Sleep Disturbances in Older Adults: Causes, Consequences, and Evaluation

Transcript

• 00:12Hi everyone, my name is Brian Minor.
• 00:14I'm an assistant professor in
• 00:17geriatrics at Yale University.
• 00:18I've done training in internal medicine,
• 00:20geriatrics and Sleep Medicine and
• 00:22today I'm going to talk to you about
• 00:25sleep disturbances in older adults
• 00:26causes consequences and evaluation.
• 00:28So let me start by telling you
• 00:32how I ended up where I am today.
• 00:35I'm showing you this picture of these
• 00:37two people sitting on this bench,
• 00:39and this is outside the Adler clinic,
• 00:41where I see patients who have sleep
• 00:45problems in addition to a lot of other
• 00:48problems that come along with older age.
• 00:51And our mission at the Adler
• 00:53Center is to improve the health,
• 00:56quality of life and independence
• 00:58of all older people.
• 00:59And this is how I got interested in sleep,
• 01:01because sleep problems are actually
• 01:03detrimental to all of those things.
• 01:05They impair the independence of our patients,
• 01:09and of course they are problematic
• 01:11for our patients,
• 01:12but they're also problematic for families.
• 01:14So this got me very interested in thinking
• 01:17about how can I help people to sleep better,
• 01:20to help their independence and also help
• 01:22the people who are caring for them.
• 01:25And the fact is,
• 01:27among this population,
• 01:28sleep problems are very common
• 01:30and detrimental.
• 01:31So what I'm showing you now is a graph
• 01:33where along the X axis we see the number
• 01:35of chronic conditions and along the Y
• 01:37axis we see prevalence of sleep problems.
• 01:39And the message here is that sleep
• 01:42problems increase with multimorbidity.
• 01:45So with people,
• 01:46older adults who have at least
• 01:48three chronic conditions,
• 01:50nearly 70% of them will report
• 01:52a sleep problem.
• 01:55And as I said, these are also
• 01:58detrimental to these people.
• 02:00So there are a lot of things that we
• 02:03know to be associated with poor sleep.
• 02:05Today, I'm going to focus on the things
• 02:08that are important to me as I care
• 02:10for older people in the community.
• 02:13We know that sleep problems cause
• 02:15problems with physical function,
• 02:17hospitalization,
• 02:18depression and other mood disturbances,
• 02:21cognitive impairment and
• 02:23institutionalization in a nursing home.
• 02:26This is really important to people.
• 02:28This is something they want to avoid.
• 02:29This is something and their
• 02:31family wants to avoid.
• 02:32So this becomes then a very important
• 02:35problem to have better solutions for.
• 02:37And the fact is that I know,
• 02:39as a geriatrician,
• 02:40there are a lot of things that we
• 02:42might consider in people to help
• 02:43with sleep that we don't want
• 02:45to consider in this population.
• 02:47I'm showing you now the Beers criteria,
• 02:50which is published by the
• 02:52American Geriatric Society.
• 02:53And these are medications that
• 02:56are potentially inappropriate
• 02:57for use in older adults.
• 02:59These are all the things that you might
• 03:02go to when you have somebody who's
• 03:04having trouble sleeping at night,
• 03:06You have your benzodiazepines
• 03:07and below that you have your
• 03:09benzodiazepine like medications.
• 03:11We call these oftentimes Z drugs.
• 03:13So this is your Azopo clone
• 03:15or Zopodam or Zolplon.
• 03:17And the fact is there's a strong
• 03:20recommendation from the American Geriatric
• 03:22Society to avoid use of these medications.
• 03:26And if you want to know why,
• 03:27you look need look no further than
• 03:29the rationale which shows that
• 03:31these medications are associated
• 03:33with cognitive impairment,
• 03:34delirium falls,
• 03:36motor vehicle crashes.
• 03:38So a lot of the things that we're trying
• 03:40to avoid when we care for older adults,
• 03:45also on this list but not
• 03:48necessarily listed here,
• 03:49I've added them at the bottom are other
• 03:51things you might use to help with sleep.
• 03:53These are also on the beers criteria and
• 03:55these are things like amitriptyline,
• 03:57Doxepin and higher doses and antihistamines
• 04:00like diphenhydramine or Benadryl.
• 04:04Well, I knew what I couldn't do.
• 04:06And so as I told you,
• 04:08I decided to do specific
• 04:10training and Sleep Medicine.
• 04:12And so now in the next part of the talk,
• 04:15I'm going to tell you about some of
• 04:17the things that I learned and how I
• 04:19evaluate sleep complaints in older people.
• 04:21So we'll start first with
• 04:23basic concepts and sleep.
• 04:28So first I want to talk about why
• 04:31we sleep or or rather how we sleep.
• 04:34This is the two process model that's
• 04:36well known to people in Sleep Medicine.
• 04:39And the two processes we're showing
• 04:41here are the circadian process,
• 04:43that's the yellow line,
• 04:44the yellow arrows you see going along
• 04:46the bottom and the homeostatic process,
• 04:48which is the grayish arrows that are
• 04:50going along the top of this picture.
• 04:52So these two processes interact
• 04:55and at times oppose each other.
• 04:58And this is what allows us
• 05:00to maintain sleep at night,
• 05:01but also to maintain wake during the day.
• 05:04So let me take you through.
• 05:05So first,
• 05:06if we're thinking about daytime wakefulness,
• 05:09in the first part of the day,
• 05:10we are awake because we slept at night,
• 05:13which is to say our homeostatic Dr.
• 05:15is low.
• 05:16So if you look at the
• 05:18slide and you see 9:00 AM,
• 05:19you see that very short Gray arrow.
• 05:21That's the homeostatic Dr.
• 05:23That's low because you
• 05:24slept well the night before.
• 05:26In the second part of the
• 05:28day and into the evening,
• 05:29we are awake because our
• 05:31circadian alertness is high.
• 05:33And this is opposing that sleep load,
• 05:36that homeostatic load.
• 05:37So if you look around after 3:00 PM,
• 05:41you can see the taller yellow arrows
• 05:44opposing those Gray homeostatic arrows.
• 05:47So that's why we're awake during the day.
• 05:50So then what happens at night?
• 05:52Well, at night we sleep because
• 05:54we have been awake all day.
• 05:56Again, that homeostatic Dr.
• 05:58is high and hopefully,
• 06:00as we'll get to a little
• 06:02bit later in the talk,
• 06:04you haven't napped during the day
• 06:06because napping will of course
• 06:07dissipate that homeostatic drive.
• 06:09So we get to that first part of the night
• 06:12and our drive to sleep is very high,
• 06:15and then in the second part of
• 06:17the night we are sleeping because
• 06:18the circadian alertness is low.
• 06:20So even though we're dissipating
• 06:22that homeostatic Dr.
• 06:23you see those Gray arrows getting shorter,
• 06:26Those yellow area arrows also decrease.
• 06:29So the circadian alertness is low.
• 06:31This allows us to continue to
• 06:34sleep even later into the night
• 06:36and the early morning.
• 06:38So that's how we sleep.
• 06:39Now let's talk about why we sleep,
• 06:41what are the different functions.
• 06:43This is a really interesting area
• 06:45of medicine that we're learning
• 06:46more and more about all the time.
• 06:48We know that sleep is important for
• 06:51hormone secretion and metabolic regulation.
• 06:54Sleep also helps our immune function,
• 06:56and recent studies with COVID have
• 06:59shown how people who are sleep
• 07:01deprived the night before they
• 07:02get the vaccine might not have as
• 07:04robust a response to the vaccine.
• 07:06So sleep definitely affects immune function.
• 07:10Sleep is also important for
• 07:12energy conservation,
• 07:12particularly in the brain.
• 07:15It's an important part of replenishment
• 07:19of brain macromolecules and it is
• 07:22responsible for removal of neurotoxic,
• 07:24neurotoxic waste,
• 07:25the socalled lymphatic system.
• 07:28This is a really exciting area of
• 07:30research that we're learning about.
• 07:32But the lymphatic system is
• 07:33thought to be active especially
• 07:35at night during certain
• 07:36parts of our sleep cycle.
• 07:38And those lymphatics then
• 07:40remove that neurotoxic waste,
• 07:42which otherwise might build up
• 07:44and put us at risk for things
• 07:47like Alzheimer's disease.
• 07:48Sleep is also important for cognitive
• 07:51function and memory consolidation.
• 07:53It's important for brain plasticity,
• 07:55synaptogenesis and recovery,
• 07:57and it's important for physical performance.
• 08:00So I'm showing you here a story from
• 08:03the MPA NBA showing you that even
• 08:05they have realized how important
• 08:06sleep is because they know it affects
• 08:09the performance of their athletes.
• 08:10And this is getting them very
• 08:12interested in thinking about how do
• 08:14they help their athletes sleep better
• 08:15when they're going across multiple
• 08:17time zones and they have these crazy
• 08:18schedules that might prevent sleep.
• 08:23So a little bit more about
• 08:25basics of sleep here.
• 08:27I'm showing you sleep architecture,
• 08:29by which I mean the different stages
• 08:31of sleep that we go through and how we
• 08:33cycle through them throughout the night.
• 08:35So on the X axis you see
• 08:36time across the night.
• 08:38So perhaps we start at a a sort of
• 08:40normal bedtime around 11:00 PM.
• 08:42We end at 7:00 AM and then on the Y axis
• 08:44you see the different stages of sleep.
• 08:47So we start and wake The next stage under
• 08:49that by convention is our REM sleep,
• 08:51that's our rapid eye movement or dream sleep.
• 08:54And then below that you see the
• 08:55different non REM stages of sleep.
• 08:57Stage one and stage two,
• 08:59those are our lighter stages.
• 09:00And then stage 3,
• 09:02which is our slow wave sleep.
• 09:04It can also be called M3 sleep.
• 09:06This is thought to be our most
• 09:09physically restorative sleep and
• 09:11so we may start awake around
• 09:1411:00 PM and then we fall asleep.
• 09:17We go into lighter stages and then
• 09:19early on you in the night you see we
• 09:22have that very deep restorative M3 sleep.
• 09:25And then usually about 90 minutes into sleep,
• 09:28we have our first REM period,
• 09:30which you see with that red line at the top.
• 09:33That first REM period is short,
• 09:34and then we cycle through the
• 09:36stages again and then RAM.
• 09:37As you see in the 2nd,
• 09:38between cycle two and three,
• 09:40there's a brief arousal.
• 09:42This often happens to end RAM and to
• 09:45continuous cycling through the stages.
• 09:48Towards the end of the night when
• 09:49we're looking at cycle 4 and cycle 5,
• 09:51you can see really at this point we're
• 09:53done with our deep restorative sleep
• 09:56and we're cycling between longer
• 09:58stages of REM and our lighter sleep.
• 10:01And so I like to point this out to
• 10:03say sleep is not an 8 hour coma.
• 10:05Sleep is a process through which
• 10:08we go through different stages,
• 10:10lighter and deeper.
• 10:11We cycle throughout the night and
• 10:13arousals from sleep may be normal.
• 10:18Here's another thing we know just
• 10:20about basics of normal sleep.
• 10:22I'm showing you sleep duration
• 10:24recommendations from the National
• 10:25Sleep Medicine Foundation and you
• 10:27can see there's quite a bit of
• 10:29variability across the lifespan.
• 10:30A newborn may be expected to sleep.
• 10:33That sweet spot is 14 to 17 hours a day
• 10:36that you see in that royal blue color.
• 10:38And so now let's focus on the
• 10:40other side of the screen and let's
• 10:42see that between our young adult,
• 10:45our middle-aged adult and our older adult,
• 10:48the sleep duration recommendation
• 10:50is about the same 7 to 8 hours
• 10:53in that royal blue color.
• 10:55And then in the teal color,
• 10:56you see that five or six hours on
• 10:59one side versus 9 hours on the
• 11:01other side may also be appropriate.
• 11:03So this recommendation of 7 to 8
• 11:06hours comes because we know that
• 11:08older adults who sleep for 7 to 8
• 11:10hours report better mental health,
• 11:13better physical health and better
• 11:15quality of life.
• 11:16But I do want to introduce the
• 11:18fact that there is variation here.
• 11:20There is a difference in terms of
• 11:22sleep need or in in this case,
• 11:24in terms of sleep duration.
• 11:26So shorter or longer times may
• 11:28be appropriate.
• 11:29But I also want to point out that
• 11:31very short or very long durations of
• 11:34sleep may signal that there's a sleep
• 11:37problem and that further history,
• 11:39physical and workup, is warranted.
• 11:45Now in the next part,
• 11:46since I've introduced you to basic concepts,
• 11:49I want to start to talk about what is
• 11:52unique about sleep in older adults.
• 11:56Here I'm showing you sleep
• 11:59architecture across different ages.
• 12:02And So what we know is that our time in
• 12:05different sleep stages does change as we age.
• 12:08This is normal.
• 12:09This has nothing to do with disease.
• 12:11This is just how for all of us,
• 12:14sleep will change as we get older.
• 12:16And so if we think about
• 12:17comparing a 10 year old,
• 12:19you see that down on the Y axis
• 12:21there versus a 55 year old.
• 12:23What I want to point out is that time
• 12:26in stage REM or in slow wave sleep
• 12:28will be much greater in younger ages
• 12:31than it is when we're in our fifties,
• 12:3460s and 70s.
• 12:36And there's a change so that we now
• 12:39spend more time in stage one and stage
• 12:42two sleep as we get to our 50s and older.
• 12:45So what this means is if we compare that
• 12:48sleep histogram that I showed you before,
• 12:51where we cycle through the different
• 12:53stages throughout the night,
• 12:54On the top you see the young adult,
• 12:56which is similar to the picture
• 12:57that I showed you already.
• 12:59So now let's compare what
• 13:00happens in the older adult,
• 13:01which you see at the bottom.
• 13:03And what you will notice is many more
• 13:05spikes to that awake stage of sleep.
• 13:08So arousals from sleep are much
• 13:10more common as we get older,
• 13:12and that causes a shift away from
• 13:15deeper stages towards lighter stages.
• 13:17But again,
• 13:17I want to point out these are
• 13:19arousals that are brief and the
• 13:21normal expectation is that they
• 13:23should be brief and that we are
• 13:24able to go back to sleep quickly.
• 13:29Here's another way that sleep
• 13:30may change with age. And again,
• 13:33this is another normal feature.
• 13:35So we may have something as we
• 13:37get older called a phase advance,
• 13:39which really means a preference to
• 13:41go to bed earlier and get up earlier.
• 13:43So now what I'm showing you
• 13:45in this picture is melatonin
• 13:47concentration over the night.
• 13:49And if we focus on the blue line first,
• 13:52this is our sort of normal or
• 13:54usual sleep phase where in the
• 13:56early evening around 8:00 PM,
• 13:57we have our dim light melatonin onset.
• 14:00Melatonin increases after that
• 14:02and then dissipates as we get
• 14:05towards 8:00 in the morning.
• 14:07So what is a normal feature for many
• 14:10older people is to have an advanced
• 14:12phase and that's shown in red.
• 14:13And so what's driving that is an
• 14:17earlier release of melatonin,
• 14:20so that melatonin onset comes on
• 14:22earlier and it dissipates earlier.
• 14:24And as a result,
• 14:25there may be a preference to go to bed
• 14:27earlier and therefore wake up earlier.
• 14:31The other thing that we know that
• 14:33changes with circadian rhythm and age is
• 14:35that there's a decreased amplitude of sleep,
• 14:38wake rhythm,
• 14:39body temperature and many different hormones.
• 14:42So the amplitude I'm
• 14:43showing you in this picture,
• 14:44that's the difference between
• 14:46the peak and the through of the
• 14:48concentration of different hormones,
• 14:49or even the difference in body temperature.
• 14:52So that difference that amplitude will
• 14:56naturally decrease as we get older.
• 14:59And then another thing that can be
• 15:01a normal feature of aging is the
• 15:03loss of ability to phase shift.
• 15:05So Simply put,
• 15:05this is what you need to do
• 15:07when you're changing time zones.
• 15:08You need to train your body to go
• 15:10to bed at a different time and
• 15:12wake up at a different time.
• 15:14And we know that as we get older,
• 15:15this shift becomes harder or takes longer.
• 15:21Now I want to talk about napping in older
• 15:23adults because this is a place where I
• 15:26think the literature can be very confusing.
• 15:28So let's go through this.
• 15:29So first, napping is common in older
• 15:33people and it gets more frequent with age.
• 15:35So 25 to 46% of adults greater
• 15:39than 65 years old may nap.
• 15:42And we have seen from the literature
• 15:44that napping might be associated
• 15:46with lots of negative outcomes.
• 15:48Falls, dementia, depression,
• 15:50diabetes, impaired quality of life.
• 15:52So there's a long list.
• 15:54However, some literature shows that napping
• 15:56might be associated with positive outcomes,
• 15:59like reduce cardiovascular risk
• 16:01or improved cognitive performance.
• 16:03So how do we,
• 16:05how do we rectify this difference
• 16:07that we're seeing in the literature?
• 16:10I want to take you through that to let
• 16:12you know whether when you're taking
• 16:15care of patients or seeing people in
• 16:18the community to figure out whether
• 16:20napping might be harmful or helpful.
• 16:23So first,
• 16:24we know from the literature that
• 16:26napping one to two times per week
• 16:28is associated with a lower incidence
• 16:31of cardiovascular events.
• 16:32However,
• 16:32in this same study,
• 16:34they showed no association more for more
• 16:36frequent napping or for nap duration,
• 16:39which is to say the total
• 16:40time that you're napping.
• 16:42So it does seem to suggest that lower
• 16:45frequency napping may be helpful,
• 16:47especially when we're looking
• 16:49at cardiovascular events.
• 16:51The other thing we know from the
• 16:53literature is that for persons age 75 to 94,
• 16:56a short nighttime sleep duration
• 16:59is associated with daytime naps
• 17:02being protective for mortality.
• 17:05However,
• 17:05for those people who might have
• 17:07long nighttime sleep duration
• 17:09greater than 9 hours,
• 17:10naps were associated with
• 17:12increased mortality risk.
• 17:13So here we're seeing that if the
• 17:16overnight sleep duration is long and
• 17:18that person requires a nap during the day,
• 17:21that is the napping that we think is is
• 17:24associated with more adverse outcomes.
• 17:29So if we look at napping,
• 17:30cardiovascular disease and mortality,
• 17:32I'll show you how we put
• 17:35together all of these results.
• 17:37So along the X axis, we have nap time,
• 17:39nap duration and along the Y axis here
• 17:42we have rate of cardiovascular incidence,
• 17:45rate of cardiovascular disease.
• 17:46And this is what we call a J curve.
• 17:49So in the beginning when we go from zero
• 17:51to 30, we see that risk of incident
• 17:55cardiovascular disease going down.
• 17:57And then after about 30 minutes
• 17:59the risk starts to go up.
• 18:02So here, shorter naps are better
• 18:05and longer naps suggest increased
• 18:08risk for cardiovascular disease.
• 18:11Now I'm showing you the
• 18:13mortality association.
• 18:14And so here what you can see is that
• 18:17there's a pretty linear association.
• 18:19However, when we get to about
• 18:2260 minutes on the X axis,
• 18:24that's when our 95% confidence
• 18:28interval goes above 1.
• 18:30So that's suggesting that NAP 60
• 18:32minutes and longer are significantly
• 18:35associated with increased mortality risk.
• 18:38So the bottom line here is napping for
• 18:41more than an hour is probably worse
• 18:44and associated with adverse outcomes.
• 18:46Weather napping is helpful or harmful
• 18:48has to do with a lot of things.
• 18:50It has to do with the frequency
• 18:53and the duration,
• 18:54and it has to do with the total
• 18:56overnight sleep duration.
• 18:59So next I want to talk about another
• 19:02important topic when we're thinking about
• 19:04sleep in older people. The fact is,
• 19:07as we age and we collect conditions,
• 19:08we also collect medications,
• 19:10and medications can affect
• 19:12sleep in many different ways.
• 19:14So here on the left side,
• 19:15what I'm showing you is
• 19:18the different domains.
• 19:20So we have domains of daytime drowsiness,
• 19:23we have medications that might be activating,
• 19:25we have medications that may exacerbate
• 19:28underlying primary sleep disorders or we
• 19:31have medications that may disrupt symptoms.
• 19:33And so I've I've given you
• 19:35some common examples here.
• 19:36But a medication that
• 19:37causes daytime drowsiness,
• 19:38such as an opiate or a benzodiazepine
• 19:42or even an an antihistamine,
• 19:44if that causes daytime drowsiness,
• 19:47it may then be harder for people
• 19:49to sleep at night.
• 19:50Whereas an activating medication,
• 19:52something like a steroid,
• 19:54certain antidepressants or
• 19:55methylphenidate may make it harder to
• 19:59initiate or maintain sleep at night.
• 20:01And then another one that I really
• 20:03like to focus on in my teaching
• 20:05is these medications that can
• 20:08exacerbate primary sleep disorders.
• 20:10And the commonest examples
• 20:12here are antidepressants.
• 20:13So these could be SSRI type antidepressants
• 20:17or even TCA antidepressants.
• 20:19These medications are known to
• 20:21cause restless leg syndrome or
• 20:23periodic leg movements during sleep,
• 20:26and they're also known to cause
• 20:29REM behavior disorder or RBD.
• 20:31Another very common problem that
• 20:33we run into is people taking
• 20:35Ambien or other benzodiazepine
• 20:37like medications those Z drugs.
• 20:40Those can cause parasomnia
• 20:41as things like sleepwalking,
• 20:43sleep eating,
• 20:44sleep driving.
• 20:45So those are definitely medications
• 20:47that we commonly see disrupting sleep.
• 20:50And then finally you you may be on a
• 20:53medication that's causing you to cough,
• 20:54for example,
• 20:55lisinopril that's causing nocturia
• 20:58like a diuretic medication.
• 21:00Or you might be on a medication
• 21:02like for diabetes that's causing
• 21:03you to be hypoglycemic at night.
• 21:05So that's another way that
• 21:07medications can disrupt sleep.
• 21:10And so again, I want to highlight this
• 21:13because I want you to remember going forward,
• 21:16if you have a patient with restless
• 21:18leg syndrome or REM behavior disorder,
• 21:21the first thing you want to do
• 21:22is look to the medication list
• 21:24to look for an antidepressant.
• 21:25And I also think this is good practice
• 21:28for taking care of older adults
• 21:29in general with a sleep problem.
• 21:31You should always look at
• 21:32the medication list.
• 21:36So next I want to talk about psychosocial
• 21:38and behavioral factors that may be
• 21:41especially important in older people.
• 21:43So these are things like substance use.
• 21:45This could be use of alcohol,
• 21:47nicotine or caffeine.
• 21:49The fact is, as we get older,
• 21:52our body's ability to break
• 21:53down these medications,
• 21:55to metabolize them changes.
• 21:56And so we may not be able to drink the
• 22:01same amount of alcohol or caffeine in
• 22:04our 30s and 40s and inner 80s and 90s.
• 22:07That same amount may have more
• 22:09of an effect on our body.
• 22:10And I think it's common knowledge among
• 22:12people that we take care of that.
• 22:14Alcohol may help you fall asleep,
• 22:17but they may not necessarily
• 22:18know that it may wake us up in
• 22:20the middle of the night as well.
• 22:22So substance use is definitely
• 22:24important to ask older adults about,
• 22:27especially if they have sleep problems.
• 22:29The next thing I want to
• 22:31bring up is caregiving.
• 22:32The fact is that one in five caregivers
• 22:34in this country is 65 or older,
• 22:36so they may have things related to
• 22:39that caregiver role that caused them
• 22:41to have trouble sleeping at night,
• 22:44and that may be things that are
• 22:46directly disruptive to their care.
• 22:47But it may be the burden itself of a
• 22:50caregiving that's causing sleep problems.
• 22:53Bereavement is sadly very common in this
• 22:55age group and that may impact their sleep.
• 22:59And then I want to talk a little
• 23:01bit about social social isolation
• 23:03and loss of physical function.
• 23:05These are very common in this older
• 23:07age group and so these can also
• 23:10have direct impacts on sleep through
• 23:13their effect on circadian rhythm.
• 23:16So people who are isolated or may
• 23:18have problems with physical function.
• 23:20They may have poor sleep hygiene,
• 23:22but they may also have inadequate
• 23:25exposure to zeitgebers.
• 23:26These are cues from the environment that
• 23:30help us maintain a normal circadian rhythm.
• 23:33And so you can see in this picture
• 23:35here I'm showing you the sun.
• 23:37This is our photic zeitgeber.
• 23:39This sends direct messaging
• 23:41through the eye to the SSC,
• 23:44and that's the suprachiasmatic nucleus.
• 23:46That's our master clock in our brain
• 23:49that controls time in our brain.
• 23:50But as you can see,
• 23:52it also controls the clock in all
• 23:54of our different peripheral organs.
• 23:56So that master clock gets signals
• 23:59from the sun in order to help
• 24:02us maintain a normal schedule.
• 24:04So you can see that people who
• 24:06are isolated or have poor physical
• 24:08function may not get adequate
• 24:10exposure to that site gaper.
• 24:12But also,
• 24:12I want to show you on the bottom that
• 24:15there are also nonphotic site gapers.
• 24:17These are things like physical activity,
• 24:20social time,
• 24:20and meals.
• 24:21These are also cues that help us
• 24:24maintain a normal sleepwake rhythm
• 24:25and that may be lost in people
• 24:28who are socially isolated or have
• 24:30problems with physical function and
• 24:33therefore problems getting out of
• 24:35the home to those social activities.
• 24:37So another thing that is unique
• 24:40about sleep in older
• 24:41people is that nearly every sleep
• 24:44disorder we see in the sleep clinic
• 24:47increases in prevalence with age.
• 24:49So these are things like
• 24:51obstructive sleep apnea,
• 24:52restless leg syndrome, insomnia,
• 24:54REM sleep behavior disorder and
• 24:56advanced sleep wake phase disorder.
• 24:58I haven't listed every single one,
• 25:00but these are some of the more
• 25:03prevalent ones that I want to talk
• 25:05about in the next few slides.
• 25:07So obstructive sleep apnea.
• 25:09I'm showing you in this picture in
• 25:12the bottom corner that very simply,
• 25:14this is obstruction of the airway during
• 25:17sleep that impairs the passage of oxygen
• 25:19from the upper airway to the lungs.
• 25:22And the most common feature we think of,
• 25:25as you can see in the picture,
• 25:26is snoring.
• 25:27That's a sign that people are having
• 25:30friction of flow through the airway and
• 25:32it could be a sound that people make
• 25:35once they open up their airway again.
• 25:37So that's obstructive sleep apnea.
• 25:40This, the prevalence,
• 25:41as I mentioned, increases with age.
• 25:43However,
• 25:44it is frequently undiagnosed
• 25:46in older people and so I want
• 25:48to tell you why that is.
• 25:50It's because it may present
• 25:52differently in this group.
• 25:53There's less snoring or pauses
• 25:56in breathing and there are more
• 25:59sleep related complaints among
• 26:00older people who have sleep apnea.
• 26:03And So what that means is that
• 26:05they might report more insomnia,
• 26:08or daytime sleepiness or even
• 26:10urination at night.
• 26:12Those are probably more commonly
• 26:14experienced and reported than things like
• 26:17snoring or witness pauses and breathing.
• 26:20The other things that I want to point
• 26:23out here are that obesity does not
• 26:25appear to be a major risk factor
• 26:28for sleep apnea and older people,
• 26:30and that as opposed to a middle-aged
• 26:33population where men have sleep
• 26:35apnea apnea more frequently
• 26:37when we get to our older ages,
• 26:39the prevalence among men and
• 26:41women of sleep apnea is the same.
• 26:46I think it's important if we're think
• 26:48specifically about sleep in older adults
• 26:50to talk about REM behavior disorder.
• 26:52The majority of these cases occur in
• 26:55people in their 6th or 7th decade.
• 26:58And REM sleep behavior disorder is
• 27:00often associated with an underlying
• 27:03neurodegenerative disorder that
• 27:04could be something like Parkinson's
• 27:07disease or Lewy body disease or
• 27:11other alpha synucleinopathies.
• 27:12And So what happens to cause this disorder
• 27:15is that there is a loss of REM atonia.
• 27:18So during our REM sleep,
• 27:20the only muscles that should have
• 27:21any tone or eye muscles and our
• 27:24diaphragm and that's protective.
• 27:26It keeps us from acting out our dreams.
• 27:28So people with REM behavior disorder
• 27:30have a loss of that atonia.
• 27:32And so you may see these symptoms acting
• 27:35out dreams and they may be injurious
• 27:37to the person or the bed partner.
• 27:40And then I mentioned recall and timing.
• 27:43First recall is that the person often
• 27:45wakes from the dream doing that
• 27:48activity that they were dreaming about
• 27:51and so they oftentimes remember it.
• 27:54And then in terms of timing,
• 27:55if you'll remember from our sleep histogram,
• 27:57most REM sleep occurs later on in
• 27:59the night and in the early morning.
• 28:01So therefore we think these symptoms
• 28:03are this acting out of dreams tends to
• 28:06happen more during that time of night.
• 28:10This is diagnosed through
• 28:13polysomnography which I'm going
• 28:15to talk about in a few slides.
• 28:18And treatment for this disorder
• 28:20includes both non pharmacologic
• 28:21and pharmacologic treatments.
• 28:23So non pharmacologic treatments are focused
• 28:26on making the bed environment safer,
• 28:29removing dangerous things from the bedside,
• 28:32removing things that a person
• 28:34might injure him or herself with
• 28:37during a dream enactment and
• 28:39then pharmacologic treatments.
• 28:40The mainstays of therapy are melatonin
• 28:43and clonazepam and melatonin.
• 28:45This is in higher doses,
• 28:466 milligrams and above is becoming
• 28:49favored because it has a better side
• 28:52effect profile than clonazepam,
• 28:53especially in older adults where
• 28:55we might be worried about over
• 28:57sedation and cognitive impairment.
• 29:01So, restless leg syndrome.
• 29:03This becomes more common with age.
• 29:05And so I just want to review
• 29:07how this is diagnosed.
• 29:08This is a clinical diagnosis,
• 29:10so a person might report an urge to move.
• 29:15And this is worse during inactivity.
• 29:18So it comes on.
• 29:18Perhaps when they're sitting in a
• 29:20chair for a prolonged period of time,
• 29:22or maybe they're on the couch watching TV,
• 29:25it is relieved by movement.
• 29:27So they'll tell you that they
• 29:28have to get up and walk,
• 29:30get up and move.
• 29:31But this is fleeting.
• 29:32As soon as they are inactive again,
• 29:35the sensation will return and
• 29:38then finally there is a circadian
• 29:40component to this diagnosis.
• 29:42These symptoms really should come
• 29:44on or be worse in the evening.
• 29:47So if a person has those four criteria,
• 29:51they meet a clinical diagnosis
• 29:53of restless leg syndrome.
• 29:54And what I'm showing you on the
• 29:56bottom here is that urge to move can
• 29:59be described in many different ways.
• 30:00A crawling and itching, A throbbing,
• 30:03a pulling in energy in the legs.
• 30:06So I usually like when I'm asking
• 30:09people about this to start with
• 30:11telling me do they have any
• 30:14bothersome feelings in their legs?
• 30:16And then I allow them to describe those.
• 30:19And if they can't come up with a
• 30:21specific characteristics that I
• 30:23provide them some options like these
• 30:24that I'm showing on the bottom to to
• 30:27fill us in on what they're actually
• 30:29sensing so that we can make a diagnosis.
• 30:34So next I'll talk about insomnia.
• 30:37So these the diagnosis
• 30:39here is based on symptoms,
• 30:41difficulty initiating sleep,
• 30:43difficulty maintaining sleep
• 30:46or early morning awakening.
• 30:49And these symptoms lead
• 30:51to a daytime impairment.
• 30:53This could be fatigue or low energy,
• 30:55could be cognitive or mood problems
• 30:58or impaired social functioning.
• 30:59So that's how we differentiate
• 31:02insomnia symptoms from insomnia disorder.
• 31:04The disorder is when the criteria #2 are met.
• 31:11And then I also want to talk about
• 31:13advanced sleep wake phase disorder,
• 31:15which I alluded to earlier
• 31:17in the in this presentation.
• 31:20So this is someone who has
• 31:22an advanced sleep phase,
• 31:23but now this is causing a complaint.
• 31:27Oftentimes the complaint comes
• 31:29from the bed partner or the spouse,
• 31:33the significant other,
• 31:34because they don't like the fact that
• 31:38around 7:00 or 8:00 at night their
• 31:41partner doesn't want to go out and do things.
• 31:43But it can also cause problems
• 31:46for the patient.
• 31:47And that's when we would differentiate
• 31:49between advanced sleep wake phase,
• 31:51an advanced sleep wake disorder.
• 31:53So somebody with this disorder might say
• 31:56that they wake up too early in the morning.
• 31:59Again, if they're going to bed
• 32:01around 8:00 in the morning,
• 32:02in the evening,
• 32:03they may wake up at 3:00 or 4:00
• 32:05in the morning.
• 32:08The other thing they may tell you is that
• 32:11they miss out on early evening activities
• 32:15because of when that sleep need occurs.
• 32:18So the treatment for this is the
• 32:21mainstays would really be timed
• 32:23light exposure and melatonin.
• 32:24So you would try to have early evening
• 32:28light exposure which would delay the
• 32:30sleep phase or melatonin in the morning,
• 32:33which would also delay the sleep phase.
• 32:36And it's important to tell these
• 32:38people to avoid early morning light.
• 32:40And that's because early morning
• 32:43light will advance them further
• 32:45and you're trying to delay them.
• 32:47The other thing you want to tell them
• 32:49is to avoid napping during the day.
• 32:51Again, you want to avoid dissipating
• 32:53that sleep drive during the day.
• 32:56So when they go to bed at night,
• 32:57they have a higher homeostatic Dr.
• 33:00and can hopefully stay asleep longer.
• 33:05So if I were to sum up everything I've shown
• 33:08you so far about sleep and older adults,
• 33:11I would show you this slide,
• 33:12which is to say that sleep problems
• 33:15in older adults are multifactorial.
• 33:17There are often multiple things
• 33:20going on simultaneously.
• 33:21I've shown you how there
• 33:23are changes in sleep,
• 33:24in the architecture that happen as we
• 33:27age that causes to have lighter sleep
• 33:30and perhaps more easily aroused from sleep.
• 33:34These people tend or as we get older,
• 33:36we collect chronic conditions,
• 33:38we collect medications,
• 33:40and those can affect our
• 33:41sleep in many different ways.
• 33:43There are psychosocial and
• 33:45behavioral factors, substance use,
• 33:47caregiving that I alluded to before
• 33:49that can cause sleep disturbance,
• 33:51and finally sleep disorders.
• 33:53Nearly all of these become
• 33:55more common as we get older.
• 33:57And so when you are taking care of
• 33:59an older adult with a sleep problem,
• 34:01you want to think of this slide
• 34:03and think of all of the different
• 34:05things that you might modify
• 34:06in order to help sleep,
• 34:08and maybe you might attack
• 34:09these things simultaneously.
• 34:15So in the last part of the talk today,
• 34:17I want to talk about how we
• 34:19should evaluate sleep complaints.
• 34:23So first, let's focus on
• 34:26taking a sleep history.
• 34:28And when you're doing this,
• 34:30it's important to be very specific.
• 34:33So when somebody tells you
• 34:34they have a sleep problem,
• 34:36you need to get more information.
• 34:37You want to know what time
• 34:39they're getting into bed,
• 34:41how long it's taking them to fall asleep,
• 34:44and you want to know what time
• 34:46they're getting out of bed for good.
• 34:49And so this can help us get a
• 34:51sense of their duration of sleep
• 34:53if there's variability in that.
• 34:55So it can give you a lot of information
• 34:57that's informing A differential of
• 34:59what might be causing a sleep problem.
• 35:01You want to know if awakenings are happening,
• 35:03if they're brief or they're prolonged.
• 35:06You want to know if they're
• 35:07napping during the day.
• 35:08Again,
• 35:08if you get a sense of a long sleep duration,
• 35:12you know long sleep overnight
• 35:13and napping during the day,
• 35:15that suggests napping that's associated with
• 35:17adverse outcomes and needs further work up.
• 35:20And then finally, you want to know
• 35:22about their overall sleep duration.
• 35:23Again,
• 35:24the sweet spot is 7 to 8 hours.
• 35:26Realizing that five to six hours
• 35:28on one end or up to 9 hours on
• 35:31the other end may be appropriate.
• 35:33And then you might ask about symptoms.
• 35:36So snoring,
• 35:37gasping pauses and breathing or nocturia.
• 35:41And these can all be signs
• 35:42of untreated sleep.
• 35:43Apnea like discomfort preventing sleep,
• 35:46which is suggestive of restless leg syndrome,
• 35:49sleepwalking or dream enactment
• 35:51could suggest a parasomnia.
• 35:53And dream enactment is our
• 35:55REM sleep behavior disorder,
• 35:57vivid dreams or nightmares, anxiety,
• 36:00rumination, or mind raising.
• 36:01And finally,
• 36:02you want to ask about inadvertent
• 36:05dosing or drowsy driving.
• 36:10So in the sleep world,
• 36:11we commonly use this measure,
• 36:13the Insomnia Severity Index and this is a
• 36:18validated measure for insomnia disorder.
• 36:20So it does map onto a DSM diagnosis
• 36:23of insomnia, which can be helpful.
• 36:26You can do this in the beginning
• 36:28of evaluating somebody and
• 36:29you can follow it over time.
• 36:30And so you see the first three questions
• 36:33are related to insomnia symptoms.
• 36:36And then the next questions are what map
• 36:39onto a DSM diagnosis of insomnia disorder.
• 36:44And we can further break this score down
• 36:46into scores above 8 which are abnormal.
• 36:49Or we can look at mild,
• 36:51moderate, and severe based on
• 36:53the score for this questionnaire.
• 36:57Another questionnaire that we commonly
• 37:00use is the Epworth Sleepiness Scale.
• 37:02And this asks people to rate
• 37:04their chance of dozing or falling
• 37:06asleep in different situations.
• 37:08So that might be things like reading,
• 37:11talking to people,
• 37:13or even while they're driving.
• 37:14So this range is 0 to 4,
• 37:17zero to 24 and a clinically significant
• 37:20score is thought to be 10 or above.
• 37:23And then severity is further
• 37:25broken down into moderate,
• 37:26which is 10 to 15 or severe,
• 37:28which is 16 to 24.
• 37:32Many of you probably know that the
• 37:35gold standard for objective sleep
• 37:37evaluation is polysomnography.
• 37:39And so here on the left you see what
• 37:41we do with a person when they come
• 37:43to our sleep lab and all of the
• 37:44different things we hook them up to.
• 37:46And this is the gold standard
• 37:49because it's a very sensitive and
• 37:51also specific way to determine what
• 37:54sleep disorders might be present in
• 37:57somebody who has sleep complaints.
• 37:59So on the top, if you look on the right,
• 38:01we have the EE G and that's helping us
• 38:04to see what stage of sleep people are in.
• 38:07We have eye movements that can be used to
• 38:10determine when somebody's in REM sleep.
• 38:13Chin tone is also useful for that.
• 38:15We have leg movements to see if people
• 38:17have periodic leg movements during sleep
• 38:19and then the next set of sensors tell
• 38:22us whether they might have sleep apnea.
• 38:24So and that could be central
• 38:26events or obstructive events.
• 38:29And along with those events
• 38:31we also get pulse oximetry.
• 38:33We do look at EKG and that allows
• 38:36us to see rhythm and heart rate.
• 38:38So that's our gold standard
• 38:41evaluation for sleep.
• 38:42And so I as I've told you before,
• 38:45we have all of these different
• 38:47sensors that allow us to get very
• 38:49detailed information about sleep.
• 38:53We also have now a home sleep apnea test.
• 38:58And notice I'm referring to it as not a
• 39:00home sleep study or a home sleep test.
• 39:02This is a home sleep apnea test.
• 39:05And that is because this is a
• 39:07test really for sleep apnea and
• 39:10not for other sleep disorders.
• 39:12So what we miss out on here,
• 39:14you see the grayed out areas.
• 39:16We don't have EE G so we can't
• 39:18tell whether people are asleep and
• 39:20what stage of sleep they're in and
• 39:23we can't look at leg movements.
• 39:25But this is a very good test for sleep apnea.
• 39:28If your suspicion for sleep apnea
• 39:31is already quite high.
• 39:33If your suspicion is high and you have
• 39:35a negative home sleep apnea test,
• 39:38then we would probably move to
• 39:41the more sensitive and specific
• 39:42test which is the in lab.
• 39:44Polysomnogram
• 39:48actigraphy is something that we may also
• 39:51use for objective estimates of sleep.
• 39:54So this is not detecting sleep directly,
• 39:57it is detecting sleep through movement.
• 40:00So this is commonly a watch
• 40:03that has accelerometer.
• 40:05An accelerometer in it which will
• 40:07detect patients movements and use
• 40:09those to estimate when they're
• 40:11sleeping and when they're awake.
• 40:12And so this is a very good and well
• 40:16validated way to evaluate sleep.
• 40:18I think particularly if you're
• 40:20looking at duration,
• 40:22this is shown to to to correlate
• 40:25very well with total sleep duration
• 40:27on our gold standard polysomnogram.
• 40:29And the other benefit of actigraphy is
• 40:32you can have multiple nights of sleep
• 40:35and this is done in the home environment.
• 40:38So what I'm showing you here in this picture,
• 40:40if we look at that blue interval,
• 40:43this is once the data is scored,
• 40:46it's showing you when that
• 40:48sleep period is occurring.
• 40:49So you can get a sense of duration,
• 40:51but also habitual sleep patterns and how
• 40:53they may be changing from night to night.
• 40:56So this may or may not be used in a
• 40:59clinical setting in the sleep lab to
• 41:02look at sleep and it's certainly very
• 41:05commonly used in sleep research studies.
• 41:10So the key points that I want to
• 41:12bring up from the series of talks
• 41:14about sleep in older people first,
• 41:16sleep is fundamentally important
• 41:18for health, quality of life
• 41:21and independence of everybody,
• 41:22including our older adults.
• 41:25And that you should be specific
• 41:28when eliciting sleep patterns
• 41:30and daytime consequences.
• 41:31So you may need to seek collateral
• 41:34information in this circumstance to
• 41:36understand when people are sleeping,
• 41:38how long they're sleeping and what
• 41:41that pattern is like or whether
• 41:43there are any symptoms occurring
• 41:45during sleep that may better be
• 41:47reported by a bed partner Treatment.
• 41:49I would say you want to start with
• 41:52a thorough history and workup and
• 41:54identify important domains that may
• 41:56be contributing to a sleep problem.
• 41:59And that's it.
• 42:01Thank you very much for your attention.