Additional Material

Normal Sleep/Disordered Sleep

  • Nocturnal sleep is lighter, less efficient  w/increase in awakenings. Increased Stage I sleep at the expense of deeper Stages II and III.
  • REM sleep declines w/ age. 
  • There is disruption in circadian rhythmicity:
    • less light exposure; irregular meal times
  • Chronic illness like COPD disrupts sleep
  • Excessive daytime sleepiness is often considered a “normal” attribute of aging and therefore frequently goes unrecognized and unreported
  • Sleep disordered breathing
    • may accelerate dementia due to hypoxemia
    • exacerbates hypertension which reduces cerebral blood flow 

Sleep and Opioids


  • Change respiratory rhythm and cause respiratory depression
  • Increase sleep fragmentation
  • Worsen neuropathic pain by up regulation of receptors
  • Always cause constipation
  • Often cause nausea, hallucinations, itching


  • Good sleep enhances pain relief
  • Strategies to improve sleep in the older opioid user
    • Sleep hygiene
    • Vitamin D
    • Melatonin

Opioids: Mechanism of Action

  • Opioid receptors activate inhibitory intracellular pathways that lead to the closing of voltage sensitive Ca+ channels, stimulation of K+ efflux and reduction of  cAMP.
  • This leads to a reduction of neuronal excitability
  • Inhibition also affects Respiratory Function1


1Pattinson, 2008, British J Anesthesia

Patient Assessment Example

You can watch Dr. George Comerci of Project ECHO patient assessment video with standardized patient here.

Patient Interview Example

You can watch Dr. George Comerci of Project ECHO interviewing a standardized patient in pain here.

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