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1 : Sleep Disorders in Long-Term Care Thomas Magnuson, M.D. Assistant Professor Division of Geriatric Psychiatry UNMC
2 : To Get Your Nursing CEUs After this program go to Your program ID number for the July 12th program is 10CE028. Instructions are on the website. **All questions about continuing education credit and payment can be directed towards the College of Nursing at UNMC.** Heidi KaschkeProgram Associate, Continuing Nursing
3 : Objectives Discuss the causes of sleep disruption in long-term care Identify non-pharmacologic interventions possible to remedy sleep disruption Assess pharmacologic interventions for sleep disruption
4 : Impact Significant problem Many residents with sleep problems 50% of the elderly have sleep problems 65% in Los Angeles area ALFs Effect Cognition Physical health Mood Quality of life Staff morale
5 : Well Elderly Spend more time in bed to get the same amount of sleep Total sleep time only mildly decreased from when younger Increase in nighttime awakenings and daytime napping Earlier bedtimes Increased time to fall asleep More easily aroused by sound Daytime sleepiness not part of normal aging
6 : Long-Term Care More often self-report sleep problems More severe self-report Asleep at all hours, even mealtimes Wake and sleep fragmentation Wakefullness interrupted by brief sleep Leads to extreme sleep-wake disruption Distributed across the entire day Rarely awake or asleep for hours
7 : Effects of Poor Sleep Variety of problems Irritability Poor concentration Decreased memory Lessened reaction time Poorer performance on tasks Community dwelling elderly More falls Increased mortality
8 : Case 78-year-old demented female Up at night, loud and disruptive Sleeps much of the day No activities CAD, HTN, depression, hypothyroidism, h/o breast cancer, arthritis, GERD, constipation, incontinence ASA, APAP, sertraline, synthroid, esomeprazole, metoprolol, furosemide, senna, MOM, oxybutynin, donepezil, memantine, hydrocodone/APAP
9 : First Questions How much are they sleeping? Usually no one really knows Up at night…sleeping pill Up in the day…stimulant Shifts need to talk to each other Sleep is poorly documented When are they sleeping? Daytime? Nighttime? Both?
10 : First Intervention Sleep chart Daily Every hour, on the hour Not 4:01, just 4:00 24 hours a day For a week Good general idea Usually is around 9-11 hours a day
11 : Causes Primary sleep disorders Medical conditions Psychiatric disorders Medications/polypharmacy Circadian rhythm problems Environment Noise and light at night Low daytime light Behavioral Physical inactivity More time in bed
12 : Primary Sleep Disorders Sleep disordered breathing (SDB) Restless Leg Syndrome (RLS) Periodic Limb Movement Disorder (PLMD) REM sleep behavior disorder (RBD)
13 : Sleep Disordered Breathing (SDB) Airflow interrupted Obesity common cause Apnea/hypopnea 10 second episodes 15 times an hour Low oxygen to brain Disrupts sleep LTC residents 50-66% have at least mild SDB Treatment is CPAP Air forces airway open
14 : Restless Leg Syndrome (RLS) Uncomfortable feeling in legs Relieved by moving legs Worse later in the day Falling asleep is hard Symptoms come on and worsen with age Possible cause of motor restlessness and wandering Treatment ropinerole (Requip) and pramipexole (Mirapex)
15 : Periodic Limb Movement Disorder (PLMD) Legs kick, jerk during nighttime sleep Easier to identify if one has asleep partner Causes sleep fragmentation Treatment Much as RLS ropinerole (Requip) pramipexole (Mirapex)
16 : REM Sleep Behavior Disorder (RBD) Usually CNS motor is paralyzed in REM Except for breathing Act out dreams Prominent in older men, certain dementias Safety is an issue Treatment clonazepam (Klonopin) Secure the environment
17 : Case Workup Sleep chart Broken up Averages 9.4 hours a day Range 4-13 hours a day Lab, medical tests Oxygen saturation unremarkable TSH normal CBC, BMP normal
18 : Medications Near bedtime Lung medications/bronchodilators caffeine, albuterol Stimulants methylphenidate (Ritalin) Daytime sedation Antihistamines promethazine (Phenergan) Anticholinergics diphenhydramine (Benedryl) Sedating antidepressants nortriptyline, mirtazapine (Remeron) less than 30mg/d
19 : Medical Conditions Common Pain Parasthesias Nighttime cough Dyspnea GERD Incontinence or frequent nighttime urination Neurodegenerative disorders Parkinson’s disease, e.g.
20 : Dementia Common sleep problems More sleep disruption Lower sleep efficiency More light sleep Less deep sleep Less REM Sundowning
21 : Circadian Rhythm Body’s pattern of sleep/wake Elderly Blunted in amplitude Less time in each sleep/wake cycle Shifted in time More daytime somnolence, nighttime awakenings Less stable in LTC than in the community May correlate with degree of dementia Decreases survival in LTC
22 : Circadian Rhythm Exerts much influence on the timing of sleep Weak CR or reset CR may strongly influence sleep problems How to try and fix Exposure to bright light in the daytime Regular scheduled exposure Physical activity less important than light Bright in the day, dark at night
23 : Case Medical conditions GERD Well controlled, no evidence of nighttime heartburn No food for an hour before bedtime Pain No complaints on routine APAP Signs of worsened pain not present Incontinence Oblivious at night Toileting right before bedtime
24 : Case Medical conditions Mood Stable symptoms Hypothyroidism TSH normal Primary sleep disorders Oxygenation normal No noted movements awake or asleep that resemble RLS or PLMD No odd or unusual nighttime behavior Dementia Pattern of sleep problem sounds familiar
25 : Case Medications hydrocodone/APAP (Vicodin) Pain controlled well on APAP Not used in awhile sertraline (Zoloft) Not a sedating antidepressant Could give at nighttime oxybutynin (Ditropan) Anticholinergic, antihistaminergic Can choose a less concerning agent L-thyroxine (Synthroid) Only if underused
26 : Night in LTC Many sleep problems in the environment Shared rooms Frequent noise and light interruptions Extended, nightly basis Most noise caused by workers Doing personal cares Room level light Suppresses melatonin Disrupts sleep Changes CR
27 : Treatment Nonpharmacologic Timed light exposure More alert right after exposure More active in the day Mixed results Lower noise and light levels Hard to change the environment
28 : Treatment Mixed approach Daytime light exposure Increased physical activity Bedtime routine Less time in bed Minimize nighttime disruption Results Lessened daytime sedation More social energy More physically active Hard to change nighttime noise and light levels
29 : Treatment Pharmacologic treatment Hypnotics zolpidem (Ambien) zaleplon (Sonata) ramelteon (Rozerem) Adverse events Dizziness Drowsiness Falls Not efficacious Don’t give to someone sleeping 13 hours a day Psychological dependence
30 : Treatment Pharmacologic Benzodiazepines alprazolam (Xanax) lorazepam (Ativan) clonazepam (Klonopin) Adverse events Falls Confusion Sedation Dependency
31 : Treatment Pharmacologic Sedating antidepressants Tricyclics Nortriptyline Amitriptyline Trazodone Mirtazapine Adverse events Daytime sedation Falls, orthostasis Confusion, bladder retention, constipation, tachycardia
32 : Treatment Melatonin Hormone Mixed results Bad idea Antipsychotics Alcohol Caffeine Exercise prior to bedtime
33 : Case No noisy roommate No routine awakenings Environment is noisy Often sitting in chair near front door Falls asleep in her room Rarely goes outside
34 : Case Likely dementia related Timed light therapy Take outdoors to sit in the sun Discontinue prn narcotic Changed oxybutynin Allowed timed naps to limit time in bed Made rigid bedtime routine Dark at night, bright in the daytime No sleeping pill
35 : Objectives Discuss causes of sleep disruption in long-term care Identify non-pharmacologic interventions possible to remedy sleep disruption Assess pharmacologic interventions for sleep disruption


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