Basic of Geriatrics and Internal Medicine for Physiotherapist by Rasheedy D - HTML preview

Sleep problems

Normal age related changes in sleep:

• Decreased sleep efficiency (time asleep divided by time in bed)
• Decreased total sleep time
• Stable or increased sleep latency (time to fall asleep)
• Earlier bedtime and earlier morning awakening
• More arousals during the night
• More daytime napping
• Decreases in deeper stages of sleep stage 3 and stage 4 sleep.
• Stages 1 and 2 (the lighter stages of sleep) increases.

Common sleep problems include:

1. Insomnia: difficulty initiation or maintaining sleep for at least 3 nights per week (primary or secondary to psychiatric, medical problems, or medications.
2. Sleep disordered breathing: Obstructive sleep apnea, Central sleep apnea, mixed
3. REM behavioral disorder: enactment of dreams
4. Circadian rhythm related sleep disorder: jet lag, advance phase disorder
5. Restless leg syndrome, and periodic limb movements.

Consequences of sleep disorders: Depression, poor quality of life, day time fatigue and somnolence, falls, irritability, and cognitive impairment. Resistant hypertension may occur in cases with chronic insomnia. Sleep disordered breathing: is also an independent risk factor for hypertension and is associated with obesity, pulmonary hypertension, and cardiac arrhythmias. The respiratory events may cause oxyhemoglobin desaturation, which may cause morning headaches and decreased cognitive functioning.

Types:

1. Insomnia: acute<3months- chronic >3 months may be primary or secondary It occurs 2ry to psychiatric disorders e.g. depression, generalized anxiety disorder or medical problems e.g. pain due to arthritis and neuropathy, nocturnal dyspnea and cough in heart failure, nocturia, and GERD. Insomnia can be secondary to medications use e.g alpha methyldopa, levodopa/carbidopa, diuretics, beta- blockers, glucocorticoids, Decongestants, SSRI.

Main treatment is treating cause and behavioral therapy (sleep hygiene), short term pharmacotherapy if other lines fail.

Short-acting agents (Eszopiclone, zaleplon) are recommended for problems with initiating sleep

Lower associations with falls and hip fractures

But produce the most pronounced rebound and withdrawal syndromes after discontinuation Intermediate-acting agents (tenazepam)are recommended for problems with sleep maintenance Other sedating drugs:

Low doses of sedating antidepressants such as mirtazapine or trazodone at bedtime

Sedating antihistamines (eg, diphenhydramine)

Valerian is an herbal product with mild sedative action

Melatonin receptor agonists

2. Obstructive apneas are caused by an anatomic obstruction of the airway during sleep. Patients attempt to breathe and may appear to be choking or gasping for breath; Bed partner may report loud snoring, cessation of breathing, and choking sounds during sleep. Main treatment = nasal CPAP = continuous positive airway pressure and surgical correction of the obstruction. Weight loss in obese patients with SDB can significantly reduce or eliminate the respiratory events. Oral appliances have been developed for both obstructive sleep apnea and snoring.

3. Central apneas are caused by failure of the central nervous system respiratory centers. Central apnea is common in patients with heart failure or stroke. Treatment is limited to treatment of heart failure.

4. Periodic limb movement: Debilitating, repetitive, stereotypic leg movements that occur in non- REM sleep. May present as difficulty maintaining sleep or excessive daytime sleepiness its diagnosis requires polysomnography. Good response to dopamine agonist.

5. Restless legs syndrome: The diagnosis of restless legs syndrome is based on the patient’s description of symptoms. The patient’s complaint is usually of nighttime leg discomfort or difficulty in initiating sleep. There may be a family history of the condition and, in some cases, an underlying medical disorder (eg, iron deficiency anemia, or renal or neurologic disease). Treatment mainly by iron replacement and dopamine agonist.

Association between poor sleep quality and neurologic conditions, rehabilitation outcomes, and mortality

• Emerging evidence suggests that poor sleep quality may also contribute to the development of neurologic conditions e.g. Alzheimer’s disease, Parkinson’s disease, and other neurodegenerative diseases.
• Sleep disturbances are likely present in many individuals receiving PT services, which may exacerbate their condition and slow recovery and impact their outcomes. Poor nighttime sleep quality) was associated with less functional recovery.
• As sleep contributes to the modulation of pain, thus; addressing sleep disturbances may potentially impact pain severity.
• Lower survival rates among the elderly during inpatient post-acute rehabilitation was associated with self-reported poor sleep quality. Furthermore, healthy individuals (age range 30–70 years) who sleep less than 6 hours or more than 8 hours each night had a higher risk for mortality compared with those with adequate sleep (6–8 hours)

Role for Physical Therapist

1. Assess overall sleep health and screen for risk of sleep disorders.
2. Refer for additional assessment if individual is identified as at increased risk for a sleep disorder: to sleep lab (polysomnography)
3. Provide sleep hygiene education.
4. Provide an appropriate exercise program.
5. Consider positioning to promote sleep quality.
6. Address bed mobility issues.

Screening for Common Sleep Disorders

Pittsburgh Sleep Quality Index (PSQI): https://www.med.upenn.edu/cbti/assets/user- content/documents/Pittsburgh%20Sleep%20Quality%20Index%20(PSQI).pdf

Epworth Sleepiness Scale (ESS): http://www.sleepapnea.org/assets/files/pdf/ESS%20PDF%201990- 97.pdf

Sleep hygiene:

Maintain a regular rising time

Maintain a regular bedtime, unless not sleepy

Decrease or eliminate naps, unless necessary

Exercise daily, but not immediately before bedtime

Do not use bed for reading or watching television

Relax mentally before going to sleep

If hungry, have a light snack (except with symptoms of gastroesophageal reflux or medical contraindications), but avoid heavy meals at bedtime

Limit or eliminate alcohol, caffeine, nicotine.

Control the nighttime environment with comfortable cool temperature, quiet, and darkness

Try a fan or other “white noise” machine

Wear comfortable bed clothing

If unable to fall asleep within 30 minutes, get out of bed and perform soothing activity (avoid bright light)

Get adequate exposure to bright light during the day.

Bathing before sleep has been demonstrated to enhance the quality of sleep in older people, perhaps related to changes in body temperature with bathing.

Exercise

• Acute and chronic exercise has a moderate positive benefit on sleep characteristics by increasing slow-wave sleep (deep stages) and total sleep time and decreasing sleep onset latency.
• Moderate-intensity exercise has also been shown to improve sleep in healthy, sedentary people aged 50 and older who reported moderate sleep complaints at baseline. However, strenuous exercise should not be performed immediately before bedtime.
• Exercise should be conducted in the morning or early afternoon but not in the evening.
• Meditative movement, including tai chi, and yoga, also appears to improve sleep quality
• The exact mechanism of how exercise improves sleep characteristics remains unknown:

1. One theory is that exercise raises body temperature, which triggers heat-loss mechanisms and leads to sleep onset.
2. Another theory suggests that exercise uses energy and produces “wear and tear” on the body, which leads to sleep to recuperate and restore energy.
3.  It is also possible that exposure to bright light while exercising outside and the production of inflammatory cytokines in response to exercise may influence sleep characteristics and sleep quality.
4.  Changes in depressive symptoms, improvements in physical function, and weight loss have also been associated with improvements in sleep due to exercise.

Positioning for Sleep and Addressing Bed Mobility to Facilitate Sleep Quality

Education about positioning for sleep in a pain-free or pain-reduced position may limit sleep disruption. For example, an individual with low back pain may benefit from instruction to sleep side-lying with a pillow between his knees or to sleep supine with pillows under his knees to reduce the lordosis of the back.

The therapist should address the difficulty with transfers and bed mobility. Adequate bed mobility is needed to change position while sleeping, and improved ease with changing position with sleep may reduce sleep disruptions.