Sleeping Late
Alice Pomidor, MD, MPH
FSU College of Medicine
Supported by a grant from the D.W. Reynolds
Foundation
If you had the time, would you….
• Go to bed early, or do something with
your family/friends?
• Sleep in, or catch up on stuff around
the house?
• Study, watch TV/movie, or take a nap?
• Eat, or sleep?
Objectives
• List 3 differences in sleep patterns
between older and younger adults
• Recognize the effects of disturbed sleep
on functional abilities of older adults
• Describe 3 methods for assessing sleep
• Describe 3 aspects of the social
environment which affect sleep
• List 3 therapeutic interventions for sleep
Sleep Terminology
• Sleep continuity—balance of sleep and
wakefulness through the night
• Sleep latency—how long it takes to fall asleep
• Sleep architecture—amount of sleep relatively
spent in REM, NREM; uses stages of sleep 0-4
as well as “light” or “deep” sleep as terms
• Sleep study—usually polysomnography
w/EEG, O2 monitoring, eye and breathing
movement monitoring. Sometime may be
include or substitute simpler tests of
wakefulness, latency, or actigraphy
“Normal” Sleep
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Stage 1-NREM-5%-falling asleep
Stage 2-NREM-50%-light sleep
Stages 3 & 4-NREM-deep sleep-10-20%
REM-20-25%-”dream” sleep
REM/NREM cycle every 80-100 minutes
all night; more NREM early, more REM
towards morning
Circadian Rhythms
• Controlled by the suprachiasmatic nucleus in
the anterior hypothalamus (SCN) via
hormonal proteins, autofeedback loops
(melatonin, glucose metabolism)
• Synchronized to environment (light)
• Varies from person to person—morning vs.
night people
• Most common schedule biphasic; decreased
alertness most common between 2-4pm and
worst 4-6am
Barion Sleep Med 2007
Normal Changes with Age
• Decreased total sleep time (childhood 10-12
hours; adults 5-9 hours)
• Decreased sleep efficiency—lie in bed awake
• Less deep sleep—don’t feel rested
• Increased light sleep—easier arousals
• Decreased REM sleep—link to memory?
• Phase shift to earlier times with increased
difficulty accommodating shift work, jet lagearly morning awakening, early bedtimes
• Normal changes stabilize about age 60
Perceived Sleep Problems
• 2003 “Sleep in America” survey found
36% health elderly over age 65, 52%
with 1-3 comorbidities, and 69% with 4
or more comorbidities reported
disturbed sleep
• Most frequent survey causes: nocturia,
worry, noise, dreaming, thirst, pain
(presenting complaints)
DSM IV TR Diagnoses
• Insomnia—difficulty falling or maintaining sleep for
over a month
• Primary hypersomnia—prolonged or daytime sleep
episodes occurring almost daily for over a month
• Breathing-related sleep disorder—obstructive or
central sleep apnea, or hypoventilation
• Circadian Rhythm sleep disorder—Delayed sleep
phase, jet lag, shift work types
• Dyssomnias—Restless legs, periodic limb movements,
sleep deprivation, environmental factors
• Parasomnias—Nightmares, sleep terrors,
sleepwalking
• Causes functional impairment, not due to another
cause
Medical comorbidities
• Substance misuse (EtOH, nicotine, caffeine,
meds)
• Anxiety
• Depression
• Pain
• Reflux
• Breathing problems from heart or lung
disease
• Neuro disorders (dementia, stroke)
• True primary sleep disorders under diagnosed
but still relatively rare
Adverse Functional Effects
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Cognitive impairment
Independent risk factor for more falls
? diabetes and obesity
Hypoxic effect on cardiac function
Driving impairment
Chicken or the egg?—depression,
anxiety, pain, nocturia
Sleep Expectations
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Eight hours long
Uninterrupted
Fall asleep within 15 minutes
Wake up refreshed and ready to go
Will feel better than when went to bed
Sleep Assessment
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Screening-NIH recommendation
Composite Scale of Morningness
Epworth Sleepiness Scale
BEARS mnemonic
Functional impact evaluation
Comorbidities assessment
Medication inventory
NIH Consensus Screening Q’s
• Is the person satisfied with his or her
sleep?
• Does sleep or fatigue interfere with
daytime activities?
• Does the bed partner or others
complain of unusual behavior during
sleep, such as snoring, interrupted
breathing, or leg movements?
Composite Scale of Morningness
• Morning vs. Evening person relatively
recent terminology for cohort
• Helps determine fit between schedule
and circadian rhythm
• Particularly frequent problem for
persons in structured settings
• Scoring: 22 or less = evening person,
44 and above morning person
Epworth Sleepiness Scale
• Intended to screen for true sleep
disorders
• Rating scale of 0-3 in severity for each
of 8 items
• Scoring: 6-7 normal, 8-11 mild, 12-15
moderate (c/w apnea), 16-18 severe
(potential narcolepsy)
BEARS
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Bedtime
Excessive sleepiness
Awakenings, night and early morning
Regularity and duration of sleep
Snoring
Sleep Studies
• Obstructive apnea—near/complete obstruction of
airflow for 10 seconds or more with continued
respiratory effort
• Central apnea—cessation of respiratory effort
• Hypopnea—2001 Medicare definition of 30%
reduction from baseline in thoracoabdominal effort or
airflow lasting 10 seconds or more accompanied by a
4% or great oxygen desaturation (usually below
85%).
• Respiratory-effort related arousals—10 seconds of
attempted inspiration followed by arousal
• Respiratory Disturbance Index—number of apnea and
hyponea and respiratory effort-related arousals per
hour of sleep, 10-15 considered significant
Special Problems
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Dementia
Blindness
Hospitals
Nursing homes
Postmenopausal symptoms
Treatment Expectations/Goals
• Discuss who wants what: patient,
caregiver(s), health care professional
• Set targets
• Develop intervention plan to reach
targets
• Keep a sleep diary to monitor progress
• Follow-up at regular intervals depending
on the intervention plan
Environmental Interventions
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Noise
Light
TV
Substance use
Roommates
Facility interruptions
Medication schedule
Behavioral Interventions
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Sleep hygiene education
Relaxation techniques
Stimulus control-TV, reading, exercise
Sleep restriction
Sleep compression
Cognitive therapy
Alternative Interventions
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Light therapy
Electrical stimulation
Herbals (lavender)
Traditional remedies (chamomile tea,
warm milk)
• Nutrition
Medication Interventions
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Sedative-hypnotics
Antidepressants
Melatonin and derivatives
Anticholinergics
Dopamine agonists
Stimulants
Hormone therapy
Self-medication issues
Risks of Intervention
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Medication dependency
Psychomotor impairment
Parasomnias
Tolerance
Anticholinergic side effects
Other medication side effects
Tolerance of equipment
Caregiver impact
Objectives
• List 3 differences in sleep patterns
between older and younger adults
• Recognize the effects of disturbed sleep
on functional abilities of older adults
• Describe 3 methods for assessing sleep
• Describe 3 aspects of the social
environment which affect sleep
• List 3 therapeutic interventions for sleep