Sleep and Pain in the Elderly

Objectives

Elderly woman asleep in a chair
Elderly woman asleep in chair

At the end of this session the participant will:

  1. Describe sleep patterns in older adults.
  2. Identify common sleep abnormalities.
  3. Discuss medications used to improve sleep quality.

Issues of Age Overview

80% of elderly have sleep complaints

34% insomnia

15% non-restorative sleep

20% sleep-disordered breathing

20% restless legs syndrome

0.5% rapid eye movement (REM) sleep behavior disorder

Issues of Age

  • Sleep disorders result in daytime sleepiness, which is a known factor in automobile accidents
    • A particular concern when driving skills may already be impaired by age-related declines in reaction time and information processing
  • Sleepiness and disturbed nocturnal sleep may increase the risk of falls
    • May lead to hip fractures or other trauma
  • Disturbed sleep and nocturnal delirium (sundowning) is a major factor in precipitating the transfer of elderly patients to nursing homes

Circadian Rhythm

Pie chart illustration showing sleep/dream cycle

Sleep Cycle

Illustration showing sleep cycle of different stages of sleep and REM

Circadian Disruption

  • Inadequate exposure to zeitgebers (e.g., exposure to light and dark), resulting in defective circadian rhythmicity
  • Insufficient exercise due to physical infirmity
  • Poor exposures to light in those confined to long-term care facilities
  • Irregular meal times associated with living alone

Changes in Sleep Architecture with Age

  • Nocturnal sleep becomes lighter, more frequently disrupted, and shorter
  • Sleep efficiency decreases to 70%-80% compared with > 95% for younger individuals
  • Higher number of arousals and awakenings
  • Greater proportion of nonrapid eye movement (NREM) I sleep at the expense of deeper stages of sleep (i.e., NREM II and III)
  • Slow-wave sleep starts to decline about age 20 and may disappear entirely in the later years.
    • Slow waves have a frequency of 0.5-2.0 (delta waves) with an amplitude of > 75 µV
  • REM sleep declines with age
  • Defect in the ability of the individual’s circadian pacemaker to respond appropriately to various zeitgebers, such as exposure to morning bright light
  • Tendency for circadian rhythms to phase advance (i.e., move the time of sleep onset and awakening forward )

Normal Adult Brain Waves

Different brain wave signatures of a normal adult

Consequences of Sleep Deprivation

  • Increase in pain sensitivity
  • Increase in sympathetic cardiac modulation
  • Decrease in parasympathetic cardiac modulation
  • Impaired immune response
  • Alteration in metabolic and endocrine systems
  • Behavioral: impaired attention and psychomotor performance, increased daytime sleepiness, and impaired mood that includes fatigue and irritability
  • REM deprivation may include mood and memory alterations

Reference

Bonnet & Arand, 2003

Physical Disorders that Disrupt Sleep

Physical and emotional disorders take their toll on sleep depth and continuity

  • Rheumatologic disorders
    • Pain, inability to change position
  • Parkinson disease
    • Inability to change position
  • Congestive heart failure
    • Orthopnea/paroxysmal nocturnal dyspnea
  • Chronic lung disease
    • Dyspnea, cough, wheezing
  • Diabetes
    • Nocturia*
    • Peripheral neuropathy
  • Prostatism
    • Nocturia*

*Nocturia is the leading cause of disturbed sleep

Medications/Preparations that May Disturb Sleep

Medications

  • Anticonvulsants
  • Levodopa
  • Diuretics
  • Bronchodilators
  • Thyroid replacement
  • Calcium antagonists
  • Corticosteroids
  • Beta-blockers
  • Antidepressants that are activating

Preparations

  • Herbal preparations (gingko, caffeine, ginseng)
  • Nicotine
  • Caffeine

Emotional Disorders that Can Affect Sleep

  • Depression
  • Anxiety associated with bereavement
  • Major life changes such as retirement
  • Fear of dying
  • Post-traumatic stress disorder

Freedom to Nap?

  • Sleep requirements
  • No changes in sleep requirements
  • Sleep is rescheduled
  • Less sleep at night and more during the daytime napping
  • Excessive daytime sleepiness is often considered a “normal” attribute of aging and therefore frequently goes unrecognized and unreported
  • Early-morning awakenings may be secondary to depression or significant comorbidities
  • Freedom to nap
    • Retirement, boredom

Sleep Disorders with Increased Prevalence in the Elderly

Restless Leg Syndrome (RLS)

  • Irresistible urge to move the legs during periods of inactivity
  • 80% of patients with RLS will also have periodic limb movements in sleep (PLMS)
  • Patients often complain of sleep-onset insomnia because of the irresistible urge to move their limbs

Periodic Limb Movement Disorder (PLMD)

  • Movement of the legs occurring in a repetitive manner during sleep
  • Movement may cause frequent arousals
  • Sleep maintenance insomnia
  • Daytime symptoms of sleepiness
  • Estimated 4% of younger age group has PLMD/RLS
  • Age > 60: > 20% endorse symptoms of RLS
  • Age > 65: 45% had > 5 PLMS
  • Don’t treat everything that moves

Reference

Ancoli-Israel et al., 1991

RLS/PLMD in the Elderly

  • Treatment often involves dopamine agonists pramipexole and ropinirole
  • A side effect can be sleepiness
  • Gabapentin also useful and has a favorable profile to decrease evening pain and promote sleepiness (pregabalin)
    • Renal excretion: decrease dose in elderly
  • Clonazepam useful; however, must be used cautiously in the elderly
    • Hip fractures increased
    • Long half-life of 20 hours
  • Opioids very effective (acetaminophen with codeine)
  • Careful use of benzodiazepines and opioids with COPD and untreated sleep-disordered breathing

Sleep Disorders with Increased Prevalence in the Elderly: Sleep-Disordered Breathing

  • 2%-4% of the adult population have sleep apnea syndrome (laboratory diagnosis plus symptoms); middle-aged working adults
  • 20% at age 60
  • After menopause, sleep apnea prevalence between males and females the same
  • Edentulous subjects (those who remove their dentures at bedtime) have more sleep apnea than do control subjects
  • Smoking is a risk factor for sleep apnea

Sleep-Disordered Breathing (SDB)

  • Sleep-disordered breathing may accelerate dementia due to hypoxemia
  • SDB exacerbates hypertension with resultant cerebrovascular disease, reduced cerebral blood flow during respiratory events leading to localized infarcts or the effect of repeated hypoxia
  • Cognitive function in older persons with mild-moderate sleep-disordered breathing is related to the amount of respiratory disturbances occurring at night. Increase in respiratory disturbance index was associated with cognitive performance over time
  • Treatment typically for symptomatic disease

Reference

Cohen-Zion et al., 2004

Treatments for Sleep-Disordered Breathing

  • Positive airway therapy
  • Oral appliance, mandibular advancement devices
  • Uvulopalatopharyngoplasty with cure rates ranging 30%-50%
  • Many elderly individuals are not surgical candidates due to comorbid conditions
  • Avoidance of alcohol and sedative agents prior to bedtime
  • Sleep position training for patients with predominantly supine sleep apnea

Rapid Eye Movement (REM) Behavioral Disorder (RBD)

  • May be idiopathic
  • Associated with CNS diseases
  • Precipitated by medications
    • Tricyclic antidepressants, serotonin-norepinephrine reuptake inhibitors
  • Drug or alcohol withdrawal
  • Responds well to melatonin and clonazepam
  • RBD is characterized by violent behaviors during REM sleep due to loss of REM sleep atonia
  • Behaviors are usually in context with a dream
  • > 90% are males > 60 years of age
  • Frequently seen in the α-synucleinopathies Parkinson disease, dementia with Lewy body disease, multiple system atrophy

Sleep and Dementia

  • Senile dementia of the Alzheimer’s type (AD)
  • More NREM I sleep
  • Greater numbers of arousals and awakenings than occur in the nondemented elderly
  • Nocturnal delirium (sundowning): defined as the appearance or exacerbation of behavioral disturbances at night
  • Agitation, pacing, restlessness, inappropriate verbalization, decreased alertness, confusion, aggression, paranoid ideation
  • Prevalence of sundowning in nursing home residents 12%-14%
  • Prevalence of sundowning in AD 12%-25%
  • Factors include: worsening dementia, nocturnal awakenings by caregivers, room changes, incontinence, and sensory deficits
  • Neuronal degeneration of the suprachiasmatic nucleus and melatonin secretion
    • Loss of circadian rhythmicity
  • This affects the normal physiology of sleep, the biological clock, and core body temperature
  • With disease progression, it becomes difficult to separate EEG features of NREM 1 and NREM II sleep
  • Sleep spindles and K complexes are poorly formed, are of lower amplitude, are of shorter duration, and are much less numerous
  • The percentage of time spent in REM sleep is reduced
  • This decrease is attributed to degeneration of the nucleus basalis of Meynert

Reference

Weldemichael & Grossberg, 2010

Sleep and Dementia: Treatment

  • Eliminate metabolic, toxic, pharmacologic, and infectious factors that may exacerbate delirium
  • Avoid daytime napping
  • Morning bright light
  • Regular activities during the day
  • Minimize nighttime awakenings (bed checks, lights on at night)
  • Sleeping agents: melatonin first line, Z-drugs second line
  • If all else fails: consider scheduling nighttime activities for the sundowning nursing home resident

Elderly and cognitively impaired populations:

  • Often underreport pain
  • May be nonverbal
  • “Acting out” is often secondary to pain
    • Acetaminophen at bedtime
    • Melatonin
    • Vitamin D

Don’t be afraid to treat the cognitively impaired!

Reference

Shega et al., 2012; Dalacorte et al., 2011

Vitamin D Study

  • 2000 IU vitamin D daily
  • Mayo Rehab Center: Rochester, NY; 267 outpatient chronic pain patients
  • Vitamin D-deficiency group required more morphine
  • Mean duration of opiate use: 71 months vs. 43 months
  • Vitamin D-deficiency group averaged 133 mg/day opioid use vs. 70 mg/day in the Vitamin D-adequate group

Reference

Turner et al., 2008

Melatonin

  • Melatonin to promote good sleep
  • Decreases with age
  • Neuroprotective effect
  • Used in ICUs to decrease delirium
  • Used with AD patients to blunt sundowning
  • Doses: 0.5-10 mg 2 hours prior to anticipated bedtime
  • Pharmacy grade (No B6!)

Treatment for Sleep

Medications

  • Good sleep hygiene is the best “drug”
  • Treat pain aggressively to improve sleep quality
    • Acetaminophen at bedtime
    • Hydrocodone
    • Avoid diphenhydramine
  • Treat underlying depression aggressively
  • Melatonin--pharmacy grade
    • Avoid B6
  • Mirtazapine 7.5 mg
    • Ask about new onset RLS
  • Trazodone 12.5-50 mg
  • Z-drugs: zaleplon, zolpidem, eszopiclone

Sleep Hygiene

  • Regular bed times
  • Regular wake-up times with bright light
  • Avoid afternoon caffeine and tobacco
  • Don’t fall asleep in front of the TV
  • Avoid blue light 1 hour prior to sleep
  • Limit afternoon nap to < 1 hour between 1 and 3 PM

Conclusion

  • Sleep deprivation results in an increase in pain sensitivity
  • Aggressively treat pain and depression
  • Good sleep hygiene is the best medication
  • Start with melatonin and vitamin D
  • Add other agents slowly and carefully
  • Avoid anticholinergics (diphenhydramine) and benzodiazepines
  • Mirtazapine, trazodone, Z-drugs

References

  1. Ancoli-Israel, S., Kripke, D. F., Klauber, M. R., Mason, W. J., Fell, R., & Kaplan, O. (1991). Periodic limb movements in sleep in community-dwelling elderly. Sleep, 14(6), 496-500 http://www.journalsleep.org.libproxy.unm.edu/ViewAbstract.aspx?pid=24892
  2. Bonnet, M. H., & Arand, D. L. (2003). Clinical effects of sleep fragmentation versus sleep deprivation. Sleep Medicine Reviews, 7(4), 297-310, http://www.ncbi.nlm.nih.gov/pubmed/14505597
  3. Cohen-Zion, M., Stepnowsky, C., Johnson, S., Marler, M., Dimsdale, J. E., & Ancoli-Israel, S. (2004). Cognitive changes and sleep disordered breathing in elderly: Differences in race. Journal of Psychosomatic Research, 56(5), 549-553.
  4. Dalacorte, R. R., Rigo, J. C., & Dalacorte, A. (2011). Pain management in the elderly at the end of life. North American Journal of Medical Sciences, 3(8), 348-354, doi: 10.4297/najms.2011.3348 PMCID: PMC3234146, http://www.ncbi.nlm.nih.gov/pubmed/22171240
  5. Shega, J. W., Andrew, M., Hemmerich, J., Cagney, K. A., Ersek, M., Weiner, D. K., & Dale, W. (2012). The relationship of pain and cognitive impairment with social vulnerability – An analysis of the Canadian Study of Health and Aging. Pain Medicine, 13(2), 1-8.
  6. Turner, M. K., Hooten, W. M., Schmidt, J. E., Kerkvliet, J. L., Townsend, C. O., & Bruce, B. K. (2008). Prevalence and clinical correlates of vitamin D inadequacy among patients with chronic pain. Pain Medicine, 9(8), 979-984.
  7. Weldemichael, D. A., & Grossberg, G. T. (2010). Circadian rhythm disturbances in patients with Alzheimer’s disease: A review. International Journal of Alzheimer’s Disease, 10, 1-9, Article ID 716453, http://dx.doi.org/10.4061/2010/716453

Acknowledgements

Frank M. Ralls, M.D.

Assistant Professor, Internal Medicine

Sleep Disorders Center

University of New Mexico

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