Sunday, July 1, 2018

Insomnia in elderly people

Insomnia in elderly people
Dr. Dwijesh Kumar Panda
 Insomnia is a condition of impaired sleep, with difficulties in initiating or maintaining sleep. It is a very common medical complaint in primary care patients. The prevalence of insomnia is over 60 percent.  Insomnia is associated with multiple consequences that have a negative impact on quality of life and the ability to perform normal functions. In addition, insomnia is a strong predictor of the development of psychiatric disorders
Medication side effects – Medications that are being used for other indications may have arousal or stimulant properties that can exacerbate sleep disturbances. These include opioids, steroids, beta-receptor agonists, many antidepressants, and psychostimulants.
 Symptoms of insomnia — People with insomnia often:
●Have trouble falling or staying asleep
●Feel tired or sleepy during the day
●Forget things or have trouble thinking clearly
●Get cranky, anxious, irritable, or depressed
●Have less energy or interest in doing things
●Make mistakes or get into accidents more often than normal
●Worry about their lack of sleep
Measures to improve insomnia 
 ●Sleep only long enough to feel rested and then get out of bed
●Go to bed and get up at the same time every day
●Do not try to force yourself to sleep. If you can't sleep, get out of bed and try again later.
●Have coffee, tea, and other foods that have caffeine only in the morning
●Avoid alcohol in the late afternoon, evening, and bedtime
●Avoid smoking, especially in the evening
●Keep your bedroom dark, cool, quiet, and free of reminders of work or other things that cause you stress
●Solve problems you have before you go to bed
●Exercise several days a week, but not right before bed
●Avoid looking at phones or reading devices ("e-books") that give off light before bed. This can make it harder to fall asleep.
Other things that can improve sleep include:
●Relaxation therapy, in which you focus on relaxing all the muscles in your body 1 by 1
●Working with a counselor or psychologist to deal with the problems that might be causing poor sleep
 Medicines to help sleep — Yes, there are medicines to help with sleep. But you should try them only after you try the techniques described above. You also should not use sleep medicines every night for long periods of time. Otherwise, you can become dependent on them for sleep.
Insomnia is sometimes caused by mental health problems, such as depression or anxiety. If that's the case for you, you might benefit from an antidepressant rather than a sleep aid. Antidepressants often improve sleep and can help with other worries, too.
Addressing the environment — Environmental steps that appear to help reduce insomnia include:
Keeping patient rooms cool, well ventilated, and with low light at night
The use of white noise machines.
Limitations on the use of computers, smartphones, and iPads at night and other stimuli
(Television, loud music)
Lifestyle modifications — a number of lifestyle modifications may promote a more regular sleep pattern and can be instituted in a palliative care setting. These include reducing or avoiding:
Daytime naps
Large meals or excessive fluids at bedtime
Stimulants (caffeine)
Benzodiazepines — while being the most commonly prescribed class of medications for insomnia in the general population, benzodiazepines are associated with adverse effects that should be carefully considered in the palliative care patient
Nonbenzodiazepines — Nonbenzodiazepines are a class of prescription medicines that are somewhat similar to benzodiazepines. These medications may have fewer side effects compared with benzodiazepines because they work more on sleep centers and less on other areas of the brain. They tend to be short acting, so they are also less likely to produce hangover sedation in the morning. Some can also be prescribed for a longer period of time.
Nonbenzodiazepines used to treat insomnia include zaleplon , eszopiclone , zolpidem,  and zolpidem extended release, Zolpidem is also available as a dissolving tablet, an oral liquid spray, and as a dissolving tablet at a lower dose for middle of the night use,
Do not take these medicines with alcohol or other sedating drugs, and do not take more medicine than your doctor recommends.
Melatonin — Melatonin is a neurohormone secreted by the pineal gland that can assist with maintaining sleep-wake cycle. It is a widely available over-the-counter agent that is often used to alleviate insomnia, despite the lack of prospective data
PREGABALIN has shown efficacy for generalized anxiety disorder (GAD) in comparison with placebo in several randomized trials. Pregabalin inhibits calcium currents via high-voltage-activated channels containing the a2d-1 subunit, though the relationship of this mechanism to its efficacy in GAD is not known. It was approved in 2006 for the treatment of anxiety in Europe. Pregabalin is not approved for treating GAD by the US Food and Drug Administration. The doses for pregabalin range from 50 to 300 mg, though many patients may need a total daily dose of greater than 150 mg. Side effects include sedation and dizziness. Tolerance, withdrawal, and dependence are possible, but pregabalin is generally better tolerated than benzodiazepines
Dementia — Patients with dementia are at an increased risk for experiencing insomnia as a potential symptom of their underlying dementia illness or from associated conditions (sun downing, agitation, or other delirium).
Maximizing exposure to natural light in the mornings and light exercise, when feasible, can help entrain more normal circadian rhythms.

Insomnia is a condition of impaired sleep, with difficulties in initiating or maintaining sleep, and/or experiencing sleep as nonrestorative and unrefreshing, despite having the appropriate opportunity for sleep to occur. It is estimated that insomnia affects over 70 percent of palliative care patients.
Addressing environmental issues may help address external factors exacerbating insomnia in these patients. This includes keeping patient rooms cool, well ventilated, and with low light at night, the use of white noise machines, and limitations on the use of computers at night and other stimuli ( television, loud music)
A number of lifestyle modifications may promote a more regular sleep pattern and can be instituted in a palliative care setting. These include reducing or avoiding daytime naps, large meals before bedtime, drinking a large amount of fluid in the evening, or stimulants, including caffeine. Daytime light exposure and activity levels should be increased when possible.
Clinicians and staff should minimize disruptions of a patient’s sleep. Regardless of setting, dimming lights in the vicinity of the palliative care patient’s room may provide a simple cue to others to maintain a calm, quiet, sleep-promoting environment.
Medications be prescribed for insomnia only after attempting nonpharmacological-based modifications. There is no single pharmacologic approach that can be recommended for all patients. The approach to the selection of a sleep aid must be individualized, and the lowest effective dose should be administered. As with most drugs, patients in palliative care must be carefully and continually monitored for both positive effect and the development of adverse effects, particularly as the patient’s disease progresses.