MANAGEMENT OF SLEEP

DISORDERS IN ELDERLY
PRINCIPLES OF TREATMENT OF SLEEP DISTURBANCES IN THE ELDERLY

•Initial step is an accurate assessment of diagnosis.

•Treat associated conditions causing or exacerbating sleep dysfunction.
•Treat primary sleep disorder according to standard medical practice (e.g., sleep apnea, insomnia,
RLS-PLMS, RBD, advance sleep phase disorder).
•Consider altered pharmacokinetics and drug metabolism in the elderly (start with a small dose and
gradually increase paying attention to drug–drug interactions).
•Pay special attention to lifestyle considerations, situational stress, and environmental situations.
•Encourage regular exercise (e.g., walking).
•Be aware of special situations in the elderly (e.g., confusional episodes, disorientation, and agitation)
and treat accordingly.
 MANAGEMENT OF CHRONIC INSOMNIA

The first step in treating insomnia is to identify and remove the contributing factors. Insomnia
specific management includes –

Non-Pharmacological: First Line therapy for older persons with insomnia

Pharmacological
 NON-PHARMACOLOGICAL MANAGEMENT OF CHRONIC
INSOMNIA
The main objective of psychological and behavioral approaches is to alter factors that perpetuate or
exacerbate sleep disturbances.
Such features may include hyperarousal, sleep scheduling factors, poor sleep habits, and
misconceptions
about sleep and the consequences of insomnia.
Although numerous factors can precipitate insomnia, when it becomes a persistent problem,
psychological and behavioral factors are almost always involved in perpetuating it over time, hence the
need to target those factors directly in treatment
NON-PHARMACOLOGICAL THERAPIES FOR
INSOMNIA
SleeSleep restriction therapy
Sleep Restriction
Sleep hygiene education
Stimulus Control Therapy
Relaxation Therapy
Cognitive Behaviour Therapy for Insomnia (CBT-I)
:
Sleep hygiene education

Stimulus control therapy

Relaxation therapy and imagery

Cognitive behavioral therapy for insomnia (CBT-I)

p restriction therapy

Sleep hygiene education

Stimulus control therapy

Relaxation therapy and imagery

Cognitive behavioral therapy for insomnia (CBT-I)
 Therapy Description
Sleep restriction therapy A method designed to restrict time spent in bed as close as possible to the actual sleep time, thereby producing mild
sleep deprivation. Time in bed is then gradually increased over a period of few days/weeks until optimal sleep
duration is achieved.
Before starting sleep restriction therapy, a sleep log for 2 weeks is maintained which gives an estimate of average
sleep time versus actual time in bed, i.e. sleep efficiency (SE). The allowed sleep time is the average subjective sleep
time but is never less than 5 hours. As SE improves (more than 90%), time in bed is increased by 15-minute
increments until adequate sleep duration is attained.

Sleep hygiene education General guidelines about health practices (e.g., diet, exercise, and substance use) and environmental factors (e.g.,
light, noise, and temperature) that may promote or interfere with sleep. This may also include some basic information
about normal sleep and changes in sleep patterns with aging

Stimulus control therapy A set of instructions designed to strengthen the association between the bed/bedroom with sleep and to re-establish a
consistent sleep-wake schedule: (1) Go to bed only when sleepy; (2) get out of bed when unable to sleep; (3) use the
bed/bedroom for sleep only (no reading, watching TV, etc.); (4) arise at the same time every morning; and (5) no
napping

Relaxation therapy and imagery Relaxation training originally used to alleviate anxiety is used for the treatment of sleep onset insomnia. Several
techniques have been used in the treatment of insomnia that includes 1) Progressive muscle relaxation, 2) Autogenic
training (induction of sensations of warmth and heaviness are used to promote somatic relaxation), 3) Imagery
(pleasant imagery can be used along with relaxation to improve sleep). Individuals must practice the chosen technique
at least twice a day, and it may require several weeks of practice before the skill is acquired.

Cognitive behavioral therapy for This has been specifically developed for insomnia that comprises of cognitive approaches that target cognitive
insomnia (CBT-I) distortions and misconceptions related to insomnia, behavioral approaches such as stimulus control and sleep re ‐
striction, and educational approaches such as sleep hygiene. CBT-I in elderly has mild effect for sleep problems and
works best for sleep maintenance insomnia
PHARMACOLOGICAL MANAGEMENT OF INSOMNIA
The ideal hypnotic in the elderly should have the following features:
1)be able to induce sleep rapidly, 2) have no adverse effects on normal sleep architecture,
3)demonstrate no significant residual effects, 4) be safe in patients with respiratory and cardiac
conditions, 5) have minimal effects on memory, 6) not impair functioning, 7) have no risk of
tolerance or rebound insomnia, 8) be safe during overdose, and 9) possess no potential for
abuse or dependence.
However, there is no ideal hypnotic available till date.
The basic rules of rational pharmacotherapy for insomnia in the elderly:
Prescribing the lowest effective dose (which is usually half of adult dose)
Prescribing for shortest possible time (no more than 3–4 weeks),
Prescribing intermittent dosing (two to four times weekly) if possible,
Using drugs that have shorter elimination half-lives and lesser daytime sedation,
Using drugs which can be gradually discontinued without causing rebound insomnia.
PHARMACOLOGICAL MANAGEMENT OF INSOMNIA

Many medications have been used for insomnia. Some are approved by the US
Food and Drug Administration (FDA) and have demonstrated safety and efficacy,
many are not approved for insomnia and are used off-label.
 Drugs used for insomnia are often limited by treatment associated risks, such as
falls, next-day drowsiness, and risk for dependence
 Many drugs are listed in the Beers Criteria as medications that should be avoided
in older adults. These include benzodiazepines, tricyclic antidepressants,
antihistamines, mirtazapine, and benzodiazepine receptor agonists.
PHARMACOLOGICAL MANAGEMENT OF INSOMNIA
 FDA Approved Medication for Insomnia
 Benzodiazepine receptor agonists: Includes three Benzodiazepines (Triazolam, Temazepam, Flurazepam) and
Z-drugs like Zolpidem, Eszopiclone, Zaleplon.
• Prolonged use of these drugs can lead to tolerance, dependence, rebound insomnia, residual daytime sedation,
motor incoordination, cognitive impairment, and increased risk of falls in institutionalized older individuals.
Because of these adverse effects, and the equivalent or superior response seen with CBT-I for longer duration
therapy, use of these drugs should be avoided in older individuals.
• The 2015 Beers criteria strongly advise avoiding these drugs in the elderly
 Ramelteon: A Melatonin agonist. Can be used in the elderly
• Dose: 8mg; Decreases Sleep Latency; Side Effects- Drowsiness, dizziness, fatigue.
 Doxepin: An antidepressant with H1 receptor blocker.
• Dose: 3-6mg; Improvements in total sleep time, sleep efficiency, wake time after sleep onset, and patient
reported sleep quality;
• Side Effects- Drowsiness. At higher doses, drowsiness, dizziness, confusion, blurred vision, dry mouth,
constipation, urinary retention, arrhythmias, orthostatic hypotension, and weight gain, Exacerbation of restless
legs, periodic limb movements, or REM sleep behavior disorder
PHARMACOLOGICAL MANAGEMENT OF INSOMNIA
 Dual orexin receptor antagonists: Block Orexin receptors OX1 and OX2 to inhibit
wakefulness
• Lemborexant: Improves sleep onset and maintenance. May be preferred for sleep efficiency,
latency, and total sleep time. Longest half life of 18 hours is a disadvantage.
• Dose: 5mg at bedtime for older adults.
•Suvorexant
• Daridorexant
 Other Agents used for insomnia in elderly
 Melatonin: 1 to 6mg
 Trazodone 50 mg improves sleep parameters in Alzheimer's disease and is tolerated well.
MANAGEMENT OF SLEEP DISORDERED BREATHING
 Whenever SDB is suspected further Evaluation and management requires referral and
consultation to a specialist setting.
 Treatment for mild Obstructive Sleep Apnea (OSA)without any other medical
comorbidity includes lifestyle modification strategies such as regular exercise and weight
loss, smoking cessation and reducing caffeine, alcohol, and avoiding the use of sedatives
and other recreational drugs, and optimizing sleep and medical management of
comorbidities. These patients should be followed up every three months to clinically assess
symptoms and progress of weight reduction.
In mild-to-moderate SDB, positional measures and oral mandibular advancement splints
are used.
 In moderate to severe cases of OSA or symptomatic cases (associated with other
comorbidities)mainstay of therapy is positive airway pressure devices and it is considered
the gold standard treatment.
 Hypnotics and other sedating medications worsen SDB by inducing or worsening OSA
and Central Sleep Apnea (CSA). These medications should be avoided if SBD is suspected.
MANAGEMENT OF REM SLEEP BEHAVIOUR DISORDERS
 First Line Management for both Idiopathic and Secondary RBD: Non-Pharmacological
 Injury-Preventing techniques: These include modification of environment such as sleeping on the floor to
avoid falling from bed, padding corners of furniture, keeping the window and door locked at night and
removing potentially dangerous objects from the room. Using heavy curtains on bedroom windows reduces
sleep disruption. The bed partner may be asked to sleep separately till the condition improves.
Discontinue or Dosage titration of medications known to exacerbate RBD: Medications that are known to
exacerbate RBD should be discontinued if possible. These include antidepressants (selective serotonin
reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, tricyclic antidepressants and monoamine
oxidase inhibitors), beta-blockers (atenolol, bisoprolol), tramadol and cholinesterase inhibitors. If there is
comorbid depression, bupropion is preferred as it doesn’t worsen RBD.
Treat underlying cause: If any specific underlying cause is found (e.g. brain stem tumor), it requires
specific treatment.
Prognostic counseling: Patients need to be educated regarding the possibility of RBD being an early marker
of neurodegenerative disease.
Bed alarm: A bed alarm can be used for the treatment of RBD. It consists of a pressure sensor that is placed
on the shoulders which get activated during dream enactment. At that time a pre-recorded message is played
which tells them that it is a dream, thereby calming the patient and they go back to sleep.
MANAGEMENT OF REM SLEEP BEHAVIOUR
DISORDERS
 Second Line Management: Pharmacotherapy
 Clonazepam: The preferred pharmacological treatment for RBD is low-dose clonazepam at
doses from 0.5-1 mg/day.
Concerns in elderly: residual sleepiness, unsteadiness leading to falls and fractures, delirium
and cognitive impairment. Limits its use in frail patients. Should also be avoided in RBD
patients with comorbid OSA, as it is potential respiratory suppressant.
 Alternative Agents: Medicines causing enhancement of melatonin signaling within the
brain.
 Melatonin: 2 -6mg.
 Ramelteon: Melatonin receptor agonist. Dose: 8mg at bedtime; evidence for their efficacy is
low.
SLEEP RELATED MOVEMENT DISORDERS
 Restless Leg Syndrome (RLS):
 Non-Pharmacological Treatment
Several lifestyle modifications are useful to control RLS. Patients are instructed to
take a hot shower or massage their legs before bedtime, have regular sleeping and
waking timings, regular exercise.
Sleep hygiene should be corrected before all the pharmacological treatment. Sleep
deprivation, sleep disturbances and factors that can result in insomnia should all be
avoided.
Another common but easily neglected disorder is Obstructive Sleep Apnea Syndrome
(OSAS). Early treatment for OSAS is beneficial for improving sleep for RLS
patients.
RESTLESS LEG SYNDROME (RLS):
 Pharmacological Treatment: Pharmacotherapy is indicated when RLS symptoms impair
functioning, sleep, and quality of life.
Dopaminergic agents: The first-line treatment for RLS in patients with very severe
symptoms, over-weighted, comorbid depression, risk of falls, or cognitive impairment.
Pramipexole: 0.125-0.75 mg/day
Ropinirole: 0.25-4 mg/day
Rotigotine patch: 0.5-3mg
Pergolide: Only used in cases refractory to all other treatments
 Levodopa: 50-200mg
RESTLESS LEG SYNDROME (RLS):
 Other First Line Agents: a2d (alpha2delta) agonists are advised as first-line agents in patients with
severe sleep disturbance, comorbid anxiety, RLS-related pain, or previous history of Impulse Control
Disorders (ICDs)
 Gabapentin enacarbil (pro drug of Gabapentin):
Pregabalin: 150- 450mg
Iron replacement therapy should be considered for RLS treatment when serum ferritin levels are
lower than 50 μg/L, even if patients do not have iron deficiency anemia. Oral supplementation or
intravenous formulations are indicated so that the ferritin levels increase to more than 50 μg/L. It is not
effective if ferritin levels are higher than 100 μg/L and anemia is absent.
 As depression is a very common comorbidity in RLS and many antidepressants such as selective
serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants (TCAs) can worsen the symptoms
of RLS, treatment of depression in RLS patients should be cautious.
 Bupropion, doesn’t show any evidence of exacerbation of RLS symptoms, it is used as an effective
antidepressant in these patients
PRINCIPLES OF PHARMACOTHERAPY FOR
RESTLESS LEGS SYNDROME
Individualize the therapy.
Start with monotherapy rather than polytherapy.
Begin with a very small dose and gradually increase every 3–5 days to an optimal or
maximal tolerable dose.
Try monotherapy even in an apparently severe case using small-to-medium dose (a
surprising number of such patients will respond satisfactorily).
Try to convert patients on polytherapy (placed on treatment before referral to you) to
monotherapy if possible (it is possible to do so in many such patients).
Try to reduce the dose or eliminate some medications if patients complain of undesirable
side effects from multidrug treatment.
Perform regular follow-up to monitor for side effects, progression of the disease,
augmentation, tolerance, and rebound.
MANAGEMENT OF PERIODIC LEG MOVEMENT DISORDER
(PLMD)
The iron status should be carefully evaluated and oral or IV iron treatment considered even
for low normal iron stores, provided transferrin saturation is <50 %. Iron treatment options
are the same as that for RLS.
Possible causes for the inflammation or low iron should also be evaluated and appropriate
treatment considered.
Treatment of PLMD other than with iron starts with a2d agents to reduce the Periodic Leg
Movements of Sleep (PLMS) and also generally improve sleep.
Low-dose L-dopa and dopamine agonists are also very effective for reducing PLMS, but
the dopamine treatment of PLMS without RLS can lead to the development of RLS and
therefore should be used very cautiously and only at very low doses.
ADVANCED SLEEP-WAKE PHASE DISORDER
(ASWPD)
Light therapy: The principle involves reducing morning light that advances phase and
increasing evening light which delays phase. Patients are instructed to avoid going out and
stay in a dark room during the early morning. Also, they are instructed to remain outdoors
in the late afternoon and early evening and use bright lights inside the home during the
evening. Bright light is recommended in the evening, between 7 to 9 PM (at least 5000 lux
for 2 hours) to delay the circadian phase.
 Pharmacological Treatment
Melatonin: Phase delay can be induced by administration of melatonin in the early
morning; the optimal time is in the early morning following spontaneous awakening. Light
exposure should be minimized so that phase delay with melatonin is not countered by the
phase advance effect of early morning light.
Doses: 0.5 to 10 mg.
REFERENCES AND RECOMMENDATIONS FOR FURTHER READING:
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2. Abou-Saleh M.T., Katona C. and Kumar A. (2011). Principles and Practice of Geriatric Psychiatry. (3rd ed). John Wiley & Sons, Ltd. ISBN: 978-
0-470-74723-0
3. Sadock, B. J., et al. (2017). Kaplan and Sadock's Comprehensive Textbook of Psychiatry. (10th ed.). Wolters Kluwer.
4. Chokroverty S & Ferini- Strambi L. (2017). Oxford Textbook of Sleep Disorders. Oxford University Press.
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Clinical Diagnosis and Management. Front. Aging Neurosci. 9:171.
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