From Sleeplessness to Slumber: Person-Centered Approach to Insomnia

Abstract

Speaking at a session during the AMDA - The Society for Post-Acute and Long-Term Care Medicine’s annual conference, “Sleeplessness in the Nursing Home,” Ariel Cole, MD, FAAFP, CMD, admitted that she doesn’t always feel completely effective at managing sleep. “My name is on some [pill] bottles; that causes my chagrin,” she said. But she added that a patient’s first day in the nursing home is not the time to take that person off the sleep medication he or she has been taking for years. Ultimately, she suggested, addressing sleep problems in residents is not about “absolutes,” but about “doing what is best for each individual patient.” Over the course of a period of sleep, non-REM and REM sleep alternate cyclically. There are four stages of non-REM sleep, and these represent a continuum of relative depth. Stage 1, which serves a transitioning role to deep-stage cycling, usually lasts 1 to 7 minutes per cycle and contributes 2% to 5% of total sleep. Stage 2, which lasts approximately 10 to 25 minutes per cycle, constitutes 45% to 55% of total sleep. Stage 3 lasts only a few minutes and contributes only 5% to 8% of total sleep. Stage 4 lasts about 20 to 40 minutes in the first cycle and makes up about 10% to 15% of sleep. REM sleep is the fifth phase of the sleep cycle and constitutes about 20% to 25% of an average night’s sleep. The first cycle typically begins 90 minutes after falling asleep. The most restful sleep occurs in stages 3 and 4. Irregular cycling or absent sleep stages are associated with sleep disorders. “It is important to recognize the sleep changes across our life span; and as we age, we spend less time in the deeper stages of sleep,” said Dr. Cole. “Sleep is more fragmented and shallower in the elderly.” Also, she observed, as people age and have more medical comorbidities, insomnia is more common. Issues such as lack of light exposure, inactivity during waking hours, poor sleep hygiene (such as waking and retiring at different hours every day or daytime napping), and sleep-related disorders such as restless leg syndrome, sleep disordered breathing, limb movement in sleep, and REM sleep behavior disorder also keep older adults awake. Some people have sleep-disordered breathing issues — ranging from benign snoring to obstructive apneas, which affect 33% to 70% of older nursing home patients — for which continuous positive airway pressure (CPAP) machines have become the gold standard of treatment. Poor sleep is more than just an annoyance or discomfort. It can result in slower response times, difficulty sustaining attention, problems with memory on neuropsychiatric tests, daytime sleepiness, fatigue and decreased energy levels, depression, and falls. At the same time, sleeplessness can lead to agitation, impaired cognition, and increased mortality rates. Insomnia is a primary factor in caregivers’ or family members’ decisions to admit an older loved one to a long-term care facility, with 20% to 52% of admissions directly attributable to sleep disturbances. As Dr. Cole explained, insomnia in older adults has an annual incidence of 5%. It is more common in women and individuals with depression and chronic illness or chronic pain. More than half of community-dwelling older adults use over-the-counter or prescription medications for sleep, and chronic use of these medications is associated with increased dementia and mortality. Insomnia may be transient (caused by acute stressors, such as travel or hospitalization), short term (caused by severe stressors such as surgery, divorce, or loss of a loved one), or chronic (related to medical, respiratory, psychiatric, or other conditions). It is important to note, Dr. Cole said, that untreated short-term insomnia may progress to chronic insomnia. In general, primary insomnia is defined as difficulty sleeping that lasts for at least 1 month, affects functioning, and isn’t caused by another condition, medication, or substance. A thorough sleep history that includes symptoms, the person’s sleep schedule and daytime activities, and the effects of sleep disturbances on daily functioning should be conducted for patients with sleep complaints. After identifying the cause of the sleep problem, Dr. Cole suggested, “We should be looking at nonpharmacologic interventions.” Among the possibilities:•Improving the environment (such as reducing nighttime noise levels, ensuring comfortable room temperatures, and/or increasing light exposure during the day and limiting it at night).•Increasing daytime physical activity.•Following a consistent bedtime routine.•Adjusting medications. Dr. Cole stressed the importance not adding to a patient’s insomnia by prescribing drugs that may exacerbate the condition. For instance, certain medications contribute to insomnia. These include:•Antidepressants•Antihypertensives•Appetite suppressants•Beta agonists•Calcium channel blockers•Central nervous system (CNS) stimulants•Diuretics•Other contributing medications include glucocorticoids, respiratory stimulants, sedatives/hypnotics, and over-the-counter allergy, cold, or cough products. Pharmacist Alan Obringer, RPh, CPh, CGP, said, “I’m the perfect person to talk about nonpharmacologic treatments.” He noted that there is much that can be done to help patients with insomnia that doesn’t involve medications. For instance, he suggested, “We can start by determining what is happening during the day that keeps someone from sleeping at night.” He stressed that when a patient says that he or she can’t sleep, the response should be to explore what is going on — not to go immediately for a prescription. He suggested, “The answer may be as simple as moving a person into a room with someone who shares his or her sleeping habits.” It is important to consider treatment goals, including improvement in sleep quality, sleep time, insomnia-related daytime impairment, and psychological distress. “After we find out what is happening, then we can think about treatment,” he said. In choosing the appropriate treatment regimen, said Dr. Obringer, the team needs to consider the time course of insomnia (e.g., whether the person can’t fall asleep versus can’t stay asleep), comorbidities such as depression, and the potential for adverse effects. If the individual is cognitively able, he or she can keep a sleep journal to help determine what might be causing sleep disturbances. For instance, a resident may reveal that the lights or sounds on his phone have been keeping him awake. Dr. Obringer said, “At times like this, the patient needs to make choices. Is it more important to have 24/7 access to the phone or to get a good night’s sleep?” He added, “When you find a nonpharmacologic intervention that works, repeat it.” Cognitive-behavioral therapy for insomnia (CBT-I) has shown positive results for many patients, Dr. Obringer noted. This therapy is designed to help a person avoid negative thought patterns that contribute to insomnia. It also promotes better sleep habits by using relaxation techniques and other behavioral interventions. Specifically, he said, “CBT-I changes a patient’s beliefs and expectations about sleep using psychotherapeutic methods.” It may also include paradoxical interventions, designed to eliminate patients’ anxiety about sleep performance by training them to confront their fear of staying awake. Biofeedback therapy, which reduces somatic arousal by training the patient to control physiologic variables using visual and auditory mechanisms, also may be helpful. Behavior treatments such as stimulus control, relaxation training, and sleep restrictions also may encourage better sleep in the older population. However, the patient must be cognitively intact to some degree for most of these to have maximum impact. There are times, Dr. Obringer said, when medications are necessary. He stressed, “The idea is not to have all patients off of insomnia drugs but to ensure that, if medications are necessary, we use the right drug at the right dosage for the right time.” There are a number of classes of drugs designed to treat insomnia, said Wendy Ethridge, PharmD, CPh, and some are better for older patients than others. Whatever medication is used, it is important to start with a low dose and monitor for side effects. Melatonin receptor agonists, Dr. Ethridge said, are “probably the best first step.” For instance, mirtazapine has an off-label use for insomnia, and it can increase appetite and help with depression as well. Ramelteon also has proven effective but comes with a higher price tag. These drugs have a minimal side-effect profile, and tapering is not required. Other common drug choices for the older patient population include:•Zolpidem sublingual tablets (for middle of the night awakening)•Eszopiclone, extended release zolpidem, suvorexant, and temazepam (for sleep initiation and sleep maintenance insomnia)•Low-dose doxepin (for sleep maintenance insomnia) The “Z” class of sedative-hypnotics are used to treat insomnia. Zolpidem, which is approved for short-term treatment of insomnia, has a short half-life; its side effects are dizziness and drowsiness, which should be monitored closely. Zaleplon, a short-acting agent with a rapid onset of action, is useful for patients having problems with sleep latency; its main side effects are dizziness and headache. Eszopiclone is approved for sleep initiation and sleep maintenance-related insomnia; its main side effects are metallic tastes, drowsiness, and daytime sleepiness. None of these drugs should be used in combination with two or more CNS-active medications. The dual orexin receptor antagonist suvorexant is another choice, which may be used for both sleep-onset and sleep-maintenance insomnia. Its main side effects are drowsiness, dizziness, headache, and abnormal dreams. The tricyclic doxepin is used for insomnia characterized by the inability to maintain sleep. It has a risk of orthostatic hypotension and syncope, and it should not be combined with other anticholinergic agents and/or two or more CNS-active drugs. Its side effects include confusion, delirium, dry mouth, constipation, and sedation. Benzodiazepines are sometimes used for insomnia. However, there are newer, safer drugs to treat this condition in the geriatric population. The American Geriatrics Society (AGS) Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults (J Am Geriatr Soc 2019;67:674–694) “helps us to know what drugs to avoid if possible,” Dr. Ethridge said. “If you used medications on the Beers list, have documentation about why you chose those drugs.” In general, Dr. Ethridge said, “Think of drugs like training wheels. It is better to use them and enable patients to get needed sleep.” The key is to monitor for side effects, taper doses as appropriate, and combine medication use with helpful nonpharmacologic interventions. Senior contributing writer Joanne Kaldy is a freelance writer in Harrisburg, PA, and a communications consultant for the Society and other organizations.