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דר' דורון גרפינקל מנהל מחלקה גריאטרית - פליאטיבית שהם – המרכז המשולב לרפואת הגיל השלישי, פרדס חנה. דר' דורון גרפינקל מנהל מחלקה גריאטרית - פליאטיבית שהם.

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Presentation on theme: "דר' דורון גרפינקל מנהל מחלקה גריאטרית - פליאטיבית שהם – המרכז המשולב לרפואת הגיל השלישי, פרדס חנה. דר' דורון גרפינקל מנהל מחלקה גריאטרית - פליאטיבית שהם."— Presentation transcript:

1 דר' דורון גרפינקל מנהל מחלקה גריאטרית - פליאטיבית שהם – המרכז המשולב לרפואת הגיל השלישי, פרדס חנה. דר' דורון גרפינקל מנהל מחלקה גריאטרית - פליאטיבית שהם – המרכז המשולב לרפואת הגיל השלישי, פרדס חנה. הפרעות שינה ב ג י ל ה מ ב ו ג ר הפרעות שינה ב ג י ל ה מ ב ו ג ר

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

3 Sleep and Aging How does sleep change as we age? How does sleep change as we age? Do we need less sleep as we get older? Do we need less sleep as we get older? Can a person expect to experience more sleep problems or have a sleep disorder as they advance in age? Can a person expect to experience more sleep problems or have a sleep disorder as they advance in age? As we age, how does sleep affect our overall health, medical conditions and general well being? What can we do to get good sleep?

4 Specific Problems - Snoring Partial blockage of airway causing abnormal breathing & sleep disruptions Partial blockage of airway causing abnormal breathing & sleep disruptions 90 million in the US; 37 million experience on a regular basis 90 million in the US; 37 million experience on a regular basis Males Males Those who are overweight and with large neck size most at risk Those who are overweight and with large neck size most at risk Loud snoring can be a symptom of sleep apnea Loud snoring can be a symptom of sleep apnea

5 Specific Problems - Sleep Apnea Increases as we age: affecting 4% and 2% of middle-aged men and women and close to 27% and 19% of older men and women Increases as we age: affecting 4% and 2% of middle-aged men and women and close to 27% and 19% of older men and women Characterized by pauses or gaps in breathing due to an obstruction of the airway Characterized by pauses or gaps in breathing due to an obstruction of the airway RESPIRATORY SLEEP DISORDERS

6 Specific Problems - Specific Problems - Sleep Apnea (continued) Signs and Symptoms Signs and Symptoms Loud, regular snoring Loud, regular snoring Large neck size Large neck size Obesity Obesity Associated with major medical conditions Associated with major medical conditions Most common treatment Most common treatment CPAP CPAP RESPIRATORY SLEEP DISORDERS

7 Restless Legs Syndrome - RLS  Unpleasant/uncomfortable feelings in the legs during rest, evening...  creeping, crawling, tingling, aching...  Urge to move, improves by moving  Any age, increases with age  Sleeping problems  Causes (imbalance of dopamin?)

8 Periodic Limb Movement Disorder (PLMD) Neurological movement disorders /nighttime leg twitching / myoclonus Neurological movement disorders /nighttime leg twitching / myoclonus Involuntary jerking of legs > arms during sleep (periodic, flex/extend), without being aware... Involuntary jerking of legs > arms during sleep (periodic, flex/extend), without being aware... If severe, may also occur while awake If severe, may also occur while awake Not all patients with PLMD have RLS BUT most patients with RLS have PLMD Not all patients with PLMD have RLS BUT most patients with RLS have PLMD

9 Primary RLS Overall prevalence: 3-15% Overall prevalence: 3-15% Mean age of onset: 34 +/- 20 years Mean age of onset: 34 +/- 20 years Highly variable course Highly variable course Primary (idiopathic) RLS make up majority of cases; Primary (idiopathic) RLS make up majority of cases; majority are hereditary majority are hereditary

10 Secondary RLS Iron deficiency (5% of patients with RLS have iron deficiency; 25-30% of patients with iron deficiency anemia have RLS) Iron deficiency (5% of patients with RLS have iron deficiency; 25-30% of patients with iron deficiency anemia have RLS) Renal failure Renal failure Pregnancy Pregnancy Parkinson’s Disease Parkinson’s Disease Neuropathy Neuropathy Medications may aggravate: antihistamines, TCAs, SSRIs, DA receptor LITHIUM, CAFFEIN, Medications may aggravate: antihistamines, TCAs, SSRIs, DA receptor LITHIUM, CAFFEIN,

11 RLS / PLMS - Treatment Healthy lifestyle – baths, massages, warm packs, meditation – yoga Healthy lifestyle – baths, massages, warm packs, meditation – yoga EXERCISE EXERCISE Avoid alcohol, tobacco, caffein Avoid alcohol, tobacco, caffein Sleep hygiene Sleep hygieneMedications: Dopaminergic, Opioids, muscle relaxants & sleep medications (clonex), Gabapentin Dopaminergic, Opioids, muscle relaxants & sleep medications (clonex), Gabapentin

12 Specific Problems - Specific Problems - Insomnia A perception or complaint of inadequate or poor sleep A perception or complaint of inadequate or poor sleep Difficulty falling asleep Difficulty falling asleep Frequent awakenings Frequent awakenings Waking too early and having difficulty falling back to sleep Waking too early and having difficulty falling back to sleep Waking unrefreshed Waking unrefreshed A highly prevalent condition affecting as many as 48% of older persons A highly prevalent condition affecting as many as 48% of older persons Next day consequences Next day consequences

13 Sleep Disturbances in the Elderly Prevalence of Insomnia by age group* : Age – 14% Age – 15% Age – 20% Age – 25% * Mellinger GD et al. Arch Gen Psychiatry 1985;42: Prevalence of Insomnia by age group* : Age – 14% Age – 15% Age – 20% Age – 25% * Mellinger GD et al. Arch Gen Psychiatry 1985;42:

14 Sleep Problems/Disorders Prevalent Among Older Persons SYMPTOMS OF SLEEP PROBLEMS BY AGE Symptoms: a few nights a week or more Insomnia 49% 46% 50% Snoring 41% 28% 22% Sleep Apnea 9% 6% 7% Restless Legs Syndrome (RLS) 15% 17% 21%

15 Z SLEEP DISORDERS IN THE ELDERLY Z SLEEP DISTURBANCES IN NURSING HOMES & GERIATRIC WARDS HOMES & GERIATRIC WARDS Z NOCTURNAL RESPIRATORY DISTURBANCES SLEEP DISORDERS IN THE ELDERLY THE ROLE OF MELATONIN IN SLEEP Z THE ROLE OF MELATONIN IN SLEEP Z THE ROLE OF HYPNOTICS (SLEEPING PILLS) Z THE RATIONAL DIAGNOSTIC & THERAPEUTIC APPROACH THERAPEUTIC APPROACH POINTS FOR CONSIDERATION

16 The information in this publication was independently developed by the National Sleep Foundation. © 2003 National Sleep Foundation Sleep and Aging Well

17 Awake Stages The Sleep Cycle in Adults REM Hours in Sleep

18 Normal Sleep and Aging: Less Deep Sleep

19 The ability to get continuous and consolidated sleep may become more difficult as we age may become more difficult as we age The ability to get continuous and consolidated sleep may become more difficult as we age may become more difficult as we age

20 Health and Environment Affect Our Sleep With age, we become more sensitive to: With age, we become more sensitive to: Hormonal Changes Hormonal Changes Physiological Conditions Physiological Conditions Environmental Conditions Environmental Conditions Light Light Noise Noise Temperature Temperature

21 SLEEP DISTURBANCES IN THE ELDERLY A MAJOR CLINICAL & SOCIAL PROBLEM A MAJOR CLINICAL & SOCIAL PROBLEM

22 SLEEP DISORDERS IN THE ELDERLY HEALTHY ELDRLY INDIVIDUALS: HEALTHY ELDRLY INDIVIDUALS:  TAKE LONGER TIME TO FALL ASLEEP ( LATENCY)  HAVE DECREASED TOTAL SLEEP TIME and DECREASED “SLOW WAVE” SLEEP  HAVE INCREASED FREQUENCY & DURATION OF ARAUSALS DURING SLEEP (W.A.S.O.) ARAUSALS DURING SLEEP (W.A.S.O.) HAVE AN INCREASED INCIDENCE OF DAYTIME SLEEPINESS  HAVE AN INCREASED INCIDENCE OF DAYTIME SLEEPINESS  HAVE HAVE AN INCREASED INCIDENCE OF OF DAYTIME SLEEPINESS WITH AGE, THE INCIDENCE OF SLEEP DISORDERS INCREASES & THE QUALITY OF SLEEP DECREASES

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

24 SLEEP DISORDERS IN THE ELDERLY SLEEP DISORDERS IN THE ELDERLY MANY ELDERLY PEOPLE WHO REPORT ON SUBJECTIVE DIFFICULTIES TO FALL ASLEEP AND MANY AWAKENINGS, MAY BE FOUND TO HAVE NORMAL LATENCY AND W.A.S.O. MANY ELDERLY PEOPLE WHO REPORT ON SUBJECTIVE DIFFICULTIES TO FALL ASLEEP AND MANY AWAKENINGS, MAY BE FOUND TO HAVE NORMAL LATENCY AND W.A.S.O. ON THE OTHER HAND, SOME ELDERS WHO REPORT A “GOOD NIGHT SLEEP”, ARE FOUND TO HAVE SEVERE SLEEP DISTURBANCES WHEN OBJECTIVELY ASSESSED BY ACTIGRAPHY A POINT OF CRUCIAL IMPORTANCE IN RESPIRATORY SLEEP DISORDERS

25 THE “BAD SIDE” OF AGING: AGE-RELATED DISEASES & DISFUNCTIONS ATHEROSCLEROSIS C A N C E R C A N C E R D E M E N T I A D E M E N T I A D E P R E S S I O N (ANXIETY) D E P R E S S I O N (ANXIETY) IMPAIRED IMMUNITY INCONTINENCE OSTEOPOROSIS & OSTEOARTHROSIS DIABETES MELLITUS, F A L L S (#) CATARACT, GLAUCOMA, AMD, HEARING LOSS, PROSTATIC HYPERTROPHY, PARKINSON’S DISEASE G.I. PROBLEMS, SKIN PROBLEMS DIABETES MELLITUS, F A L L S (#) CATARACT, GLAUCOMA, AMD, HEARING LOSS, PROSTATIC HYPERTROPHY, PARKINSON’S DISEASE G.I. PROBLEMS, SKIN PROBLEMS THE BAD SIDE OF D R U G S

26 SLEEP DISORDERS IN THE ELDERLY 1. SECONDARY TO THE INCREASED INCIDENCE OF DISEASES ASSOCIATED WITH PAIN, DYSPNEA, NOCTURIA, G. I. DISCOMFORT ETC. 1. SECONDARY TO THE INCREASED INCIDENCE OF DISEASES ASSOCIATED WITH PAIN, DYSPNEA, NOCTURIA, G. I. DISCOMFORT ETC. P O S S I B L E C A U S E S 2. SECONDARY TO THE INCREASED CONSUMPTION OF DRUGS: SPECIFIC ADVERSE EFFECTS ON SLEEP, OR NONSPECIFIC (PALPITATIONS, NAUSEA, URINATION, PRURITUS ETC.) 2. SECONDARY TO THE INCREASED CONSUMPTION OF DRUGS: SPECIFIC ADVERSE EFFECTS ON SLEEP, OR NONSPECIFIC (PALPITATIONS, NAUSEA, URINATION, PRURITUS ETC.) 3. A PRIMARY ENDOGENOUS AGE - RELATED SLEEP DISORDER ( MELATONIN ?) 3. A PRIMARY ENDOGENOUS AGE - RELATED SLEEP DISORDER ( MELATONIN ?)

27 Medications Can Also Cause Sleep Problems

28 The Use of Alcohol, Caffeine and Nicotine Impacts on Sleep

29 Examples of ‘Legal’ Drugs That Cause Insomnia Alcohol Decongestants CNS stimulants Stimulating antidepressants Beta-blockers Diuretics Thyroid hormones Bronchodilators Nicotine Nicotine Calcium channel blockers Calcium channel blockers Caffeine Caffeine Corticosteriods Corticosteriods CNS Depressants CNS Depressants Quinidine Quinidine Anticonvulsants Anticonvulsants Antiparkinsonian agents Antiparkinsonian agents

30 Summary: Sleep Changes Sleep during the night changes with age: Sleep during the night changes with age: Less deep sleep / more lighter sleep Less deep sleep / more lighter sleep More difficulty maintaining sleep due to arousals & awakenings More difficulty maintaining sleep due to arousals & awakenings Sleep is less efficient and more fragmented Sleep is less efficient and more fragmented The internal biological clock shifts to earlier bed and wake times The internal biological clock shifts to earlier bed and wake times Older persons experience a higher prevalence of medical conditions and take more medications that are associated with sleep problems/disorder Older persons experience a higher prevalence of medical conditions and take more medications that are associated with sleep problems/disorder

31 Summary: Consequences of Sleep Changes Tendency to stay in bed longer to get a sufficient amount of sleep results in worse sleep Tendency to stay in bed longer to get a sufficient amount of sleep results in worse sleep More likely to take more naps to meet sleep need - may result in worse sleep More likely to take more naps to meet sleep need - may result in worse sleep Inadequate or poor sleep results in daytime sleepiness and fatigue Inadequate or poor sleep results in daytime sleepiness and fatigue Ability to function well, enjoy life and overall quality of life is affected Ability to function well, enjoy life and overall quality of life is affected

32 Consequences of Poor Sleep in older adults Difficulty sustaining attention & slowed response time Difficulty sustaining attention & slowed response time Decreased ability to accomplish daily tasks Decreased ability to accomplish daily tasks Impairments in memory & concentration Impairments in memory & concentration Increased consumption of healthcare resources Increased consumption of healthcare resources higher incidence of symptoms related to depression and anxiety higher incidence of symptoms related to depression and anxiety Increased risk of falls Increased risk of falls Shorter survival Shorter survival Increased institutionalization rate Increased institutionalization rate Inability to enjoy social relationships Inability to enjoy social relationships Decreased QOL Decreased QOL Increased incidence of cognitive decline Increased incidence of cognitive decline Increased incidence of pa Increased incidence of pain Ancoli-Israel s, Cook JR. J Am Geriatr Soc 2005;53 (suppl):S264-S271

33 SLEEP DISORDERS SHOULD BE HANDLED BY THE PHYSICIAN SHOULD BE HANDLED BY THE PHYSICIAN IN THE SAME CLINICAL APPROACH AS THAT USED FOR OTHER SYMPTOMS OR SIGNS: IN THE SAME CLINICAL APPROACH AS THAT USED FOR OTHER SYMPTOMS OR SIGNS: FIRST OF ALL, DEFINE THE UNDERLYING CAUSE & MAKE THE CORRECT DIAGNOSIS APPROACH TO SLEEP DISORDERS (IN THE NURSING HOME SETTING)

34 Evaluating Causes of Insomnia Situational factors that are major stressors such as a life trauma or an upcoming important event Situational factors that are major stressors such as a life trauma or an upcoming important event Environmental factors such as too much noise, temperature that are too hot or too cold, or working a night shift Environmental factors such as too much noise, temperature that are too hot or too cold, or working a night shift Factors related to medications, both prescription and nonprescription (i.e. CNS stimulants/ activating antidepressants) Factors related to medications, both prescription and nonprescription (i.e. CNS stimulants/ activating antidepressants) Medical problems such as pain, endocrine, menopause, BPH, incontinence, CHF, PUD/GERD, COPD, allergic rhinitis, seizure d/o Medical problems such as pain, endocrine, menopause, BPH, incontinence, CHF, PUD/GERD, COPD, allergic rhinitis, seizure d/o

35 . A. PROVE IT: CHECK OVERNIGHT URINE FOR 6-STM 3. A. PROVE IT: CHECK OVERNIGHT URINE FOR 6-STM B. CONSIDER A THERAPEUTIC TRIAL WITH 2mg OF B. CONSIDER A THERAPEUTIC TRIAL WITH 2mg OF CONTROLLED - RELEASE MELATONIN..... OR CONTROLLED - RELEASE MELATONIN..... OR 1. RULE OUT AND TREAT SITUATIONS LEADING TO SECONDARY SLEEP DISORDERS PARTICULARY SLEEP APNEA (PATIENT’S STORY, ANXIETY, DEPRESSION, PHYSICAL, IMAGING & LAB FINDINGS). 1. RULE OUT AND TREAT SITUATIONS LEADING TO SECONDARY SLEEP DISORDERS PARTICULARY SLEEP APNEA (PATIENT’S STORY, ANXIETY, DEPRESSION, PHYSICAL, IMAGING & LAB FINDINGS). 2. NO APPARENT UNDERLYING CAUSE FOR SLEEP DISORDER and ADVANCED AGE - CONSIDER A PRIMARY MELATONIN DISORDER DISORDER and ADVANCED AGE - CONSIDER A PRIMARY MELATONIN DISORDER APPROACH TO SLEEP DISORDERS (IN THE NURSING HOME SETTING ) TRY A SLEEPING PILL… PREFERABLY NOT A 4. TRY A SLEEPING PILL… PREFERABLY NOT A BENZODIAZEPINE AS THE FIRST CHOISE BENZODIAZEPINE AS THE FIRST CHOISE

36 How To Enhance Your Sleep: Practical Tips for Good Sleep Establish a regular schedule with consistent bed and wake times Maintain a relaxing bedtime routine Create a sleep-promoting environment that is comfortable, quiet, dark and preferably cool Establish a regular schedule with consistent bed and wake times Maintain a relaxing bedtime routine Create a sleep-promoting environment that is comfortable, quiet, dark and preferably cool

37 Sleep Tips (continued) Limit fluids and don’t eat too much close to bedtime Avoid caffeine, nicotine and alcohol too close to bedtime and even after lunch Exercise, but not within 3 hours before bedtime Limit fluids and don’t eat too much close to bedtime Avoid caffeine, nicotine and alcohol too close to bedtime and even after lunch Exercise, but not within 3 hours before bedtime

38 If You Have Difficulty Sleeping Limit time in bed Use your bed only for sleep and satisfying sex Avoid watching the clock Limit naps Limit time in bed Use your bed only for sleep and satisfying sex Avoid watching the clock Limit naps

39 Keep a Sleep Diary to Identify Your Sleep Habits and Patterns

40 SLEEP WELL !


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