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Causes and Treatment of Insomnia for Geriatric Patients

Causes and Treatment of Insomnia for Geriatric Patients


Thad Nuel B. Natividad
Deanelle Raina B. Paggao
Joan Marie B. Ibanez
University of Santo Tomas
College of Rehabilitation Sciences
Physical Therapy Department

Causes and Treatment of Insomnia for Geriatric Patients


Normal human sleep comprises two states -- non-rapid eye movement
(NREM) and REM sleep -- that alternate cyclically across a sleep episode.

State

characteristics are well defined: NREM sleep is associated with low muscle tones
and minimal psychological activity; the REM sleep is associated with atonic muscles,
and dynamic psychological activity -- where dreaming occurs. A nightly pattern of
sleep in mature humans sleeping on a regular schedule includes several reliable
characteristics: Sleep begins in NREM and progresses through deeper NREM stages
(stages 2, 3 and 4) before the first episode of REM sleep approximately 80-100
minutes later.

Thereafter, NREM sleep and REM sleep cycle with a period of

approximately 90 minutes. NREM stages 3 and 4 concentrate in the early NREM


cycles, and REM sleep lengthens across the night.
Age-related changes are also predictable: Newborns enter REM sleep (also
called Active Sleep) before NREM (also called Quiet Sleep) and have a shorter sleep
cycle (approximately 50 minutes); sleep stages emerge as the brain matures during
the first year.

At birth, active sleep is approximately 50% of total sleep and

declines over the first 2 years to approximately 20% - 25% across childhood,
adolescence, adulthood, and into old age except in dementia. Other factors can
predictably alter sleep, such as phase of circadian rhythm, ambient temperature,
drugs, and sleep disorders.
According to a simple behavioral definition, sleep is a reversible behavioral
state of perceptual disengagement from and unresponsiveness to the environment.
A clear appreciation of the normal characteristics of sleep provides a strong
background and template for understanding clinical conditions in which "normal"
characteristics are altered, and for interpreting certain consequences of sleep
disorders.
Sleep disorders are broadly classified into dyssomnias , parasomnias,
circadian rhythm sleep disorders involving the timing of sleep, and other disorders
including ones caused by medical or psychological conditions and sleeping sickness.
Some common sleep disorders include sleep apnea (stops in breathing during
sleep), narcolepsy and hypersomnia (excessive sleepiness at inappropriate times),
cataplexy (sudden and transient loss of muscle tone while awake), and sleeping

Causes and Treatment of Insomnia for Geriatric Patients


sickness (disruption of sleep cycle due to infection).

Other disorders include

sleepwalking, and night terrors.


Sleep patterns change substantially and continuously with age across
adulthood. Altered sleep architecture can greatly affect and heighten the severity
of different sleep disorders.

Insomnia is common in people older than 65 years,

with about 30% complaining of sleep maintenance problems and about half that
number complaining of prolonged sleep latency. Effectively diagnosing and properly
providing treatment to geriatric patients suffering from insomnia can cause an
improvement to their rehabilitation development.
Insomnia is a frequent and widespread complaint in the general population
and in clinical practice. It is a sleep disorder that is characterized as the difficulty in
initiating and/or maintaining sleep despite adequate opportunity to sleep, and in
addition, complaints of sleep-related daytime impairment.
total lack of sleep.

It overall refers to a

Insomnia can begin at any time during the course of the

persons life style, but onset of the first episode usually occurs more commonly in
young adulthood. It may stem from a disruption of the bodys circadian rhythm, an
internal body clock that governs the timing of hormone production, sleep, body
temperature, and other functions.

It is also often triggered by stressful life

circumstances such as, marital separation, occupational or family stress, and


interpersonal conflicts. In rare cases, insomnia starts in childhood, in the absence
of psychological or medical problems, and persists throughout adulthood. Insomnia
increases the risk of substance abuse, motor vehicle accidents, headaches, and
depression. Recent surveys show that 50% of people suffer from sleep difficulties,
and 20-36% of them struggle with such difficulties for at least a year.

Other

surveys indicate that one out of three persons in the United States has insomnia,
but only 20% tell their health care providers about it.
There are three main types of insomnia: difficulty initiating sleep (sleep onset
insomnia), awakening frequently during the night (sleep maintenance insomnia),
and awakening long before the desired time to get up (early morning awakening or
terminal insomnia).

Insomnia also implies awakening with trouble returning to

sleep, tossing and turning during the sleep period, feeling tired upon awakening,
and feeling irritable or moody after the major sleep period.

In addition, sleep

Causes and Treatment of Insomnia for Geriatric Patients


disturbance

causes

clinically

significant

distress

or

impairment

in

social,

occupational, educational, academic, behavioral, or other important areas of


functioning. While intermittent restless nights are normal, prolonged insomnia can
inhibit with daytime function, concentration, and memory. Difficulty sleeping may
occur at least 3 nights per week, present for at least 3 months, and even with
adequate opportunity for sleep. It is not explained by and does not occur solely
during the course of another sleep-wake disorder (e.g., narcolepsy, breathingrelated sleep disorder, and parasomnia).

Insomnia is not attributable to the

physiological effects of a substance (e.g., drug abuse, medication). Lastly, mental


disorders and medical conditions that a patient already has do not sufficiently
explain the prevalent issue of insomnia.
Insomnia can be classified as transient, acute, or chronic.

First, transient

insomnia lasts for less than a week. It can be brought about by another mental
ailment, by environmental changes in sleep, by the timing of sleep, severe
depression, or by stress. Its consequences sleepiness and impaired psychomotor
performance- are similar to those of sleep deprivation.

The second is acute

insomnia, also known as short-term insomnia or stress related insomnia). This is


the inability to consistently sleep well for a period of less than a month. Insomnia
is present when initiating sleep is difficult, sleep is non-restorative, or when the
sleep that is obtained is non-refreshing or of poor quality. These troubles occur
despite enough opportunity and circumstances for sleep and result in diminished
daytime function. Lastly, there is chronic insomnia. This type of insomnia lasts for
longer than a month and can be cause by another disorder, or it can be a primary.
People with high levels of stress hormones are more likely to have chronic
insomnia. Its consequences can differ according to its causes. These might include
muscular fatigue, hallucinations, double vision, and/or mental fatigue.
The following factors may increase an individuals risk for insomnia: age (the
elderly more prone to insomnia), gender (women are more likely to have insomnia
than men), stressful or traumatic event, night shifting/changing work schedule,
travel across time zones, substance abuse, asthma, excessive computer work,
depression, and sedentary lifestyle.

Causes and Treatment of Insomnia for Geriatric Patients


Insomnia is usually seen in the geriatrics population (aged 65 years old and
older) and is accompanied with several individual and socioeconomic consequences.
Elderly patients more commonly suffer from chronic insomnia characterized by
difficulty staying asleep than difficulty in starting the sleep period. Despite the fact
that more that 50% of elderly people have insomnia, it is typically under
recognized, under diagnosed, and undertreated even by geriatric specialists.
Insomnia is a serious problem among elderly older individuals because of its
widespread prevalence and because poor sleep can have harmful consequences for
many of the aspects of vitality and resilience required for successful aging. Sleep
disturbances among the elderly are correlated with important indisposition and
mortality and increase the risk for nursing home placement. Insomnia is also linked
with risk for falls.

Sleep maintenance, rather than sleep initiation, is the most

commonly reported problem among older people with sleep disturbance and can
have serious consequences. Treatment of insomnia in these patients requires very
careful evaluation and exclusion of an underlying medical or psychiatric condition.
Non-pharmacologic interventions, particularly behavioral therapy, have exemplified
some success.

However, while a range of treatment options exists, there is still

currently a lack of pharmacologic medications that can provide an optimum


combination of therapeutic benefits. Ideal pharmacologic outcomes would include
improved sleep initiation, sleep maintenance without next-day residual effects, and,
ideally, improved next-day functioning.

Newer and more advanced agents are

currently under examination for insomnia that is expected to be safe and would
have good efficacy for the aged population.
In

1982,

the

National

Institute

on

Aging

conducted

multicenter,

epidemiologic study to assess the prevalence of sleep complaints among more than
9000 non-institutionalized elderly persons ranging from persons 65 years of age
and older. 57% reported some form of chronic disruption of sleep while only 12%
reported no sleep complaints.

Among all participants, 43% of the prevalence of

chronic sleep complaints included difficulty in beginning or staying asleep, 30% was
nocturnal waking, 29% complained about insomnia, 25% was daytime napping,
19% trouble falling asleep, 19%waking up too early, and 13% reported waking and
feeling unrested. For 3 years, follow-up studies were made and studies showed an

Causes and Treatment of Insomnia for Geriatric Patients


annual rate of about 5%, with around 15% of elderly insomniacs resolving their
symptoms each year.
Chronic insomnia is also found to more likely occur in this population.
1991,

the

National

Sleep

Foundation

held

survey

with

1000

In

American

respondents, 18 years of age or older and were divided by age into 6 groups (1824, 25-34, 35-44, 45-54, 55-64, and

group

65).

The results showed 20% of the

65 years old had chronic insomnia, the highest reported among all the

age groups.
Symptoms of insomnia may include: harder time falling asleep, awakening
more frequently (about 3-4 times each night) and have greater memory of being
awake, falling asleep then awakening suddenly which makes the person feel like a
light sleeper, feeling of not getting enough sleep even if the overall sleep time may
not have changed, the circadian rhythm shifts so that the person may sleep earlier
and wake up earlier than usual, and lastly, the confusion between day and night.
In geriatrics, insomnia can be caused by many factors.
physical, environmental/behavioral, drugs, and mental causes.
causes

are

cardiovascular

diseases;

COPD

(Chronic

These include
Under physical

Obstructive

Pulmonary

Disease), asthma, or other lung problems; long-term pain; bladder of prostate


problems; epilepsy; sleep apnea; dementia or Alzheimers disease; joint disease,
such as arthritis; and gastroesophalegeal reflux. Environmental/behavioral factors
may also instigate insomnia. These causes are noise, late-night eating, late-night
exercise, and having a sedentary lifestyle.
cause insomnia.
cola

drinks,

Abuse of substance intake may also

These substances may include: caffeinated drinks (coffee, tea,

chocolate,

some

cold

medications),

alcohol,

nicotine,

some

antidepressant medications, and stimulants. Also, taking medication at night, like


diuretics (water pills), may cause the sudden waking up in the middle of the night.
Lastly, psychological or mental factors may affect the development of insomnia.
These are anxiety, depression, retirement, loss of personal identity, death of a
significant person, stress, financial problems, and the belief that one is unhealthy.
A good nights sleep often becomes more abstract as we age, because
insomnia has been prevalent more commonly in older people. Lacking in sleep may

Causes and Treatment of Insomnia for Geriatric Patients


be a burden in the elderly. According to recent reviews, economic costs of insomnia
on society were found to be $13.9 billion in 1995, and according to a 1996 study,
the total direct, indirect, and related costs were calculated to be as high as $30 to
$35 billion yearly. While there is no specific economic cost regarding insomnia in
the elderly population have not been calculated, there are studies that have
provided with direct and indirect costs of unfavorable effects of insomnia on the
quality-of-life in the elderly. Insomnia may cause injuries, such as falls, and may
aggravate coexisting health conditions.

Consequent fall-related injuries are an

important factor for nursing home placement and it was estimated that of $158
billion of lifetime economic costs of injury in the United States, fall-related injuries
contributed to a total of $10 billion.

Insomnia in elderly, and the consequential

disruption of the caregivers sleep, makes it difficult for supporting family members.
It has been known that sleep disturbances in the elderly causes caregivers to admit
an elder to long-term care directly specializing to insomnia in geriatrics. Insomnia
may also impair a persons optimal daytime functioning by increasing the need to
nap, reducing cognitive ability including memory and alertness, slowing response
time, unfavorably affecting interpersonal relationships, and having the total feeling
of being unwell.
Prior to initiating symptomatic therapy for insomnia, physicians are advised
to provide patients with educational, behavioral, and cognitive interventions aimed
at introducing adaptive behaviors. One of the most crucial education approaches
includes revising unfavorable sleep-hygiene habits that patients
developed over the course of their life.

may have

According to Hauri, the simple essential

elements of good sleep hygiene include limiting naps to less than 30 minutes per
day, avoiding stimulants or sedatives, limiting liquids at bedtime, and integrating
structured sleep hygiene with late-afternoon moderate exercise and early-morning
light therapy.
Originally developed stimulus-control therapy by Bootzin and Nicassio,
proposes that sleep disturbances are habits developed, and therefore need to be
reconditioned. Some of the guidelines of this therapy include instructing patients to
go to bed only when they feel tired, to get out of bed after 20 minutes of inability to
sleep, and return to bed when they feel drowsy. It is also recommended to avoid

Causes and Treatment of Insomnia for Geriatric Patients


looking at the clock, shorten daytime naps, use the bed for sleeping purposes only,
and rise at a consistent time every morning. Other recommended for the elderly
are: avoidance of caffeine, alcohol, and nicotine; perform regular exercise
(preferable in the morning or early afternoon); avoidance of heavy late-night meals
and fluids; make sure of comfort, peace, and quiet in the bedroom; make time for
interpersonal relationships during the day; and reduce time spent awake in bed,
and if unable to fall asleep, leave the bedroom and engage in relaxing activities.
Spielman and associates proposed that sleep-restriction therapy has in its
merits the need to restrict wake time in bed to provide for better sleep efficiency.
These methods involves restricting time spent in bed and overall sleep time, which
may initially lead to a state of sleep deprivation. Its aim is to prevent patients from
becoming frustrated by limiting the time spent awake in bed.
Other commonly used therapies for insomnia include cognitive intervention,
which assists patients acquire knowledge into maladaptive beliefs and attitudes
towards sleep, and relaxation methods and biofeedback, which aims to lower the
degree of patient anxiety and arousal linked with insomnia.
Many insomniacs rely on sleeping tablets and other sedatives to get rest.
The percentage of adults using a prescription sleep aid increases with age. As an
alternative to taking prescription drugs, research indicates that an average person
seeks short-term help in over-the-counter antihistamines such as diphenhydramine,
or doxylamine.

Certain classes of sedatives such as benzodiazepines and newer

non-benzodiazepine drugs can also assist in physical dependence, which emanates


in withdrawal symptoms if the drug is not carefully given in the right doses. These
medications can have a number of side effects.

The principal aim is to use

medication with the fewest side effects at the lowest possible does that will be
clinically efficient. All hypnotics will, if given in appropriate doses, improve
insomnia. Drugs that may prove to be more effective and safe than existing drugs
for insomnia are still currently under research.
Benzodiazepines and non-benzodiazepines have similar efficacy that is not
significantly better than antidepressants. Reports showed that persistent users of
hypnotic medications for insomnia do not have improved sleep than chronic
insomniacs not taking medications.

It is know, rather, that users of hypnotic

Causes and Treatment of Insomnia for Geriatric Patients


medications wake up more often in the middle of the night than those medicationfree. In addition, studies established that these drugs can cause dangerous risk to
the individual and to public health and there is an insufficient proof of long-term
effectiveness.

It is advised that these drugs be taken in the lowest effective

dosages or avoided altogether wherever possible in the elderly.


Some antidepressants such as amitriptyline, doxepin, mirtazapine, and
trazodone can have a tranquilizing effect, and are prescribed to treat insomnia.
Amitriptyline

and

doxepin

both

have

antihistaminergic,

anticholinergic,

and

antiadrenergic properties, which add to their side effect profile, while mirtazapines
side effects are primarily antihistaminergic, and trazadones side effects are
primarily antiadrenergic.

Mirtazapine is known to promote sleep efficiency and

increasing the total amount of sleeping time in people with both depression and
insomnia.

Agomelatine is an antidepressant with sleep-improving qualities that

does not cause daytime sleepiness.


Insomniacs also use alternative medicine.

These include herbs such as

valerian, chamomile, lavender, cannabis, hops, Withania somifera, and passionflower. Purified valerian extract has undergone multiple studies and appears to be
effective. L-Arginine, L-aspartate, S-adenosyl, L-homocysteine, and delta sleepinduced peptide may also be advantageous in improving insomnia. In 1973 a study
about Psychopharmacologia was published. In this study, it was found that orally
administered

THC

significantly

lessened

disturbances in 9 healthy subjects.

sleep

latency

and

regular

sleep

A 20 mg dose of THC was found to be most

effective, reducing sleep latency by over an hour on average.

A 2010 study

published in Anesthesia and Analgesia found that synthetic THC was more effective
than the antidepressant amitriptyline at improving sleep quality in patients with
fibromylagia.
Insomnia can be short-term or long-term. Prevention of this sleep disorder
should be highly taken into account. It is better to avoid sleeping inconsistencies
rather than dealing with consequent insomnia later on. These can be very difficult
especially in geriatric patients.

Therefore, a good sleep-hygiene should be

exercised regularly to avoid long-term consequences.


significant burdens in personal lives and in public society.

This may also reduce

Causes and Treatment of Insomnia for Geriatric Patients


As a sleeping disorder, insomnia is the most common with patients ranging
from pediatric to geriatric, and is commonly separated into three types: transient
insomnia, acute insomnia, and chronic insomnia.

Transient insomnia, which may

last from a few nights to less than two weeks, is caused by changes in the Circadian
rhythm, sleep environment, emotional state, or stress.

Acute insomnia, which is

more common among adolescents and adults below 30 years of age, lasts for a less
than a month. And chronic insomnia is a common underlying symptom for diseases
that are diagnosed in the years past ones middle age specifically for geriatric
patients, wherein it lasts for more than a month and requires specific forms of
treatment.
The common causes of acute and/or chronic insomnia are chronic medical
conditions(such as Parkinsons disease and depression), substance and medication
use(such as alcohol and caffeine), and primary sleep disorders (such as periodic
limb movement disorder and obstructive sleep apnea).
Diagnosis, of either acute or chronic insomnia, is primarily done through
evaluation of the patients sleep history, supplemented by specific physical
examinations, sleep diaries, and ancillary tests.

Questions to be asked during

diagnosis begin with general characterization of the type of insomnia, its severity,
duration, variability, and daytime consequences, as the patients sleep history. A
sleep diary includes a record of naps, caffeine and alcohol consumption, medication
use, bedtime and rising time, perceived sleep quality, etcetera.
Management of insomnia addresses both nighttime sleep complaints and
daytime consequences through pharmacologic treatment and placebo, experimental
hypnotics, behavior and relaxation therapies, as well as sleep hygiene education
and exercise.

Exercise and sleep hygiene education, whose goal is to eliminate

lifestyle factors that have an immediate effect on sleep, are most preferred as
modalities for insomnia over hypnotics and medication, given that they are nonpharmacologic treatments that work for all three types of the disorder, and that
prescribed drugs need increasing dosage as the bodys system adapts to the effects
of the medication varying greatly for each patient.

Causes and Treatment of Insomnia for Geriatric Patients


Recommendation
For better understanding of the scope of insomnia, the researchers
recommend a future study similar to the causes and/or treatment of sleep
deprivation. Patients must take note of, and perform proper sleep hygiene as well
as aerobic exercise. The researchers also recommend the efficient use of sleep
and/or relaxation therapy as treatment for elderly patients suffering from insomnia.
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Hening

W.,

&

Walters

A.

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