state"
- Stage 1: transition phase, low voltage mixed frequency EEG (3-7 eps), 5%-10% of total sleep time (TST)
- Stage 2: sleep spindles (12-14 cps, 1/2-2 see) and K complexes, 40%-50% of TST
- Delta sleep: >20% waves with frequency 1/2-2 cps or slower, amplitude 75 uv peak to peak, 20%-30% TST. Sleep Stages-REM: paradoxical sleep, the "D-state"
- Alternates with NR.EM at 90-minute intervals
- Decreased muscle tone
- High incidence of sequential dream recall if awakened
- Low voltage, fast EEG with sawtooth waves
- Increased penile turgidity
- Increased cerebral blood flow
- Increased oxygen consumption
IX. Sleep Cycles
- First cycle progression: relaxed wakefulness (alpha waves) - stage 1 » stage 2 » delta (30-45 min after sleep onset) » stage 2 » REM (lst REM usually 70-90 rain after sleep onset for approximately 5 rain)
- Second cycle progression: starts when stage 2 recurs after 1st REM stage
- Stage 2 and REM alternate at 90 rain cycles
- Delta sleep is rare in later cycles
- Delta sleep is "deepest" sleep
X. Circadian Rhythm
-An innate endogenous rhythm of bodily functions
- Rhythm trained by environmental cues (Zeitgebers, eg, clocks, alarms, sun)
- Usually a 25-hour rhythm
- Adjustments to shift work take approximately one week
- The rhythm can be manipulated behaviorally; can force only wakefulness, not sleep
XI. Neurological Basis of Sleep
- 1890: (Mauthner)--speculated that area bear nucleus of 3rd cranial nerve related to sleep induction based on postmortem exams of patients with encephalitis and sleepiness
-1935: (Bremer)-encephale isole, cerveau isole, concluded that junction between diencephalon and brain stem crucial to sleep and wakefulness
-1949: (Momzzi & Magoun)--proposed existence of reticular activating system (RAS) for maintaining arousal
-1974: (Hobson)--wake-sleep-REM depends on 3 neurological systems
XII. Hobson-McCarley Model
-Wakefulness: maintained via activity in the ascending RAS
- Sleep: need both active hypnagogic sleep system and low activity in RAS
- REM: active involvement of nucleus ceruleus and gigantocellular field
XIII. Biochemical Basis of Sleep
- Norepinephrine: lesions of, noradrenergic neurons (locus ceruleus) result in decreased EEG signs of wakefulness and decreased REM
- Serotonin: lesions at serotonergic neurons (raphe nuclei in cats) result in insomnia relieved by treatment with serotonin precursors, eg, L-tryptophan administration decreases sleep latency
XIV. Sleep Lab Studies in the Elderly
- Show marked reduction in NKEM stages 3 and 4 (delta)
- Show marked reduction in sleep efficiency
- Show increased number of awakenings after sleep onset
- Show increased daytime sleepiness
- Show a longer adjustment time to sleep-wake schedule changes
XV. The Need for Sleep
- Not all people need the same amount
- We can decrease our need for sleep
- Sleep deprivation results in fatigue, irritability, paranoia
- Selective KEM deprivation results in REM rebound
XVI. Sleep Hygiene
-Exercise: athletes have more delta sleep
- Environment: unfamiliar surroundings, uncomfortable sleeping surfaces, noise and changes in temperature disrupt sleep
- Food: weight gain is associated with long uninterrupted sleep, while weight loss is associated with short fragmented sleep
- Sedative-hypnotics often worsen sleep
XVII. Primary Sleep Disorders
- Narcolepsy
- Sleep apnea
- Primary insomnia
- Primary hypersomnia
- Nocturnal myoclonus: stereotyped twitches every 2040 seconds
- Restless legs syndrome: 1/3 familial, a pre-sleep problem
- Nourestorative sleep: chronic alpha intrusion
- Pseudoinsomnia: claims of little sleep despite observation of sleep
- Periodic hypersomnia
- Kleine-Levin syndrome: increased sleepiness and appetite, mostly in young males
- Neutral state syndrome: excessive daytime sleepiness, automatic behaviors, microsleeps
- REM interruption insomnia
- Painful nocturnal erections
XVIII. Narcolepsy
- Sleep attacks: brief, 10-15 min, irresistible, and may occur in inappropriate circumstances
- Cataplexy: transient weakness while conscious, triggered by emotions
- Sleep paralysis: upon falling asleep or awakening, broken by touch, respiration not affected
- Hypnagogic hallucinations
- Pathophysiology: a disorder of immediate REM onset
XIX. Sleep Apnea
XX. Secondary Sleep Disorders: Medical- Diagnosed: by having >30 apneic episodes during seven hours of REM and NREM sleep
- Symptoms: excessive daytime sleepiness, snoring, decreased attention, irritability, depression, and abnormal behaviors during sleep
- Signs: obesity, hypertension
- Types: central, upper airway, mixed
- Neurological disorders: disruption of the sleep-wake-REM systems
- Thyroid disorders: hyper » fragmented sleep; hypo » increased sleepiness and decreased delta
- Renal insufficiency: short, fragmented sleep
- Stimulants: insomnia
- Starvation: insomnia
- Pain: insomnia
- Sleep-exacerbated disorders: e.g., paroxysmal nocturnal dyspnea
- Iatrogenic problems: use of hypnotics
XXI. Considerations in Prescribing Hypnotics to the Elderly
- Consider changes in absorption, distribution, and elimination; in general, decrease the dose by 30%-50%
- Beware of the effect on sleep apnea
- Consider long-lasting effects on daytime performance and alertness
- The elderly have twice the incidence of adverse side effects and drug interactions
XXII. Evaluation of Hypnotic Agents
- How well does the drug work initially?
- How long does the drug work?
- How good is the daytime performance?
- How good is sleep after chronic use of the drug?
- What happens when the drug is discontinued?
XXIII. Sleep Medications
- Benzodiazepines: effective, fatal OD is rare
- Barbiturates, glutethimide, ethchlorvynol: potentiate liver enzymes; high risk of abuse
- Antihistamines: potentiate anticholinergic agents; relatively safe
- Chloral hydrate: affects protein binding
- Tricyclic antidepressants: non-specific; low margin of safety
- Antipsychotics: risk of tardive dyskinesia
- Over-the-counter agents: scopolamine causes grogginess
XXIV. Secondary Sleep Problems: Psychiatric
- Depression: early morning awakening; reduced REM latency
- Manic-depressive illness: decreased % REM sleep with mania
- Schizophrenia: sleep worse in acute phase
- Alcoholism: decreases REM and ages sleep pattern
- Anxiety: causes pre-sleep worry
XXV. Secondary Sleep Problems: Behavioral Problems
- Conditioned insomnia
- Internal arousal
- Disturbance of sleep-wake rhythm
- Self image and sleep phobia
XXVI. Parasonmias: Types
- Somnambulism: sleepwalking; delta stage; not usually associated with dreaming; low levels of arousal; amnestic on arousal- Night tenors: extreme autonomic arousal
- Enuresis: bedwetting; predominantly NREM; outgrown
- Nocturnal bruxism: teeth grinding; often follows an alerting response
- Violent rhythmic movements during sleep
XXVII. Parasornnias: Characteristics
- More common in children
- Tend to occur early in the night
- An individual may show more than one type
- Individuals are usually amnestic for an episode
- Difficult to arouse during an episode
XXVIII. Sleep-Wake Disorders in the Elderly
- Sleep apnea is common: 35% without sleep complaints have it; 50% of all elderly referred to sleep centers have it
- Periodic leg movements increase with age
- Sleep pathology related to drugs, alcohol, and chronic medical illness increases
- Daytime sleepiness is more common
- Sleep problems in association with depression increase
- Circadian rhythm disturbances increase
XXIX. Excessive Daytime Sleepiness
- Narcolepsy
- Sleep apnea
- Kleine-Levin syndrome
- Neurological disorders
- Metabolic abnormalities
- Toxins
- Drugs
XXX. Questions to Ask Related to Excessive Daytime Somnolence
- Are there unusual muscular experiences?
- Is there snoring?
- What medications are being used?
XXXI. Insomnia
- Primary or idiopathic
- Psychiatric disorders
- Environmental problems
- Phase shifts
- Dream-related
- Sleep apnea
- Restless legs syndrome
- Nocturnal myoclonus
- Oversleeping
- Drug-related
- Neurological
- Medical
XXXII. Questions to Ask When Insomnia is Present
- Are there medical problems?
- Are there psychiatric problems?
- Are there behavioral problems?
- Does wakefulness occur every 90 minutes?
- Does insomnia really exist?
- Has the problem always existed?
XXXIII. Factors that Destroy Sleep
- Excessively noisy surroundings
- Excessively hot rooms
- Chronic use of hypnotics
- Caffeine in the evening
- Alcohol before bedtime
- Chronic use of tobacco
XXXIV. Factors that Improve Sleep
- Sleep only until refreshed
- Establish regular arousal time
- Maintain steady, daily exercise
- Eat light bedtime snack
- Read in bed instead of brooding