SLEEP CONCERNS
Educational Objectives
| The goal of this program is to improve the management of sleep problems in the elderly and restless leg syndrome (RLS).
After hearing and assimilating this program, the clinician will be better able to:
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 | 1. Describe typical sleep changes that occur with aging.
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| 2. Discuss the significance of sleep disturbance as a comorbidity to other health burdens.
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| 3. Counsel patients about sleep hygiene and cognitive behavioral therapy.
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| 4. Recognize RLS based on patient history and clinical findings.
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| 5. Review recommendations for pharmacologic treatment of RLS.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning
committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts
of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health
care and not a proprietary business or commercial interest. For this program, the following has been disclosed: Dr. Vitiello
is a consultant for and is on the Speakers’ Bureau for Takeda Pharmaceuticals North America.
Acknowledgements
Dr. Vitiello spoke in Orlando, FL, at Sleep Disorders 2008, presented March 17-19, 2008, by World Class CME and
Loma Linda University School of Medicine. Dr. Simpson was recorded in Kiawah Island, SC, on June 21, 2007, at An
Intensive Review of Family Medicine, presented by the Medical University of South Carolina. The Audio-Digest Foundation
thanks the speakers and the sponsors for their cooperation in the production of this program.
| SLEEP ISSUES IN THE ELDERLY —Michael V. Vitiello, PhD, Professor, Department of Psychiatry and Behavioral Sciences,
University of Washington, School of Medicine, Seattle
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| Sleep changes with aging: time in bed increases; takes longer to fall asleep; duration of sleep decreases; frequency of
awakening during night increases; sleepiness during day and napping increase (new data suggest decrease in older populations);
dissatisfaction with sleep increases; typical circadian changes include phase advancement (ie, advanced sleep
phase syndrome [typically does not progress to circadian sleep disorder]); patients complain about sleep maintenance and
sleep-onset problems (fewer complaints from men than from women)
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| Sleep disturbance: sleep disorders associated with other disorders (eg, hypertension, cardiovascular disease, stroke); sleep
apnea, shortened sleep duration, and unusually lengthened sleep associated with metabolic syndrome and diabetes; insomnia
associated with depression, alcohol and drug dependence, and anxiety; sleep disorders almost always multifactorial
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| Sleep complaints: 50% of aging patients complain, but 50% do not (even with evidence of significant sleep changes with
advancing age); age-related sleep change—study found many older adults with significantly disturbed objective sleep quality
(based on sleep efficiency [duration of sleep divided by time in bed x 100]) adapt to perception of what is acceptable
sleep and therefore do not complain; if older person complains about sleep problems solely due to age-related change, education
important; older patients understand that physiologic changes occur that lead to changes in functional ability (eg, ability
to sleep)
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| Normative sleep for older adults: 18 to 60 yr of age—meta-analysis of 38 studies of ≈1200 patients with normal aging
(ie, no pathology) found total sleep time, sleep efficiency, slow-wave sleep, rapid eye movement (REM) sleep, and
REM latency negatively correlated (ie, declined) with age; conversely, sleep latency, stage 1 and 2 sleep, and awakening
during sleep directly correlated (ie, increased) with age; sleep patterns change across life span; 60 to 100 yr of age—no
relationship between total sleep time and age; average sleep time slightly >6.5 hr per night (“you shouldn’t target 8 hr per
night; set reasonable goals”); change in sleep efficiency, 3% per decade (1% every 3 yr); most age-related objective sleep
changes occur early and during middle years of life, and “effectively asymptote” in older adults; objective sleep quality
of healthy older adults remains relatively constant from age 60 to 90 yr; older adults can expect sleep efficiency to decline
slowly; significant treatable sleep disturbances exist in many older adults with medical, psychiatric, and psychosocial
burdens (“and they didn’t enter these analyses”)
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| Sleep disturbance comorbid with health burdens: frequency of acute and chronic illnesses increases with age;
causes of adverse effects on sleep—illnesses (eg, osteoarthritis with uncontrolled pain); consequences of treatment for illnesses
(eg, pain after surgery); bed rest and inactivity; medications (eg, inappropriately timed diuretics; stimulants for
respiratory disorders); when prescribing drugs, set target and review medications; polypharmacy; changed pharmacokinetics;
meta-analysis of health burden—≈50% of patients had pain; slightly <25% had indigestion or gastroesophageal reflux;
17% of men had benign prostatic hypertrophy; 16% had depression; relationship of medical burden and prevalence
of sleep complaints—nighttime and daytime complaints and possible diagnosis of insomnia highly related to medical burden
and depression; patients with nighttime complaints at 3 times greater risk for significant medical burden (ie, ≥3 medical
conditions); daytime complaints and possible insomnia highly related to comorbidity; 3-yr prospective
epidemiologic study of 7000 older adults showed appearance or resolution of insomnia complaint highly associated with
respective appearance or resolution of health burden
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| Sleep disorders: primary or intrinsic; incidence of sleep-disordered breathing, restless leg syndrome (RLS), and REM
behavior disorder higher in older populations; complex relationship between aging and sleep apnea
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| Treatment: education key to effective treatment; sleep disturbance comorbid with medical burden—treat sleep problem
directly while treating illness; sleep disturbance (eg, insomnia) and medical burden can wax and wane separately (“they
exist comorbidly so they should be treated congruently”); primary sleep disorder—treat sleep disturbance directly; sleep
disturbance not wholly result of age-related sleep change, health burden, or primary sleep disorder—common in older
population; likely due to development of poor sleep habits or conditioned emotional responses; use behavioral and pharmacologic
approaches as appropriate; carefully review patient and optimize sleep hygiene practices; cognitive behavioral
therapy (CBT) as appropriate; judicious use of hypnotics with or without CBT
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| Education and sleep hygiene: accurate fact-based information about sleep (eg, normal sleep for older adult, slightly
>6.5 hr per night); explain consequences of mild sleep loss; address erroneous assumptions, misperceptions, and dysfunctional
beliefs (also important in CBT); sleep hygiene—behavioral and environmental factors typically under patient’s
control; 1) maintain habitual bed and rise times; restrict time in bed; explore usefulness of napping (in healthy older
adults, data suggest afternoon napping does not greatly affect nighttime sleep time); 2) consider environmental principles,
eg, dark bedroom with minimal noise; use appropriate bedding; consider placement of night lights and clocks; 3)
consider diet and drug use principles; explore which foods affect sleep; avoid caffeine, alcohol, and tobacco; 4) consider
general principles; know what normal age-appropriate sleep is; explore bedroom habits that disrupt sleep (eg, reading at
night); develop relaxing bedtime rituals; regular exercise; spend time outdoors and in natural light; avoid bright light during
night
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| Cognitive behavioral techniques: relaxation techniques—eg, Benson deep-breathing relaxation response (focusing
on breathing leads to parasympathetic response); CBT for insomnia (CBTI)—consists of stimulus control therapy, sleep
restriction therapy, and sleep hygiene; 1999 study—found CBTI and pharmacotherapy (benzodiazepines) effective and
comparable for late-life insomnia in short term (ie, posttreatment); CBTI rated more effective than drug therapy by participants,
significant others, and clinicians; sleep improvements better sustained by CBTI over 2-yr follow-up; can be delivered
in group settings in general practice by appropriately trained staff (eg, community nurses); CBTI typically
delivered in 6 or 8 sessions over several weeks, but can be delivered in two 40-min sessions; British study—reported
CBTI improved sleep quality, reduced use of hypnotic drugs, and improved health-related quality of life (QOL) among
long-term hypnotic-drug users with chronic sleep difficulties; CBTI resulted in significant discontinuation of hypnotic
drugs and significant cost savings; 2005 study—demonstrated that CBTI improved insomnia comorbid with osteoarthritis,
coronary artery disease, or chronic obstructive pulmonary disease (COPD) in older adults (despite continued disease-
related health burden); in patients with osteoarthritis, CBTI improved sleep and pain scores
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| Pharmacotherapeutic approaches: no data to suggest efficacy of melatonin in older adults with sleep problems
(some data suggest usefulness for circadian rhythm disorders); ramelteon (Rozerem) useful for sleep-onset problems;
valerian root (Valeriana officinalis) ineffective
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| Effectively treating sleep disorders in aging: age-related sleep change—education; primary sleep disorder—treat
directly; comorbid insomnia—treat sleep disturbance directly while appropriately treating comorbid condition; primary
insomnia or general sleep disturbance—pharmacotherapy appropriate for acute problems (eg, insomnia in healthy older
person due to death of spouse); for chronic problems, educate, review sleep hygiene, and attempt behavior change, then
follow with appropriate use (eg, minimum dose) of approved hypnotic agents
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| Do elderly patients who sleep well live longer? limited data suggest older individuals who have greater polysomnographic
sleep fragmentation than their cohorts tend to die sooner
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| RESTLESS LEG SYNDROME —William M. Simpson Jr, MD, Professor, Department of Family Medicine, Medical University
of South Carolina, Charleston
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| Introduction: RLS affects 10% to 15% of US population; higher incidence in women than men; more likely to occur in
older population; affects QOL and sleep; genetic predisposition likely (especially when onset before age 45 yr); secondary
causes include iron deficiency, pregnancy, end stage renal disease, and peripheral neuropathy; most patients present
with complaints about sleep (eg, daytime drowsiness) rather than complaints about pain or restless legs; patients with suspected
obstructive sleep apnea (OSA) or their bed partners may complain about “moving at night,” rather than snoring
and apneic spells
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| Causes of sleep problems: people doing shift work or with multiple jobs may have changes in sleep pattern during
week (lifestyle problem; not due to RLS or OSA); drugs; alcohol; caffeine
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| Features of RLS: may be described as pain or as “creepy- crawly” sensation; sense of need to move; difficult to describe
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| Criteria for RLS: 1) urge to move limbs, often accompanied by uncomfortable or unpleasant sensation; 2) usually begins
with periods of rest or inactivity (eg, while watching television during evening, bedtime); not triggered by specific
body position; symptoms more likely with restful positions and longer durations of rest; 3) symptoms partially or completely
relieved by movement; as symptoms worsen, period of relief from movement becomes shorter; 4) symptoms occur
exclusively (or worsen) during evening; in rare severe cases, symptoms may persist despite movement
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| Periodic leg movements of sleep: experienced by ≈85% of patients with RLS; may occur independent of RLS, especially
in elderly population; slow (0.5-5.0 sec) movements occur every 20 to 40 sec; sometimes associated with arousal;
may be associated with other sleep disturbances
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| Pathophysiology of RLS: associated with dopaminergic system; correlated with iron storage in putamen and substantia
nigra
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| Management: check for iron deficiency (first diagnostic intervention for RLS); if patient iron-deficient, determine cause
and provide iron supplementation; if patient not iron-deficient, start with dopaminergic agents; anticonvulsants, opioids,
and sedative hypnotic agents can be used if patient does not respond to dopaminergic agents or iron supplementation;
iron deficiency—low (<45 ng/mL) serum ferritin associated with RLS; start iron supplement if serum ferritin <18 ng/mL,
or iron saturation <20%; serum ferritin target, 50 ng/mL; iron saturation target, 20%; ferrous sulfate with vitamin C recommended
(preferably on empty stomach with stool softener); discontinue supplementation when iron saturation reaches
target; choice of drugs depends on severity and frequency of symptoms
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| Dopaminergic agents: levodopa; pergolide (Permax); ropinirole (Requip); pramipexole (Mirapex); effective for treatment
of RLS and periodic limb movement disorder (PLMD); doses lower than those used for Parkinson’s disease, so side
effects minimal; augmentation—may occur (especially with levodopa; less likely with ropinirole and pramipexole);
symptoms early in day become more severe; reported in nearly 80% of patients on levodopa; levodopa—onset rapid (15-
20 min; good choice for patients with intermittent symptoms); not likely to cause augmentation if used intermittently (2-
3 times/wk); ropinirole and pramipexole—approved by Food and Drug Administration (FDA); dopamine agonists; start
with low dose and gradually titrate up, depending on therapeutic response; patients who respond to ropinirole usually respond
to lowest dose (0.25 mg/day)
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| Sedative hypnotic agents: may be useful if patient continues having difficulty falling asleep due to symptoms, even
after treatment of iron deficiency anemia and treatment with dopaminergic agent and/or dopamine agonist; symptomatic
therapy; no evidence of augmentation; potential for tolerance and abuse (risky intervention); reserve for patients who become
nonfunctional due to severe difficulty with sleep
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| Anticonvulsant agents: gabapentin and carbamazepine—do not appear to cause augmentation; second- or third-line
therapy; might be used as first-line agents in patients who report pain as major symptom (not common); sedative property
of gabapentin may be useful in patients with sleep disturbance; start with low doses
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| Opioids: may be used as first-line agent in patients who report pain as major symptom (not common); potential for tolerance
and dependence; no evidence of augmentation; recommendations—based on expert panel; intermittent therapy;
nightly therapy for patients with significant nightly symptoms; start 1 to 2 hr before onset of symptoms (“better to prevent
than to treat”); consider timing of subsequent doses; titrate up if needed to reach symptom control
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| Overall recommendations: watch dosing regimen (can be changed frequently because of short half-lives); watch for tolerance;
if patient does not respond to first-line agent at maximum dose, consider trying other agents; combining therapy not
FDA-approved; if no response after trying several agents at maximum dosages, refer to specialist; nightly symptoms—use
dopamine agonists (ie, ropinirole, pramipexole); gabapentin as second-line therapy; opioid or gabapentin as third-line therapy;
frequent symptoms—dopamine agonists; different agonist or gabapentin as second-line agent; opioid or gabapentin as third-
line therapy
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| Nonpharmacologic therapies: RLS does not respond to typical sleep hygiene interventions (eg, going to quiet room,
reading dull book); tactile stimulation (eg, rubbing legs with rough towel, movement) or mental activity (eg, reading)
may temporarily relieve symptoms; promote mental or physical activity during day; caffeine and alcohol may aggravate
symptoms; foot and leg massages; hot baths
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| Drugs that may exacerbate RLS: dopamine antagonists; some antihistamines; tricyclic antidepressants; lithium; selective
serotonin reuptake inhibitors (SSRIs)
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| RLS and pregnancy: pregnant women at greater risk for iron deficiency anemia; high prevalence (11%-27%) during
pregnancy; usually mild, but worsens during third trimester; resolves at time of delivery; no effect on health of mother or
infant; avoid pharmacotherapy; dopamine agonists at lowest dose possible during third trimester may be acceptable for
severely affected women
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| RLS and end stage renal disease: common in patients on long-term dialysis; ≤60% of uremic patients have RLS; duration
of dialysis associated with onset of RLS; erythropoietin can reduce periodic leg movements; infusion of high-dose
iron dextran transiently reduces RLS symptoms (expensive; not effective long term); dopamine agonists not as effective as
in other RLS patients
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| Conclusion: patients often have difficulty describing symptoms; RLS distinct from Parkinson’s disease; patients with
RLS not at increased risk for Parkinson’s disease; RLS manageable condition; RLS not mental disorder; treatment
depends on frequency and severity of symptoms; individualize therapy (eg, pharmacologic interventions and lifestyle
adaptations)
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Suggested Reading
Allen B: The patient's page. Sleepless nights and restless legs syndrome. South Med J 101:573, 2008; Ancoli-Israel S:
Sleep and aging: prevalence of disturbed sleep and treatment considerations in older adults. J Clin Psychiatry 66 Suppl 9:24,
2005; Buysse DJ et al: Quantification of subjective sleep quality in healthy elderly men and women using the Pittsburgh
Sleep Quality Index (PSQI). Sleep 14:331, 1991; Buysse DJ: Insomnia, depression and aging. Assessing sleep and mood
interactions in older adults. Geriatrics 59:47, 2004; Chitnis S: Ropinirole treatment for restless legs syndrome. Expert
Opin Drug Metab Toxicol 4:655, 2008; Connor JR: Pathophysiology of restless legs syndrome: evidence for iron involvement.
Curr Neurol Neurosci Rep 8:162, 2008; Hening W: The clinical neurophysiology of the restless legs syndrome
and periodic limb movements. Part I: diagnosis, assessment, and characterization. Clin Neurophysiol 115:1965,
2004; Milligan SA et al: Restless legs syndrome in the older adult: diagnosis and management. Drugs Aging 19:741,
2002; Morin CM et al: Behavioral and pharmacological therapies for late-life insomnia: a randomized controlled trial.
JAMA 281:991, 1999; Rybarczyk B et al: A placebo-controlled test of cognitive-behavioral therapy for comorbid insomnia
in older adults. J Consult Clin Psychol 73:1164, 2005; Satija P et al: Restless legs syndrome: pathophysiology,
diagnosis and treatment. CNS Drugs22:497, 2008; Stiasny K et al: Restless legs syndrome and its treatment by dopamine
agonists. Parkinsonism Relat Disord 7:21, 2000; Taibi DM et al: A systematic review of valerian as a sleep aid: safe
but not effective. Sleep Med Rev 11:209, 2007; Vitiello MV: Growing old should not mean sleeping poorly: recognizing
and properly treating sleep disorders in older adults. J Am Geriatr Soc 55:1882, 2007.
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