sl sleep eep di disorders sorders in the elderly Geriatrics - PowerPoint PPT Presentation

Ma Managing aging sl sleep eep di disorders sorders in the elderly Geriatrics Center Tehran University of Medical Sciences. Zeiain Hospital Dr.Mohammad Bodaghabadi M.D

 HAZZARD – 2017 , CHAPTER 49 , SLEEP DISORDERS  2009 National Sleep Foundation ; Sleep and Aging Well , , www.sleepfoundation.org  Kamel NS, Gammack JK. Insomnia in the elderly: cause, approach, and treatment. Am J Med. 2006 Jun; 119 ( 6 ): 463 - 9 . Review  Townsend-Roccichelli J, Sanford JT, VandeWaa E; Managing sleep disorders in the elderly. Nurse Pract. 2010 May; 35 ( 5 ): 30 - 7  Schroeck JL, Ford J, Conway EL, Kurtzhalts KE, Gee ME, Vollmer KA, Mergenhagen KA.; Review of Safety and Efficacy of Sleep Medicines in Older Adults.Clin Ther. 2016 Nov; 38 ( 11 ): 2340 - 2372 . doi: 10 . 1016 /j.clinthera. 2016 . 09 . 010 . Epub 2016 Oct 15 . Review.  Markota M, Rummans TA, Bostwick JM, Lapid MI. ;Benzodiazepine Use in Older Adults: Dangers, Management, and Alternative Therapies. ; Mayo Clin Proc. 2016 Nov; 91 ( 11 ): 1632 - 1639 . doi: 10 . 1016 /j.mayocp. 2016 . 07 . 024 . Review.  Rawtaer I, Mahendran R, Chan HY, Lei F, Kua EH . A nonpharmacological approach to improve sleep quality in older adults.Asia Pac Psychiatry. 2017 Oct 10 . doi: 10 . 1111 /appy. 12301  Tsapanou A, Gu Y, O'Shea D, Manly J, Schupf N, Scarmeas N, Stern Y. Self- Reported Sleep Disordered Breathing as Risk Factor for Mortality in the Elderly. J Stroke Cerebrovasc Dis. 2016 Jun; 25 ( 6 ): 1524 - 31 .

Sleep and aging

Sleep is Essential to Our Overall Health and Well-Being  Key to our health, performance, safety and quality of life  As essential a component as good nutrition and exercise to optimal health  Essential to our ability to perform both  cognitive and physical tasks,  engage fully in life,  function in an effective safe and productive way

Normal Sleep and Normal Aging : Our Internal Clock  The biological clock resides in the brain  It helps regulate when we feel sleepy and when we are alert  It works in tandem with light and dark, and our body temperature and hormones

The Sleep Cycle in Adults Awake 1 2 Stages 3 REM REM REM REM REM 4 0 1 2 3 4 5 6 7 8 Hours in Sleep

SLEEP ARCHITECTURE  The progression of sleep across the night is called sleep architecture. It is displayed as a sleep histogram or hypnogram.  Sleep architecture is composed of 3 segments.  NON REM First segment light sleep (stages 1 and 2 ), I. Second segment deep sleep (stages 3 and 4 ). II.  Taken together, stages 3 and 4 are referred to as delta sleep or slow wave sleep (SWS). SWS is believed to be the most restorative part of sleep. Stages 1 to 4 constitute non rapid eye movement (non-REM).  REM III. The third sleep segment includes the period of REM sleep.  Stages 3 and 4 are generally observed during the first half of the sleep period, and REM sleep occurs most frequently during the second half.  Typically, subjects cycle through non-REM and REM sleep stages with a periodicity of 90 to 120 minutes.

Sleep Stages Electroencephalography Typical Nighttime Sleep Pattern Recordings in a Young Adult Awake Awake Stage 1 Stage 1 and REM Stage 2 Stage 2 Stage 3 Stage 3 Stage 4 Delta 4 1 2 3 4 5 6 7 Time (hours) a Rapid eye movement

Sleep Architecture in the Elderly  The sleep architecture changes significantly in the healthy elderly individual a) Sleep initiation is more difficult; b) total sleep time and sleep efficiency are reduced; c) delta wave or SWS decreases; d) sleep fragmentation increases; e) and more time is spent in bed awake after retiring.  Natural physiologic changes in circadian rhythm influence many older people to go to bed earlier and to wake up earlier. These factors can contribute to deterioration in sleep quality and less total sleep.  With aging, the duration of REM sleep tends to be more preserved , but sleep latency is significantly decreased, suggesting the elderly are more somnolent than the younger population.

Change in sleep stages with age

Normal Sleep and Normal Aging: Less Deep Sleep

chronological age itself may not be the greatest predictor of sleep quality  age-related changes in sleep are due to a decreased ability to sleep rather than a decreased need to sleep.  When older poor sleepers and good sleepers are compared, poor sleepers have worse  health-related quality of life,  increased medication use,  greater health care utilization  Many of the illnesses associated with aging can disrupt sleep, which may inhibit the normal progression through sleep stages.  lower sleep efficiency and higher amount of wake after sleep onset are associated with more cognitive decline compared to those in whom sleep is well preserved.  Since N 3 sleep is associated with growth hormone secretion, the reduction in N 3 sleep with aging may be partly responsible for the decrease in growth hormone in older men.

Normal Sleep and Normal Aging: Sleep Efficiency Changes with age (% Time in Bed Sleeping) Sleep Efficiency Men Age Women

The ability to get continuous and consolidated sleep may become more difficult as we age  Adults often require less sleep as they get older, and adults in their late 70 s need 30 to 60 minutes less than people in their early 20 s.  Harbison 5 notes that the proportion of REM sleep to non-REM sleep is preserved throughout life.  Older adults spend less time in the later stages of non-REM sleep, which results in a lighter sleep and easy arousal.  Consequently, even though elders need a shorter duration of sleep, they may need to spend longer in bed to get it.

END OF PART 1

PART 2 :

Sleep Problems/Disorders Among Older Persons  SLEEP-DISORDERED BREATHING  RESTLESS LEGS SYNDROME AND PERIODIC LIMB MOVEMENT DISORDER  OTHER PARASOMNIAS  CIRCADIAN RHYTHM DISORDERS  INSOMNIA  SLEEP IN INSTITUTIONALIZED OLDER ADULTS AND NEURODEGENERATIVE DISORDERS

SLEEP-DISORDERED BREATHING  Sleep-disordered breathing (SDB) : disturbed respiration during sleep arising from repetitive events of complete (ie, apnea) or partial (ie, hypopnea) cessation of airflow lasting at least 10 seconds. A. OSA : due to an obstructed airway, which is determined by the persistence of respiratory effort. B. CSA: concomitant cessation of breathing effort, because there is a momentary defect in the central control of breathing.  OSA is by far the most common sleep-related breathing disorder; however, there is often overlap between the two clinical syndromes.

CSA (central sleep apnea) Common cause: • Heart failure is the most commonly recognized cause of CSA and is often characterized by Cheyne-Stokes respiration, which is periodic cycling between ypoventilation and hyperventilation. • cerebrovascular accidents, opioid use, hypoventilation syndromes.

The severity of SDB It is generally determined by the apnea hypopnea index (AHI), which is the number of apneas and hypopneas per hour of sleep. SDB can be diagnosed : • AHI is greater than 15 , or • when it is greater than 5 with significant symptoms or related comorbidities. • An AHI greater than 30 is generally considered to indicate severe SDB. The consequences of respiratory events during sleep include arousals from sleep, intrathoracic pressure swings, and cyclical drops in the blood oxygen level & leads to sleep fragmentation and nocturnal hypoxemia. Sever SDB is increase in young population due to obesity from 4 F & 9 M to 6 F & 13 M in 2010 in 30 to 60 years old.

Association of obstructive sleep apnea (OSA) with age.

Epidemiology OSA is underdiagnosed in the general population, particularly in women he risk of OSA increases with increasing age until the age of 70 at which time there is a plateau premenopausal status appears to protect against OSA meaning that the gender discrepancy between men and women narrows in the older population. OSA may be more severe in African-American and Asian populations compared to the Caucasian population. It is estimated that upwards of 50 % of patients with stable heart failure have some form of SDB. patients with end-stage renal disease have a very high prevalence of SDB Other conditions associated with CSA include stroke, neurodegenerative diseases, respiratory disorders leading to hypoventilation, and chronic pain requiring opiates.

Pathophysiology  There are three types of SDB events: central, obstructive, and mixed. 1 . Central events result from a failure of the respiratory control center to send a signal to breathe.  abnormal sensitivity of the respiratory controller, which can lead to oscillations between hyperventilation and hypoventilation. 2 . Obstructive events occur from anatomic obstruction of the upper airway despite respiratory effort.  Features that govern the size of the upper airway include excess adiposity, craniofacial structure, excessive tonsilar and peritonsilar soft tissue, and lower lung volumes. 3 . Mixed events are a combination of central and obstructive components.  The most significant immediate consequence of OSA is excessive daytime sleepiness and the risk of motor vehicle accidents.  Significant epidemiologic associations of OSA with adverse cardiovascular and metabolic consequences have been reported.