sleep disorders in long-term care：睡眠障碍的长期护理

Sleep Disorders in Long-Term CareThomas Magnuson, M.D.Assistant ProfessorDivision of Geriatric PsychiatryUNMCTo Get Your Nursing CEUsn After this program go to /nursing/mk.n Your program ID number for the July 12th program is 10CE028.n Instructions are on the website.n *All questions about continuing education credit and payment can be directed towards the College of Nursing at UNMC.*Heidi KaschkeProgram Associate, Continuing Nursing EObjectives n Discuss the causes of sleep disruption in long-term caren Identify non-pharmacologic interventions possible to remedy sleep disruptionn Assess pharmacologic interventions for sleep disruptionImpact n Significant problemq Many residents with sleep problemsn 50% of the elderly have sleep problemsn 65% in Los Angeles area ALFsq Effect n Cognitionn Physical healthn Moodn Quality of lifen Staff moraleWell Elderlyn Spend more time in bed to get the same amount of sleepq Total sleep time only mildly decreased from when youngern Increase in nighttime awakenings and daytime nappingq Earlier bedtimesq Increased time to fall asleepq More easily aroused by soundn Daytime sleepiness not part of normal agingLong-Term Caren More often self-report sleep problemsq More severe self-reportn Asleep at all hours, even mealtimesq Wake and sleep fragmentationn Wakefullness interrupted by brief sleepn Leads to extreme sleep-wake disruptionn Distributed across the entire dayq Rarely awake or asleep for hoursEffects of Poor Sleepn Variety of problemsq Irritabilityq Poor concentrationq Decreased memoryq Lessened reaction timeq Poorer performance on tasksn Community dwelling elderlyq More fallsq Increased mortalityCase n 78-year-old demented femaleq Up at night, loud and disruptiveq Sleeps much of the dayq No activitiesn CAD, HTN, depression, hypothyroidism, h/o breast cancer, arthritis, GERD, constipation, incontinenceq ASA, APAP, sertraline, synthroid, esomeprazole, metoprolol, furosemide, senna, MOM, oxybutynin, donepezil, memantine, hydrocodone/APAPFirst Questionsn How much are they sleeping?q Usually no one really knowsn Up at nightsleeping pilln Up in the daystimulantq Shifts need to talk to each otherq Sleep is poorly documentedn When are they sleeping?q Daytime?q Nighttime?q Both?First Interventionn Sleep chartq Dailyn Every hour, on the hourn Not 4:01, just 4:00q 24 hours a dayn For a weekq Good general idean Usually is around 9-11 hours a dayCauses n Primary sleep disordersn Medical conditionsn Psychiatric disordersn Medications/polypharmacyn Circadian rhythm problemsn Environmentq Noise and light at nightq Low daytime lightn Behavioralq Physical inactivityq More time in bed Primary Sleep Disordersn Sleep disordered breathing (SDB)n Restless Leg Syndrome (RLS)n Periodic Limb Movement Disorder (PLMD)n REM sleep behavior disorder (RBD)Sleep Disordered Breathing (SDB)n Airflow interruptedq Obesity common causen Apnea/hypopneaq 10 second episodesq 15 times an hourn Low oxygen to brainq Disrupts sleepn LTC residentsq 50-66% have at least mild SDBn Treatment is CPAPq Air forces airway openRestless Leg Syndrome (RLS)n Uncomfortable feeling in legsq Relieved by moving legsn Worse later in the dayq Falling asleep is hardn Symptoms come on and worsen with ageq Possible cause of motor restlessness and wanderingn Treatment q ropinerole (Requip) and pramipexole (Mirapex)Periodic Limb Movement Disorder (PLMD)n Legs kick, jerk during nighttime sleepq Easier to identify if one has asleep partnerq Causes sleep fragmentationn Treatmentq Much as RLSq ropinerole (Requip)q pramipexole (Mirapex)REM Sleep Behavior Disorder (RBD)n Usually CNS motor is paralyzed in REMq Except for breathingn Act out dreamsq Prominent in older men, certain dementiasq Safety is an issuen Treatmentq clonazepam (Klonopin)q Secure the environmentCase n Workupq Sleep chart n Broken upq Averages 9.4 hours a dayq Range 4-13 hours a dayq Lab, medical tests n Oxygen saturation unremarkablen TSH normaln CBC, BMP normalMedications n Near bedtimeq Lung medications/bronchodilatorsn caffeine, albuterolq Stimulants n methylphenidate (Ritalin) n Daytime sedationq Antihistaminesn promethazine (Phenergan) q Anticholinergicsn diphenhydramine (Benedryl)q Sedating antidepressantsn nortriptyline, mirtazapine (Remeron) less than 30mg/dMedical Conditionsn Commonq Painq Parasthesiasq Nighttime coughq Dyspneaq GERDq Incontinence or frequent nighttime urinationq Neurodegenerative disordersn Parkinsons disease, e.g.Dementia n Common sleep problemsq More sleep disruptionq Lower sleep efficiencyq More light sleepq Less deep sleepq Less REMq Sundowning Circadian Rhythmn Bodys pattern of sleep/wakeq Elderlyq Blunted in amplituden Less time in each sleep/wake cycle q Shifted in timen More daytime somnolence, nighttime awakeningsq Less stable in LTC than in the community q May correlate with degree of dementiaq Decreases survival in LTCCircadian Rhythmn Exerts much influence on the timing of sleepq Weak CR or reset CR may strongly influence sleep problemsn How to try and fixq Exposure to bright light in the daytimen Regular scheduled exposureq Physical activity less important than lightq Bright in the day, dark at nightCase n Medical conditionsq GERDn Well controlled, no evidence of nighttime heartburnn No food for an hour before bedtimeq Pain n No complaints on routine APAPn Signs of worsened pain not presentq Incontinencen Oblivious at nightn Toileting right before bedtimeCase n Medical conditionsq Moodn Stable symptomsq Hypothyroidismn TSH normalq Primary sleep disordersn Oxygenation normaln No noted movements awake or asleep that resemble RLS or PLMDn No odd or unusual nighttime behaviorq Dementian Pattern of sleep problem sounds familiarCase n Medicationsq hydrocodone/APAP (Vicodin)n Pain controlled well on APAPn Not used in awhileq sertraline (Zoloft)n Not a sedating antidepressantn Could give at nighttimeq oxybutynin (Ditropan)n Anticholinergic, antihistaminergicn Can choose a less concerning agentq L-thyroxine (Synthroid)n Only if underusedNight in LTCn Many sleep problems in the environmentq Shared roomsq Frequent noise and light interruptionsn Extended, nightly basisn Most noise caused by workersq Doing personal caresq Room level lightn Suppresses melatoninn Disrupts sleepn Changes CRTreatment n Nonpharmacologicq Timed light exposuren More alert right after exposureq More active in the dayn Mixed resultsq Lower noise and light