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Assessment and Treatment of Sleep Disturbances in Senior Adults Susan M. McCurry, PhD Northwest Research Group on Aging University of Washington.

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Presentation on theme: "Assessment and Treatment of Sleep Disturbances in Senior Adults Susan M. McCurry, PhD Northwest Research Group on Aging University of Washington."— Presentation transcript:

1 Assessment and Treatment of Sleep Disturbances in Senior Adults Susan M. McCurry, PhD Northwest Research Group on Aging University of Washington School of Nursing Generational Resilience Conference October 29, 2014

2 Agenda for Today’s Talk  What is sleep?  What causes sleep disturbances as we age?  How do you measure sleep disruption and quality?  What are your treatment options?  Why are non-pharmacological treatments not more widely used?

3 Sleeping is no mean art: for its sake one must stay awake all day. ~Friedrich Nietzsche

4 What is Sleep Anyway????

5 STAGE 1 Transition to Sleep Easily awakened Muscle twitching STAGE 2 Light Sleep Heart rate, eye movements slow down STAGE 3 Deep Sleep Slow brainwaves Hard to wake Restorative STAGE 4 Deepest Sleep BP, body temp decrease Rhythmic breathing REM Sleep Dreaming Body paralysis Increased HR, BP, temp Delta wave sleep

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7 Hypnogram: Young vs. Old Older Adult Sleep Stages Awake REM Awake REM Hours of Sleep Sleep Stages Young Adult Courtesy of Carol Landis, PhD

8 What Regulates Sleep? 1.Homeostatic Process Sleep need (“drive”) increases the longer you are awake. 2. The Circadian Process (Biological Clock) The propensity to sleep varies as a function of the time of day/night over 24 hours. Awake Sleep Awake Sleep sleepy  Germain A, Buysse DJ. Brief behavioral treatment of insomnia. In: Perlis M, et al. (eds.). Behavioral treatments for sleep disorders, pp Elsevier, 2011.

9 Edgar DM, Dement WC, Fuller CA, et al. Effect of SCN lesions on sleep in squirrel monkeys: evidence for opponent process in sleep-wake regulation. J Neurosci. 1993;13: Homeostatic and Circadian Sleep Processes Work Together “Drive”

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11 Circadian Rhythm Changes: Advanced Sleep Phase Ancoli-Israel, S All I want is a good night’s sleep. Mosby Normal Phase Sleepy, Go to bed Wake Up Advanced Phase Sleepy Wake upGo to bed

12 Points to Remember #1 Older adults do not need less sleep than younger adults BUT Aging reduces ability to achieve desired quantity and quality of sleep

13 Sleep Disturbance Risk Factors Age-related change in sleep mechanisms Dementia Primary sleep disorders Other co-morbid conditions and treatments Environmental and behavioral factors Any combination of the above Bloom et al. J Am Geriatr Soc. 2009; 57(5): ; McCurry et al. Sleep Med Rev. 2000; 4: LeastModifiable MostModifiable

14 Sleep and Dementia  Alzheimer’s disease Loss of neurons that regulate circadian sleep-wake cycles (SCN: the body’s internal “clock”) and thermoregulatory processes Sleep architecture changes resemble an acceleration of normal age-related changes  Parkinson’s disease and related disorders Sleep problems nearly universal in advanced PD Tremors, muscle contractions and cramps, limb jerks, nocturia, nightmares, daytime “sleep attacks”

15 Primary Sleep Disorders  Obstructive sleep apnea (OSA) Overlapping risk factors for stroke (HTN, diabetes, atrial fibrillation, cardiac and carotid disease) Widely underdiagnosed; compliance w/CPAP often poor  Periodic leg movement syndrome (PLMS)  Restless legs syndrome Linked to low iron levels In persons with dementia more strongly associated with nocturnal agitation than OSA and PLMS  REM sleep behavior disorder (RBD) Most common in older men Philips B, et al Arch Intern Med, 160: Gehrman PR, et al J Am Geriatr Psychiatry, 11: Young T, et al JAMA, 291: Rose KM, et al Sleep, 34: Increased in persons with Parkinson’s

16 Laugh and the world laughs with you, snore and you sleep alone. Anthony Burgess

17 Insomnia and Medical / Psychiatric Conditions Insomnia and Medical / Psychiatric Conditions (National Health Interview Survey) Pearson NJ, Johnson LL Nahin RL.. Arch Intern Med :

18 Drugs that Can Worsen Sleep Alcohol CNS stimulants (e.g., caffeine, theophylline, nicotine) Beta-blockers, calcium channel blockers Bronchodilators Corticosteroids Decongestants Diuretics Stimulating antidepressants, cognitive enhancers Thyroid hormones

19 Environmental & Behavioral Causes Noise Light Temperature Season of year Bedding Television Dietary practices Exercise routines Pets Roommate or bed partner behaviors

20 There is no snooze button on a cat who wants breakfast. ~Author Unknown

21 Points to Remember #2 Many physical and environmental risk factors for sleep problems are common in older adults and should be considered as part of any sleep assessment and plan.

22 What is Insomnia?

23 Diagnostic Criteria (DSM-5)  Dissatisfaction with sleep quality or duration  Subjective difficulties initiating/maintaining sleep (generally lasting 30+ minutes/night)  Insomnia (or daytime fatigue) causes marked distress or significant impairment in social or occupational functioning  Sleep difficulties are present 3 nights or more per week and for more than 3 months Despite adequate opportunity to sleep

24 Sleep Dissatisfaction Prevalence of insomnia Insomnia Symptoms with Daytime Impairments 33% 10% Ohayon MM. Sleep Med Rev 2002; 6:97-111; Morin et al. Sleep Med 2006; 7: Insomnia Diagnosis 6-12% 15%

25 Insomnia Assessment: History 1.The healthcare practitioner should screen patients for symptoms of insomnia during health examinations. 2.An in-depth sleep history is essential in identifying the cause of insomnia. 3.Polysomnography is not indicated for the routine evaluation of chronic insomnia. Standard. AASM Practice Parameters for the Evaluation of Chronic Insomnia Chesson A. et al. Sleep. 2000; 23(2): 1-5.

26 Edinger JD et al. Sleep 2004; 27(8): (Research Diagnostic Criteria for Insomnia)

27 Insomnia History  Daytime activities and impairments: Napping, fatigue, cognitive function, mood  Sleep related practices and environment (“sleep hygiene”)  Longitudinal course  General medical history (including diagnoses of primary sleep disorders)  Psychiatric history  Medication and substance use  Life situation and circumstances (stressors)

28 Self-Administered Questionnaires Assessment DomainInstrument Global sleepPittsburgh Sleep Quality Index (PSQI) Insomnia symptomsInsomnia Severity Index (ISI) FatigueFlinders Fatigue Scale (FFS) SleepinessEpworth Sleepiness Scale (ESS) Attitudes about sleepDysfunctional Beliefs About Sleep (DBAS) scale Sleep-related behaviorsSleep Hygiene Index (SHI) Quality of lifeSF-36 (includes pain subscale) Psychological symptomsPatient Health Questionnaire (PHQ-9) Generalized Anxiety Disorder scale (GAD-8) Pre-Sleep Arousal Scale (PSAS) Undiagnosed primary sleep disorders Berlin Apnea Questionnaire Restless legs single question* * When you try to relax in the evening or sleep at night, do you ever have unpleasant, restless feelings in your legs that can be relieved by walking or movement? (Ferri R. et al. 2007)

29 Purpose of Questionnaires  Capture subjective aspects of sleep experience that may not be reflected in objective measures  Generally quick to administer  Many have good validity/reliability data and shown to be sensitive to change in RTCs  Many validated with senior populations  Can use multiple measures to assess the heterogeneous context of insomnia symptoms

30 Limitations to Questionnaires  No consistency in referent time frame (generally 1 week to 1 month)  Subjects often fill out incorrectly (e.g., leave items blank, circle 2 options, write explanatory notes in the margins)  Poor readers, non-native English speakers may have difficulty with them  Few are validated for use with other cultures  Can be expensive to use proprietary instruments

31 Purpose of Daily Sleep Diaries  Teach people to observe their own sleep habits and patterns  Gather daily sleep quality/satisfaction data over time  Can collect other real-time data related to sleep (e.g., daily pain or depression ratings)  Provide validation check for actigraphy data editing

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34 Graphic sleep diary in insomnia patient DJ Buysse. Advanced Practice in Primary and Acute Care Conference, November 10, 2007, Seattle, WA

35 Limitations to Daily Diaries  Wide variability in diaries across users (c.f., Carney et al. Sleep 2012; 35(2): )  Some people don’t like to keep them, especially for weeks at a time  They are often filled out incorrectly  If not completed every day poor recall can invalidate data  Computing daily sleep stats for clinical review can be cumbersome

36 Tricks for Getting Good Diary Data  Provide clear written instructions and repeated practice in how to complete  Review diaries every week when they are returned and follow up immediately when there are problems  Particularly look for patterns suggestive of backfilling  Keep diary as brief and as simple as possible  If using paper diaries, put all weeks into a single booklet

37 Purpose of Actigraphy/Acclerometers  Provide objective measure of sleep/wake (activity) across the 24 hour period  Data can be collected for longer period of time and at less cost/personnel training than PSG  Some provide additional sensory measures (e.g., light or sound readings)  Some insurance companies are covering

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39 Actigraphic Sleep Assessment Normal Sleeper Person with dementia Sleep/inactivity Wake/activity Time of day

40 Problems with Actigraphy  Although cheaper than PSG, actigraphs plus software are not inexpensive  Wide variability in types of equipment, scoring algorithms, and editing procedures across studies  Some people don’t like to wear them  Data failure is not rare  Analysis can be complicated and time-consuming (Note: Although easy to use, devices like Fitbit are not comparable to actigraphic scoring)

41 Tricks for Getting Good Actigraphy Data  Careful training and QA monitoring of persons who do initialization, downloading, and editing  Hospital bands for at-risk patients can facilitate compliance keeping the device on  Don’t count on devices being fully waterproof  Make friends with your company tech support staff

42 Points to Remember #3 Assessment of insomnia should include a combination of sleep history and standardized self-report questionnaires. Sleep diaries and actigraphy provide additional information on day-to-day variability and sleep patterns. All have been validated with older adults.

43 How Is Insomnia Treated???

44 Treatment for insomnia Pharmacologic Cognitive- Behavioral (CBT-I) Treatment Strategies

45 Pharmacological Approaches  Hypnotics – Benzodiazepines  Hypnotics – Benzodiazepines Receptor Agonists (BZRAs) Zaleplon (Sonata) Zaleplon (Sonata) Zolpidem (Ambien, Ambien-CR*) Zolpidem (Ambien, Ambien-CR*) Eszopiclone (Lunesta*) Eszopiclone (Lunesta*)  Melatonin agonists Ramelteon (Rozerem*) Ramelteon (Rozerem*)  Antidepressants Doxepin (Silenor*) Doxepin (Silenor*)  Others agents currently available or in development: OTC - Melatonin, valerian, anti-histamines, etc. OTC - Melatonin, valerian, anti-histamines, etc. Prescription - Anti-depressants (e.g.,trazodone), anti- psychotics, HTN meds (prazosin; PTSD nightmares) Prescription - Anti-depressants (e.g.,trazodone), anti- psychotics, HTN meds (prazosin; PTSD nightmares) In development –5HT, GABA and Hypocretin/Orexin In development –5HT, GABA and Hypocretin/Orexin

46 Sedating Medications and Aging  Don’t always help or they stop working  Can cause unwanted side effects (poor balance, confusion, paradoxical reactions)  Primarily tested in younger adults with different pharmacokinetics  Polypharmacy is always a concern  Not preferred by many older adults  Few randomized efficacy trials with specialty populations, e.g., persons with dementia

47 Advantages of CBT for Insomnia  Addresses perpetuating and, in some cases, precipitating causes of sleep disturbances  No interactions with other medications or side effects  Can improve symptoms of comorbid conditions  Can reduce need for long-term hypnotic medications (or help taper off)  Empowering for patients; provides tools they can use in future situations

48 The 3-P Model of Insomnia How did your insomnia start? Predisposing factors (genetics, biological traits, personality, “owls” and “larks”) Precipitating factors (“triggers,” e.g., illness, pain, bereavement, work stressors, shift changes) Why is it still here? Perpetuating factors that undermine underlying homeostatic (sleep drive) or circadian processes (e.g., staying in bed longer, going to bed early, napping, practicing counter-fatigue [e.g., caffeine] or self- medication [e.g., ETOH, OTC sleep aid] strategies)

49 Spielman’s Modified 3-P Model Insomnia Threshold Insomnia No Insomnia Preclinical Acute Onset Chronic Insomnia Predisposing PrecipitatingPerpetuating Kryger MH, et al. Principles and Practice of Sleep Medicine. 4th ed. New York, NY: Saunders; 2000; Perlis et al Cognitive Behavioral Treatment of Insomnia. New York, NY: Springer; 2005 Early Insomnia

50 CBT-I Multicomponent Approach DomainTechniqueAim Behavioral components Sleep hygiene Promote habits and environments that help sleep Stimulus control Strengthen bed and bedroom as sleep stimuli Sleep (bed) restriction Restrict time in bed to improve sleep depth and consolidation Cognitive components Cognitive therapy Address thoughts and beliefs that interfere with sleep Relaxation training Reduce arousal and decrease anxiety Acceptance based Decrease struggle to control sleep at cost of living your life Circadian components Circadian rhythm entrainment Reset or reinforce biological rhythm

51 Cognitive-Behavioral Treatment for Insomnia Multicomponent Approach DomainTechniqueAim Behavioral components Sleep hygiene Promote habits and environments that help sleep Stimulus control Strengthen bed and bedroom as sleep stimuli Sleep (bed) restriction Restrict time in bed to improve sleep depth and consolidation

52 Sleep Hygiene Recommendations Regularize sleep / wake schedules (especially rise time) Establish a relaxing bedtime routine Increase daytime light exposure, keep sleep areas dark Reduce alcohol and caffeine use Keep bedroom a comfortable (cooler) temperature Eliminate environmental factors that interrupt sleep (pets!) Avoid stimulants and stimulating behavior at night (including screens and radio if you wake up during at night) Don’t watch the clock if you can’t sleep (turn it around!) Get regular exercise Ask your pharmacist about medication side effects Stepanski EJ, Whatt JK Sleep Med Rev, 7(3)::

53 Sleep Hygiene: Contraindications Non-compliance “There is nothing more uncommon than common sense.” ~Frank Lloyd Wright People so rarely follow suggestions on lists like this that sleep hygiene recommendations are often used as a control condition in randomized trials When they do try to make changes, they often don’t stick with them

54 Stimulus Control  To prevent your bedroom from becoming associated with poor night sleep, do the following: Get up at the same time every day, no matter how much you slept the night before Don’t go to bed if you are not sleepy Get out of bed if you wake up and can’t fall back to sleep right away (~15 mins) rather than stay in bed fretting about being awake Do not nap during the day (except brief “power naps”) Use bed only for sleep and sex

55 If you can't sleep, then get up and do something instead of lying there worrying. It's the worry that gets you, not the lack of sleep. ~Dale Carnegie

56 Stimulus Control: Contraindications Stimulus control is contraindicated in those: Persons who are disabled and cannot easily get out of bed unassisted People at risk for slips and falls Persons without cognitive capacity to follow stimulus control instructions People who develop a habit of getting up in the middle of night to “do things” Bootzin RR & Perlis ML. Stimulus control therapy. In: Perlis M, et al. (eds.). Behavioral treatments for sleep disorders, pp Elsevier, 2011.

57 Bed Restriction If you reduce your time in bed, you increase your time awake Being awake longer will help you fall asleep faster and stay asleep for more of the night How long should I stay in bed? Keep a sleep diary for 5 – 7 days Write down time you went to bed, time you got up, and estimate how much of that time you were asleep Bed restriction time = estimated week sleep time average plus 30 minutes

58 Bed Restriction Example 7 day sleep log How long should I stay in bed? Write down time you went to bed, time you got up, and estimate how much of that time you were asleep Bed restriction time = estimated weekly sleep time average So in this example, you would restrict yourself to 7 hours in bed per night for one week (reduced from 9 hours) Pick your target rising time and work backwards to set bed time Monitor with daily log Went to Bed Got upI was awake about this much So I got about this much sleep 11:15 pm8:45 am3 hr6.5 hr 10:20 pm8:20 am3 hr7 hr 10:30 pm8:00 am3 hr6.5 hr 10:30 pm8:15 am45 mins9 hr 11:00 pm7:30 am1 hr7.5 hr 11:30 pm8:30 am2.5 hr6/5 hr 12:15 am7:45 am2 hr5.5 hr Averages:11:03 pm8:09 am2.2 hrs6.9 hrs

59 Modifying Bed Restriction Plans  If after one week you are Falling asleep at night in less than 30 minutes AND Spending less than 30 minutes awake during the night OR Sleep percent (TST/TIB) > 85% (=“sleep efficiency”) THEN increase your time in bed “sleep window” 15 minutes  If you are still having trouble sleeping  Stick with the plan another week OR  Cut back your time in bed by going to bed 15 minutes later

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61 Bed Restriction: Contraindications Bed restriction is contraindicated in those: Conditions that are exacerbated by sleepiness (epilepsy, mania, parasomnias [e.g., sleep walking], sleep disordered breathing) People who need to maintain vigilance, e.g., long- haul truck drivers, air traffic controllers, etc. Short sleep latencies and regular compact sleep times Some people will refuse to follow restricted schedule Spielman AJ, et al. Sleep restriction therapy. In: Perlis M, et al. (eds.). Behavioral treatments for sleep disorders, pp Elsevier, 2011.

62 Sleep Compression: A Kinder, Gentler Way…. 7 day sleep log How long should I stay in bed? TIB this week = ~9 hours/night Target TIB = ~7 hours/night Subtract target from current TIB (9 – 7 = 2 hours) Divide difference by 4 (2 hours / 4 = 30 minutes) Set rise time then reduce TIB 30 minutes each week −Week 1: 10:30-7:00 −Week 2: 11:00-7:00 −Week 3: 11:30-7:00 −Week 4: 11:30-6:30 Went to Bed Got upI was awake about this much So I got about this much sleep 11:15 pm8:45 am3 hr6.5 hr 10:20 pm8:20 am3 hr7 hr 10:30 pm8:00 am3 hr6.5 hr 10:30 pm8:15 am45 mins9 hr 11:00 pm7:30 am1 hr7.5 hr 11:30 pm8:30 am2.5 hr6/5 hr 12:15 am7:45 am2 hr5.5 hr Averages:11:03 pm8:09 am2.2 hrs6.9 hrs

63 General Disadvantages to Behavioral Strategies Meds are widely available and work rapidly (when effective) Non-compliance and attrition are common due to effort and discomfort Things may get worse before they get better (improvements may not be seen until 3-4 weeks) Require closer diary monitoring than meds

64 Cognitive-Behavioral Treatment for Insomnia Multicomponent Approach DomainTechniqueAim Cognitive components Cognitive therapy Address thoughts and beliefs that interfere with sleep Relaxation training Reduce arousal and decrease anxiety Acceptance based Decrease struggle to control sleep at cost of living your life

65 Attention to sleep Intention to sleep Effort to sleep Attention-Intention Effort (AIE) Pathway Normal and automatic sleep processes become disrupted when individuals selectively focus on: Espie, C.A., et al. Sleep Medicine Reviews, 10: , In other words, worrying about sleep makes it harder to sleep

66 Insomnia and Cognitive Effort People with insomnia … Tend to use more thought control strategies (suppression, reappraisal, worry) Are more involved in excessive and counter- productive thinking about sleep and daytime function Have more hyper-arousal and anxiety

67 Cognitive Therapy Address misconceptions about sleep I must get 8 hours/sleep at night to function I can control how much I sleep All daytime problems are due to my lack of sleep Cognitive arousal (“Insomnia Brain”) “Constructive worry” scheduling to reduce in-bed rumination Cognitive errors Catastrophizing (“If I don’t get a good sleep tonight, xx will happen”) Overgeneralization (“There’s nothing that will help my sleep.”) Magnification (“Insomnia is destroying my life.”)

68 Relaxation and Stress Management Progressive muscle relaxation Deep breathing Mindfulness meditation or prayer Pleasant visual imagery Engaging the mind in something other than worry or planning (mental math, repeated words) Creating a “buffer zone” between ending day activities and going to bed Practice during the day to enhance nighttime effectiveness

69 Acceptance-Based Strategies We cannot control sleep Sleep is an automatic, physiological process “Trying to sleep” increases arousal and risk for insomnia Thoughts and feelings are not your enemy Mindfulness: Notice – don’t resist – judgments, evaluations, criticisms, negative or positive thinking about sleep and self, feelings and sensations, memories, beliefs Life is about more than a good night’s sleep Normal sleepers have bad nights too Value-based action: What is important to you that you’ve been missing out on because of your insomnia?

70 CBT-I Multicomponent Approach DomainTechniqueAim Circadian components Circadian rhythm entrainment Reset or reinforce biological rhythm

71 Strengthening Circadian Rhythms Set consistent first exposure to light Increase daytime light Get outside whenever you can Open household curtains during the day Use full spectrum lighting if possible Regular morning light will help you fall asleep earlier at night, evening light will help you fall asleep later Use of a bright light box may help (http://www.sltbr.org/; see Corporate members list) Decreasing nighttime light Use bathroom night lights not overhead lights Close curtains to outside traffic and street light No screens (computer, TV, smart phone) at night

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73 Light Therapy: Contraindications Bright light therapy is contraindicated in those: Persons with eye abnormalities, systemic illnesses that affect the retina, or those using photosensitizing medications Persons who are unable to sit still and stay awake the correct angle and distance from the light for the prescribed treatment period Bright light can induce migraines (in ~1/3 of migraine sufferers), mania in bipolar individuals, agitation in cognitively impaired individuals

74 Points to Remember #4 Multiple non-pharmacological strategies for improving sleep in persons with insomnia exist and have relatively few contraindications for their use. All have been validated in older adult populations.

75 Common Stated Barriers to CBT-I  Doesn’t work  Not as effective as pharmacotherapy  Takes too long  Requires too much specialized training  Costs too much  Not suitable for individuals with contributing medical conditions  Patient unwillingness to participate

76 Does CBT-I Work? Effect Size CBTPCT Morin CM, et al. Am J Psychiatry. 1994;151: Murtagh DR, et al. J Consult Clin Psychol. 1995;63: MEDIUM SMALL LARGE Nowell PD, et al. JAMA. 1997;278: Smith MT, et al. Am J Psychiatry. 2002;159:5-11. QUALTSTFMAWASOSOL Courtesy of Charles Morin, PhD

77 It is Frustrating When Treatment Doesn’t Seem to Be Effective Expectations Reality HUGE GAP

78 What Do Improvements Look Like? “Practice makes perfect” Changes in sleep are gradual and not necessarily steady Sleep Improvement Time Buysse D. Personal communication. BBTI Workbook. v

79 Abbreviated Cognitive-Behavioral Insomnia Therapy 1 Two 25- minute sessions, 2 weeks apart Eliminate sleep-incompatible activities in bed/bedroom Avoid all daytime napping Follow a consistent sleep-wake schedule Brief Behavioral Treatment for Insomnia 2 One session with booster phone call 2 weeks later Reduce your time in bed Don’t go to bed unless you are sleepy Don’t stay in bed unless you are asleep Get up at the same time every day of the week, no matter how much you slept the night before 1.Edinger JD, et al. Sleep. 2003;26: Buysse DJ et al. Arch Intern Med. 2011; 171(10); Does CBT-I Take Too Long?

80 Does CBT-I Cost Too Much? Vitiello MV et al. J Am Geriatr Soc. 2013; 61(6): ; McCurry SM et al. Sleep. 2014; 37(2): ; Lovato N et al. Sleep. 2014; 37(1): ; Bastien CH et al. J Consult Clin Psychol. 2004; 72(4): ; Arnedt JT et al. Sleep. 2013; 36(3): ; Savard J et al. Sleep. 2014; 37(8): ; Espie CA et al. Sleep. 2012; 35(6): ; Cheng SK, Dizon J. Psychother Psychosom. 2012; 81: ; Espie CA. Sleep. 2009; 32(12): Shorter interventions help contain costs More cost-effective delivery models are being developed and tested in RTCs − Group administered sessions − Telephone − Video recordings − Internet Stepped care approaches

81 Does CBT-I Require A Sleep Specialist? Newer brief interventions developed for primary care typically use non-sleep specialist delivery (e.g., RNs, MS-level sleep educators) Not all patients are appropriate for CBT-I, however, so practitioners need to be qualified to assess and refer as needed.

82 Does CBT-I Work In Comorbid Disease?  Common age-related comorbidities/general primary care (Buysse et al. Arch Intern Med. 2011; 171: ; Espie et al. Sleep. 2007; 30: )  Osteoarthritis pain (Vitiello et al. J Am Geriatr Soc. 2013; 61: ; McCurry et al. Sleep 2014; 37: )  Mixed psychiatric conditions (Edinger et al. Sleep. 2009; 32: )  Cancer (Espie et al. J Clin Oncol. 2008; 26: )  Major depression (Manber et al. Sleep, 2008; 31: )  Mixed medical (OA, CAD, COPD) (Rybarczyk et al. J Consult Clin Psychol. 2005; 73: )  Dementia (McCurry et al. J Am Geriatr Soc. 2005; 53: ; McCurry et al. J Am Geriatr Soc. 2011; 59: ; McCurry et al. Am J Geriatr Psychiatry 2012; 20: )

83 Are People Willing to Do It? Unrealistic patient expectations Daytime side-effects (fatigue, poor concentration, mood swings) Real/perceived obstacles to sleep plan (bed partner, physical mobility, “it’s cold and dark out there!”) Boredom during increased out-of-bed time Paradoxical reactions (e.g., anxiety during relaxation)

84 I’m for anything that gets you through the night, be it prayer, tranquilizers or a bottle of Jack Daniel’s. ~Frank Sinatra

85 Preparing the Patient Takes Time Introduce self-management approach Gauge patient expectations Assess acceptability of non-pharmacological approach Importance of a sleep diary Setting short-term goals Negotiate a time-limited contract Secure support from significant others Morin CM. Insomnia: Psychological assessment and management. Guilford; 1993.

86 CBT-I ContraindicationsTry Instead Patient takes < 30 mins to fall asleep, and is awake for < 30 mins/night, but still has sleep or daytime complaints Educate patient; refer for evaluation for primary sleep disorder causing nonrestorative or fragmented sleep Untreated medical and/or psychiatric illness causing sleep disruptions Wait and see if insomnia resolves with appropriate diagnosis & treatment; reassess for CBT-I at later time Medical condition that may prevent patient from doing sleep restriction or stimulus control Consider alternative CBT-I components (e.g., relaxation training); pharmacological treatment may be indicated Perlis ML et al. Cognitive behavioral treatment of insomnia. Springer; A Few General Guidelines

87 Ethical Issues to Consider What are the implications of increased daytime sleepiness for the functioning and well-being of the client? Insomnia is a suicide risk factor: Is this risk being monitored? Non-prescribing clinicians cannot taper meds, alter CPAP protocols without physician oversight

88 Points to Remember #5 Many commonly cited arguments against the use of CBT-I are untrue BUT Non-pharmacological interventions do require time and commitment – on the part of both patient and provider – to be successful

89 Want to Know More? Books for Clients Edinger JD, Carney CE. Overcoming Insomnia: A Cognitive-Behavioral Therapy Workbook. Oxford University Press, Hauri P, et al. No More Sleepless Nights. John Wiley & Sons, Book and Workbook. Meadows, G. The Sleep Book. London: Orion House, Books for Clinicians Edinger JD, Carney CE. Overcoming Insomnia: A Cognitive-Behavioral Therapy Approach Therapist Guide. Oxford University Press, Perlis ML et al. Cognitive Behavioral Treatment of Insomnia: A Session- by-Session Guide. Springer, Perlis ML et al. (Eds). Behavioral Treatments for Sleep Disorders: A Comprehensive Primer of Behavioral Sleep Medicine Interventions (Practical Resources for the Mental Health Professional). Elsevier, 2011.

90 Websites px?topicID=68&cnt=1&areaID=0

91 A good laugh and a long sleep are the best cures in the doctor's book. ~Irish Proverb


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