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Sleep Disorders in the Elderly

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1 Sleep Disorders in the Elderly
Matthew J. Beelen, M.D. November 17th, 2010

2 Sound Familiar? Why am I so tired all of the time?
I don’t have any energy… I just can’t sleep well anymore… My husband’s always falling asleep, he doesn’t do anything anymore… I wish I could just get some rest… I don’t have any “get up and go…” I just lie awake, I can’t get back to sleep… I think my memory is slipping… Sound Familiar?

3 “A bodily disease which we look upon as whole and entire within itself, may, after all, be but a symptom of some ailment of the spiritual part.” -Nathaniel Hawthorne ( )

4 Objectives Understand normal sleep physiology and age-related changes
Appropriately recognize and diagnose sleep disorders Understand indications for formal sleep studies Recommend appropriate treatment measures

5 Agenda Significance of sleep disorders Physiology: Normal and Aging
Classifying sleep disorders Sleep hygiene Evaluation for sleep disorders Insomnia (Sleep-disordered breathing) Other sleep disorders

6 Significance of Sleep Disorders
Survey of 9000 people > age 65 No sleep complaints (12%) Difficulty initiating/maintaining (43%) Nocturnal waking (30%) Insomnia (29%) Chronic sleep difficulties (>50%) Daytime napping (25%) Trouble falling asleep (19%) Waking too early (19%) Waking without feeling rested (13%) Ancoli-Israel S. JAGS 2005;53:S264-S271.

7 Significance of Sleep Disorders
>50% of sedatives are used by people age > 65 In age , 19% of patients were taking a sleep medicine (in one study) Disturbed sleep is a strong predictor of ECF placement, especially in patients with dementia Mortality due to common conditions is 2 times higher in elderly with sleep disorders than in those without. Daytime somnolence can interfere with activities and function Sleep disorders negatively impact quality of life Sleep disorders can lead to depression and cognitive impairment

8 Agenda Significance of sleep disorders Physiology: Normal and Aging
Classifying sleep disorders Sleep hygiene Evaluation for sleep disorders Insomnia Sleep-disordered breathing Other sleep disorders

9 Normal Physiology - Basics
Non-REM sleep Stage 1: very light, easy to arouse Stage 2: most of the night’s sleep Stage 3,4: slow wave, deeper sleep REM sleep EEG similar to stage 1 Low/absent muscle tone Dreaming occurs here Greatest cardiac and respiratory instability

10

11 Normal Physiology - Basics
Sleep Architecture REM latency is about 90 minutes (wide variation) Very short in narcolepsy REM normally occurs every 90 to 120 minutes More stage 3,4 in first half of night, more REM 2nd half Brief awakenings (30 sec) common, not usually remembered Brief arousals (3 sec) are normal

12 An 83-year-old woman who resides in a long- term care facility complains of chronic insomnia. She is bedridden and is legally blind secondary to diabetes mellitus. Which of the following age related changes most likely contributes to this patient’s sleep disturbances? Reduction in total sleep time Reduction in melatonin secretion Reduction in stage 3 or 4 sleep Increase in percentage of REM sleep Breakdown of the segregation of sleep and wakefulness

13 Age-Related Changes Non-REM REM Architecture
Less slow wave sleep (stage 3 and 4), may be entirely absent, easier to awaken REM Shorter REM latency Decreased REM percentage and duration Architecture Increased overall sleep latency More awakenings/arousals = less sleep efficiency Less sleep in 24 hour period* Reduced sleep latency during day – harder to stay awake Espiritu JR. Clin Geriatr Med 2008;24:1-14.

14 Age-Related Changes Circadian cycle shifted earlier
Decreased melatonin levels at night Decreased modulation of circadian rhythm between day and night More naps during the day (1 hour) May have little impact on night-time sleep May enhance cognitive and psychomotor performance due to increase total sleep Espiritu JR. Clin Geriatr Med 2008;24:1-14.

15 Age Related Changes Less physiologic flexibility with schedule changes
More comorbidities that can interfere with sleep It is hard to know if sleep problems are more common independent of other conditions The ability to get restorative sleep gets worse with age, the need for sleep does not.

16 Mechanisms Underlying Sleep Complaints
Vaz Fragoso CA. JAGS 2007; `

17 Precipitating Factors
Declining Health Status Nocturia Pain (DJD, neuropathy) Cardiac Disease Angina, CHF, arrhythmia Pulmonary Disease GER Endocrine: thyroid, menopause, DM polyuria CKD

18 Precipitating Factors
Medications – impact sleep architecture and sleep-disordered breathing CNS stimulants/depressants Diuretics, hypoglycemics Neuropsychological Impairments Depression, Anxiety Cognitive Impairment/Psychosis Primary Sleep Disorders

19 Perpetuating Factors - Psychosocial
Caregiving The work of caregiving Associated mental and physical health problems Social Isolation Poorer sleep hygiene Decline in activity Bereavement, Widowhood, Retirement Loss of zeitgebers* (physical, sensory)

20 Agenda Significance of sleep disorders Physiology: Normal and Aging
Classifying sleep disorders Sleep hygiene Evaluation for sleep disorders Insomnia Sleep-disordered breathing Other sleep disorders

21 Classifying Sleep Disorders
“Existing classifications differ, and many terms remain inadequately defined, which leads to diagnostic confusion. Historically, insomnia has been classified according to symptom type, symptom duration, and underlying cause, but these classifications have not been based on evidence of their utility, and newer research suggests the need for change.” Krystal AD. JAGS 53:S258-S263, 2005.

22 Primary Sleep Disorders
Primary Insomnia Sleep onset (Initial) Sleep maintenance (Middle) Sleep disordered breathing Obstructive sleep apnea Central sleep apnea Mixed sleep apnea Circadian rhythm disturbances

23 Primary Sleep Disorders
Restless Legs Syndrome Periodic Limb Movements of Sleep REM Sleep Behavior Disorder All primary disorders can be mixed with other primary and with secondary causes

24 Secondary Sleep Disorders
Underlying conditions that should be addressed first Medical Illness – causing nocturnal symptoms Psychiatric Illness Medications Social/behavioral

25 Secondary Sleep Disorders
Psychophysiologic Insomnia (stimulus/response) Adjustment Insomnia – recent stressor Inadequate Sleep Hygiene Lack of schedule (retirement!) Sedentary or naps during daytime Voluntary sleep deprivation (doctors!) Mixed-type insomnia

26 A 67 y. o. woman asks you for sleeping pills
A 67 y.o. woman asks you for sleeping pills. She reports initial insomnia and restless sleep with frequent awakenings. She is retired and sedentary. Reads, watches TV in bed, often naps despite caffeine intake during the day. PE is WNL. Which is most likely to help her sleep disturbance? Exposure to early morning daylight Proper sleep habits Sustained-release melatonin Zolpidem Referral for sleep study

27 Agenda Significance of sleep disorders Normal physiology
Age related changes Classifying sleep disorders Sleep hygiene Evaluation for sleep disorders Insomnia Sleep-disordered breathing Other sleep disorders

28 Sleep Hygiene The bed is for sleeping (and sex) only
Increase activity, decrease naps Avoid late meals Avoid caffeine, ETOH, cigarettes Environmental control (light, noise, temp) Decrease stress Establish a routine

29 Agenda Significance of sleep disorders Physiology: Normal and Aging
Classifying sleep disorders Sleep hygiene Evaluation for sleep disorders Insomnia Sleep-disordered breathing Other sleep disorders

30 Evaluation - History Is there a sleep disorder (fatigue)?
Or normal age-related change? False beliefs about sleep? What is the nature of the problem? Initial, middle, early awakening, EDS Assess impact on daily life/function Identify contributions from secondary causes Look for clues of primary disorders Consider sleep diary and partner/caregiver interview

31 Polysomnography Formal Sleep Test – indications
Diagnosis of sleep-disordered breathing CPAP titration Suspected narcolepsy Suspected REM sleep movement disorder Difficult to diagnose parasomnias (e.g. PLMS) Not usually for: RLS Circadian rhythm disorders Primary insomnia

32 Agenda Significance of sleep disorders Physiology: Normal and Aging
Classifying sleep disorders Sleep hygiene Evaluation for sleep disorders Insomnia Sleep-disordered breathing Other sleep disorders

33 Insomnia - Definition Difficulty with initiation, maintenance, duration, or quality of sleep that results in the impairment of daytime functioning, despite adequate opportunity and circumstances for sleep. Can lead to fatigue, mood disturbance, interpersonal and job problems, and reduced quality of life. From DSM-IV

34 Insomnia - Definitions
Sleep latency usually > 30 minutes Sleep efficiency < 85% Transient: less than 1 week Short-term: 1-4 weeks Chronic: > 1 month May be perpetuated by worrying in bed or unrealistic expectations of sleep duration More common in women, elderly, and chronic disease (medical and psychiatric)

35 83 y.o. woman who has HTN and DJD has 3 wk h/o difficulty falling asleep and several awakenings per night. Has symptoms related to psychosocial stressors. You decide to try short course hypnotic agent. Which is most appropriate? Amitriptyline Diphenhydramine Melatonin Triazolam Zolpidem tartrate

36 Insomnia - Treatment Non-pharmacologic therapy
Improvement in 70-80% of patients (though some studies used psychologists) Stimulus control therapy – bed for sleeping only, same wake time daily, 1 small nap only Sleep restriction therapy – reduce time in bed to achieve 90% efficiency, gradually increase (up to 6-7 hours) Relaxation therapy – biofeedback, imagery, meditation, muscle relaxation Cognitive therapy – beliefs and attitudes Sleep hygiene education Joshi S. Clin Geriatr Med 2008;24:

37 Insomnia - Medications
Use lowest effective dose Use intermittent dosing Short term use (< 1 month if possible) Gradual discontinuation (rebound) Medications with shorter half lives are preferred to prevent next-day sedation

38 Insomnia - Medications
Short acting medications More improvement with sleep latency More withdrawal and dependence Long acting More improvement with sleep duration More next day symptoms (sedation, cognitive impairment, falls) Most medications have not been studied extensively in the elderly or more than 6 months

39 Insomnia - Medications
Benzodiazepines – GABA-A receptors Benefits: cheap, improve sleep latency, total sleep time, number of awakenings, sleep quality Disadvantages: More next day effects (drowsy, dizzy) More dependency/withdrawal More rebound symptoms More anterograde amnesia (especially with shorter acting agents) Falls and hip fracture risk (long acting) Tariq SH. Clin Geriatr Med 2008;24:

40 Insomnia - Medications
Benzodiazepine receptor agonists Advantages more specific targeting of GABA receptors in the brain – so less side effects Disadvantages Not well studied in the elderly (use lower starting doses) Not compared against each other More expensive ($ per month) Dependence/withdrawal still occur Still can increase risk of falls and fractures

41 Zolpidem (Ambien) Short half life (2.6 hours, 2.8 for “CR”)
Better for sleep onset insomnia Minimal impact on sleep architecture “CR” not directly compared with Ambien Can see rebound insomnia, mild next day drowsiness, mild antergrade amnesia “CR” approved for long term use

42 Zaleplon (Sonata) Ultrashort half-life (1 hour)
Better for sleep onset insomnia Can increase total sleep time and efficiency Can be taken after a middle of night awakening Rare rebound and next day effects Not approved for long term use But reported to be safe for long term use in elderly

43 Eszopiclone (Lunesta)
Medium half life (5-7 hours) Better for sleep maintenance insomnia Increased total sleep time 49 min Helps with sleep onset (27min) Few next day effects (but longer half life suggest risk for next day effects in elderly) Approved for long term use

44 Sedative-Hypnotics Risk/Benefit
Meta-analysis of 24 studies, > 2400 patients older than age 60 treated with benzo’s or benzo receptor agonists Benefits – compared to placebo (NNT = 13) Small improvement in sleep quality Sleep time increased (25 minutes) Decrease number of awakenings (0.63) Harms (NNH = 6) Cognitive impact (4.78 times more common) Psychomotor events (2.61 times as common) Daytime fatigue (3.82 times more common) Glass et al. BMJ 2005;331:

45 Other Medications Ramelteon (Rozerem)
Melatonin receptor agonist Small improvement in sleep onset (8 min) Improved total sleep time (12 min) Increase prolactin levels, few other side effects. Not compared to other drugs or melatonin. Approved for chronic use. Sedating antihistamines – BEERS LIST

46 Other Medications Sedating Antidepressants
Tricyclics: they help, but side effects Trazadone: helps, not as much as Ambien May improve SWS (stage 3 and 4) Remeron: increased sleep efficiency, increases duration of slow wave sleep in elderly These drugs are not well studied (or approved) for insomnia in the elderly Best used for depression with insomnia

47 Other Medications - Melatonin
Levels correlate with circadian rhythm Deficiency is more common in elderly and associated with insomnia Effects (0.1 to 10mg QHS) 7.8 minute  latency in primary insomnia 38.8 minute  latency in delayed sleep phase syndrome No impact on sleep efficiency Minimal side effects, if any Nutritional supplement – dosing? Gooneratne NS. Clin Ger Med 2008;24:

48 Drugs vs No Drugs Unclear if cognitive behavioral therapy or medication therapy is better Both help Medications may work more quickly CBT may have more lasting benefit Hard for PCP’s to do cognitive therapy Medications not studied more than 6 months It is best to attempt education and non- pharmacologic therapy first, and continue even if medications are used

49 Other Treaments for Insomnia
Bright Light Therapy Light -> suprachiasmatic nucleus -> inhibits production of melatonin by pineal gland Threshold between lux (normal indoor fluorescent light) Treatment uses ,000 lux Cochrane: no trials focused on elderly, but benefit seen with younger patients Dosing, timing, duration, effectiveness not established in the elderly Best evidence for SAD in younger people Gammack JK. Clin Geriatr Med 2008;24:

50 66 year old man asks for Viagra. Has DM2, HTN, CHF, obesity
66 year old man asks for Viagra. Has DM2, HTN, CHF, obesity. Takes digoxin, lasix, norvasc, insulin. ROS: +for ED, fatigue, frequent daytime sleepiness. 5’10’’, 250#. BP 160/90, poorly alert. Wife says he drinks 1-2 beers/night, snores loudly, is sleepy during the day. Which would be most beneficial: Avoid alcohol CPAP Methylphenidate Oropharyngeal surgery Viagra

51 Agenda Significance of sleep disorders Normal physiology
Age related changes Classifying sleep disorders Sleep hygiene Evaluation for sleep disorders Insomnia Sleep-disordered breathing Other sleep disorders

52 Sleep-disordered Breathing
Usually present with daytime somnolence Snoring: alone is not usually a problem Hypopnea Apnea – increased incidence in the elderly, can be seen in 10-40% Obstructive Central Mixed

53 Sleep-disordered Breathing
Significance, Signs, and Symptoms Daytime somnolence, effect on function Decreased cognition, dementia may be worse CHF, arrythmias, HTN, cor-pulmonale Polycythemia Nocturia Personality changes Morning headaches Decreased libido, impotence May increase mortality

54 Sleep-disordered Breathing
Other Symptoms Snoring Restless sleep Choking/gasping during sleep Witnessed apnea

55 Obstructive Sleep Apnea (OSA)
Definition: repetitive episodes of uper airway obstruction with continued movement of chest and abdominal walls, leads to desaturations and arousals. Risk factors: people with classic symptoms and: Male Large neck circumference (>18 inches) Obesity Crowding of oropharynx

56 OSA - Diagnosis Classic Symptoms and Polysomnography
EEG (at least 2 channel) EMG (muscle activity – chin) EOG (eye movements) ECG Respiratory airflow and effort Oxygen saturation Snoring intensity and body position Reports an “Apnea-Hypopnea Index” - AHI

57 OSA - Stages Mild: sleepiness when sedentary, little attention required, not daily, minor impairment of function Mean sat >90 and min sat >85, AHI 6-20 Moderate: daily sleepiness when minimaly active and moderate attention required (driving, meetings, movies) Mean sat >90 and min >70, AHI 21-40

58 OSA - Stages Severe – daily sleepiness during tasks that require significant attention (driving, conversation, eating, walking), marked impairment in function Mean sat <90 or min <70, AHI > 40

59 OSA - Treatment Unclear benefit to treating mild or minimally symptomatic patients Treatment is likely to improve: HTN CHF Daytime function Cognition and health-related quality of life

60 OSA - Treatment Weight loss, avoid supine position (tennis balls)
Avoid sedating drugs Prescription drugs not helpful CPAP/BIPAP – Most efficacious Compliance issues Oral appliance – less effective, use for mild cases or if CPAP not tolerated Surgery – trach, uvuloplasty, bariatric surgery – not first line, various effectiveness

61 Central Sleep Apnea - CSA
Definition – Periodic complete cessation of airflow and respiratory effort, followed by desaturations and arousals. Related to chemoreceptors and CO2 physiology. Hypercapneic – underlying hypoventilatory disorders blunts chemoreceptor responsiveness Nonhypercapneic – underlying hyperventilatory disorder causing periodic hypocapnea which turns off respiratory drive

62 CSA Associated Conditions
Congestive heart failure Prior Stroke and cerebrovascular disease Other neurologic disorders – ALS, mucular dystrophy Chronic renal failure Hypothyroidism Baseline CO2 retainers (COPD, kyphoscoliosis)

63 CSA – Diagnosis and Treatment
Diagnosis – Polysomnography Treatment CPAP/BIPAP can help Nocturnal Oxygen can help (offsets “overshoot”) Consult your local pulmonologist

64 Agenda Significance of sleep disorders Normal physiology
Age related changes Classifying sleep disorders Sleep hygiene Evaluation for sleep disorders Insomnia Sleep-disordered breathing Other sleep disorders

65 A 66 y.o. man reports excessive daytime sleepiness and an intense, irrisistable urge to move about, especially in evening. He is nervous, tense, irritable, has initial insomnia. Wife notes he is restless during night, moves legs abnormally. Which med is most likely to be beneficial? Carbamazepine Carbidopa-levodopa Clonazepam Clonidine Iron supplementation

66 Other Sleep Disorders Restless Legs Syndrome
Periodic Limb Movements of Sleep REM Sleep Behavior Disorder Nocturnal Leg Cramps Circadian Rhythm Disturbances

67 Restless Legs Syndrome (RLS)
Sensorimotor neurologic condition, possibly caused by abnormal iron metabolism and dopaminergic dysfunction – unclear Compelling urge to move limbs (legs>arms) Worse at rest Worse at night May have dysesthesia or pain Relieved with movement Disrupts sleep, alertness, daytime function, QOL

68 RLS – Facts 5-15% prevalence, increased in the elderly, more common in women Associated features FH positive in 60% PLMS in 80% (but 30% PLMS pts have RLS) Diagnosis Classic symptoms Responds to trial of therapy

69 RLS – Associated Conditions
Pregnancy ESRD Fe Deficiency Check ferritin, iron Parkinson’s Radiculopathy Neuropathy Rheumatoid arthritis DM Depression/anxiety Drugs can exacerbate Sedating antihistamines Metoclopramide Calcium channel blockers Neuroleptics TCA’s SSRI’s Caffeine Nicotine ETOH

70 RLS – Treatment Non-pharmacologic Pharmacologic
Avoid caffeine, ETOH, associated medications Sleep hygiene Bedtime bath Mild exercise before bedtime Pharmacologic see handout – most drugs used off label 70-100% effective

71 RLS Treatment Dopaminergics
Requip/ropinirole and Mirapex/pramipexole– only FDA approved meds) Use for daily or intermittent symptoms First line treatment (most studied) Benzos – intermittent use, klonopin is best choice Opioids – daily or intermittent use Neurontin – daily use, similar efficacy to Requip (average dose 800mg) Neuropsychobiology 2003;48(2):82-6. Magnesium, folate have “slight” evidence

72 Periodic Limb Movements of Sleep
PLMS: Periodic episodes of repetitive and highly stereotypc limb movements during sleep 34-45% prevalence in the elderly, increases with age Associated with RLS, arousals, difficulty achieving and maintaining sleep Most are asymptomatic Unclear significance Associated conditions similar to RLS

73 PLMS – Diagnosis and Treatment
Clinical history and response to treatment Polysomnography can be used Treatment Dopamine agonists Benzo’s – decrease arousals but not movements Opioids

74 REM Sleep Behavior Disorder
Lack of normally low muscle tone during REM sleep Cause unknown Usually male, onset age 50-60 Act out dreams which can be violent Vivid memory of dreams Can diagnose with polysomnography 1/3 of Patients will develop Parkinson’s Treat with benzo (klonopin 90% effective)

75 Nocturnal Leg Cramps Cause – not known Associated factors
Meds (diuretics, nifedipine, beta agonists, steroids, morphine, cimetidine, statins, lithium) Conditions (uremia, DM, thyroid, electrolyte d/o’s) Diagnosis – history, check labs

76 Nocturnal Leg Cramps Treatment Review associated factors
Calf stretching exercises Quinine ( mg QHS) Evidence of moderate benefit Toxicity – careful in elderly, kidney/liver disease Digoxin interaction Hematologic (thrombocytopenia) Cinchonism Blindness, arrhythmias, death! Tonic Water… ? Dr. Gott – soap…

77 Circadian Rhythm Disturbance
Advanced sleep phase syndrome Neurologic control of rhythms is altered Early to bed, early to rise Can interfere with societal norms Total sleep time and daytime function usually not affected Melatonin and light therapy are theorized to help Reassure patients

78 Summary Sleep problems are very common in the elderly
Sleep problems have significant impact on health and quality of life Be as specific as possible in diagnosing sleep disorders Treatment should include all contributing factors, and should include counseling Avoid a “pill for every symptom”

79 The way it used to be… Chronic enlargement of the tonsils – symptoms:
“As a result of the obstruction to nasal respiration the patient snores during sleep. The facial expression is somewhat dull, and the mind is often as dull as the face betrays. Aprosexia, or difficult attention, is a common symptom.” Eye, Ear, Nose, and Throat. A Manual for Students and Practitioners. Lea Brothers and Co. Philadelphia, PA

80 References Salzman C. Pharmacologic treatment of disturbed sleep in the elderly. Harv Rev Psychiatry 2008;16: Glass J. et al. Sedative hypnotics in older people with insomnia: meta-analysis of risks and benefits. BMJ 2005;331: Vaz Fragoso CA et al. Sleep complaints in community-living older persons: A multifactorial geriatric syndrome. JAGS 2007;55: Ancoli-Israel S et al. Sleep disorders in the geriatric population: Implications for health. Supplement to Geriatrics Dec Butler JV et al. Nocturnal leg cramps in older people. Post Grad Med J 2002;78: Thorpy MJ. New paradigms in the treatment of restless legs syndrome. Neurology 2005;64 (supp 3):S28-S33.

81 References Silber MH. Chronic insomnia. NEJM 2005;353:803-810.
Ancoli-Israel S et al. Prevalence and comorbidity of insomnia and effect on functioning in elderly populations. JAGS 2005;53:S264-S271. Clinics in Geriatric Medicine 2/08: Sleep in elderly adults. Age-related sleep changes Evaluation of sleep disturbances in older adults The effect of chronic disorders on sleep in the elderly Pharmacotherapy for insomnia Nonpharmacologic therapy for insomnia Complimentary and alternative medicine for sleep disturbances in older adults Light therapy for insomnia in older adults Restless legs syndrome in older adults

82 65 y. o. woman, 5 mo. of difficulty falling/staying asleep
65 y.o. woman, 5 mo. of difficulty falling/staying asleep. Notes uncomfortable sensation in legs removed in part by moving/rubbing legs. Husband notes her kicking legs and moving arms at night. Not falling asleep until 2 am, excessive daytime fatigue, impacting function. Sertraline started 4 weeks ago for mild depression. What is most likely cause of her symptoms? A. Primary insomnia B. Major depressive disorder C. Anxiety disorder D. Restless legs syndrome E. Delayed sleep phase disorder

83 73 year old man with urinary urgency, nocturia x 3, has had urologic eval and medications given. Symptoms improved from nocturia x 6 when switched from terazosin to tolterodine. Also has loud snoring and leg kicking at night which distrubs wife. He is moderately obese and has small prostate. PVR and urine are normal. Which is the next most appropriate step? A. Switch from tolterodine to tamsulosin B. Refer for urologic eval C. Prescribe furosemide in late afternoon D. Refer to sleep clinic E. Prescribe finasteride

84 71 y.o. man has violent movement in sleep for last 8 months (kicks, punches, yells 2-3 hours after sleep onset). His wife says he snores lightly occasionally and has nocturia x 1. He has PD and MDD without recurrence. Only med is mirapex. Speelp study confirms the movements and shows no OSA. Best treatment? A. clonazepam B. Venlafaxine C. Ropinarole D. Trazodone E. Gabapentin

85 72 y.o. man with mild dementia comes to office saying he has had difficuly falling and staying asleep for the last 4 months. He has vivid dreams a few times per month. Problems started after another MD prescribed a new medication. Which drug most likely caused his symptoms? A. Buspirone B. Trazodone C. Donepezil D. Melatonin E. Ramelteon

86 82 y. o. man has EDS x 6 mo. Falls asleep during day in late morning
82 y.o. man has EDS x 6 mo. Falls asleep during day in late morning. Falls asleep easily at 8pm, wakes up q2-3h at night. Social activities limited by his need for naps. Has h/o CVA, MCI, HTN. Wrist actigraphy testing shows 3 sleep periods during 24 hour period with no dominant nocturnal sleep period. Most likely diagnosis? A. Idiopathic hypersomnia B. Advanced sleep phase disorder C. Irregular sleep/wake rhythm disorder D. Sundowning E. REM sleep behavior disorder


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