Sleep Disorders In Older Adults Harrison G. Bloom, M.D. Director, International Geriatrics Clinical Education and Consultation Service International Longevity Center-USA New York, NY 翻翻 : 翻翻 I N T E R N A T I O N A L L O N G E V I T Y C E N T E R - U S A
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Sleep Disorders In Older Adults Harrison G. Bloom, M.D.
I N T E R N A T I O N A L L O N G E V I T Y C E N T E R - U S A. Sleep Disorders In Older Adults Harrison G. Bloom, M.D. Director, International Geriatrics Clinical Education and Consultation Service International Longevity Center-USA New York, NY 翻译 : 唐莉. 老年人睡眠障碍. 哈里森 . 布鲁姆医学博士 - PowerPoint PPT Presentation
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Sleep Disorders In Older Adults
Harrison G. Bloom, M.D.Director, International Geriatrics Clinical Education and Consultation Service
International Longevity Center-USANew York, NY
翻译 : 唐莉
I N T E R N A T I O N A L L O N G E V I T Y C E N T E R - U S A
老年人睡眠障碍
• 哈里森 . 布鲁姆医学博士• 国际老年医学临床教育中心主任 • 国际长寿中心,纽约
Consensus Conference to Develop Guidelines for the Assessment and Treatment of Sleep Disorders in Older Adults
ILC-USADecember 6 & 7, 2007
Made possible by an unrestricted grant from Takeda Pharmaceuticals North America
I N T E R N A T I O N A L L O N G E V I T Y C E N T E R - U S A
• 老年睡眠障碍评估和治疗的共识和指南 • 2007年 12月 6~7 日
“If sleep doesn’t serve an absolutely vital
function it is the biggest mistake that
evolution has ever made.”
• 如果睡眠不能完全恢复人体的活力和机能将是极大的错误,而这种错误在不断发生。
Goal
Develop consensus guidelines that are practical and relevant to the primary care practitioner in an ambulatory
setting.
目标
形成和初级保健医生共识的医疗开发的实用性与基础护理相关的治疗背景
Guidelines
Evidence Based
Best Practices
指导思想
以实践为依据
Gallup Survey on
Sleep and Healthy Aging
October, 2005
睡眠和健康的民意调查
2005年 10 月
Gallup Survey Objective
Document older adults’ awareness and attitudes on a range of issues: – Knowledge of the importance of sleep– Sleep behaviors and coping mechanisms– Attitudes toward sleep and aging
民意调查目的
老年人对睡眠问题的意识和态度:– 睡眠的重要性
– 睡眠行为和应对机制
– 对于睡眠和衰老的态度
Survey Goal
Use survey results to help encourage discussion among healthcare
professionals about sleep problems within the aging population.
调查目的
通过调查结果鼓励医疗保健专家关注讨论老年人睡眠障碍
Methodology
The Gallup Organization interviewed 1,003
Americans 50 years of age and older via random
telephone surveys.
Results are nationally representative of all adults
age 50 and older.
方法学
盖洛普通过电话随机调查了 1003位 50 岁以上的美国老年人
调查结果能够代表美国 50 岁以上人群的意见
Summary of Findings:
Older adults recognize the importance of sleep…
研究结果摘要:
中老年人意识到睡眠的重要性
睡眠的重要性
0%
10%
20%
30%
40%
50%
60%
70%
80%
Great deal Some Very little/Notmuch
Don't know
大部分老年人相信睡眠对健康非常重要
One in two (47%) report they are getting less then seven hours a sleep a night
One in three (34%) feel they need more sleep than they are currently getting
Sleep Patterns
睡眠模式
二分之一 (47%) 的老年人一夜睡眠不足 7 小时
三分之一 (34%) 的老年人认为他们需要比现在睡眠时间更长的睡眠
45% feel they need more sleep today than when they were younger
24% agree that getting more than 9 hours of sleep a night is a sign of laziness
Attitudes Toward Sleep
睡眠的态度
45% 的人感觉需要比他们年轻时更多的睡眠
24% 的人认为睡眠时间超过 9 个小时是懒惰的表现
One in three (33%) report using at least one “sleep aid” in the past month
18% reported using the respective “sleep aid” every night
One in four (25%) believes she/he has a sleep problem
72% who feel they have a sleep problem have spoken to their healthcare providers
More than half (53%) who have spoken with their healthcare providers are not receiving treatment
25% of people who feel they have a sleep problem report taking Rx sleep medication
Treatment of Sleep Problems
睡眠障碍的治疗
四分之一( 25% )的人认为自己有睡眠障碍72% 感觉自己有睡眠障碍的人已经报告了医
生
一半以上( 53% )报告过医生的人未得到治疗
25% 认为自己有睡眠障碍的人正在服用处方睡眠药
处方睡眠药安全吗 ?
331%
213%
123%
414%
59% 不是很安全
2
3
4
非常安全
不知道
Most Frequently Cited Safety Concerns
• Not knowing long-term effects of drug (73%)• Becoming addicted (68%)• Next-day grogginess (67%)• Interactions with other medications (63%)• Next-day “hangover” feeling (63%)
最常见的安全隐患
• 长期药效不详 (73%)
• 成瘾性 (68%
• 次日感觉头昏 (67%)
• 对其他药物的影响 (63%)
• 次日“宿醉”感 (63% )
“It ain’t so much what we don’t know that gets us into trouble as what we do know
that ain’t so.”
我们遇到的困难不是我们所能预料的
Sleep: A marker of Physical and Mental Health in the ElderlyKathryn J. Reid, et al
Objective: The objective of this study was to
determine the occurrence and recognition of
common sleep-related problems and their
relationship to health-related quality-of-life
measures in the elderly.
Am J Geriatr Psychiatry 14:10,October 2006
睡眠:老年人身心健康的标志
目的:这项研究的目的是确定常见睡眠相关问题的发生和鉴别,以及睡眠与健康生活质量的关系。
TABLE 2. Five-Item Sleep Questionnairea
1. Do you feel excessively sleepy during the day? Yes No2. Do you find yourself falling asleep when you do not want to? Yes No3. Do you snore frequently and loudly or stop breathing? Yes No4. If yes to 3, do you feel unrefreshed on awakening? Yes No5. Do you have difficulty falling asleep, staying asleep, or being able to sleep? Yes No
-------------------- aData collection for educational data was initiated after enrollmenthad begun at the first several project sites (N1,323). For otherdemographic variables, the full sample size is 1,503.
A positive response to the question about excessive daytime sleepiness best predicted both poor physical and mental health.
The results of this study also demonstrates a significant relationship between sleep disturbances with both physical and mental health-related quality-of-life status.
Am J Geriatr Psychiatry 14:10,October 2006
讨论
白天过度嗜睡预示体力和精力的减弱
这项研究的结果也证实睡眠与身心健康相关的生活质量有密切关系
Discussion
Although the results of the current study indicate that sleep complaints are prevalent in the elderly and are often accompanied by higher rates of mental and physical health problems, primary care professionals are not identifying sleep problems in their patients’ charts.
Although only speculation, the low detection rate of sleep disorders in this sample maybe the result of a common belief that sleep problems are part of normal aging and the perception among both patients and physicians that little can be done to improve sleep quantity and quality in the elderly.
Furthermore, even when recognized, the increasing demands and time constraints in primary care practices require efficient tools to screen for sleep disorders. Results from this study indicate that asking just one question about sleep can be reasonably predictive of poor mental and poor physical health-related quality of life.
This study indicates that although there has been more than a decade of discussion about the prevalence and low detection rates of sleep problems, little has changed in primary care practice in recognition of sleep problems in the elderly.
Source: Foley, Monjan, Brown et al. SLEEP 18:425-432, 1995
Per
cen
t
Men
Women
Most Common Drugs Affecting Sleep
Alcohol
Nicotine
Caffeine
Television
影响睡眠的最常见因素
酒精
尼古丁
咖啡因
电视
Combining Pharmacologicand CBT-I Approaches
• No conclusive evidence exists to favor either pharmacologic therapy or CBT-I
• Pharmacologic treatment provides immediate benefit with risk of side effects
• CBT-I takes longer to help, but the gains are maintained up to 2 years later with no known side effects or potential for drug interactions
• The benefits of combined therapeutic approaches are unclear and currently being explored
Courtesy of M. Vitiello PhD
药物和行为结合治疗
• 没有存在有益于药物疗法或 CBT 确定的迹象
• 药物治疗收到很快的疗效但有副作用的风险
• CBI收到长久疗效,效果会持续,两年来带着未知的或潜在的药物相互作用
• 综合的治疗疾病的方法和收益还不清楚,目前正在研讨中
2005 – Sleep Conference – Consensus Statements
• Sleep can be viewed as a new “vital sign” and sleep disturbances are important enough to be routinely addressed by clinicians at most office visits for all patients.
• For those with mild to moderate cognitive impairment, sleep information should be obtained from both the patient and a knowledgeable caregiver.
• Poor sleep and/or excessive sleepiness are often associated with poor physical or mental health.
• Primary sleep disorders such as sleep apnea and restless leg syndrome are common and treatable.
• Primary care physicians/clinicians need education about the importance and impact of sleep and sleep disorders, and on appropriate treatments and referrals for various disorders.
• Clinicians often pay too little attention to sleep-related problems and routinely ignore sleep complaints. They are often hesitant to ask their patients about sleep complaints because many clinicians have neither the expertise not time to deal with such complaints.
• Behavioral/psychological interventions, alone or in combination, have been shown to be very effective in the treatment of insomnia. Examples include cognitive behavioral therapy, stimulus control, and sleep restriction. Light therapy, exercise, and sleep hygiene may be effective as well, although further study is needed to confirm this.
• Prescription medications, over-the-counter (OTC) medications and nutraceuticals, other than those approved for sleep, can significantly adversely affect sleep either directly or indirectly. Attention by clinicians to these possible effects is important.
• Significant numbers of caregivers develop sleep problems themselves, which may or may not be causally related to patient nighttime disturbances. Sleep problems in both patients and caregivers can be treated with psychological/behavioral therapies as well as medications.
• Sleep disturbances are especially prevalent in long-term care facilities. In general, the environment in such facilities is not conducive to sleep quality or quantity.
• The potential benefits and risks associated with daytime napping are controversial.
• Pharmacologic therapies (prescription and OTC) are widely utilized methods to assist sleep in those with insomnia. New medications with different mechanisms of action from traditionally utilized sleep meds are now approved for both short- and long-term use.
• It is acceptable to recommend prescription medications, in appropriate patients, for short-term use.
• It is acceptable to continue prescription medication use over a longer-term period in appropriate patients, for whom the benefits of continued use outweigh the potential risks.
• Troubled sleep in older individuals is highly related to diminished qualities of life.
2005– 睡眠会议–共识
• 对白天小睡的潜在益处和风险有争议。• 药物治疗 ( 处方和非处方 )被广泛用于治疗失
眠。与常规使用的睡眠药物作用机理不同的新药现在被批准短期和长期应用。
• 为有适应症的病人推荐短期应用的处方药是可取的。
• 有适应症的病人长期持续使用处方药是可取的,持续使用的益处超过可能的风险。
• 老年人的睡眠紊乱与生活质量减退高度相关。
2006 Sleep Conference Outcomes
The primary outcome of the 2006 scientific consensus
conference on Sleep and Chronic Disease in Older People,
was the decision to create a national coalition of aging,
geriatric, and sleep organizations in support of guidelines
for sleep in older people. The coalition will develop,
endorse, and disseminate a set of comprehensive,
evidence, and expert opinion-based guidelines for the
diagnosis and management of sleep disorders in older
• AARP• Alliance for Aging Research• American Association for
Geriatric Psychiatry• American Geriatrics Society• AGS Foundation• American Medical Directors
Association• American Society of
Consultant Pharmacists
• Association of Directors of Geriatric Academic Programs
• Association for Gerontology in Higher Education
• Gerontological Society of America
• International Longevity Center• National Sleep Foundation• Sleep Research Society
Disclosure: The creation of the National Coalition for Sleep Disorders in Older People was made possible by a grant from Takeda Pharmaceuticals North America.
The National Coalition for Sleep Disorders in Older People (S-DOP)
Would we assess and treat this person differently from an 84 y.o. women without any of the chronic problems presenting the same way?
Obviously, yes. It is clinically, rationally, and intuitively obvious.
But, is this based upon evidence?
理想的延续
我们估计并且对待这个 84 岁妇女没有提出的慢性问题的不同方式?
显然, 它是合理的并是显而易见的。
但是,可以基于这些证据么?
85
I N T E R N A T I O N A L L O N G E V I T Y C E N T E R - U S A
Restless Legs Syndrome(RLS)
Written by: Barbara Phillips, M.D.Presented by: Harrison G. Bloom, M.D.
不宁腿综合症
Restless Legs Syndrome (RLS)
Restless legs syndrome (RLS) is a sleep
disorder characterized by unpleasant leg
sensations that disrupt sleep.
不宁腿综合症
不宁腿综合症是一个以腿部感觉不适引起睡眠片断化的睡眠障碍
RLS
Sensations include: Compelling urge to move the lower extremities (most common); creepy crawly, itching, burning, and pain are reported as well.
Symptoms of sleep disruptions may lead to a complaint of insomnia or of daytime sleepiness.
不宁腿综合症
症状包括:不由自主的下肢活动(最常见);蚁走感、瘙痒、烧灼感和疼痛也有报告。
睡眠中断可能导致失眠主诉或白天嗜睡。
RLS
The symptoms most commonly involve the lower extremities, but have also been described in the upper extremities and even the trunk.
RLS has a circadian pattern, with the intensity of the symptoms worse at night and improving toward the morning.
不宁腿综合症
症状最常累及下肢,但也有是上肢,甚至是躯干。
不宁腿综合症呈昼夜节律变化,夜间加重,早晨改善
RLS
Symptoms are also classically worse at rest and improve with movement such as walking, rubbing, or stretching.
The diagnosis is made by history without the need for a formal sleep study.
不宁腿综合症
症状在休息时加重,活动如散步、按摩或伸屈肢体可缓解。
诊断主要根据病史,而不是正式的睡眠监测。
RLS
RLS may be classified as primary or secondary.
Primary or idiopathic RLS is more likely to develop at an earlier age, has no known associated or predisposing factors, and likely has a genetic basis.
First-and second-degree relatives of patients with idiopathic RLS have a significantly increased risk of developing RLS compared with relatives of matched controls.
RLS may also be secondary to a variety of medical conditions which have iron deficiency in common.
These include iron-deficiency anemia, end-stage renal disease, and pregnancy.
不宁腿综合症
不宁腿综合症也继发于多种疾病,其中与缺铁有着共同之处
这包括缺铁性贫血、肾功能衰竭和妊娠。
RLS
The prevalence of RLS symptoms is about
10% in most population-based surveys, and
there are consistently higher rates of RLS
symptoms in women than in men.
不宁腿综合症
调查显示,大多数人群中不宁腿综合症患病率在 10 %左右,女性多于男性。
RLS
The prevalence of RLS symptoms increases with aging for both men and women, at least until the seventh or eighth decade.
Some of this age-related increase in prevalence occurs because RLS can develop at any age, but rarely remits.
Increasing prevalence of RLS with age may also result from increasing prevalence of secondary causes, such as iron deficiency and renal failure.
不宁腿综合症
不论男女,至少至七十或八十岁,不宁腿综合症患病率随着年龄的增加而增加。
患病率随着年龄而增加的原因是不宁腿综合症可以在任何年龄发生,但很少报告。
不宁腿综合症患病率随着年龄而增加,也可能是因为继发性原因的增多,如缺铁和肾功能衰竭。
RLS
The exact pathophysiology of RLS and periodic limb movements is still being worked out, but there appear to be contributions from the spinal cord, peripheral nerves, and central dopamine and narcotic receptors.
The impairment of dopamine transport in the substantia nigra due to reduced intracellular iron appears to play a critical role in most patients with this disorder.
In addition, several social or lifestyle factors appear to contribute to RLS symptoms.
These include increasing body mass index, increasing caffeine intake, a sedentary lifestyle, smoking, and earning a lower income.
不宁腿综合症
此外,一些社会或生活方式因素似乎有助于不宁腿综合症的发生
这些因素包括体质指数增加、咖啡因摄入增加、久坐的生活方式、吸烟和收入较低。
RLS
The treatment for RLS patients with frequent
and/or intense symptoms include both
nonpharmacologic and pharmacologic
modalities.
不宁腿综合症
有频繁和 /或严重症状的病人的治疗包括非药物和药物治疗两种方式。
RLS
Nonpharmacologic measures include
education, moderate exercise, smoking
cessation, alcohol avoidance, caffeine
reduction or elimination, and discontinuation
of offending medications if it is safe to do so.
不宁腿综合症
非药物措施包括教育、适度的运动、戒烟、避免饮用酒类和咖啡因,并停止可能加重病情的药物 。
RLS
Pharmacologic therapies include primarily
the dopaminergic agents, although opioids,
Benzodiazepines, and anticonvulsants have
been used.
不宁腿综合症
虽然阿片类药物、苯二氮卓类、抗癫痫药物已被使用,药理治疗首先应包括多巴胺受体激动剂。
RLS
If pharmacologic treatment is required, evidence supports the use of dopaminergic agents, especially the newer dopamine receptor agonists such as ropinirole or pramipexole (both of which are FDA-approved) as first line.
These agents have less rebound and augmentation of symptoms than dopamine precursors such as levodopa-carbidopa.
The side effects of these agents include nausea, orthostatic hypertension, sleepiness, headache, and compulsive behaviors.
In the older patient, particular consideration should be given to drug interactions and the risk of orthostasis.
不宁腿综合症
这些药物的副作用包括恶心、体位性高血压、嗜睡、头痛和强迫行为。
老年病人应该考虑到药物的相互作用和直立平衡的风险。
RLS: Table 1
Diagnostic Criteria for RLS In Adults:
A. The patient reports an urge to move the legs, usually accompanied or caused by uncomfortable and unpleasant sensations in the legs.
B. The urge to move or the unpleasant sensations begins or worsens during periods of rest or inactivity such as lying or sitting.
不宁腿综合症:表 1
成年人不宁腿综合症诊断标准:
A. 病人主诉:渴望不断移动下肢,通常伴有下肢不适感。
B. 下肢移动或不适感在休息或静止时出现或恶化,如坐卧时。
RLS: Table 1, Continued
C. The urge to move or the unpleasant sensations are partially or totally relieved by movement, such as walking or stretching, or at least as long as the activity continues.
D. The urge to move or the unpleasant sensations are
worse, or only occur, in the evening or night.
E. The condition is not better explained by another current sleep disorder, medical or neurological disorder, mental disorder, medication use, or substance use disorder.
不宁腿综合症:表 1 续
c. 运动如行走或伸腿,只要是持续活动就可以部分或完全缓解下肢移动或不适感。
D.下肢移动或不适感在晚间加重,或只发生在晚间。
E. 出现的症状不能以其他睡眠疾病、内科或神经科疾病、 精神疾病、使用药物来解释。
• Prevalence of Insomnia in the elderly is higher than in younger adults
• EVIDENCE LEVEL II
• 老年人的失眠率普遍高于年轻人• 二级水平证据
不同年龄失眠患病率
14 15
20
25
0
5
10
15
20
25
30
18-34 35-49 50-64 65-79
Age Groups (years)
Perc
ent
Age Group (years)
不同年龄失眠患病率
Mellinger, et al., 1985; Foley, et al., 1995
老年人主诉不适症状的百分比( 9282 人;平均年龄 74 岁)
25
29
30
43
19
19
13
0 10 20 30 40 50
原发病持续存在
夜间醒来
失眠
白天午睡
入睡困难
早醒
睡眠持续困难
Percent
Foley, et al., Sleep, 1995, 18:452-432
Consequences of Disturbed Sleep• Difficulty sustaining attention• Slowed response time• Difficulty with memory• Decreased performance• May all be misinterpreted as dementia
• Insomnia in the elderly is not a function of age, but rather a function of other factors
associated with aging
• EVIDENCE LEVEL II
• 老年人失眠不是年龄所致,而是由伴随着衰老的其他因素所引起
• 二级水平证据
Factors Affecting Ability to Sleep in the Elderly
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC: American Psychiatric Association; 2000:597-661.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC: American Psychiatric Association; 2000:597-661.
Hauri PJ. Insomnia. Clin Chest Med. 1998;19:157-168. A Special Report: Sleep Disturbance. Boston, MA: Harvard Medical School Health Publications Group; 1999; Ancoli-Israel S, Cooke JR.. J Am Geriatr Soc 2005;53:S264-S271.
• CBT (stimulus control, sleep restriction, sleep hygiene and cognitive therapy) vs. temazepam (7.5-30mg) vs. both vs. placebo– PSG: pre- and post-treatment
– subjective report: pre-, post-treatment and F/U 3 active treatments > placebo
• 3 active treatments all effective at post-treatment (8 weeks)
• Those treated with CBT maintained clinical gains at F/U (3, 12, 24 mos)
• Behavioral and cognitive-behavioral therapies (CBTs) have demonstrated efficacy in RCTs.
• Found to be as effective as prescription medications are for brief treatment of chronic insomnia.
• Moreover, there are indications that the beneficial effects of CBT, in contrast to those produced by medications, may last well beyond the termination of treatment.
• There is no evidence that such treatment produces adverse effects, but thus far, there has been little, if any, study of this possibility. NIH State of the Science Conference Statement Manifestations and Management of Chronic Insomnia in Adults. Sleep 28(9): 1049-1057, 2005