number of hours sleep required each night varies significantly between
individuals
as people age, they tend to have shorter overall sleep period &
spend more time in the lighter sleep stages, often being interrupted by
brief periods of wakefulness
insomnia or difficulty in getting to sleep is a symptom and thus a
cause should be sought
depression - tends to cause sleep which is interrupted by
frequent awakenings
environmental factors:
bedroom too hot, too cold, too noisy (eg. crying baby, restless
child, partner with snoring)
bed cramped or uncomfortable
physical factors:
obstructive sleep apnoea
chronic airways limitation
restless legs syndrome
disturbed sleep cycles:
poor sleep habits
lack of daytime exercise
excessive time in bed
shift work
jet lag
how some doctors approach managing insomnia:
consider maintaining a sleep log to help ascertain extent & type
of disturbance
older people:
discuss & agree on therapeutic objectives with the patient
assess the complaint - what is causing it?
treat or improve the underlying cause
educate the patient about good sleep habits - see behavioural Rx
below
avoid use of hypnotic drugs whenever possible as adverse effects
usually outweigh benefits except perhaps in short term usage, when
prescriptions should be only for 2 weeks maximum
behavioural Rx of insomnia:
sleep hygiene includes a number of social & behavioural
interventions:
routines that incorporate the following techniques will help even
older people, whatever their residential setting, have a better
sleep:
get up at the same time each day regardless of the amount of
sleep that night
going to bed at a constant time is not as important, but might
help
avoid daytime naps esp. in late afternoon as total sleep hours
is preserved so night sleep will be less
use bed only for sleep & sex, not for eating, reading or
watching television - avoid excessive time in bed
bedroom should be comfortable & quiet & not the focus
of arguments, anger or distress
indulge in relaxing evening activities do not do exercise late
in evening
if unable to sleep, avoid clock watching, get up and do
something
avoid alcohol & stimulants such as caffeine & nicotine
for 2-3hrs before going to bed
avoid large evening meal
consider anxiety management & relaxation techniques if pts worried
& anxious they will not be able to get to sleep
consider cognitive behavioural therapy techniques
drug treatment of insomnia is only a temporary help:
benzodiazepines:
long half-life benzodiazepines (esp. in elderly) result in
increased risk of:
doubles risk of road traffic accidents in all age groups, but
in addition, in persons over 65yrs, have an additional 50% risk
if brief duration Rx or 30% risk if long term Rx.
most benzodiazepines lose their hypnotic efficacy after
approx. 14 consecutive nights, even though people still keep taking
them
quality of sleep is modified - less deep & relaxed sleep;
tendency to fall asleep & awake earlier;
day-time: feelings of tiredness; lack of energy; mood
disturbances;
the 'Z drugs':
act on same receptor as benzodiazepines
said to have less adverse effects & less dependency than
benzodiazepines, but these are still present
zolpidem has caused delirium, hallucinations, nightmares & hip
fractures (2x risk of no Rx & more than Rx with benzo's,
anti-psychotics or antidepressants)
zopiclone:
causes hangover effects & impairs psychomotor performance
similar to temazepam & nitrazepam
has bitter taste
zaleplon:
short half-life, thus useful for sleep-onset insomnia
valerian:
herbal extract with mild hypnotic activity, but limited studies as
yet.
melatonin:
a naturally occurring hormone secreted from pineal gland
widely used to regulate sleep-awake cycles in circadian-based
disorders such as jet lag