12:50 – 1:50 PM Disclosures This session is supported by an independent educational grant from Eisai Inc. Managing Sleep Maintenance Insomnia in Older Adults The following relationships exist related to this presentation: ► Russell P. Rosenberg, PhD: Advisory Board for Harmony Biosciences, LLC and Jazz Pharmaceuticals, Inc. Consultant for Bose Corporation and Eisai Inc. Contracted Research for SPEAKER Eisai Inc.; Fitbit, Inc.; Idorsia Pharmaceuticals Ltd; Johnson & Johnson; and Merck & Co., Inc. Russell P. Rosenberg, PhD Services Provided for Promotional Purposes (not for CME/CE Services) for Jazz Pharmaceuticals, Inc. Off-Label/Investigational Discussion ► In accordance with pmiCME policy, faculty have been asked to disclose discussion of unlabeled or unapproved use(s) of drugs or devices during the course of their presentations. ASK QUESTIONS USING OUR NEW SOCIAL Q&A FEATURE! Learning Objectives Navigate to www.midwest.cnf.io • Describe current challenges associated with managing sleep maintenance insomnia, especially in older and elderly patients • Utilize currently available and emerging treatments to manage sleep Ask a maintenance insomnia, including those that avoid residual next-day Question effects, especially in older and elderly populations Click a Session Up-Vote a Question Syllabi/slides for this program are a supplement to the live CME session and are not intended for other purposes. Agenda • Defining insomnia • Impact of sleep maintenance insomnia • Sleep maintenance insomnia: • Current management approaches and unmet needs in older adults • Novel and emerging agents • Practical management approaches Pre-Activity Little Difference in Diagnostic Criteria DSM-5 Diagnostic Criteria ICSD-3 Diagnostic Criteria A. A predominant complaint of dissatisfaction with sleep quantity or A. The patient reports, or the caregiver observes, one or more of the quality, associated with one (or more) of the following symptoms: following: 1. Difficulty initiating sleep 1. Difficulty initiating sleep 2. Difficulty maintaining sleep – frequent awakenings or problems 2. Difficulty maintaining sleep returning to sleep after awakenings 3. Waking earlier than desired 3. Early-morning awakening with inability to return to sleep 4. Resistance to going to bed on appropriate schedule B. Causes clinically significant distress or impairment in social, 5. Difficulty sleeping without parent or caregiver intervention occupational, educational, academic, behavioral, or other important B. The patient reports, or the caregiver observes, one or more of the areas of functioning following related to nighttime sleep difficulty: C. Occurs at least 3 nights per week 1. Fatigue/malaise D. Present for at least 3 months 2. Attention, concentration, or memory impairment E. Occurs despite adequate opportunity for sleep 3. Impaired social, family, occupational, or academic performance Defining Insomnia F. Not better explained by/does not occur exclusively during the course of 4. Mood disturbance/irritability another sleep-wake disorder (eg, narcolepsy, a breathing-related sleep 5. Daytime sleepiness disorder, a circadian rhythm sleep-wake disorder, a parasomnia) 6. Behavioral problems (eg, hyperactivity, impulsivity, aggression) G. Not due to coexisting mental disorders and medical conditions 7. Reduced motivation, energy, initiative H. Not attributable to the physiological effects of a substance (eg, a drug 8. Proneness for errors/accidents of abuse, a medication) 9. Concerns about dissatisfaction with sleep C. Cannot be explained purely by inadequate opportunity or inadequate circumstances for sleep American Psychiatric Association. (2013). Diagnostic and statistical D. Occur at least 3 times per week manual of mental disorders (5th ed.); World Health Organization. (1992).; E. Present for at least 3 months American Academy of Sleep Medicine (2014). The International F. Cannot be explained by another sleep disorder Classification of Sleep Disorders, Third Edition (ICSD-3). Syllabi/slides for this program are a supplement to the live CME session and are not intended for other purposes. Insomnia Occurs When the Wake-sleep Insomnia is Characterized by Problems in Circuit is Disrupted Initiating and Maintaining Sleep Integrated Factors Sleep onset insomnia Sleep maintenance insomnia Homeostatic Drive • Difficulty falling asleep • Difficulty staying asleep and/or Circadian Rhythms • More common in younger difficulty getting back to sleep adults after middle-of-the-night waking Allostatic Signaling • More common in older/elderly Sleep Wake adults • Early morning awakening GABA Orexin galanin Activates Inhibit wake- wake- promoting promoting neurons neurons Fiorentino L, et al. J Clin Psychol. 2010;66(11):1161-1174. Saper CB, et al. Nature, 2005;437(7063):1257-1263. Sleep-wake Circuit Pathophysiology Ventrolateral Upper pons Locus coeruleus Hypothalamus preoptic nucleus pedunculopontine How do I identify patients with laterodorsal Acetylcholine tegmental nuclei Dopamine insomnia and does pattern GABA Histamine Orexin galanin Norepinephrine matter? Acetylcholine Serotonin Hypothalamus Thalamus Cerebral Cortex Brain Stem Cerebral Cortex Which ones might also have Sleep Wake OSA? Saper CB, et al. Nature, 2005;437(7063):1257-1263. Syllabi/slides for this program are a supplement to the live CME session and are not intended for other purposes. Prevalence of Insomnia and Psychiatric Comorbidity Insomnia and Its Related Symptoms Across Four Primary Diagnoses • Population- and clinic- • 98% of elderly individuals • 62% of individuals with based studies: high rates of with symptoms of sleep maintenance • 400 treatment-seeking outpatients psychiatric comorbidities in depression or anxiety had insomnia also had a • Depressive, bipolar affective, anxiety, and schizophrenia spectrum patients with chronic impaired sleep psychiatric comorbidity disorders insomnia • Anxiety more frequently • Depression (50%) • Early waking and associated with waking-up • GAD (23%) • DSM-5 Insomnia by Brief Insomnia Questionnaire hypersomnia was during the night • SAD (14%) associated with a 2- to • 31.8% had DSM-5 insomnia disorder 3-fold increased risk of • Panic disorder (12%) bipolar disorder Insomnia and psychiatric Sleep maintenance insomnia Insomnia and psychiatric comorbidities are common in commonly occurs with comorbidities are common1-4 the elderly5 depression or anxiety6 GAD, generalized anxiety disorder; SAD, social anxiety disorder 1. Ohayon MM, et al. J Psychiatr Res. 2003;37(1):9-15. 2. Breslau N, et al. Biol Psychiatry. 1996;39(6):411-418. 3. Chang PP, et al. Am J Epidemiol. 1997;146(2):105-114. 4. Geoffroy PA, et al. J Affect Disord. 2018;226:132-141. 5. Press Y, et al. Aging Clin Exp Res. Seow LSE, et al. J Clin Sleep Med. 2018;14(2):237-244. 2018;30(7):755-765. 6. Bolge SC, et al. Popul Health Manag. 2010;13(1):15-20. Significant Impact of Insomnia in the Elderly • 93.9% reported difficulty • Increased risk of falls • More emergency room staying asleep visits • Decreased EQ-5D scores • 65.1% reported early • More provider visits morning awakenings • Impaired functional status • More days hospitalized • 68.9% reported difficulty • Impaired cognitive falling asleep function Impact of Sleep • Wake after sleep onset Maintenance Insomnia 62.5 ± 41.5 min Quality of Life and Health-system Sleep Quality1 Functioning2-7 Burden8 1. Sidani S, et al. Clin Nurs Res. 2018 Oct 15. [Epub ahead of print] 2. Ensrud KE, et al. J Am Geriatr Soc. 2009;57(11):2085-2093. 3. Stone KL, et al. J Am Geriatr Soc. 2014;62(2):299-305. 4. Stone KL, et al. Arch Intern Med. 2008;168(16):1768-1775. 5. Lubetkin EI, et al. Sleep Health. 2018;4(2):182-187. 6. Spira AP, et al. J Gerontol Series B Psychol Sci Social Sci. 2014;69(Suppl 1):S35-S41. 7. Bernstein JPK, et al. Neuropschology. 2018;32(2):220-229. 8. Bolge SC, et al. Popul Health Manag. 2010;13(1):15-20. Syllabi/slides for this program are a supplement to the live CME session and are not intended for other purposes. Comorbid Conditions Can Contribute to or Challenges to Treating Insomnia in the Elderly Worsen Because of Insomnia Lack of treatments to manage sleep maintenance insomnia 1 Mood without undue daytime consequences and adverse events Disorders Physical Dementia Disability Elderly patients more likely to have impaired drug metabolism2 Restless CV Disease Legs Syndrome Elderly patients more likely to be on multiple medications that may interact with currently available insomnia treatments2 Snoring/ Pain Insomnia Apnea Elderly patients are more prone to accidents due to sleep medications and hypersomnolence2 Adapted from: Gulia KK, et al. Psychogeriatrics. 2018;18(3):155-165. 1. Bolge SC, et al. Popul Health Manag. 2010;13(1):15-20. 2. Gooneratne NS, et al. Clin Geriatr Med. 2014;30(3):591-627. Image: www.presentationgo.com. For sleep maintenance insomnia, which treatment(s) Current Management do I try first and why? Approaches for Sleep Maintenance Insomnia Syllabi/slides for this program are a supplement to the live CME session and are not intended for other purposes. Components of Cognitive Behavioral Using Brief CBTi in Primary Care Therapy (CBT-I) • Sleep hygiene: essential but not effective alone • Start with review of sleep hygiene • Cognitive therapy • Common sense recommendations-usual suspects • Stimulus control • Avoid light (computer/phone screens) • Sleep restriction • Don’t watch the clock • No news is good news • Relaxation/mindfulness therapies. (calm.com) • Morning exercise • Stimulus Control: associate the bed with sleep Delivery