Insomniain the Elderly

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Insomniain the Elderly March 2019 CURRENT APPROACHES TO MANAGING Insomnia in the Elderly Insomnia in the Elderly ACTIVITY OVERVIEW Faculty Daniel J. Buysse, MD This supplement consists of four sections on the diagnosis UPMC Professor of Sleep Medicine and management of older patients with chronic insomnia. Professor of Psychiatry and Clinical and Translational Science University of Pittsburgh School of Medicine Intended Audience Sharon M. O’Brien MPAS, PA-C This activity is intended for PAs and NPs treating elderly Practicing PA and Contributing Medical Editor, Clinical Advisor patients with chronic insomnia. Teresa D. Valerio, DNP, MSA, APRN, FNP-BC, DBSM Learning Objectives Family Nurse Practioner, Essentia Health DNP Leader and Assistant Instructional Professor, Upon completion of this activity, participants will be able to: Mennonite College of Nursing at Illinois State University 1. Understand underlying mechanisms of systems that drive and maintain sleep. AAPA and the faculty acknowledge the valuable contribu- tions of our medical writer, Linda Peckel, to the develop- 2. Recognize, medical, psychiatric, pharmacologic, and envi- ment of this CME/CE activity. ronmental factors that contribute to chronic insomnia. 3. Identify the most appropriate first-line chronic insomnia Disclosure Policy Statement It is the policy of both AAPA and AANP to require the disclo- therapies for individual elderly patients and second-and sure of the existence of any significant financial interest or any third-line treatments along with adjunctive measures, based other relationship a faculty member has with the commercial on clinical recommendations. interest of any commercial product discussed in an educational presentation. Please review disclosures associated with authors How to Receive CME/CE Credit on original articles. There are no fees for participating and receiving CME/CE Daniel J. Buysse, MD - Consultant for BeHealth and Consultant credit for this activity. Participants must: and CME Content Development for CME Institute 1. Read the learning objectives. Sharon M. O’Brien MPAS, PA-C - Nothing to disclose 2. Read each article in the supplement. Linda Peckel - Nothing to disclose 3. For AAPA CME go to www.aapa.org/InsomniaCME to Teresa D. Valerio, D.N.P., M.S.A., APRN, FNP-BC, DBSM - complete the online post-test and evaluation in Leaning Nothing to disclose Central (Post-test questions cover all articles in the sup- Disclaimer plement.) To obtain credit, participants must complete It is the policy of both AAPA and AANP to require the disclosure of the post-test and evaluation. A minimum score of 70% is the existence of any significant financial interest or any other rela- required on the post-test. Your certificate will be available tionship a faculty member has with the commercial interest of any under “My transcript” for your records. commercial product discussed in an educational presentation. Please 4. For AANP CE go to https://aanp.inreachce.com review disclosures associated with authors on original articles. NPs go to http://aanp.inreachce.com in CE Center > browse Acknowledgement of Commercial Support by keyword “insomnia”. To obtain credit, participants must This supplement is supported by an educational grant from complete the post-test and evaluation. A minimum score Merck Sharp & Dohme Corp. of 70% is required on the post-test. Your certificate will be available under >My account > Portfolio. TABLE OF CONTENTS Accreditation Statement Section I: Overview of Insomnia in the Elderly . 3 This activity has been reviewed by the AAPA/AANP Review Pan- Section II: Screening for Insomnia in the Elderly . 5 el and is compliant with AAPA CME and AANP CE criteria. This Section III: Assessment of Insomnia and activity is designated for 1 AAPA CME Category 1 credit and Contributing Factors in the Elderly . 6 AANP 1.0 CE and 0.5RX contact hours of credit. PAs and NPs Section IV: Treatment of Chronic Insomnia should only claim credit commensurate with the extent of their in the Elderly . 10 participation. Approval is valid until April 30, 2020. Appendix . 21 Post-Test . 23 2 March 2019 Insomnia in the Elderly SECTION I: OVERVIEW OF INSOMNIA Circadian Rhythms and Sleep IN THE ELDERLY Like all animals, humans have an endogenous circadi- Insomnia is defined as dissatisfaction with the quality or an clock that has a period of about 24 hours. Circadian quantity of sleep, indicated by difficulty falling asleep, or rhythms are an expression of self-regulating transcrip- difficulty returning to sleep after an awakening, and clin- tion-translation feedback pathways (a molecular “clock”) in ically significant daytime impairment or distress, despite every cell of our bodies. 1,2 adequate opportunities for sleep. Prevalence estimates of The suprachiasmatic nucleus (SCN) functions as a sort of insomnia in very healthy older adults have indicated that “conductor” to synchronize the circadian rhythms in all of they are similar to younger people of very good health—and our cells and tissues to control a range of body functions, yet, nearly half of all older individuals report some form of including metabolism, hormonal balances, cardiac rhythms, 3,4 sleep disturbance. The high prevalence of insomnia among and most notably, sleep/wake cycles.7,8 the elderly is often attributed to other factors associated with aging, particularly the onset of one or more comorbid Circadian rhythms represent the balance of multiple clocks conditions. driven by clock genes in all cells as they provide feedback to the main clock controlled by the SCN.8 These multiple rhythms operate in a delicate balance that becomes entrained to the environmental light-dark cycle, which THE 4 STAGES OF SLEEP varies by location and day of the year, and they are modified The human sleep cycle is made up of 4 stages.5,6 The first by the physiologic needs of the body, which can be altered 3 are non-rapid eye movement (NREM) stages, which on a daily basis. take up an average of 18%, 48%, and 16% of sleep time Circadian rhythms govern all physical and mental functions; in adults over 60. The last cycle of rapid eye movement and that behavior, in turn, exerts feedback control over (REM) sleep occupies about 18% of sleep time. circadian timing. Sleep-wake cycles are the most obvious expression of circadian rhythmicity. Circadian rhythms and Stage N1 – Light sleep. sleep-wake patterns can be disrupted by environmental fac- Stage N2 – Deeper sleep, characterized by slowing of tors such as shift work, jet lag, noisy environments, changes brain waves, drop in body temperature and heart rate in meal or activity patterns, and the use of light-emitting Stage N3 “Delta” Sleep – The deepest state, electronic devices. Endogenous factors can also affect circa- characterized by very slow brain waves and the highest dian rhythms and sleep; common examples include anxiety arousal threshold. or depression, pain, neurological disorders (such as Alzhei- mer’s disease), and various medications.7,8 REM Sleep – Sometimes called “paradoxical sleep” because it mimics the brain activity level of the awake Features of Sleep Affected by Aging state, although voluntary muscles remain atonic In general, older adults fall asleep earlier and wake earlier (except eye movement). REM is accompanied by than they did when they were younger. These changes may variability in heart rate and blood pressure. Dreaming result from advancing of circadian phase (ie, earlier timing), occurs predominantly during REM sleep, although some and a reduced homeostatic sleep drive (ie, sleep drive that dreaming can also occur during NREM. increases as a function of prior wakefulness). The timing (phase) of core body temperature, melatonin, and corti- These 4 stages typically cycle 4-5 times in a single night sol levels have all been shown to shift to earlier times in of sleep, punctuated by brief awakenings that typically middle-aged and older adults as compared to people in their occur during lighter NREM or REM stages.6 twenties.7 3 Insomnia in the Elderly Sleep is characterized by a number of different parameters 5 of both timing and structure that are affected by aging to VARIATIONS IN DEFINITIONS OF INSOMNIA varying degrees:9 Clinical definitions of insomnia vary, depending upon the guidelines used: • Total sleep time ranges decrease from 10-14 hours in childhood to 6.5-8.5 in young adulthood, and further to The Diagnostic and Statistic Manual for Mental 5-7 hours in middle age, plateauing in the sixth decade. Disorders-5 (DSM-525): defines insomnia as a pattern TST decreases by about 10-12 minutes per decade of life, of sleep disturbance occurring at least 3 nights weekly over 3 months, despite adequate opportunities for starting in the twenties. sleep, causing significant distress or functional impair- • Sleep efficiency declines slowly throughout life, continu- ment. The DSM-5 definition removed the criteria for ing past age 60. “nonrestorative sleep.” • Sleep maintenance refers to the ability to stay asleep. Af- The International Statistical Classification of Diseases ter childhood, this decreases as the number of nighttime and Related Health Problems-10 (ICD-10):5,11 arousals and time to sleep onset both increase, plateauing specifies symptoms of nonrestorative sleep lasting at at about age 60. least 1 month not triggered by another sleep-wake cycle disorder, medical or psychiatric disorder, or Insomnia in the Elderly substance abuse. Some older patients may report falling asleep and wak- The International Classification of Sleep Disorders-3 ing earlier, awakening more frequently during the night, (ICSD-3):12 defines insomnia as difficulty initiating or and taking daily naps. These sleep characteristics may be maintaining sleep occurring at least 3 nights weekly experienced as normal, acceptable patterns, which are not over 3 months, producing daytime consequences reported as problems. On the other hand, the most com- and not caused by environmental disturbances or mon sleep complaints of people in their sixties and older insufficient opportunities for sleep.
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