Geriatric Sleep Medicine


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Sleep initiation is more difficult in the elderly, and thus more time is spent awake in bed before falling asleep. Delta-wave sleep decreases, and sleep becomes more fragmented. Changes in the circadian rhythm caused by the normal aging process dictate patterns of falling asleep and waking up earlier in the older population. Daytime napping can also compound the problem.

For these reasons, insomnia is more common in people over the age of While some accept this as a typical part of aging, others seek medical or pharmaceutical care. Insomnia can be caused by stress or by disturbances in the normal sleep-wake cycle. Comorbidities such as physical disability, respiratory problems, medication use, depressive symptoms, environmental factors, poor living conditions, and loss of a spouse, close friend, or relative have all been associated with higher rates of insomnia in individuals over the age of Depression and dementia, which are quite common in the elderly, have been associated with sleep disturbances in this population.

Several types of medications have been known to cause insomnia in older people. These include central nervous system CNS stimulants diet pills or amphetamines , antidepressants, corticosteroids, diuretics, anticonvulsants, and certain antihypertensives e. Additionally, alcohol and nicotine can have a profound negative effect on the quality and quantity of sleep. From the foregoing discussion, it follows that the causes of insomnia usually fall into one of three types: 1 medical and psychiatric, 2 iatrogenic, and 3 psychosocial TABLE 1.

It is imperative that pharmacists conduct a brief medical history when counseling patients with insomnia, asking specifically about diagnosed medical disorders, medications, herbs and supplements, caffeine, alcohol, tobacco, and sleep hygiene. Sometimes chronic insomnia can be a red flag for conditions that require medical referral e. Attention to the underlying causes of sleeplessness is critical to alleviating both short-term and long-term insomnia.

The pharmacist may be the initial point of contact for patients with insomnia, and they can provide referrals to physicians. Pharmacists can give patients and their physicians important feedback whenever treatable or reversible underlying causes of insomnia are suspected. Proper sleep hygiene should be explained to the patient TABLE 2 ; for example, patients should be instructed to establish routine times for retiring and waking and to avoid daytime naps, alcohol, caffeine, and stimulant decongestants.

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It is important to reduce ambient lighting at least 1 hour prior to bedtime; this signals the pineal gland to release melatonin, a hormone that promotes sleep in response to darkness. Although regular exercise is important, the patient should be advised to avoid exercising close to bedtime. The bedroom must be kept quiet and be used only for sleeping, reading, or sexual activity e.

Stressful activities should be avoided close to bedtime. Patients should be discouraged from eating large meals or heavy snacks right before bedtime, and fluid intake should be restricted as well. Once underlying medical, psychosocial, or iatrogenic causes have been addressed and appropriate sleep hygiene has been initiated, OTC sleep aids may be considered. Antihistamines such as diphenhydramine e. A variety of herbal preparations e. When recommending nonprescription therapy to older patients, it is important to consider the risk of possible drug interactions because this population is more likely to take multiple medications.

Elderly patients also are more sensitive to the side effects of medications. Antihistamines: Diphenhydramine and doxylamine are the two most widely available OTC medications marketed as sleep aids. Both are ethanolamine derivatives with potent histamine 1 H 1 receptor antagonist activity and anticholinergic properties. The effective dose for doxylamine is 25 mg before bedtime. These studies indicate that patients who have no prior history of using antihistamines for sleep respond best, and that next-day "hangover" sedation may occur in some patients.

No symptoms of drug dependence have been observed. Pharmacist-to-Patient Counseling Tips: The geriatric population is especially sensitive to the anticholinergic properties of nonprescription and prescription antihistamines. Diphenhydramine may cause confusion and sedation and is not recommended for use as a hypnotic agent in the elderly. Older men with prostate disease e. The consumption of alcoholic beverages concurrently with antihistamines should be discouraged because of additive CNS-depressant effects.

Pharmacists should remind patients that these drugs may impair motor activity and that it is therefore unadvisable to drive or operate heavy machinery when taking diphenhydramine or doxylamine. Valerian Valeriana officinalis : Valerian root has been used for its sedative and hypnotic effects for centuries.

It was used to treat shell shock during World War I. The recommended dose of valerian for insomnia is mg to mg standardized to 0. Studies have shown that valerian is most effective when it is used continuously, and results are not usually noted for 2 to 4 weeks. Other side effects seen in clinical trials included headaches, excitability, and uneasiness. Chamomile Matricaria recutita : Although few studies in humans have been performed on chamomile, the herb is cultivated worldwide for use as a sedative, spasmolytic, anti-inflammatory, and wound-healing agent.

The active component apigenin has been shown to bind to the same receptors as benzodiazepines to exert an anxiolytic and mild sedative effect in mice. In vitro, chamomile has been shown to be bactericidal to some Staphylococcus and Candida species. Chamomile is considered safe by the FDA but it should be used with caution in individuals who are allergic to ragweed, as cross-allergenicity may occur. Symptoms include abdominal cramping, tongue thickness, tight sensation in throat, angioedema of the lips or eyes, diffuse pruritus, urticaria, and pharyngeal edema.

Chamomile is commonly consumed as a tea for its calming effect. It can be brewed using 1 heaping teaspoon of dried flowers steeped in hot water for 10 minutes and may be consumed up to 3 times per day.


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Melatonin: Melatonin is an endogenous hormone secreted by the pineal gland that may have some utility in treating circadian rhythm-based sleep disorders. The dosage used was flexible; the mean stable effective dose was 5. Benefits were most apparent during the first week of treatment. Pharmacist-to-Patient Counseling Tips: Owing to the widespread availability and marketing of the aforementioned nutraceuticals for insomnia to the general public, their use often is not supervised by pharmacists.

However, the pharmacist may be on the receiving end of consumers' questions about the safety and efficacy of these products. The use of herbs and supplements for chronic insomnia that is not medically supervised should be discouraged because an underlying, treatable cause of insomnia may otherwise be masked. The pharmacist should first address sleep hygiene and other nonmedical or psychiatric causes of insomnia before recommending these supplements.

The pharmacist should remind patients that dietary supplements such as valerian, chamomile, and melatonin are not supported by large, prospective, placebo-controlled studies. Patients should be advised to take the same dosage and frequency that have been studied in clinical trials and not to exceed labeled amounts. The purchase and use of natural products that do not list the exact amount contained in each dosage unit should be discouraged. The pharmacist should elicit a careful history from the patient regarding any allergies, especially to ragweed and daisies, keeping in mind that many patients with allergic rhinitis may not know which allergens trigger their attacks.

Patients who are allergic to ragweed and flowers in the daisy family asters, chrysanthemums may have allergic reactions to products containing chamomile. Benzodiazepines: The currently marketed benzodiazepines and their respective usual doses for insomnia are listed in TABLE 4. The use of benzodiazepines for insomnia is somewhat controversial because of their potential to produce euphoria and their potential association with withdrawal symptoms after prolonged use. Abuse, dependence, and addiction are another concern, especially in patients with a history of substance abuse.

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Unlike other hypnotic agents, benzodiazepines are effective anxiolytics. Drug accumulation due to decreased renal clearance is a consideration in the elderly. Benzodiazepines differ primarily in their pharmacokinetic profile, such as rate of absorption, elimination of half-life, pathways of metabolism, and lipid solubility--factors that contribute to the overall effect by influencing the onset and duration of action.

Long-acting benzodiazepines can accumulate and lead to an increased risk of dizziness, confusion, hypotension, and cognitive impairment. Active metabolite accumulation is even more problematic in the elderly because of the slowed hepatic and renal metabolic activity that is part of the aging process. When restricted to short-term use e. Benzodiazepines can produce undesirable side effects such as psychomotor impairment, amnesia, and withdrawal symptoms. Commonly reported withdrawal symptoms are anxiety and insomnia; others include tinnitus, involuntary movements, perceptual changes, confusion, and depersonalization.

Geriatric Sleep Medicine - CRC Press Book

Withdrawal symptoms can be attenuated by using the smallest dose and shortest duration possible and by tapering the dose gradually. The pharmacist should counsel patients to restrict their intake of alcohol and other CNS depressants concurrently with benzodiazepines.


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Nonbenzodiazepine Hypnotics: Zolpidem Ambien , eszopiclone Lunesta , and zaleplon Sonata are nonbenzodiazepine sedative-hypnotic drugs approved for the short-term treatment of insomnia. Ramelteon Rozerem is a melatonin receptor agonist approved for the treatment of insomnia characterized by difficulty initiating sleep onset. Zaleplon is indicated only for the short-term treatment of insomnia. These agents have been proven to significantly improve sleep latency.

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They have less potential for abuse and addiction than benzodiazepines and thus should be tried before benzodiazepine therapy is initiated. Nonbenzodiazepine hypnotics have less potential for producing pharmacologic tolerance and do not possess anticonvulsant or anxiolytic properties when used at hypnotic doses.

Compared with other nonbenzodiazepine hypnotics, eszopiclone has the longest half-life, about 5 hours in geriatric patients; zaleplon, with a half-life of 1 hour, has the shortest half-life. In the elderly, it is important to initiate nonbenzodiazepine hypnotic therapy at the lowest possible effective dose. This will help prevent dose-related adverse effects such as daytime drowsiness, falls, and sedation.

Alcohol use should be discouraged.

tempfootbgeteve.tk Patients should be educated about the possible side effects associated with nonbenzodiazepine hypnotic therapy, and they should be advised to report any abnormal cognitive or behavioral changes to their physician. Nonbenzodiazepine hypnotics should not be taken with or after a high-fat meal. The most common side effects of eszopiclone are headache and dizziness. Patients should not take zolpidem unless they can devote 7 to 8 hours to sleep.

The most common side effects of zolpidem are drowsiness, headache, dizziness, and diarrhea; activities such as driving, cooking, or eating while asleep also have been reported.

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