Sleep in elderly people from theory to practice.ppsx

Presentation of physiologic changes and common sleep disorders in older population. It was presented at ASUMC 2024.

1. Sleep in elderly people:
From theory to practice
Presented by
Heba Mohamed Tawfik
Associate Professor of Geriatrics and Gerontology
Co-director of AGE BRAIN TEAM
Co-founder and director of cognitive training lab
Faculty of Medicine, Ain-Shams University
44th Ain Shams university medical congress (ASUMC)
24 April 2024

2. Sleep Stages
S T A G E O F
S L E E P
% T O T A L
S L E E P T I M ED E S C R I P T I O N F U N C T I O N EEG
E Y E
M O V E M E N T SM U S C L E T O N E
Awake (eyes
closed)
- • Restful state but not sleeping Wakefulness, mental
coordination, mind-body
integration
Alpha waves, 8-12 Hz Eyes move High voluntary
tonic activity
Stage N1
(Stage 1)
5% • Also known as “light sleep.” It is the transition from
wakefulness → sleep and vice versa
• Individuals may often be in this stage and think they
are “not sleeping.”
•Increased light quality sleep indicates sleep
disruption
May have jerks or hypnagogic hallucinations
Becoming more drowsy •Theta waves (low amplitude, mixed
frequency), 4-8 Hz and some alpha
waves, 8-12 Hz
• In N1, alpha makes <50% of EEG and
is mixed with theta waves
• N1 can be very similar to a waking
EEG
Slow rolling eye
movements
(SREMs) are usually
the first evidence
of drowsiness seen
on the EEG
Decreasing levels
of high tonic
activity
Stage N2
(Stage 2)
50% • Most of the night is spent in N2
• Sleep spindles and K-complexes emerge during this
stage and are thought to be the brain's way of
evaluating potential threats (i.e. -external stimuli)
while sleeping and to dampen arousals if the threats
are not real.
•Sleep spindles (Sigma waves), 11-16
Hz
•K-complexes (negative sharp wave
followed by positive slow waves), 12-
14 Hz
None Low tonic activity
Stage N3
(Stage 3 and
4)
10-20% • The “deepest” stage and hardest to awaken, also
called Slow Wave Sleep (SWS)
• Associated with sleep inertia when awoken in this
stage. Nocturnal enuresis occurs in this stage.
•It is also the most restorative sleep.
This is homeostatic sleep
(reduced BP, HR, cardiac
output, RR). Growth hormone
is released.
•Delta waves, 0.5-4 Hz
• This is the lowest frequency, highest
amplitude EEG
None Low tonic activity
Rapid Eye
Movement
(REM)
25% • A “paradoxical state” that resembles awake state,
except there is muscle atonia
• Arousal with increased oxygen use, increased
variability of autonomic state (BP, HR). Increased
brain temperature, cerebral glucose metabolism and
cerebral blood flow.
• Release of acetylcholine in the cortex is highest
during wakefulness and also during REM sleep.
• Occurs every 90 minutes, and REM length grows
longer through the night.
Cognitive sleep, learning,
cognitive restructuring.
•High (fast waves) and mixed
frequency, with low voltage
• Also includes: saw-tooth waves, theta
activity, and slow alpha activity
• Looks similar to EEG of awake
individual with their eyes closed
Rapid eye
movement
Almost total
muscle paralysis
(during tonic phase
of REM). There can
be very brief
movement during
phasic periods.
Adopted from https://www.psychdb.com/neurology/polysomnography
Before sleep there is a stage of awake with eyes opened (beta waves)

3. Different brain waves
during sleep
https://www.helpguide.org/harvard/biology-of-
sleep-circadian-rhythms-sleep-stages.htm

4. Neurotransmitters
and sleep
TMN: Tuberomammillary nucleus
LDT-PPT: cholinergic neurons at the
junction of midbrain and pons
VLPO: Ventrolateral preoptic nucleus

5. Sleep in elderly people
ThetimespentinstageN3sleepdecreases,andthe
timeinstageN2increases.
Sleepisshiftedearlierintime.
Latencytofallasleepandthenumberanddurationof
overnightarousalperiodsincrease,increasingtotal
timeinbed(canleadtocomplaintsofinsomnia).
Sleepfragmentationmaybeexacerbatedbythe
increasingnumberofco-morbidities,includingsleep
apnea,musculoskeletaldisorders,&cardiopulmonary
disease(increasingovernightarousals).
PercentageofREMsleepisdecreased.
Importanttimecues(zeitgebers)forcircadianrhythm
mayerode.
Image adopted from https://www.psychdb.com/neurology/polysomnography

6. The National Sleep Foundation recommends 7 to 8 hours of sleep
for older adults,similar to the 7 to 9 hours recommended for those
under age 65 years.

7. Age related
changes affecting
sleep

8. •Inthemedialprefrontalcortex,whichisanareawhere
NREMsleepslowwavesshowadominanceinorigin
anddensityoverEEGderivations,Graymatteris
reduced.Notably,oldersubjectsshowlowerslow-wave
amplitudeanddensity,specificallyinprefrontaland
frontalbrainareas
•Thecentralcircadianpacemakerliesinthe
suprachiasmaticnucleus(SCN)oftheanterior
hypothalamus.AgerelatedchangesintheSCNis
thoughttounderliesleepdisturbancesinelderlypeople.
•Itmaycauseoraggravatehealthproblems,like
neurodegenerativedisordersandcardiovascular
disease.
•Dimlightmelatoninonset,commonlyoccursearlierin
thedayinhealthyolderadults,resultinginadvanced
sleepphase.

9. Effect of sleep
disturbance on
the aging
process
Carvalhas-Almeida et al.,
2022

10. Sleep and cognition

11. Both NREM and REM sleep are
thought to regulate different aspects
of memory systems.
Accordingtothe“dualprocesshypothesis”
ofmemoryconsolidation,SWS(earlynight
sleep)isthoughttopromotetheformation
ofdeclarativehippocampus-dependent
memory(suchasspatialmemory),
whereasREMsleep(latenightsleep)is
thoughttosupporttheformationofnon-
declarativehippocampus-independent
memory(suchasproceduraland
emotionalmemory).
Clinicalobservationshave
documentedthatpatientswho
sufferfromaclinicalsleep
disorder(insomnia)oftenexhibit
spatialmemorydeficits.

12. The bidirectional
relationship
between sleep
disturbance and
AD
Image adopted from Ju et al., 2014

13. Medications and
sleep disorders
Cohen et al., 2022

14. Sleep disorders in
elderly people

15. INSOMNIA
Insomniaisthemostprevalentsleep
disorder(15-30%),canreachupto50%of
adultpopulation,andsymptomburden
increaseswithage,particularlyin
women.
Althoughinsomniacanmanifestasa
primarydisorder,itisfrequently
comorbidandmultifactorialinorigin.
“Comorbidinsomnia”referstoinsomnia
thatisdirectlyrelatedtoanunderlying
medical,psychiatric,orenvironmental
cause.

16. Definition of insomnia
•AccordingtotheInternationalClassificationofSleepDisorders(3rdedition)(ICSD-3)bythe
AmericanAcademyofSleepMedicine,‘Insomniaisdefinedasapersistentdifficultywithsleep
initiation,duration,consolidation,orqualitythatoccursdespiteadequateopportunityand
circumstancesforsleep,andresultsinsomeformofdaytimeimpairment’.
•AccordingtotheDiagnosticandStatisticalManualofMentalDisorders,5thedition(DSM-5)
criteria,‘insomniaisdefinedasreporteddissatisfactionwithsleepquantityorqualityandassociated
withdifficultywithsleepinitiation,maintenance,orearly-morningawakeningandthatcauses
clinicallysignificantdistressorimpairment,occursatleast3nightsperweekfor3months,occurs
despiteadequateopportunityforsleep,andisnotbetterexplainedbyanotherdisorderorsubstance
abuse’.

17. Algorithm for
diagnosis of
insomnia
https://www.geriatricfastfacts.co
m/fast-facts/evaluating-insomnia

18. Pharmacologic
treatment of
insomnia
Daridorexantis Dual orexin
antagonists (DORA)
Table adopted from Kallweitet al.,
2023

19. Non
pharmacologic
treatment of
insomnia
Suzuki et al., 2017

20. Obstructive sleep apnea (OSA)
•The most common SBDs, OSA can reach frequencies of 25–46% in population-based studies.
•The higher prevalence of OSA with aging may also be associated with non-related-to-weight
factors, including morpho-functional changes in pharyngeal skeletal muscles. Although fat
deposition has been related to OSA in general populations, lean mass reduction plays a
significant role in the development of OSA among older adults.
•Sleep arousal and arterial hypoxia happen due to intermittent partial or complete closure of
upper airways, resulting in respiratory cessation for 20–30 seconds after a brief gasping.
Apneais a complete cessation of breathing, while hypopnea is a reduction in the airflow by
30% with ≥ 4% oxygen desaturation.

21. •ClassificationofOSAseverityisdefinedbytheapnea-hypopneaindex(AHI,events/hour)
asmild(AHI>5and<15),moderate(AHI>15and<30),orsevere(AHI>30events).
•Inadditiontotheanatomiccharacteristics,pulmonaryandmuscle-relatedproblemsalso
playimportantroleinthemechanismofOSA,andithasalreadybeenshownthatthese
mechanismsarechangedinolderpopulation,whichcouldjustifyhigherfrequenciesof
OSAindependentlyoftheobesitystatusinthisagegroup.
•SevereOSAwasassociatedwithhypertension,cognitiveimpairment,stroke
cardiovasculardiseases,particularlyintheolderpopulation.

22. Management
Smoking cessation, weight loss, positional therapy
Treatment of comorbid diseases (hypothyroidism), and treatment withoral
devices, positive airway pressure (PAP) devices (In moderate-to-severe SBD,
AHI > 15, a positive airway pressure device is the gold standard therapy),
surgical interventions, and hypoglossal nerve stimulation.
Pharmacological treatment: There is not yet any primary pharmacological
treatment for SRBDs. Some data indicate that oxygen application and/or the
use of acetazolamidemay be helpful in some particular types of SRBDs and as
an adjunctive treatment.

23. Pharmacologic treatment
for EDS of OSA
Excessivedaytimesleepiness(EDS)/fatigue:5–10%ofOSA
patients,whoareundereffectivePAPtreatment,still
describeEDS.Thisconditionofteniscalled“residualEDS(R-
EDS)inOSA”.
Modafinil(off-labelintheEU)andarmodafinilhavebeen
usedforthetreatmentofR-EDSinOSA.
Recently,solriamfetol[dopamineandnorepinephrine
reuptakeinhibitor(DNRI)]andpitolisant(histamine3
(H
3)receptorantagonist/inverseagonist)havebeen
studiedandapprovedforthetreatmentofR-EDSinOSA.
BothhaveshowntobeefficaciousinthereductioninEDSin
thesepopulations.

24. Sleep related movement
disorders

25. Restless leg
syndrome (RLS)
•Itisanurgetomovethelegswith
orwithoutabnormallegsensation,
resultinginsleep-initiationand/or
sleep-maintenance problems,
occurringatrest,usuallyinthe
eveningoratnight.
•The updated International Restless Legs
Syndrome Study Group (IRLSSG) consensus
criteria in 2014
•Table adopted from Suzuki et al., 2017

26. Epidemiology
•Prevalence of RLS generally increases with age at a rate of 10% to 35% in patients more than 65
years old. RLS is more common in females and is related to iron deficiency, uremia, neuropathies,
and cardiovascular disease.
Diagnosis
•The diagnosis is clinical, including an overwhelming sensation of crawling, tingling, or pain that
cause the limb to move to relieve the urge and the discomfort. It can be unilateral or bilateral.
•Common comorbidities with RLS include depression, and dialysis.
Nonpharmacological management
•Lifestyle changes and dietary modifications is usually helpful in controlling RLS.Medications such as
antipsychotics, antiemetics, antidepressants, beta-blockers, anticonvulsants, and lithium are known
to exacerbate RLS and should be avoided.Dysfunction of the dopaminergic system and iron
deficiency is thought to be involved in its pathogenesis.

27. Pharmacologicalmanagement
•Pharmacologicaltreatment:non–ergot-baseddopamineagonists
(ropinirole,pramipexole,androtigotine)arethefirst-linetreatmentsof
primaryRLSandhavehighlevelsofevidenceforefficacyandsafety.
•Second-linetreatmentsincludethedopamineprecursors(levodopa)and
ergot-baseddopamineagonists(eg,cabergoline).
•Gabapentin,pregabalin,andGABA-Aagonists(cautioninoldpeople).

28. Periodic limb
movement
disorder (PLMD)
•PLMDisdefinedasperiodicepisodesofsleep-relatedphenomenathatare
characterizedbyinvoluntaryrepetitive,stereotypicalmovementsofthelimbs.
•TheprevalenceofPLMDisupto80%inpatientswithRLSandupto4%to11%
intheolderadultpopulation.Bothconditionsincreasesasthepatientages.
Diagnosis
•ThepolysomnogramservesasanimportantdiagnostictoolforPLMD.
•AccordingtoICSD-3,thediagnosticcriteriaincludesthepresenceofPLMSof
morethan15periodiclimbmovementsperhourinadultsandcausingsleep
problems,whichimpactsdaytimefunctioningintheabsenceofanyothersleep,
psychiatry,ormedicalillnesses.Instudieswithsleepcomplaintsrelatedtoother
medicalconditions,acut-offof5distincteventsrecordedperhourofsleepis
consideredpathologicPLMS
•Itisassociatedwithahighcardiovascularandcerebrovascularriskastheymay
representthemotormanifestationofsympatheticoveractivity.
•Patientsoftenhaveanon-restedsleepanddaytimefatigue.

29. Nonpharmacologicalmanagement
•AvoidcertainmedicationsthatmayaggravatePLMD,includingantidepressantslike
mirtazapine,venlafaxine,sertraline,fluoxetine,andamitriptyline.
•Caffeine-containingproductsshouldalsobeavoided.
Pharmacologicalmanagement
•DopaminergicmedicationsusedtotreatRLS,andotherdrugslikegabapentinand
pregabalin,willreducetheperiodiclimbmovementsinpatientswithPLMD.
•Basedonafewsmallstudies,clonazepam1mgatbedtime(cautioninelderly),melatonin
3mg30minutesbeforebedtime,andvalproate150–600mgatbedtimemayimprove
sleepquality.

30. Rapid eye movement (REM) sleep behavior disorder (RBD)
•IsaparasomniathatoccursduringREMsleepandischaracterizedbyactingoutofdream
content,includingtalking,shouting,punching,andkicking.
•REMsleepwithoutatonia(RWA),asdocumentedonpolysomnographyiscommon.
•AbnormalnocturnalbehaviorsduetoRBDareoftenassociatedwithinjuryofthepatientsandtheirbed
partnersduringsleep.
•DiagnosisofRBDrequiresrepeatedepisodesofsleep-relatedvocalizationand/orcomplexmotor
behaviors;thesebehaviorsaredocumentedbyPSGduringREMsleeporpresumedtooccurduring
REMsleepbasedonclinicalhistory,andthepresenceofRWAonPSG(ICSD-3).
•TheprevalenceofRBDismostlyaround0.5%ofthegeneralpopulation.

31. •About50%ofidiopathicRBDconverttoaparkinsoniandisorderwithinadecadeandthatupto90%
patientswithRBDeventuallydevelopaneurodegenerativedisorder.
•Hazardavoidance,includingremovingpotentiallydangerousobjectsfromthebedroomorplacinga
mattressonthefloor,isimportanttopreventsleep-relatedinjury.
•Clonazepamiseffectiveinapproximately90%ofpatientswithRBD,butforelderlypatients,the
potentialsideeffectsofdaytimesleepinessanddizzinessshouldbenoted.
•MelatoninatbedtimehashadclinicalefficacyintreatingRBDwithareducedriskoffall.
•Whenpatientshaveahistoryofhabitualsnoringorwitnessedsleepapnea,OSAshouldbescreenedfor
becauseclonazepammayworsensleepapneaandtheabnormalbehaviorrelatedtoOSAcanbe
effectivelytreatedwithCPAPtherapy.

32. CircadianRhythmSleep–WakeDisorders(CRSWDs)
•Riskfactorsincludeage,lessexposuretolight,andreduced
activity.About20%oftheelderlyexperienceearlymorningawakening.
•ExtrinsicCRSWDsincludeworkshiftdisorderandjetlagdisorder.
•IntrinsicCRSWDsarecausedbyalterationstotheendogenouscircadian
rhythmsystem
•Advancedsleep–wakephasedisorderismostcommonintheelderly.
Sleeponsetisinvoluntary,occurringatleast2hoursbeforetheexpected
time,andtheawakeningisspontaneousintheearlymorning.
•OSAandPLMD,shouldberuledout,anddepression(cancauseearly
morningawakening).

33. Sleep assessmentis a fundamental part of
comprehensive geriatric assessment (CGA)

34. Assessment of sleep disorders
•Acomprehensivesleephistoryistakenfromthepatientand
thebedpartner.
•Patients'complaintsaredifficultiesfallingasleep,remaining
asleep,earlymorningwakening,andthelackofrestorative
sleep,headache,fatiguewithexcessivedaytimesleepiness.
•Thecomplaintsofthebedpartnersincludessnoring,breath
pauses,andotherabnormalmovementsorbehaviorsduringthe
patient’ssleep.
•Thesleepstagesaredefinedbysetsofelectroencephalographic,
electromyographic,andelectro-oculographicfeaturesrecorded
duringpolysomnography(PSG).PSGadditionallymeasures
bloodoxygenationandinductiveplethysmography.
https://www.businessinsider.com/guides/health/sleep-cycle-
app-review

35. Technology and sleep
Actigraphy
Isanon-invasivetechniqueusedtoassesscyclesofactivity
andrestoverseveraldaystoseveralweeks.
TheAmericanAcademyofSleepMedicinecurrently
acknowledgesthepotentialbenefitsofusingactigraphyfor
peoplewiththefollowingsleepdisorders:
•Insomnia
•CRSWDs
•SleepApnea
https://soundsleepguru.com/what-is-
actigraphy/

36. Home sleep apneatest
Itmayincludeallorsomeofthefollowinginthelistbelow.
•Nasalbreathingsensor:Theyanalyzebreathingpatternsbytrackingair
pressurefrominhalingandexhaling.
•Effortbelt:it’sabandthatgoesaroundyourchesttomeasuremovement
associatedwithbreathing.Datafromthisdevicecanhelpdifferentiatebetween
OSA,andcentralsleepapnea
•Pulseoximeter
•Microphone:Generally,thenasalbreathingsensorestimatessnoring,but
sometimesanactualmicrophoneisusedtomeasuresnoring.Asoundsensor
attachedtotheneckcanalsorecordsoundandpressure.
•Datacollectiondevice:Allofthesensorstypicallyconnecttothedata
collectiondevice,eitherviawiresorflexibletubes.

37. The sleep cycle
apparatus
https://www.businessinsider.com/gu
ides/health/sleep-cycle-app-review

38. What’s new?

39. Future directions
in OSA
Several new pathways for the pharmacological treatment of OSA are
currently being explored. They include, i.e., the selective norepinephrine
reuptake inhibitor atomoxetine in combination with the antimuscarinic
oxybutynin. A trial of this combination led to a reduction in the AHI by
more than 50%.
Recently, a trial with the carbonic anhydrase inhibitor sulthiamein some
patients with moderate-to-severe OSA resulted in a reduction in the AHI
of about 40%.
Although these are promising results, still far of making any
recommendations on a primary pharmacotherapy for OSA.

40. EEG role in
diagnosing
cognitive
impairment

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43. Thank You