Treatment of insomnia
The most common complaints of older adults are issues initiating or maintaining sleep. These problems result in insufficient sleep at night, which trickles down to an increased risk of falls, difficulty with concentration and memory, and generally decreased quality of life. These sleep complaints are secondary to medical and psychiatric illnesses. The task is to isolate the etiology of these complaints and the right treatment.Insomnia:is the most common sleep complaint.It is defined as difficulty falling asleep, staying asleep, or having a nonrestorative sleep, resulting in daytime dysfunction.Although insomnia may be a primary diagnosis, in older adults, it is often comorbid with medical and psychiatric illness, concomitant drug use, circadian rhythm changes, and other sleep disorders (Ancoli-Israel & Ayalon, 2006).
Medical and Psychiatric Illnesses:
Insomnia is more common in patients with other comorbidities. The incidence of sleep disturbances (trouble falling asleep, frequent awakenings, and excessive daytime sleepiness) associated with psychiatric disorders. It is particularly common in mood disorders-major depression, and generalized anxiety disorder. Complaints of sleeping less than 6 hours per night and excessive daytime sleepiness associated with having heart disease, myocardial infarctions, angina, congestive heart failure,lung disease, a history of stroke, gastroesophageal reflux disease, hip replacement, diabetes, or prostate problems, arthritis with chronic pain also had insomnia. Medical illness can disrupt sleep, such as patients with Parkinson’s disease (PD) have sleep complaints. Some of the sleep problems arise from the disease process itself, that is, biochemical changes in the brain, dementia, bradykinesia and rigidity, tremor, and respiratory disturbances associated with airway and respiratory movements. PD causes pain in the legs and back, difficulties getting in and out of bed and turning in bed, and vivid dreams and nightmares (Ancoli-Israel & Ayalon, 2006).
The same chronic conditions that cause sleep complaints require long-term drug therapy that is also known to cause insomnia as a side effect—adjusting the dosage of the medication or the time of day that these medications taken can improve sleep. For example, alerting or stimulating drugs, when taken late in the day, may cause difficulty falling asleep at night.Generally,central nervous system stimulants(e.g., dextroamphetamine, methylphenidate), antihypertensives (e.g., beta-blockers, alpha-blockers, methyldopa, reserpine), respiratory drugs (e.g., theophylline, albuterol), bronchodilators, calcium channel blockers, corticosteroids, decongestants (e.g., pseudoephedrine, phenylephrine, Phenylpropanolamine), stimulating antidepressants (e.g., protriptyline, bupropion, selective serotonin reuptake inhibitors [SSRIs], venlafaxine, monoamine oxidase inhibitors [MAOIs]), stimulating antihistamines and hormones (e.g., corticosteroids,thyroid) are all known contributors to insomnia.
Sedating drugs such as the longer-acting sedative-hypnotics, antihistamines,antidepressants (e.g., amitriptyline, doxepin, trimipramine, trazodone, mirtazapine) taken early in the day may lead to excessive daytime sleepiness and daytime napping behavior, which adds to sleep-onset insomnia further exacerbate wakefulness.
Treatment of PD with low-to-moderate doses of dopamine agonists or antiparkinsonian agents may improve sleep by reducing rigidity and bradykinesia. Still, it may also exacerbate or even create new sleep disturbances such as those secondary to visual hallucinations associated with L-dopa, nocturnal dystonia, and choreic movements (Ancoli-Israel & Ayalon, 2006).
Changes in Circadian Rhythms:
Circadian rhythms are biologic rhythms that control many physiological functions. Examples of circadian rhythms are endogenous hormone secretions, core body temperature, and the sleep-wake cycle. Circadian rhythms controlled by the suprachiasmatic nucleus (SCN) in the anterior hypothalamus, which houses the internal circadian pacemaker; they are synchronized to the hour of the day by external Zeitgeber time givers or cues such as light and other internal rhythms. For example, the sleep-wake cycle is synchronized by the inner core body temperature and endogenous melatonin cycle and by the external light-dark rhythm, which asserts its effect on the sleep-wake period through the retinohypothalamic visual pathway.With age, the sleep-wake circadian rhythm becomes less synchronized; that is, it may no longer have the same response to external cues. The sleep-wake circadian rhythm becomes much weaker (less robust), inconsistent periods of sleeping/waking across the 24-hour day.
The sleep-wake cycle in the older adult also shifts, or advances. Changes in the sleep-wake period are likely the result of changes in the core body temperature cycle, decreased light exposure, and environmental factors.Patients with advanced rhythms complain of different waking hours, causing them to be awake (or asleep) when others around them are not. Sleeping in the early evening and waking up in the early morning hours the core body temperature is dropping earlier in the evening (perhaps at approximately 7:00 PM or 8:00 PM) and rising nearly eight hours later, at approximately 3:00 or 4:00 AM.which leads to complaints of waking up in the middle of the night and being unable to return to sleep.
There are two common scenarios for those with advanced rhythms. In the first, the older adult, although tired early in the evening, tries to stay awake until a “more acceptable” bedtime, however, because of the advanced circadian rhythm, still wakes up in the early morning hours, thus not being in bed long enough to get sufficient sleep. In the second scenario, the older adult falls asleep while reading or watching TV in the early evening, and then finally getting into bed, is unable to fall asleep because of that evening nap. Now the complaint becomes both difficulty falling asleep and difficulty staying asleep.
Advanced rhythms delayed by increasing light exposure later in the day because bright light is the most influential external Zeitgeber for the sleep-wake circadian rhythm (Ancoli-Israel & Ayalon, 2006).
Screening and Assessment:
Because sleep disturbance is a pervasive problem with serious health consequences, screening patients, especially when comorbid health problems are present. The Epworth Sleepiness Scale, Brief Insomnia Questionnaire and Insomnia Screening Questionnaire are all valid and reliable tools that are easy to administer to adults in any clinical setting. A positive screen requires a more in-depth assessment to clarify the specifics of the sleep disorder, which involves maintaining a sleep diary. Sleep diary helps identify patterns and habits and motivates clients to solve the sleep problem. The journal provides a structured format easy to keep for at least one month and up to 6 months.Information that clients record every day includes:
time to bed, time spent out of bed after initially going to bed, amount of time to fall asleep,
number of awakenings during the sleep period, total hours of sleep, and feeling upon awakening.
Also, at the end of the day before going to bed, clients record:
amount of caffeine consumed during the day and last consumption,
duration of exercise and time,nap times and frequency, times/circumstances of feeling tired, mood, and bedtime routine.The data helps target problem behaviors and clarify whether and when medication can complement the treatment approach (Limandri, B. J. (2018).
DSM-5 Diagnostic Criteria for Insomnia Disorder 307.42 (F51.01)
An official complaint of dissatisfaction with sleep quantity or quality, associated with one (or more) of the following symptoms:
Difficulty initiating sleep. (In children, this may manifest as difficulty initiating sleep without caregiver intervention.)
Difficulty maintaining sleep, characterized by frequent awakenings or problems returning to sleep after awakenings. (In children, this may manifest as difficulty returning to sleep without caregiver intervention.)
Early-morning awakening with the inability to return to sleep,
The sleep disturbance causes clinically significant distress or impairment in social, occupational, educational, academic, behavioral, or other important areas of functioning.
Sleep difficulty occurs at least three nights per week.
Sleep difficulty is present for at least three months.
Sleep difficulty occurs despite adequate opportunity for sleep.
The insomnia is not better explained by and does not occur exclusively during another sleep-wake disorder (e.g., narcolepsy, a breathing-related sleep disorder, a circadian rhythm sleep-wake disorder, a parasomnia).
The insomnia is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication).
Coexisting mental disorders and medical conditions do not adequately explain the predominant complaint of insomnia.
Specify if:With non–sleep disorder mental comorbidity, including substance use disorders
With another medical comorbidity
With other sleep disorder
Coding note: The code 780.52 (G47.00) applies to all three specifiers. Code also the relevant associated mental disorder, medical condition, or other sleep disorder immediately after the code for insomnia disorder to indicate the association.
Specify if:Episodic: Symptoms last at least one month but less than three months.
Persistent: Symptoms last three months or longer.
Recurrent: Two (or more) episodes within the space of 1 year.
Note: Acute and short-term insomnia (i.e., symptoms lasting less than three months but otherwise meeting all criteria concerning frequency, intensity, distress, and impairment) coded as another specified insomnia disorder(Gabbard, G. O. (2014).
Treatment of Insomnia:
The first-line approach to treating insomnia is cognitive-behavioral therapy for insomnia (CBT-I). CBT-I requires specialized training to conduct the 6-week intervention. It can on an individual or group level.A type ofCognitive behavior therapy (CBT) is a combination of stimulus control and sleep restriction plus cognitive restructuring, relaxation, and good sleep hygiene. A combination of both CBT and temazepam, are efficient in reducing the awake time during the night maintained clinical gains. The advantages of behavioral therapies are the durability and the lack of dependency or rebound insomnia (Ancoli-Israel & Ayalon, 2006).
Behavioral therapies used to modify maladaptive sleep habits, reduce autonomic and cognitive arousal, alter dysfunctional beliefs and attitudes about sleep, and educate patients about healthier sleep practices.Sleep complaints can be precipitated by poor sleep habits (i.e., poor sleep hygiene).It involves spending too much time in bed, having an irregular sleep schedule, not getting sufficient bright light exposure during the day, sleeping in an environment that is too bright, too noisy, or too hot or cold, and drinking alcohol or caffeinated beverages too close to bedtime.Insomnia treated with pharmacological therapy. Benzodiazepine receptor agonists (e.g., zolpidem, zaleplon, eszopiclone) are effective and safe for older adults.A melatonin receptor agonist (e.g., ramelteon) also safe and effective in older adults.A better approach to treating insomnia is a combination of pharmacologic and behavioral therapy (Ancoli-Israel & Ayalon, 2006).
Narcolepsy is a rare but potentially debilitating, rapid eye movement (REM) sleep disorder that causes significant developmental morbidity which leads to the manifestation of excessive daytime sleepiness (EDS) (Srikanta, & Kumar, 2019). Narcolepsy is typically beginning in the second or third decade of life but is associated with a significant delay in symptom recognition and diagnosis (Maresova, Novotny, Klímová, & Kuča, 2016). DSM-5 criteria require EDS in the association that requires recurrent periods of a need for sleep that cannot be avoided, the individual may constantly fall asleep or need frequent naps throughout the day. This must occur at least three times weekly over a period of three months. In addition, to at least one of the following Criterion B symptoms: Cataplexy, hypocretin deficiency, as measured using cerebrospinal fluid (CSF), results of a formal sleep study (nocturnal sleep polysomnography) conducted by a medical professional showing abnormal REM sleep latency (APA, 2013).
Psychotherapy and psychopharmacologic treatment
There is no cure for narcolepsy. However, symptoms can be manageable with medication and lifestyle modifications. Stimulants are the most prescribed medications for treating narcolepsy (Sadock, B., Sadock, V., & Ruiz, 2014). Modafinil is one of the approved medications from the FDA to improve psychomotor performance and decrease the number of sleep attacks for narcolepsy (Sadock, B., Sadock, V., & Ruiz, 2014). Other medications are methylphenidate, amphetamine, SSRIs, SNRIs, TCAs, and sodium oxybate are used to treat the symptoms of narcolepsy. Cognitive-behavioral therapy (CBT) has been found to effectively treat symptoms of narcolepsy as an adjunct to medications. It focuses on managing behaviors of patients with narcolepsy to ensure compliance with psychopharmacology regimens and engaging in good nocturnal sleep hygiene practices (Bhattarai, & Sumerall, 2017).
Patients diagnosed with narcolepsy typically present with complaints of dissatisfaction regarding the quality, timing, and duration of sleep cycle which interferes with daily life and activities. I will refer the patient to a neurologist if there is no improvement in symptoms. Pulmonologists can be consulted if the patient is experiencing respiratory problems in order to rule out sleep apnea.
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