docsound asleep: medications and behavioral strategies for older adults
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sound asleep: medications and behavioral strategies for older adults
8th Annual Spring Conference – Building Bridges & Embracing Humanity - Arizona Geriatrics Society SOUND ASLEEP: MEDICATIONS AND BEHAVIORAL STRATEGIES FOR OLDER ADULTS Jeannie Kim Lee, PharmD, BCPS, CGP, FASHP Colleges of Pharmacy and Medicine The University of Arizona Learning Objectives: Describe the role and risk versus benefit of sleep medications in older adults. Discuss effective behavioral strategies for sleep in older adults. Identify safe medications to use for sleep in older adults. DISCLOSURE OF COMMERCIAL SUPPORT Jeannie Kim Lee, PharmD, BCPS, CGP, FASHP does not have a significant financial interest or other relationship with manufacturer(s) of commercial product(s) and /or provider(s) of commercial services discussed in this presentation. The information in this document may not be reproduced or disclosed to unauthorized parties without the prior consent of the Arizona Geriatrics Society. 2015 Arizona Geriatrics Society All Rights Reserved 1 8th Annual Spring Conference – Building Bridges & Embracing Humanity - Arizona Geriatrics Society ___________________________________ ___________________________________ Sound Asleep: ___________________________________ Medications & Behavioral Strategies for Sleep in Older Adults ___________________________________ ___________________________________ ___________________________________ Jeannie K Lee, PharmD, BCPS, CGP, FASHP University of Arizona College of Pharmacy ___________________________________ Arizona Center on Aging 2 Objectives ___________________________________ ___________________________________ 1. Describe the role and risk versus benefit of sleep medications in older adults ___________________________________ 2. Discuss effective behavioral strategies for sleep in older adults ___________________________________ 3. List safe medications to use for sleep in older adults ___________________________________ ___________________________________ ___________________________________ 3 Sleep Disorders in Older Adults ___________________________________ ___________________________________ Chronic insomnia = unsatisfactory sleep on ≥ 3 nights/week x ≥ 3 months Prevalence of insomnia increases with age 57% of older adults complain of insomnia Late-life insomnia often prompts selfmedication with OTC sleep aids or alcohol ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ The information in this document may not be reproduced or disclosed to unauthorized parties without the prior consent of the Arizona Geriatrics Society. 2015 Arizona Geriatrics Society All Rights Reserved 2 8th Annual Spring Conference – Building Bridges & Embracing Humanity - Arizona Geriatrics Society 4 Prevalence (%) of Chronic Sleep Complaints Among Older Adults ___________________________________ ___________________________________ 57 57 60 50 ___________________________________ 40 31 30 22 20 Women 22 21 16 15 ___________________________________ Men 27 ___________________________________ 12 13 ___________________________________ 8 10 0 Trouble falling Awakes during asleep night Awakes frequently Naps during day Awakes not rested ___________________________________ Any chronic sleep disorder Source: Foley, Monjan, Brown et al. SLEEP. 18:425-32, 1995. Sleep Stages and Aging 5 ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ http://www.healthcentral.com/common/images/8/8692_6443_5.jpg 6 Objectives ___________________________________ ___________________________________ 1. Describe the role and risk versus benefit of sleep medications in older adults ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ The information in this document may not be reproduced or disclosed to unauthorized parties without the prior consent of the Arizona Geriatrics Society. 2015 Arizona Geriatrics Society All Rights Reserved 3 8th Annual Spring Conference – Building Bridges & Embracing Humanity - Arizona Geriatrics Society 7 Medicalization of sleeplessness ___________________________________ Data from National Ambulatory Medical Care Survey ___________________________________ Diagnosis of insomnia increase >7-fold Rx for benzodiazepine increased ~30-fold ___________________________________ A public health concern Year 1993 -1994 2007 Office visits for sleeplessness 2.7 million 5.7 million Insomnia diagnosis 840,000 6.1 million Office visits for benzodiazepine Rx 2.5 million 3.7 million Rx for benzodiazepines 540,000 16.2 million ___________________________________ ___________________________________ ___________________________________ ___________________________________ Moloney ME, Konrad TR, Zimmer CR. Am J Public Health. 2011;101:1429-1433. 8 Insomnia epidemic ___________________________________ ___________________________________ Rise in # of older adults Sleep architecture change ___________________________________ Comorbid conditions and medications ___________________________________ Nonbiological issues in younger adults Stress ___________________________________ Multiple social roles Increased technology use ___________________________________ Targeted marketing of sleep medications ___________________________________ Moloney ME, Konrad TR, Zimmer CR. Am J Public Health. 2011;101:1429-1433. 9 Insomnia epidemic ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ The information in this document may not be reproduced or disclosed to unauthorized parties without the prior consent of the Arizona Geriatrics Society. 2015 Arizona Geriatrics Society All Rights Reserved 4 8th Annual Spring Conference – Building Bridges & Embracing Humanity - Arizona Geriatrics Society 10 Solutions for sleepless America ___________________________________ ___________________________________ Annual sleep screening ___________________________________ Satisfaction with sleep Daytime fatigue interfering with activities ___________________________________ Snoring, breathing problems Excessive movements in bed ___________________________________ ___________________________________ ___________________________________ 11 Sleep Assessment Tools ___________________________________ ___________________________________ Sleep questionnaires EPWORTH Sleepiness Scale ___________________________________ Sleep Evaluation by AASM Home sleep logs Symptom checklists Bed partner interviews Psychological screening tests Sleep studies for obstructive sleep apnea ___________________________________ ___________________________________ ___________________________________ ___________________________________ AASM – American Academy of Sleep Medicine 12 Annual sleep screening ___________________________________ Complete medical history ___________________________________ Psychosocial problems ___________________________________ Cardiovascular problems Respiratory problems ___________________________________ Nocturia, restless leg syndrome, cramps Pain ___________________________________ Obesity Medications ___________________________________ Rx and OTC Alcohol use Smoking ___________________________________ The information in this document may not be reproduced or disclosed to unauthorized parties without the prior consent of the Arizona Geriatrics Society. 2015 Arizona Geriatrics Society All Rights Reserved 5 8th Annual Spring Conference – Building Bridges & Embracing Humanity - Arizona Geriatrics Society 13 Differential diagnosis ___________________________________ Central sleep apnea (primary or drug/substance induced) Cheyne-Stokes breathing pattern (associated with heart failure) High-altitude periodic breathing Jet-lag disorder Medication-related insomnia Depression Obstructive Sleep Apnea-Hypopnea Syndrome Periodic Limb Movement Disorder Restless Legs Syndrome Sleeplessness and Circadian Rhythm Disorder ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ http://emedicine.medscape.com/article/1187829-differential 14 15 Medications/substances that cause or aggravate sleep disorder in older adults ___________________________________ Class examples Medication examples α-blockers clonidine β-blockers atenolol Calcium channel blockers felodipine, nisoldipine Diuretics furosemide ___________________________________ Decongestants phenylephrine, pseudoephedrine ___________________________________ Respiratory altuterol, theophylline Hormones corticosteroids, thyroid hormones Antiepileptic lamotrigine, phenytoin Stimulants dextroamphetamine, methylphenidate Substances caffeine, alcohol, nicotine ___________________________________ ___________________________________ ___________________________________ ___________________________________ Treatment of Insomnia ___________________________________ 1. Treat the underlying cause ___________________________________ 2. Non-pharmacological therapy ___________________________________ Try a couple of them Try a combination of them ___________________________________ 3. Pharmacological therapy ___________________________________ ___________________________________ ___________________________________ The information in this document may not be reproduced or disclosed to unauthorized parties without the prior consent of the Arizona Geriatrics Society. 2015 Arizona Geriatrics Society All Rights Reserved 6 8th Annual Spring Conference – Building Bridges & Embracing Humanity - Arizona Geriatrics Society 16 Role of drug therapy ___________________________________ ___________________________________ When non-pharmacological therapies fail ___________________________________ When benefits outweigh risks Short-term use ___________________________________ Need to continuously evaluate ___________________________________ ___________________________________ ___________________________________ 17 Pharmacological Therapy ___________________________________ Sedative-hypnotics ___________________________________ Benzodiazepines ___________________________________ Non-benzodiazepines Antidepressants ___________________________________ Antipsychotics ___________________________________ Anticonvulsants Melatonin agonists ___________________________________ OTCs: Antihistamines, ___________________________________ Melatonin, Valerian 18 Risk versus benefit ___________________________________ 2005 meta-analysis of short-term treatment of sedative hypnotics in older people Compared potential benefits (subjective reports) to risks (adverse events and morning-after impairment) ___________________________________ ___________________________________ ___________________________________ RCT of any sleep medications taken at least 5 nights 60 years and older with insomnia without other psychiatric diagnosis 24 studies included (2417 participants) ___________________________________ ___________________________________ ___________________________________ Glass J, Lanctot KL, Herrmann N, et al. BMJ, doi:10.1136/bmj.38623.768588.47 (published 11 November 2005) The information in this document may not be reproduced or disclosed to unauthorized parties without the prior consent of the Arizona Geriatrics Society. 2015 Arizona Geriatrics Society All Rights Reserved 7 8th Annual Spring Conference – Building Bridges & Embracing Humanity - Arizona Geriatrics Society Sleep quality 19 ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 20 Cognitive adverse effects ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Glass J, Lanctot KL, Herrmann N, et al. BMJ, doi:10.1136/bmj.38623.768588.47 (published 11 November 2005) 21 Sedative versus placebo ___________________________________ Benefit Risk Sleep quality improved with effect size 0.14 (small effect size = 0.2) Adverse cognitive events 5 times higher Total sleep time increased by mean 25 minutes Adverse psychomotor events (dizziness, loss of balance) 2.61 times higher ___________________________________ # of nighttime awakenings decreased by 0.63 Daytime fatigue 4 times higher ___________________________________ All significant improvements but small No difference between benzo and non-benzo Number needed to treat = 13 Number need to harm = 6 ___________________________________ ___________________________________ ___________________________________ ___________________________________ Glass J, Lanctot KL, Herrmann N, et al. BMJ, doi:10.1136/bmj.38623.768588.47 (published 11 November 2005) The information in this document may not be reproduced or disclosed to unauthorized parties without the prior consent of the Arizona Geriatrics Society. 2015 Arizona Geriatrics Society All Rights Reserved 8 8th Annual Spring Conference – Building Bridges & Embracing Humanity - Arizona Geriatrics Society Memory Health ___________________________________ FDA Adverse Event Reporting System ___________________________________ Top 10 prescription drugs linked to memory side effects (2004-2011) 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. ___________________________________ Zolpidem ER (Ambien CR) Zolpidem (Ambien) Gabapentin (Neurontin) Sodium Oxybate (Xyrem) Natalizumab (Tysabri) Interferon Alfa-2b (PEG-Intron) Topiramate (Topamax) Atorvastatin (Lipitor) Paroxetine (Paxil) Clonazepam (Klonapin) ___________________________________ ___________________________________ ___________________________________ ___________________________________ Health, Medical, and Science Updates 2012 23 2014 CDC Report ___________________________________ Emergency Department (ED) visits due to psychiatric medication ___________________________________ 2011 US Data ___________________________________ 90,000 ED visits/year due to adverse events ___________________________________ 32% of older adults hospitalized ___________________________________ #1 culprit = zolpidem (ambien®) ___________________________________ 1/5 ED visits in older adults ___________________________________ Hampton LM, Daubresse M, Chang HY, et al. JAMA Psychiatry. Doi:10.1001/jamapsychiatry.2014.436 ED visits in adults ___________________________________ Top 10 psychiatric drugs causing adverse events 1. Zolpidem (Ambien) 2. Quetiapien (Seroquel) 3. Alprazolem (Xanax) 4. Lorazepam (Ativan) 5. Haloperidol (Haldol) 6. Clonazepam (Klonopin) 7. Trazodone (Oleptro) 8. Citalopram (Celexa) 9. Lithium salts 10. Risperidone (Risperdal) ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Hampton LM, Daubresse M, Chang HY, et al. JAMA Psychiatry doi:10.1001/jamapsychiatry.2014.436 The information in this document may not be reproduced or disclosed to unauthorized parties without the prior consent of the Arizona Geriatrics Society. 2015 Arizona Geriatrics Society All Rights Reserved 9 8th Annual Spring Conference – Building Bridges & Embracing Humanity - Arizona Geriatrics Society 25 Why zolpidem? What about Benzos? ___________________________________ Medicare Part D (2003) ___________________________________ Did not cover benzodiazepines Covered zolpidem until 2013 ___________________________________ State Medicaid on benzodiazepines ___________________________________ 41 states with complete coverage (AZ) Use remained stable ___________________________________ 6 states with partial supplemental coverage Use remained stable ___________________________________ 1 state with no coverage Tennessee Immediate and significant reduction ___________________________________ Hampton LM, Daubresse M, Chang HY, et al. JAMA Psychiatry doi:10.1001/jamapsychiatry.2014.436 26 ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 27 AGS Choosing Wisely campaign ___________________________________ ___________________________________ #4 Don’t use benzodiazepines or other sedative-hypnotics in older adults as first choice for insomnia, agitation or delirium. ___________________________________ ___________________________________ Falls and fracture risk Automobile accidents ___________________________________ Leading to morbidity and mortality ___________________________________ ___________________________________ American Geriatric Society Five Things Physicians and Patients Should Question: www.choosingwisely.org The information in this document may not be reproduced or disclosed to unauthorized parties without the prior consent of the Arizona Geriatrics Society. 2015 Arizona Geriatrics Society All Rights Reserved 10 8th Annual Spring Conference – Building Bridges & Embracing Humanity - Arizona Geriatrics Society 28 AVOID ___________________________________ Benzodiazepine hypnotics ___________________________________ Beers Criteria: avoid any type for insomnia Long-acting: active metabolite accumulates in older adults ___________________________________ Diazepam (Valium) ___________________________________ Insomnia + Anxiety: short-term therapy Short-acting: for sleep latency only ___________________________________ Alprazolam (Xanax), Triazolam (Halcion) Intermediate-acting: for sleep latency & nighttime awakening ___________________________________ Temazepam (Restoril), Estazolam (Prosom), Lorazepam (Ativan) ___________________________________ American Geriatrics Society 2012 Beers Criteria Update Expert Panel. J Am Geriatr Soc. 2012;60:616-631 29 Benzodiazepine Hypnotics ___________________________________ Adverse events ___________________________________ Central Nervous System (CNS) depression/motor coordination ___________________________________ Drowsiness, dizziness, and lightheadedness ___________________________________ Falls, fractures, and motor vehicle accidents Cognitive impairment, delirium ___________________________________ Anticholinergic side effects Physical and psychological dependence ___________________________________ Addiction/drug seeking ___________________________________ Withdrawal symptoms American Geriatrics Society 2012 Beers Criteria Update Expert Panel. J Am Geriatr Soc. 2012;60:616-631 30 EMPOWER Trial ___________________________________ Eliminating Medications through Patient Ownership of End Results ___________________________________ To reduce benzodiazepine use among older adults using direct patient education ___________________________________ 303 long-term benzodiazepine users aged 65-95 years from 30 community pharmacies ___________________________________ 15 pharmacies randomized to educational intervention; 15 pharmacies randomized to control ___________________________________ ___________________________________ Participants, physicians, pharmacists, evaluators blinded ___________________________________ Tannenbaum C, Martin P, Tamblyn R, et al. JAMA Intern Med. 2014;174(6):890-898. The information in this document may not be reproduced or disclosed to unauthorized parties without the prior consent of the Arizona Geriatrics Society. 2015 Arizona Geriatrics Society All Rights Reserved 11 8th Annual Spring Conference – Building Bridges & Embracing Humanity - Arizona Geriatrics Society EMPOWER Intervention 31 Eliminating Medications through Patient Ownership of End Results ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Tannenbaum C, Martin P, Tamblyn R, et al. JAMA Intern Med. 2014;174(6):890-898. EMPOWER Intervention 32 Eliminating Medications through Patient Ownership of End Results ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Tannenbaum C, Martin P, Tamblyn R, et al. JAMA Intern Med. 2014;174(6):890-898. EMPOWER Intervention 33 Eliminating Medications through Patient Ownership of End Results ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Tannenbaum C, Martin P, Tamblyn R, et al. JAMA Intern Med. 2014;174(6):890-898. The information in this document may not be reproduced or disclosed to unauthorized parties without the prior consent of the Arizona Geriatrics Society. 2015 Arizona Geriatrics Society All Rights Reserved 12 8th Annual Spring Conference – Building Bridges & Embracing Humanity - Arizona Geriatrics Society 34 EMPOWER Trial ___________________________________ Did you know? ___________________________________ Eliminating Medications through Patient Ownership of End Results Ask yourself ___________________________________ Side effects As you age ___________________________________ Alternatives Lifestyle changes ___________________________________ Stress and anxiety management Patient testimonial ___________________________________ Step-by-step tapering-off program Under doctor or pharmacist ___________________________________ Tannenbaum C, Martin P, Tamblyn R, et al. JAMA Intern Med. 2014;174(6):890-898. EMPOWER Intervention 35 Eliminating Medications through Patient Ownership of End Results ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Tannenbaum C, Martin P, Tamblyn R, et al. JAMA Intern Med. 2014;174(6):890-898. 36 EMPOWER Trial ___________________________________ Eliminating Medications through Patient Ownership of End Results ___________________________________ Discontinuation of benzodiazepine at 6 months ___________________________________ 27% in intervention group Dose reduction in additional 11% ___________________________________ 5% in control group Number needed to treat = 4 ___________________________________ Multivariate sub-analyses Age >80, sex, duration of use, indication, dose, previous attempt to taper, polypharmacy (10 or more) did not have significant interaction ___________________________________ ___________________________________ Tannenbaum C, Martin P, Tamblyn R, et al. JAMA Intern Med. 2014;174(6):890-898. The information in this document may not be reproduced or disclosed to unauthorized parties without the prior consent of the Arizona Geriatrics Society. 2015 Arizona Geriatrics Society All Rights Reserved 13 8th Annual Spring Conference – Building Bridges & Embracing Humanity - Arizona Geriatrics Society 37 AVOID ___________________________________ ___________________________________ Non-benzodiazepine Hypnotics Beers Criteria: avoid >90days ___________________________________ Increase sleep time by <12 mins Delirium, falls, fractures, sleep driving, sleep eating, sleep walking, short-term amnesia ___________________________________ True insomnia with no other option ___________________________________ Short-acting: for sleep latency ___________________________________ Zaleplon (Sonata), Zolpidem (Ambien) Long-acting: for sleep latency & nighttime awakening ___________________________________ Zolpidem ER (Ambien CR), Eszopiclone (Lunesta) American Geriatrics Society 2012 Beers Criteria Update Expert Panel. J Am Geriatr Soc. 2012;60:616-631 38 AVOID ___________________________________ Antipsychotics ___________________________________ Beers Criteria: increase stroke & mortality in dementia patients (black box warning) ___________________________________ Dizziness, hypertension, metabolic syndrome (weight gain, increased blood sugar, increased cholesterol) ___________________________________ ___________________________________ Not recommended without psychiatric problems ___________________________________ Examples: Olanzapine (Zyprexa), Risperidone (Risperdal), Quetiapine (Seroquel) ___________________________________ American Geriatrics Society 2012 Beers Criteria Update Expert Panel. J Am Geriatr Soc. 2012;60:616-631 39 AVOID ___________________________________ Tricyclic Antidepressants ___________________________________ Beers Criteria: highly anticholinergic, sedating, cause orthostatic hypotension ___________________________________ Dizziness, anxiety, confusion, delusions, disorientation, hallucinations, nightmares ___________________________________ Unlabeled use for insomnia ___________________________________ Examples: Amitriptyline (Elavil), Imipramine (Tofranil), Clomipramine (Anafranil) ___________________________________ ___________________________________ American Geriatrics Society 2012 Beers Criteria Update Expert Panel. J Am Geriatr Soc. 2012;60:616-631 The information in this document may not be reproduced or disclosed to unauthorized parties without the prior consent of the Arizona Geriatrics Society. 2015 Arizona Geriatrics Society All Rights Reserved 14 8th Annual Spring Conference – Building Bridges & Embracing Humanity - Arizona Geriatrics Society 40 AVOID ___________________________________ Sedating SSRI ___________________________________ Unlabeled use for insomnia ___________________________________ Anticholinergic side effects Hyponatremia prevalent in older adults ___________________________________ Prolonged QT, GI and sexual side effects ___________________________________ Examples: Paroxetine (Paxil) – insomnia up to 24% ___________________________________ Citalopram (Celexa) – insomnia up to 15% ___________________________________ 41 AVOID ___________________________________ Barbituates ___________________________________ Beers Criteria: ___________________________________ High rate of physical dependence Tolerance to sleep benefits ___________________________________ Risk of overdose at low doses Hypotension, syncope, dizziness, agitation, anxiety, confusion, hallucinations, nightmares, “hangover” effect ___________________________________ ___________________________________ Limited evidence for efficacy Examples: Phenobarbital, Secobarbital ___________________________________ (Seconal), butabarbital (Butisol) American Geriatrics Society 2012 Beers Criteria Update Expert Panel. J Am Geriatr Soc. 2012;60:616-631 42 AVOID ___________________________________ Chloral Hydrate ___________________________________ Miscellanious hypnotic Beers Criteria: ___________________________________ Tolerance occurs within 10 days ___________________________________ Risk of overdose at low doses 3 times recommended dose ___________________________________ Arrhythmia, hypotension, torsades de pointes, delirium, dizziness, dependence, hallucinations, “handover” effect, nightmares, vertigo ___________________________________ ___________________________________ American Geriatrics Society 2012 Beers Criteria Update Expert Panel. J Am Geriatr Soc. 2012;60:616-631 The information in this document may not be reproduced or disclosed to unauthorized parties without the prior consent of the Arizona Geriatrics Society. 2015 Arizona Geriatrics Society All Rights Reserved 15 8th Annual Spring Conference – Building Bridges & Embracing Humanity - Arizona Geriatrics Society 43 AVOID ___________________________________ 1st-Generation Antihistamines ___________________________________ Beers criteria: ___________________________________ Highly anticholinergic Reduced clearance ___________________________________ Tolerance when used as hypnotic Confusion, drug mouth, constipation, blurred vision, urinary retention ___________________________________ Examples: Hydroxyzine (Vistaril), ___________________________________ ___________________________________ American Geriatrics Society 2012 Beers Criteria Update Expert Panel. J Am Geriatr Soc. 2012;60:616-631 44 AVOID ___________________________________ OTC Sleep Aids (1st-Gen antihistamines) ___________________________________ Diphenhydramine & Doxylamine ___________________________________ Beers criteria: highly anticholinergic ___________________________________ Increased half-life up to 14hrs Diphenhydramine Doxylamine Nytol Sominex Unisom SleepTabs Tylenol PM Excedrin PM Equaline Sleep Aid Advil PM Unisom SleepGels Good Sense Sleep Aid ___________________________________ ___________________________________ Zzzquil ___________________________________ American Geriatrics Society 2012 Beers Criteria Update Expert Panel. J Am Geriatr Soc. 2012;60:616-631; Gerontological Society of America. Sleep Helath and the Appropriate Use of OTC Sleep Aids in Older Adults, White Paper. November 2013 45 AVOID ___________________________________ Alcohol ___________________________________ May induce sleep onset but fragments sleep in 2nd part of night ___________________________________ Increase daytime sleepiness and promote sleep disturbance ___________________________________ Valerian root ___________________________________ May slightly decrease sleep latency but lacks evidence ___________________________________ May be hepatotoxic ___________________________________ Gerontological Society of America. Sleep Helath and the Appropriate Use of OTC Sleep Aids in Older Adults, White Paper. November 2013 The information in this document may not be reproduced or disclosed to unauthorized parties without the prior consent of the Arizona Geriatrics Society. 2015 Arizona Geriatrics Society All Rights Reserved 16 8th Annual Spring Conference – Building Bridges & Embracing Humanity - Arizona Geriatrics Society 46 Objectives ___________________________________ ___________________________________ 1. Describe the role of drug therapy for sleep in older adults ___________________________________ 2. Discuss effective behavioral strategies for sleep in older adults ___________________________________ ___________________________________ ___________________________________ ___________________________________ 47 Non-pharmacologic Therapy ___________________________________ ___________________________________ Behavioral therapy Sleep hygiene ___________________________________ Cognitive therapy Cognitive-behavioral therapy ___________________________________ Relaxation technique Sleep restriction/compression ___________________________________ Exercise Tai Chi Acupuncture 48 ___________________________________ ___________________________________ Behavioral Strategies ___________________________________ A review of 48 clinical trials ___________________________________ Almost 80% benefited from behavioral therapies for at least 6 months after completion with no side effects ___________________________________ Counteract sleep deterrents Sleep hygiene (diet, exercise, substance use) Environmental modifications (light, temperature, noise) Self-Help CBT-I ___________________________________ ___________________________________ older adults with chronic conditions Sleep hygiene and behavioral strategies ___________________________________ Significant improvements in sleep quality & efficiency Morin CM. Principles and practices of sleep medicine. 4th ed. Philadelphia, PA: Elsevier/Saunders; 2005:726-737; Stepanski EJ, Wyatt JKSleep Med Rev. 2003;7(3):215-225; Morgan K, et al. J Am Geriatr Soc 2012;60:1803-1810. ___________________________________ The information in this document may not be reproduced or disclosed to unauthorized parties without the prior consent of the Arizona Geriatrics Society. 2015 Arizona Geriatrics Society All Rights Reserved 17 8th Annual Spring Conference – Building Bridges & Embracing Humanity - Arizona Geriatrics Society 49 Sleep Hygiene ___________________________________ Sleep as long as necessary to feel rested and do not stay in bed longer ___________________________________ Regular sleep schedule and bedtime routine ___________________________________ Avoid caffeinated beverages after noon ___________________________________ Avoid alcohol and smoking within 2 hours of bedtime ___________________________________ Exercise regularly at least 4-5 hours before bedtime ___________________________________ Create a comfortable sleeping environment ___________________________________ Avoid daytime naps 50 Cognitive Therapy ___________________________________ To educate patients on: ___________________________________ Misunderstandings regarding sleep Identify false beliefs about sleep ___________________________________ Normal changes in sleep with aging ___________________________________ Abnormal/pathological changes in sleep ___________________________________ ___________________________________ ___________________________________ 51 Tai Chi ___________________________________ Originally developed for self defense ___________________________________ Movement and balance ___________________________________ Improvements in subjects 65-92 years Sleep latency ___________________________________ Sleep quality ___________________________________ Sleep duration ___________________________________ ___________________________________ J Am Geriat Soc. 2004 Jun; 52(6): 892-900 The information in this document may not be reproduced or disclosed to unauthorized parties without the prior consent of the Arizona Geriatrics Society. 2015 Arizona Geriatrics Society All Rights Reserved 18 8th Annual Spring Conference – Building Bridges & Embracing Humanity - Arizona Geriatrics Society 52 Acupuncture ___________________________________ A possible option for patients to explore ___________________________________ Historically conflicting results on efficacy of auricular acupuncture in improving insomnia in older adults ___________________________________ Most recent findings ___________________________________ showed positive effects ___________________________________ ___________________________________ ___________________________________ Int J Clin Pract. 2008 Nov;62(11):1744-52. J Gerontol Nurs. 2007 Aug;33(8):23-8; quiz 30-1. 53 Objectives ___________________________________ 1. Describe the role of drug therapy for sleep in older adults ___________________________________ ___________________________________ 2. Identify risk versus benefit of sleep medications ___________________________________ 3. List safe medications to use for sleep in older adults ___________________________________ ___________________________________ ___________________________________ 54 Sedative Antidepressants ___________________________________ ___________________________________ Trazodone (Oleptro) Unlabeled use ___________________________________ Dose <150mg qHS Improves sleep latency and duration ___________________________________ Efficacy may be short-lived ___________________________________ Mirtazapine (Remeron) Unlabeled use ___________________________________ Used for insomnia + depression + weight loss ___________________________________ The information in this document may not be reproduced or disclosed to unauthorized parties without the prior consent of the Arizona Geriatrics Society. 2015 Arizona Geriatrics Society All Rights Reserved 19 8th Annual Spring Conference – Building Bridges & Embracing Humanity - Arizona Geriatrics Society 55 Sedative Antidepressant and Anticonvulsant ___________________________________ ___________________________________ Doxepin (Silenor) - TCA ___________________________________ Beers Criteria: Limit dose to <6mg/day highly anticholinergic at higher dose ___________________________________ Increases sleep duration and decreases nighttime awakenings ___________________________________ Gabapentin (Neurontin) Usually for neuropathic pain or restless leg syndrome ___________________________________ sedating side effect ___________________________________ Renal dosing required 56 Remelteon ___________________________________ ___________________________________ Melatonin receptor agonist Modest efficacy ___________________________________ Improves sleep latency Increases sleep time ___________________________________ Improves circadian sleep cycle ___________________________________ Not habit forming 57 No hangover sedation or rebound insomnia ___________________________________ Adverse effects: Dizziness, myalgia, headache ___________________________________ OTC Melatonin ___________________________________ Decreases sleep latency ___________________________________ Improves quality of sleep and morning alertness ___________________________________ Improves circadian sleep cycle ___________________________________ No evidence of rebound insomnia or withdrawal effects ___________________________________ No difference in nighttime awakenings or total sleep time ___________________________________ ___________________________________ The information in this document may not be reproduced or disclosed to unauthorized parties without the prior consent of the Arizona Geriatrics Society. 2015 Arizona Geriatrics Society All Rights Reserved 20 8th Annual Spring Conference – Building Bridges & Embracing Humanity - Arizona Geriatrics Society 58 Summa Health Project ___________________________________ • Retrospective chart review • Risk of delirium: Initial nursing assessment and Six-Item Screener (SIS) score • Development of delirium: Nursing Delirium Screening Scale (NuDESC) ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Shumate LA, Fosnight SM, Dinuoscio D, Wilford R. The Effects of Melatonin and Trazodone on Delirium in Hospitalized Patients. Summa Akron City Hospital, Akron, OH 59 ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Shumate LA, Fosnight SM, Dinuoscio D, Wilford R. The Effects of Melatonin and Trazodone on Delirium in Hospitalized Patients. Summa Akron City Hospital, Akron, OH 60 ___________________________________ ___________________________________ NNT = 7 ___________________________________ * ___________________________________ ___________________________________ ___________________________________ ___________________________________ Shumate LA, Fosnight SM, Dinuoscio D, Wilford R. The Effects of Melatonin and Trazodone on Delirium in Hospitalized Patients. Summa Akron City Hospital, Akron, OH The information in this document may not be reproduced or disclosed to unauthorized parties without the prior consent of the Arizona Geriatrics Society. 2015 Arizona Geriatrics Society All Rights Reserved 21 8th Annual Spring Conference – Building Bridges & Embracing Humanity - Arizona Geriatrics Society 61 CAM meta-analysis ___________________________________ Randomized controlled trials (n=12) ___________________________________ Tai-chi (n=3) ___________________________________ Acupuncture (n=4) OTC melatonin (n=5) ___________________________________ Outcome measures Pittsburg Sleep Quality (PSQI) scores ___________________________________ Index of Severity of Insomnia (ISI) Self-report (total sleep time, sleep latency) ___________________________________ Polysomnography or actigraphy ___________________________________ Song HW, Slack M, Lee JK. meta-analysis of alternative and complementary medicine for the treatment of insomnia Forest Plot of Three CAM Interventions in Treating Insomnia 62 ___________________________________ Alternative Treatment for Insomnia in Older Adults Group by Intervention Study name Total N Acupuncture Acupuncture Acupuncture Acupuncture Acupuncture Melatonin Melatonin Melatonin Melatonin Melatonin Melatonin Tai Chi Tai Chi Tai Chi Tai Chi Overall de Silva, 2005 Huang, 2006 Yeung, 2009 Yeung, 2011 22 29 60 52 Braam, 2009 Kayumov, 2001 Kumar, 2007 Montes, 2002 Zhdabova, 2001 49 22 40 10 30 Irwin, 2008 Li, 2004 Wang, 2010 52 118 29 Statistics for each study Std diff in means and 95% CI ___________________________________ Std diff Lower Upper in means limit limit p-Value -1.26 -0.47 -0.66 -0.51 -0.66 -0.41 -0.38 -0.23 -0.26 -0.10 -0.26 -0.36 -0.58 -0.30 -0.48 -0.43 -2.18 -1.42 -1.18 -1.06 -0.99 -0.98 -0.91 -0.85 -1.03 -0.54 -0.51 -0.91 -0.95 -1.04 -0.76 -0.59 -0.34 0.49 -0.14 0.04 -0.33 0.16 0.15 0.39 0.51 0.34 -0.01 0.20 -0.21 0.44 -0.20 -0.27 0.01 0.34 0.01 0.07 0.00 0.16 0.16 0.47 0.51 0.64 0.04 0.21 0.00 0.42 0.00 0.00 ___________________________________ ___________________________________ ___________________________________ -1.00 -0.50 Favors Treatment 0.00 0.50 ___________________________________ 1.00 Favors Control ___________________________________ Meta Analysis Song HW, Slack M, Lee JK. meta-analysis of alternative and complementary medicine for the treatment of insomnia Considerations for treatment 63 ___________________________________ Symptom pattern Treatment goals Past treatment responses Patient preference and cost Try non-pharmacological approach first! If using medication therapy ___________________________________ ___________________________________ ___________________________________ Comorbid conditions Concurrent medications – drug interactions Adverse effects Dependence Alcohol consumption Beers Criteria ___________________________________ ___________________________________ ___________________________________ The information in this document may not be reproduced or disclosed to unauthorized parties without the prior consent of the Arizona Geriatrics Society. 2015 Arizona Geriatrics Society All Rights Reserved 22 8th Annual Spring Conference – Building Bridges & Embracing Humanity - Arizona Geriatrics Society 64 Yes, older people are different ___________________________________ 65-year-old cyclist ___________________________________ 75-year-old golfer ___________________________________ 85-year-old with poor vision and osteoporosis 95-year-old nursing home resident ___________________________________ Yet, extended sedative use is not justified for any of them! ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Sound Asleep: ___________________________________ Medications & Behavioral Strategies for Sleep in Older Adults ___________________________________ ___________________________________ ___________________________________ Jeannie K Lee, PharmD, BCPS, CGP, FASHP University of Arizona College of Pharmacy Arizona Center on Aging ___________________________________ [email protected] The information in this document may not be reproduced or disclosed to unauthorized parties without the prior consent of the Arizona Geriatrics Society. 2015 Arizona Geriatrics Society All Rights Reserved 23
