Upload
ariel-ray
View
218
Download
0
Tags:
Embed Size (px)
Citation preview
DORON GARFINKEL, M.DDORON GARFINKEL, M.D..DORON GARFINKEL, M.DDORON GARFINKEL, M.D..
SHOHAM GERIATRIC MEDICAL CENTERSHOHAM GERIATRIC MEDICAL CENTER
PARDES – HANAPARDES – HANA , ,
ISRAELISRAEL
HEAD, GERIATRIC PALIATIVE DEPARTMENTHEAD, GERIATRIC PALIATIVE DEPARTMENT
SLEEP DISORDER IN THE ELDERLY -
EFFECT OF MELATONIN THERAPY
SLEEP DISORDER IN THE ELDERLY -
EFFECT OF MELATONIN THERAPY
Normal Sleep & Normal Aging:Our Internal Biological ClockNormal Sleep & Normal Aging:Our Internal Biological Clock
The biological clock resides in the brainThe biological clock resides in the brain It helps regulate when we feel sleepy It helps regulate when we feel sleepy
and when we are alertand when we are alert It works in tandem with light and dark, It works in tandem with light and dark,
and our body temperatureand our body temperature
and hormonesand hormones
M E L A T O N I N N ACETYL -5- METHOXYTRYPTAMINE
M E L A T O N I N N ACETYL -5- METHOXYTRYPTAMINE
ITS SYNTHESIS & EXCRETION ARE REGULATED ITS SYNTHESIS & EXCRETION ARE REGULATED
BY ANBY AN ENDOGENOUS ENDOGENOUS CLOCK LOCATED IN CLOCK LOCATED IN
THE HYPOTHALAMUS THAT IS ENTRAINED THE HYPOTHALAMUS THAT IS ENTRAINED
TO THE EXTERNAL LIGHT - DARK CYCLETO THE EXTERNAL LIGHT - DARK CYCLE
ITS SYNTHESIS & EXCRETION ARE REGULATED ITS SYNTHESIS & EXCRETION ARE REGULATED
BY ANBY AN ENDOGENOUS ENDOGENOUS CLOCK LOCATED IN CLOCK LOCATED IN
THE HYPOTHALAMUS THAT IS ENTRAINED THE HYPOTHALAMUS THAT IS ENTRAINED
TO THE EXTERNAL LIGHT - DARK CYCLETO THE EXTERNAL LIGHT - DARK CYCLE
AN INDOLE-AMINE SECRETED IN RESPONSE AN INDOLE-AMINE SECRETED IN RESPONSE
TO DARKNESS FROM THE PINEAL GLANDTO DARKNESS FROM THE PINEAL GLAND
AN INDOLE-AMINE SECRETED IN RESPONSE AN INDOLE-AMINE SECRETED IN RESPONSE
TO DARKNESS FROM THE PINEAL GLANDTO DARKNESS FROM THE PINEAL GLAND
THE HORMONE INDUCES SLEEP THROUGH ITS SYNCHRONIZING EFFECT ON THE
INTERNAL BIOLOGICAL CLOCK EASILY CROSSES THE BLOOD BRAIN BARRIER (B. B. B.)
THE HORMONE INDUCES SLEEP THROUGH ITS SYNCHRONIZING EFFECT ON THE
INTERNAL BIOLOGICAL CLOCK EASILY CROSSES THE BLOOD BRAIN BARRIER (B. B. B.)
M E L A T O N I N N ACETYL -5- METHOXYTRYPTAMINE
M E L A T O N I N N ACETYL -5- METHOXYTRYPTAMINE
IS RAPIDLY METABOLIZED IN THE LIVER AND
OVER 85% ELIMINATED IN THE URINE
AS 6 SULPHATOXY - MELATONIN (6 - S - MT)
IS RAPIDLY METABOLIZED IN THE LIVER AND
OVER 85% ELIMINATED IN THE URINE
AS 6 SULPHATOXY - MELATONIN (6 - S - MT)
EFFECT OF AGE ON M E L A T O N I N
EFFECT OF AGE ON M E L A T O N I N
THERE IS AN AGE-RELATED CHANGE IN THERE IS AN AGE-RELATED CHANGE IN THE DAILY RHYTHM OF MELATONINTHE DAILY RHYTHM OF MELATONIN
SERUM MELATONIN CONCENTRATIONS SERUM MELATONIN CONCENTRATIONS DECREASE IN OLD AGEDECREASE IN OLD AGE
IN HEALTHY ELDERLY INSOMNIACS, 6-S MT IN HEALTHY ELDERLY INSOMNIACS, 6-S MT IS SIGNIFICANTLY LOWER AND ITS ONSET IS SIGNIFICANTLY LOWER AND ITS ONSET AND PEAK TIME ARE DELAYED - AND PEAK TIME ARE DELAYED - IN COMPARISON TO AGE MATCHED IN COMPARISON TO AGE MATCHED CONTROLS WITH NO SLEEP DISTURBANCESCONTROLS WITH NO SLEEP DISTURBANCES
URINARY 6 - SULPHATOXY MELATONIN (6- S- MT) EXCRETION
URINARY 6 - SULPHATOXY MELATONIN (6- S- MT) EXCRETION
0
5
10
15
6 -
S-
MT
(u
g)
18--21 21--24 00--03 03--06 06--09
COLLECTION INTERVAL (h)
ELDERS / ELDERS / PATIENTSPATIENTS
NORMALNORMAL
EXOGENOUS MELATONIN Therapeutic Effects
EXOGENOUS MELATONIN Therapeutic Effects
EXERTS SYNCHRONIZING EFFECTS ON CIRCADIAN EXERTS SYNCHRONIZING EFFECTS ON CIRCADIAN RHYTHMS - IT PHASE ADVANCES SLEEP OF RHYTHMS - IT PHASE ADVANCES SLEEP OF
PATIENTS SUFFERING FROM PATIENTS SUFFERING FROM
DELAYED SLEEP- PHASE SYNDROMEDELAYED SLEEP- PHASE SYNDROME CAN FACILITATE THE POST - FLIGHT ADAPTATION CAN FACILITATE THE POST - FLIGHT ADAPTATION
OF OF JET - LAGJET - LAG RESYNCHRONIZES THE SLEEP - WAKE CYCLERESYNCHRONIZES THE SLEEP - WAKE CYCLE
OF OF BLIND PEOPLEBLIND PEOPLE
EXOGENOUS MELATONIN Characteristics
EXOGENOUS MELATONIN Characteristics
IS NOT ASSOCIATED WITH SERIOUS SIDE EFFECTS
IS NOT ASSOCIATED WITH SERIOUS SIDE EFFECTS
IS SHORT LIVED IN HUMANS -
SERUM HALF LIFE IS ONLY 40-50 MINUTES
IS SHORT LIVED IN HUMANS -
SERUM HALF LIFE IS ONLY 40-50 MINUTES
CONTROLLED - RELEASE MELATONIN
CONTROLLED - RELEASE MELATONIN
ENABLES RESTORATION OF NORMAL SERUM ENABLES RESTORATION OF NORMAL SERUM MELATONIN CONCENTRATIONS BY CONTROLLED MELATONIN CONCENTRATIONS BY CONTROLLED DOSAGE AND TIMINGDOSAGE AND TIMING
ACHIEVES A PHARMACOKINETIC PROFILE SIMILAR ACHIEVES A PHARMACOKINETIC PROFILE SIMILAR TO THAT OF ENDOGENOUS MELATONIN TO THAT OF ENDOGENOUS MELATONIN SECRETED BY THE PINEAL GLANDSECRETED BY THE PINEAL GLAND
THE QUALITY OF SLEEP IS MUCH BETTER THAN THE QUALITY OF SLEEP IS MUCH BETTER THAN THAT ACHIEVED BY REGULAR , SHORT ACTING THAT ACHIEVED BY REGULAR , SHORT ACTING MELATONINMELATONIN
COMPLIANCE IS IMPROVED ESPECIALLY IN THE COMPLIANCE IS IMPROVED ESPECIALLY IN THE ELDERLYELDERLY
RESEARCH PROJECTSSTUDY DESIGN
RESEARCH PROJECTSSTUDY DESIGN
RANDOMIZED, PLACEBO CONTROLLED
DOUBLE - BLIND ± CROSSOVER DESIGN
SUBJECTS GIVEN EITHER 2mg OF
CONTROLLED - RELEASE MELATONIN
(CIRCADINTM, NEURIM PHARMACEUTICALS , ISRAEL)
OR A PLACEBO,
TWO HOURS BEFORE DESIRED BEDTIME ,
FOR THREE WEEKS - SEVERAL MONTHS
RANDOMIZED, PLACEBO CONTROLLED
DOUBLE - BLIND ± CROSSOVER DESIGN
SUBJECTS GIVEN EITHER 2mg OF
CONTROLLED - RELEASE MELATONIN
(CIRCADINTM, NEURIM PHARMACEUTICALS , ISRAEL)
OR A PLACEBO,
TWO HOURS BEFORE DESIRED BEDTIME ,
FOR THREE WEEKS - SEVERAL MONTHS
S U B J E C T SS U B J E C T S
ADULTS AND ELDERLY PEOPLE LIVING IN THE COMMUNITY WHO SUFFERED FROM SLEEP DISTURBANCES INITIALLY, PEOPLE LIVING IN MEDITERRANEAN TOWERS, A RESIDENTIAL CENTER FOR SENIOR CITIZENS IN ISRAEL THEN, PATIENTS SUFFERING FROM DIABETES MELLITUS, HEART DISEASE,
HYPERTENTION etc ± SLEEPING PILLS...
ADULTS AND ELDERLY PEOPLE LIVING IN THE COMMUNITY WHO SUFFERED FROM SLEEP DISTURBANCES INITIALLY, PEOPLE LIVING IN MEDITERRANEAN TOWERS, A RESIDENTIAL CENTER FOR SENIOR CITIZENS IN ISRAEL THEN, PATIENTS SUFFERING FROM DIABETES MELLITUS, HEART DISEASE,
HYPERTENTION etc ± SLEEPING PILLS...
RESEARCH PROJECTSTOOLS
RESEARCH PROJECTSTOOLS
A SLEEP QUESTIONNAIRE ASSESSMENT OF SLEEP QUALITY FOR
THREE CONSECUTIVE NIGHTS, BY WRIST ACTIGRAPHY WHILE SUBJECTS WERE SLEEPING AT HOME
MOTION RECORDING ANALYSED USING AN AUTOMATIC SCORING ALGORHYTHM
URINE COLLECTED AT 3 HOUR INTERVALS OVERNIGHT, URINARY 6-S MT ASSAYED BY R.I.A. OR ELISA
STUDY PROTOCOL STUDY PROTOCOL
RUN INRUN IN WASH WASH OUTOUT
1 WEEK 1 WEEK3 WEEKS 3 WEEKS
CR MELATONIN
CR MELATONIN CR MELATONINPLACEBOPLACEBO OR PLACEBOOR PLACEBO PLACEBO OR
PLACEBOPLACEBO
URINE COLLECTION A C T I G R A P H (3 NIGHTS))
PLC
PLC MEL0
10
20
30
40
Min
p < .088
LATENCY
EFFECTS OF CR MELATONIN ON SLEEP PARAMETERS IN ELDERLY PATIENTS
EFFECTS OF CR MELATONIN ON SLEEP PARAMETERS IN ELDERLY PATIENTS
EFFECTS OF CR MELATONIN ON SLEEP PARAMETERS IN ELDERLY PATIENTS
EFFECTS OF CR MELATONIN ON SLEEP PARAMETERS IN ELDERLY PATIENTS
PLC
PLC MEL60
65
70
75
80
85
%
p < .001
EFFICIENCY
PLC
PLC
MEL
30
40
50
60
70
80
Min
p < .001
W.A.S.O.
EFFECTS OF CR MELATONIN ON SLEEP PARAMETERS IN ELDERLY PATIENTS
EFFECTS OF CR MELATONIN ON SLEEP PARAMETERS IN ELDERLY PATIENTS
IMPROVEMENT OF SLEEP QUALITY
IN ELDERLY PEOPLE BY
CONTROLLED- RELEASE MELATONIN
IMPROVEMENT OF SLEEP QUALITY
IN ELDERLY PEOPLE BY
CONTROLLED- RELEASE MELATONIN D. GARFINKEL, M. LAUDON, D. NOF, N. ZISAPEL
LANCET 1995; 346: 541 - 44
D. GARFINKEL, M. LAUDON, D. NOF, N. ZISAPEL
LANCET 1995; 346: 541 - 44
C O N C L U S I O N S C O N C L U S I O N S CONTROLLED - RELEASE MELATONIN
SIGNIFICANTLY IMPROVES SLEEP QUALITY IN ELDERLY INSOMNIACS
IN WHOM MELATONIN OUTPUT WAS IMPAIRED
MELATONIN REPLACEMENT THERAPY SHORTENS SLEEP LATENCY,
IMPROVES SLEEP EFFICIENCY AND DECREASES W.A.S.O.
MELATONIN REPLACEMENT THERAPY SHORTENS SLEEP LATENCY,
IMPROVES SLEEP EFFICIENCY AND DECREASES W.A.S.O.
CONTROLLED RELEASEM E L A T O N I N
CONTROLLED RELEASEM E L A T O N I N
IMPROVEMENT OF SLEEP QUALITY
IN DIABETIC PATIENTS
BY
IMPROVEMENT OF SLEEP QUALITY
IN DIABETIC PATIENTS
BY
Impaired nocturnal melatonin secretion in Non-dipper hypertensive patients
Impaired nocturnal melatonin secretion in Non-dipper hypertensive patients
Jonas M, Garfinkel D, Zisapel N, Laudon M, Grossman E
BLOOD PRESS 12 (1); 19-24, 2003.
Jonas M, Garfinkel D, Zisapel N, Laudon M, Grossman E
BLOOD PRESS 12 (1); 19-24, 2003.
BENZODIAZEPINESBENZODIAZEPINES
BENZODIAZEPINS ARE WIDELY USED IN BENZODIAZEPINS ARE WIDELY USED IN
THE ELDERLY POPULATION FOR THE THE ELDERLY POPULATION FOR THE
INITIATION OF SLEEP INITIATION OF SLEEP
VERY FREQUENTLY, COMPLAINTS ABOUT POOR SLEEP MAINTENANCE PERSIST
DESPITE BENZODIAZEPIN TREATMENT
VERY FREQUENTLY, COMPLAINTS ABOUT POOR SLEEP MAINTENANCE PERSIST
DESPITE BENZODIAZEPIN TREATMENT
WE REPORTED A DECREASED MELATONIN WE REPORTED A DECREASED MELATONIN OUTPUT IN ELDERLY PEOPLE SUFFERING FROM OUTPUT IN ELDERLY PEOPLE SUFFERING FROM INSOMNIA (Compared to Controls) INSOMNIA (Compared to Controls)
MELATONIN CAN IMPROVE SLEEP QUALITY IN MELATONIN CAN IMPROVE SLEEP QUALITY IN
MELATONIN - DEFICIENT ELDERLY PEOPLEMELATONIN - DEFICIENT ELDERLY PEOPLE
MELATONIN PRODUCTION CAN BE INHIBITED BY BENZODIAZEPINS !!!
MELATONIN PRODUCTION CAN BE !!! INHIBITED BY BENZODIAZEPINS
BENZODIAZEPINESBENZODIAZEPINES
0
25
50
75
100
O
DOSE REDUCTION - Period I DOSE REDUCTION - Period I
%%
11 22 33 44 55 66 WEEKSWEEKS
PLACEBOPLACEBO
MELATONINMELATONINGOAL
P < 0.05P < 0.05
FACILITATION OF BENZODIAZEPINE DISCONTINUATION BY
CONTROLLED-RELEASE MELATONIN
FACILITATION OF BENZODIAZEPINE DISCONTINUATION BY
CONTROLLED-RELEASE MELATONIN
FACILITATION OF BENZODIAZEPINE DISCONTINUATION BY C.R. MELATONINFACILITATION OF BENZODIAZEPINE
DISCONTINUATION BY C.R. MELATONIN
0
20
40
60
80
100
P = .05
MELATONINMELATONINPLACEBOPLACEBO
BENZODIAZEPINE DISCONTINUATION
%%
55 66 weekweek
0
25
50
75
100
O
BZD. DOSE REDUCTION VS SLEEP QUALITY BZD. DOSE REDUCTION VS SLEEP QUALITY
%%
11 22 33 44 55 66 WEEKSWEEKS
< < < M E L A T O N I N < < < < < < < M E L A T O N I N < < < <
7.5-7.5-
5.5-5.5-
6.5-6.5-
00
~11%~11%
FACILITATION OF BENZODIAZEPINE DISCONTINUATION BY C.R. MELATONINFACILITATION OF BENZODIAZEPINE
DISCONTINUATION BY C.R. MELATONIN
STILL ON BENZIDIAZEPINES - FAILURESTILL ON BENZIDIAZEPINES - FAILURE& STOPPED C. R. MELATONIN & STOPPED C. R. MELATONIN 22% 22%
FACILITATION OF BENZODIAZEPINE DISCONTINUATION BY C.R. MELATONIN
TWO YEARS AFTER TERMINATION OF THE STUDY
FACILITATION OF BENZODIAZEPINE DISCONTINUATION BY C.R. MELATONIN
TWO YEARS AFTER TERMINATION OF THE STUDY
BENZODIAZEPINE DOSE REDUCTION 78% STOPPED TAKING BZD 60% 0N C. R. MELATONIN 52% WITHOUT C. R. MELATONIN 8% REDUCED BZD DOSAGE 18% (Average 30% of Initial BZD Dose)
BENZODIAZEPINE DOSE REDUCTION 78% STOPPED TAKING BZD 60% 0N C. R. MELATONIN 52% WITHOUT C. R. MELATONIN 8% REDUCED BZD DOSAGE 18% (Average 30% of Initial BZD Dose)
CONCLUSIONS CONCLUSIONSCONTROLLED - RELEASE MELATONIN CONTROLLED - RELEASE MELATONIN
CAN FACILITATE BENZODIAZEPINE CAN FACILITATE BENZODIAZEPINE DISCONTINUATION OR ENABLES A DISCONTINUATION OR ENABLES A
SIGNIFICANT DOSE REDUCTION SIGNIFICANT DOSE REDUCTION
OF BENZODIAZEPINES, OF BENZODIAZEPINES,
WHILE MAINTAINING THE SAME OR BETTER WHILE MAINTAINING THE SAME OR BETTER SLEEP QUALITYSLEEP QUALITY
CONTROLLED - RELEASE MELATONIN CONTROLLED - RELEASE MELATONIN
CAN FACILITATE BENZODIAZEPINE CAN FACILITATE BENZODIAZEPINE DISCONTINUATION OR ENABLES A DISCONTINUATION OR ENABLES A
SIGNIFICANT DOSE REDUCTION SIGNIFICANT DOSE REDUCTION
OF BENZODIAZEPINES, OF BENZODIAZEPINES,
WHILE MAINTAINING THE SAME OR BETTER WHILE MAINTAINING THE SAME OR BETTER SLEEP QUALITYSLEEP QUALITY
D. GARFINKEL, N. ZISAPEL, J. WAINSTEIN, M. LAUDON,
Arch Int Med 159: 2456-60, 1999
D. GARFINKEL, N. ZISAPEL, J. WAINSTEIN, M. LAUDON,
Arch Int Med 159: 2456-60, 1999
FACILITATION OF BENZODIAZEPINE DISCONTINUATION BY MELATONIN :
A NEW CLINICAL APPROACH
FACILITATION OF BENZODIAZEPINE DISCONTINUATION BY MELATONIN :
A NEW CLINICAL APPROACH
שינה הפרעות בבתי אבות בקשישים
ובמחלקות סיעודיות
שינה הפרעות בבתי אבות בקשישים
ובמחלקות סיעודיות
הכנס הראשון לרפואה בגיל השלישי 2003 באפריל 28
הכנס הראשון לרפואה בגיל השלישי 2003 באפריל 28
ד"ר דורון גרפינקל מחלקה גריאטרית פליאטיבית
שהם -המרכז המשולב לרפואת הגיל השלישי פרדס חנה
ד"ר דורון גרפינקל מחלקה גריאטרית פליאטיבית
שהם -המרכז המשולב לרפואת הגיל השלישי פרדס חנה
SLEEP DISORDERS AND SLEEP SLEEP DISORDERS AND SLEEP FRAGMENTATION ARE VERY COMMON FRAGMENTATION ARE VERY COMMON
IN NURSING HOME RESIDENTS …IN NURSING HOME RESIDENTS …
APPROACH TO SLEEP DISORDERS IN THE NURSING HOME SETTING
APPROACH TO SLEEP DISORDERS IN THE NURSING HOME SETTING
Allesi CA & Schnelle JF. Sleep Med Rev 2000; 4(1): 45 - 56 (Review Article) Allesi CA & Schnelle JF. Sleep Med Rev 2000; 4(1): 45 - 56 (Review Article)
UNFORTUNATELY, THERE IS LITTLE DATA ON THE EFFECTIVENESS OF SLEEPING MEDICATIONS AND THE SPECIFIC MANAGEMENT OF SLEEP DISORDERS
IN THIS SETTING.
UNFORTUNATELY, THERE IS LITTLE DATA ON THE EFFECTIVENESS OF SLEEPING MEDICATIONS AND THE SPECIFIC MANAGEMENT OF SLEEP DISORDERS
IN THIS SETTING.
ACTIGRAPHY OF DEMENTED LONG TERM PATIENTS ACTIGRAPHY OF DEMENTED LONG TERM PATIENTS
SHOWED SLEEP EFFICIENCY SHOWED SLEEP EFFICIENCY OFOF 75%, 75%, A MEAN A MEAN
SLEEP ONSET SLEEP ONSET LATENCY OF ONE HOUR,LATENCY OF ONE HOUR, A MEAN A MEAN
W.A.S.O. OF MORE THAN TWO HOURSW.A.S.O. OF MORE THAN TWO HOURS, MORE THAN 13 , MORE THAN 13
HOURS WERE SPENT IN BEDHOURS WERE SPENT IN BED
Fetveit A, Bjorvatn B. Int J Geriatr Psychiatry 2002; 17: 604 - 9Fetveit A, Bjorvatn B. Int J Geriatr Psychiatry 2002; 17: 604 - 9
SLEEP DISTURBANCES AMONG NURSING HOME RESIDENTS
SLEEP DISTURBANCES AMONG NURSING HOME RESIDENTS
SLEEP DISTURBANCES WERE COMMON AMONG THE RESIDENTSSLEEP DISTURBANCES WERE COMMON AMONG THE RESIDENTS
THE MAIN CAUSES OF SLEEP THE MAIN CAUSES OF SLEEP DISTURBANCES IN BOTH SETTINGS WERE:DISTURBANCES IN BOTH SETTINGS WERE:
THE SLEEP OF OLDER PEOPLE IN HOSPITAL AND NURSING HOMES
THE SLEEP OF OLDER PEOPLE IN HOSPITAL AND NURSING HOMES
Ersser & al. J Clin Nurs 1999; 8(4): 360 - 8 Ersser & al. J Clin Nurs 1999; 8(4): 360 - 8
NEEDING TO GO TO THE TOILET,
NOISE
PAIN
AND DISCOMFORT
A VARIETY OF FACTORS CONTRIBUTE TO THESE SLEEPING DIFFICULTIESA VARIETY OF FACTORS CONTRIBUTE TO THESE SLEEPING DIFFICULTIES
A VARIETY OF FACTORS CONTRIBUTE TO THESE SLEEPING DIFFICULTIESA VARIETY OF FACTORS CONTRIBUTE TO THESE SLEEPING DIFFICULTIES
AGE RELATED CHANGES IN SLEEP AGE RELATED CHANGES IN SLEEP THE HIGH PREVALENCE OF DEMENTIA, DEPRESSION,
MEDICAL ILLNESS AND MEDICATIONS THAT AFFECT SLEEP
THE HIGH PREVALENCE OF DEMENTIA, DEPRESSION,
MEDICAL ILLNESS AND MEDICATIONS THAT AFFECT SLEEP
RESPIRATORY DISTURBANCES OF SLEEP RESPIRATORY DISTURBANCES OF SLEEP
LIFESTYLE CHARACTERISTICS SUCH AS: INACTIVITY, LARGE AMOUNTS OF TIME SPENT IN BED,
LACK OF BRIGHT LIGHT EXPOSURE AND POOR SLEEP HYGIENE
AND THE DISRUPTIVE NIGHT-TIME NURSING HOME ENVIRONMENT
LIFESTYLE CHARACTERISTICS SUCH AS: INACTIVITY, LARGE AMOUNTS OF TIME SPENT IN BED,
LACK OF BRIGHT LIGHT EXPOSURE AND POOR SLEEP HYGIENE
AND THE DISRUPTIVE NIGHT-TIME NURSING HOME ENVIRONMENT
APPROACH TO SLEEP DISORDERS IN THE NURSING HOME SETTING
APPROACH TO SLEEP DISORDERS IN THE NURSING HOME SETTING
Allesi CA & Schnelle JF. Sleep Med Rev 2000; 4(1): 45 - 56 (Review Article) Allesi CA & Schnelle JF. Sleep Med Rev 2000; 4(1): 45 - 56 (Review Article)
THE IMPACT OF SEDATIVE-HYPNOTIC USE ON SLEEP SYMPTOM IN ELDERLY NURSING HOME RESIDENTSS
THE IMPACT OF SEDATIVE-HYPNOTIC USE ON SLEEP SYMPTOM IN ELDERLY NURSING HOME RESIDENTSS
Monane M, Glynn RJ, Avorn J. Clin Pharmacol Ther 1996; 59(1): 83 Monane M, Glynn RJ, Avorn J. Clin Pharmacol Ther 1996; 59(1): 83
145 institutionalized elderly subjects, mean age 83.0 (range 65 - 105 years) in 12 nursing homes145 institutionalized elderly subjects, mean age 83.0 (range 65 - 105 years) in 12 nursing homes
At baseline: One or more sleep related complaints were present in 65% of the residents. No relationship was found between use of sedative - hypnotic agent and the presence or absence of sleep complaints.
AFTER 6 MONTHS OF FOLLOW UP: Improvement in functional status was significantly associated with improved sleep (p< 0.005).
THE IMPACT OF SEDATIVE-HYPNOTIC USE ON SLEEP SYMPTOM IN ELDERLY NURSING HOME RESIDENTSS
THE IMPACT OF SEDATIVE-HYPNOTIC USE ON SLEEP SYMPTOM IN ELDERLY NURSING HOME RESIDENTSS
CONCLUSIONS:CONCLUSIONS:
Monane M, Glynn RJ, Avorn J. Clin Pharmacol Ther 1996; 59(1): 83 Monane M, Glynn RJ, Avorn J. Clin Pharmacol Ther 1996; 59(1): 83
THERE WAS NO RELATIONSHIP BETWEEN DECREASED USE OF SEDATIVE - HYPNOTIC AGENTS AND WORSENED SLEEP, OR
BETWEEN THEIR INCREASED USE AND IMPROVED SLEEP REPORTS
NO DISCERNIBLE DIFFERENCE WAS FOUND IN QUALITY OF SLEEP AND WHETHER
PATIENTS FELT RESTED OR NOT,
BETWEEN THOSE
NO DISCERNIBLE DIFFERENCE WAS FOUND IN QUALITY OF SLEEP AND WHETHER
PATIENTS FELT RESTED OR NOT,
BETWEEN THOSE
THE SLEEP OF OLDER PEOPLE IN HOSPITAL AND NURSING HOMES
THE SLEEP OF OLDER PEOPLE IN HOSPITAL AND NURSING HOMES
Ersser & al. J Clin Nurs 1999; 8(4): 360 - 8 Ersser & al. J Clin Nurs 1999; 8(4): 360 - 8
PATIENTS ON HYPNOTIC MEDICATION PATIENTS ON HYPNOTIC MEDICATION
AND THOSE WHO WERE NOTAND THOSE WHO WERE NOT
AN INTERVENTION THAT COMBINES BOTH BEHAVIORAL AND ENVIRONMENTAL STRATEGIES AND THAT ADDRESSES
DAYTIME BEHAVIORAL FACTORS ASSOCIATED WITH POOR SLEEP (eg. Excessive time in bed)
The significant reduction in noise and light events … did not lead to significant improvement
in the day sleep and most night sleep measures
The significant reduction in noise and light events … did not lead to significant improvement
in the day sleep and most night sleep measures
CONCLUSIONS:CONCLUSIONS:
WOULD POTENTIALLY BE MORE EFFECTIVE IN WOULD POTENTIALLY BE MORE EFFECTIVE IN IMPROVING THE NIGHT SLEEP & THE QUALITY OF LIFE IMPROVING THE NIGHT SLEEP & THE QUALITY OF LIFE
OF NURSING HOME RESIDENTSOF NURSING HOME RESIDENTS.
THE NURSING HOME AT NIGHT: EFFECT OF AN INTERVENTION ON NOISE,
LIGHT AND SLEEP
THE NURSING HOME AT NIGHT: EFFECT OF AN INTERVENTION ON NOISE,
LIGHT AND SLEEP
Sleep disturbances were studied as a mortality risk in 272 institutionalized elderly patients
Sleep disturbances were studied as a mortality risk in 272 institutionalized elderly patients
SLEEP PATTERNS AND MORTALITY AMONG ELDERLY PATIENTS IN A GERIATRIC HOSPITALSLEEP PATTERNS AND MORTALITY AMONG ELDERLY PATIENTS IN A GERIATRIC HOSPITAL
Manabe K & al. Gerontology 2000; 46(6): 318 - 22 Manabe K & al. Gerontology 2000; 46(6): 318 - 22
Mortality after two years was significantly higher in the nighttime insomnia, daytime sleepiness and sleep onset delay groups.
Mortality after two years was significantly higher in the nighttime insomnia, daytime sleepiness and sleep onset delay groups.
Sleep disturbances may be one of the symptoms indicating poor health
or functional deficits, and be an independent risk factor for survival.
Sleep disturbances may be one of the symptoms indicating poor health
or functional deficits, and be an independent risk factor for survival.
Chronic hypoxia due to alveolar hypoventilation and/or disturbance
in ventilation/perfusion ratio,
Chronic hypoxia due to alveolar hypoventilation and/or disturbance
in ventilation/perfusion ratio,
Nocturnal Respiratory DisturbancesNocturnal Respiratory Disturbances
INTRODUCTION INTRODUCTION ::
are usually the result of a variety of cardiopulmonary & neurological maladies whose prevalence is increasing with age.
are usually the result of a variety of cardiopulmonary & neurological maladies whose prevalence is increasing with age.
Sleep disturbances may aggravate hypoxia Sleep disturbances may aggravate hypoxia
and lead to increased mortality and morbidityand lead to increased mortality and morbidity
INTRODUCTION INTRODUCTION ::
Breathing problems in general & sleep apnea in particular, are both increasing with age and represent the main causes for clinically
significant, chronic night hypoxia
Breathing problems in general & sleep apnea in particular, are both increasing with age and represent the main causes for clinically
significant, chronic night hypoxia
Nocturnal Respiratory DisturbancesNocturnal Respiratory Disturbances
R E S U L T S R E S U L T S ::
Nocturnal Respiratory Disturbances in a Prolonged Care Geriatric InstitutionNocturnal Respiratory Disturbances in a Prolonged Care Geriatric Institution
RESPIRATORY DISTURBANCE INDEX (R D I)
R D I * No. PATIENTS
( % )Normal0 - 10
4 (8%)
Mild10 - 15
5 (10%)
Moderate15 - 25
27 ( 53%)
Severe > 25
15 (29%)
* RESPIRATORY DISTURBANCE INDEX : APNEA + HYPOPNEAAS A PORTION OF TOTAL SLEEP
CONCLUSIONS:CONCLUSIONS:IN SPITE OF NORMAL OR ONLY MILDLY IN SPITE OF NORMAL OR ONLY MILDLY
IMPAIRED RESULTS OF BOTH IMPAIRED RESULTS OF BOTH THE SUBJECTIVE SLEEP REPORTS AND THE SUBJECTIVE SLEEP REPORTS AND
ARTERIAL BLOOD GASES & SPIROMETRYARTERIAL BLOOD GASES & SPIROMETRY
Nocturnal Respiratory Disturbances in a Prolonged Care Geriatric InstitutionNocturnal Respiratory Disturbances in a Prolonged Care Geriatric Institution
A SIGNIFICANT NIGHT HYPOXIA ACCOMPANIED A SIGNIFICANT NIGHT HYPOXIA ACCOMPANIED WITH MANY PERIODS OF RESPIRATORY WITH MANY PERIODS OF RESPIRATORY
DISTURBANCES (APNEA / HYPOPNEA) WERE DISTURBANCES (APNEA / HYPOPNEA) WERE FOUND IN MOST OF THE SAME SUBJECTSFOUND IN MOST OF THE SAME SUBJECTS
Seleznev I, & al. Unpublished Data Seleznev I, & al. Unpublished Data
CONCLUSIONS:CONCLUSIONS:
ALL SUBJECTS WITH SIGNIFICANT ALL SUBJECTS WITH SIGNIFICANT NOCTURNAL RESPIRATORY DISTUEBANCES NOCTURNAL RESPIRATORY DISTUEBANCES
WERE OFFERED THERAPY (CPAP) .. …WERE OFFERED THERAPY (CPAP) .. …
HOWEVER...HOWEVER...
Nocturnal Respiratory Disturbances in a Prolonged Care Geriatric InstitutionNocturnal Respiratory Disturbances in a Prolonged Care Geriatric Institution
ONLY 3 ELDERS AGREED TO TRY ONLY 3 ELDERS AGREED TO TRY THIS NON INVASIVE TREATMENT !THIS NON INVASIVE TREATMENT !
Seleznev I, & al. Unpublished Data Seleznev I, & al. Unpublished Data
COHEN - MANSFIELD J, GARFINKEL D, LIPSON S.
Arch Gerontol & Geriatr 31: 65-76, 2000
COHEN - MANSFIELD J, GARFINKEL D, LIPSON S.
Arch Gerontol & Geriatr 31: 65-76, 2000
MELATONIN FOR TREATMMENT OF
SUNDOWNING
IN ELDERLY PERSONS WITH DEMENTIA
MELATONIN FOR TREATMMENT OF
SUNDOWNING
IN ELDERLY PERSONS WITH DEMENTIA
Seleznev I, & al. Unpublished Data Seleznev I, & al. Unpublished Data
Determine the prevalence of hypoxia in
elderly people living in a nursing home
Find out whether this hypoxia was
influenced by the circadian rhythm
Look for correlations between apparent
maladies or clinical manifestations and
relevant laboratory respiratory findings.
Nocturnal Respiratory Disturbances in a Prolonged Care Geriatric InstitutionNocturnal Respiratory Disturbances in a Prolonged Care Geriatric Institution
OBJECTIVESOBJECTIVES::
.
.
.
Seleznev I, & al. Unpublished Data Seleznev I, & al. Unpublished Data
Nocturnal Respiratory Disturbances in a Prolonged Care Geriatric InstitutionNocturnal Respiratory Disturbances in a Prolonged Care Geriatric Institution
Patients Patients ::
Elderly volunteers living in a nursing home at the Shoham Geriatric Center Pardes-Hana, Israel
Elderly volunteers living in a nursing home at the Shoham Geriatric Center Pardes-Hana, Israel
Exclusion criteria :Exclusion criteria :* Significant disability defined as Karnofski * Significant disability defined as Karnofski Performance Index < 50 Performance Index < 50 * Significant cognitive impairment MMSE score<18* Significant cognitive impairment MMSE score<18* Unstable medical conditions* Unstable medical conditions
.
Pulmonary function assessments were performed using Pulmonary function assessments were performed using bedside Spirometry in the evening before polysomnography bedside Spirometry in the evening before polysomnography Arterial blood gases were determined in the morning Arterial blood gases were determined in the morning following polysomnography.following polysomnography.
Nocturnal Respiratory Disturbances in a Prolonged Care Geriatric InstitutionNocturnal Respiratory Disturbances in a Prolonged Care Geriatric Institution
Methods Methods ::
These measurements were used to calculate several parameters, enabling a quantitative comprehensive evaluation
of sleep and breathing patterns
These measurements were used to calculate several parameters, enabling a quantitative comprehensive evaluation
of sleep and breathing patterns
Subjective assessment of the quality of sleep (a questionnaire)
Objective assessment of sleep quality was performed in all subjects in their own bed by 8 channel polysomnography
Subjective assessment of the quality of sleep (a questionnaire)
Objective assessment of sleep quality was performed in all subjects in their own bed by 8 channel polysomnography
87% of the subjects had PaO2 above 70 mmHg, 9% had values of 55 - 70 mmHg,
only 4% had a PaO2 below 55 mmHg.
87% of the subjects had PaO2 above 70 mmHg, 9% had values of 55 - 70 mmHg,
only 4% had a PaO2 below 55 mmHg.
The severity of dyspnea (according to the The severity of dyspnea (according to the NYHA Functional Classification) had a NYHA Functional Classification) had a
significant positive correlation with PaCOsignificant positive correlation with PaCO22 (p=0.034, (p=0.034, RR=0.306) and negative correlation =0.306) and negative correlation
with PaOwith PaO22 (p=0.015, (p=0.015, RR=0.348).=0.348).
R E S U L T S R E S U L T S ::
Nocturnal Respiratory Disturbances in a Prolonged Care Geriatric InstitutionNocturnal Respiratory Disturbances in a Prolonged Care Geriatric Institution
Seleznev I, & al. Unpublished Data Seleznev I, & al. Unpublished Data
99 patients met our criteria but only 51 99 patients met our criteria but only 51 volunteered to participate (14 men, 37 women) volunteered to participate (14 men, 37 women)
average age 82.1± 6.89 (range 70 to 95).average age 82.1± 6.89 (range 70 to 95).
36 patients had hypertension, 20 suffered from 36 patients had hypertension, 20 suffered from ischemic heart disease (7 also had CHF), 11 had ischemic heart disease (7 also had CHF), 11 had
COPD; Depression was diagnosed in 7, COPD; Depression was diagnosed in 7, diabetes mellitus in 6, previous CVA in 5 diabetes mellitus in 6, previous CVA in 5
hypothyroidism in one.hypothyroidism in one.
R E S U L T S R E S U L T S ::
Nocturnal Respiratory Disturbances in a Prolonged Care Geriatric InstitutionNocturnal Respiratory Disturbances in a Prolonged Care Geriatric Institution
Seleznev I, & al. Unpublished Data Seleznev I, & al. Unpublished Data
The subjective assessment of sleep quality according to the sleep questionnaire: 57% complained of severe sleep disorders27% had mildly-moderately disturbed sleep16% reported a good night sleep
No correlation was found between subjective sleep quality and nocturnal
oxygen saturation, PaO2 and PaCO2.
No correlation was found between subjective sleep quality and nocturnal
oxygen saturation, PaO2 and PaCO2.
R E S U L T S R E S U L T S ::
Nocturnal Respiratory Disturbances in a Prolonged Care Geriatric InstitutionNocturnal Respiratory Disturbances in a Prolonged Care Geriatric Institution
Seleznev I, & al. Unpublished Data Seleznev I, & al. Unpublished Data
R E S U L T S R E S U L T S ::
Nocturnal Respiratory Disturbances in a Prolonged Care Geriatric InstitutionNocturnal Respiratory Disturbances in a Prolonged Care Geriatric Institution
Pulmonary Functions (FEV1)
SEVERITY *Number of
PatientsFEV1
Average ± SD
Normal 8 86.36 ± 6.48
Mild 24 69.56 ± 5.69
Moderate 11 50.85 ± 4.93
Severe 4 29.15 ± 8.71
* Normal > 80%, Mild 60 - 80%, Moderate 40 - 60%, Severe < 40% of the expected value Seleznev I, & al. Unpublished Data Seleznev I, & al. Unpublished Data
R E S U L T S R E S U L T S ::
Nocturnal Respiratory Disturbances in a Prolonged Care Geriatric InstitutionNocturnal Respiratory Disturbances in a Prolonged Care Geriatric Institution
Extent of Nocturnal Apnea and Oxygen Desaturation
SEVERITY Apnea Index *
Periods of OxygenSaturation Bellow 90%
(% of Total Sleep Time ) **
Normal 26 (51%) 14 (27%)
Mild 23 (45%) 22 (43%)
Moderate – Severe 2 (4%) 15 (30%)
* Apnea Index : normal 0 - 5, mild 5 - 10, moderate to severe > 10** Saturation of Oxygen < 90% : normal = 0, mild < 10%, moderate - severe > 10% of Total Sleep Time
SLEEP DISORDERS
SHOULD BE HANDLED BY THE PHYSICIAN SHOULD BE HANDLED BY THE PHYSICIAN
IN THE SAME CLINICAL APPROACH AS THAT USED IN THE SAME CLINICAL APPROACH AS THAT USED FOR OTHER SYMPTOMS OR SIGNS:FOR OTHER SYMPTOMS OR SIGNS:
FIRST OF ALL,FIRST OF ALL,
DEFINE THE UNDERLYING CAUSE DEFINE THE UNDERLYING CAUSE
& MAKE THE CORRECT DIAGNOSIS& MAKE THE CORRECT DIAGNOSIS
APPROACH TO SLEEP DISORDERS
(IN THE NURSING HOME SETTING)
APPROACH TO SLEEP DISORDERS
(IN THE NURSING HOME SETTING)
Evaluating Causes of InsomniaEvaluating Causes of Insomnia
Situational factors that are major stressors such as a life Situational factors that are major stressors such as a life
trauma or an upcoming important eventtrauma or an upcoming important event
Environmental factors such as too much noise, temperature Environmental factors such as too much noise, temperature
that are too hot or too cold, or working a night shiftthat are too hot or too cold, or working a night shift
Factors related to medications, both prescription and Factors related to medications, both prescription and
nonprescription (i.e. CNS stimulants/ activating nonprescription (i.e. CNS stimulants/ activating
antidepressants)antidepressants)
Medical problems such as pain, endocrine, menopause, BPH, Medical problems such as pain, endocrine, menopause, BPH,
incontinence, CHF, PUD/GERD, COPD, allergic rhinitis, incontinence, CHF, PUD/GERD, COPD, allergic rhinitis,
seizure d/oseizure d/o
33 .A. PROVE IT: CHECK OVERNIGHT URINE FOR 6-STM B. CONSIDER A THERAPEUTIC TRIAL WITH 2mg OF
CONTROLLED - RELEASE MELATONIN . . .. . OR
11 . . RULE OUT AND TREAT SITUATIONS LEADING TO RULE OUT AND TREAT SITUATIONS LEADING TOSECONDARY SLEEP DISORDERS PARTICULARYSECONDARY SLEEP DISORDERS PARTICULARY SLEEP APNEA (PATIENT’S STORY, ANXIETYSLEEP APNEA (PATIENT’S STORY, ANXIETY , ,
DEPRESSION, PHYSICAL, IMAGING & LAB FINDINGSDEPRESSION, PHYSICAL, IMAGING & LAB FINDINGS.).)
11 . .RULE OUT AND TREAT SITUATIONS LEADING TO RULE OUT AND TREAT SITUATIONS LEADING TO SECONDARY SLEEP DISORDERS PARTICULARYSECONDARY SLEEP DISORDERS PARTICULARY SLEEP APNEA (PATIENT’S STORY, ANXIETYSLEEP APNEA (PATIENT’S STORY, ANXIETY , ,
DEPRESSION, PHYSICAL, IMAGING & LAB FINDINGSDEPRESSION, PHYSICAL, IMAGING & LAB FINDINGS.).) 2. NO APPARENT UNDERLYING CAUSE FOR. NO APPARENT UNDERLYING CAUSE FOR SLEEP SLEEP DISORDER andDISORDER and ADVANCED AGE - ADVANCED AGE -
CONSIDER A CONSIDER A PRIMARYPRIMARY MELATONIN DISORDER MELATONIN DISORDER
APPROACH TO SLEEP DISORDERS (IN THE NURSING HOME SETTING)
APPROACH TO SLEEP DISORDERS (IN THE NURSING HOME SETTING)
44 . .TRY A SLEEPING PILL… PREFERABLY NOT ATRY A SLEEPING PILL… PREFERABLY NOT A BENZODIAZEPINE AS THE FIRST CHOISEBENZODIAZEPINE AS THE FIRST CHOISE