#038 Approach to Insomnia Evaluation in the Geriatric Patient
Fast Facts and Concepts #038 PDF
AUTHORS: Gretchen Wagner, Kathryn Denson, MD, Larry Hook, MD, Elizabeth Nilsson, MD, Dmitriy
OBJECTIVES: Identify strategies for evaluation of insomnia in a geriatric patient.
ACGME COMPETENCIES: Patient Care; Medical Knowledge
Insomnia: Difficulty with sleep which may include: prolonged sleep onset latency, frequent nocturnal awakenings, prolonged periods of wakefulness during the sleep period, or frequent transient arousals .
CONTEXT: Evaluation of sleep disturbances in a geriatric patient
ACTION: List evaluation strategies for insomnia which may be useful for geriatric patients
Geriatric patients commonly experience sleeping disturbances. Although sources differ, up to 60% of geriatric patients report problems with sleeping at least a few nights per week, with 6-15% meeting diagnostic criteria for insomnia1, 2. Higher rates of insomnia are seen in women, especially after the onset of menopause1. Despite the increased prevalence of insomnia in geriatric patients, insomnia is not normal aging3. Sleep disturbances in geriatric patients are associated with decreased quality of life, daytime fatigue or low energy, cognitive decline, and mood dysphoria1.
The increased prevalence of insomnia in the geriatric population is likely multifactorial in etiology. Comorbid medical, psychiatric, or neurologic illnesses leave patients more susceptible to sleep disturbances, due to the nature of the illness as well as the medications to treat the illness.
Polysomnography (PSG), a type of diagnostic sleep test, has shown that older patients experience less total nighttime sleep, spend more time in bed, have more nighttime awakenings,, and take longer to fall asleep4. Physiologically, patients show increased activation of the autonomic nervous system, as indicated by increases in heart rate, blood pressure, metabolic rate, body temperature, activity of the hypothalamic-pituitary-adrenal axis, and norepinephrine secretion . This activation may explain why patients with insomnia typically have higher frequency brain waves while sleeping, a factor which may predispose them to awaking during sleep. Additionally, with age, the circadian rhythm becomes less synchronized; possibly affected by variation in bedtime, medications and dosing administration times, mealtimes and other changes in routine (e.g., timing of “lights-out/on” in long-term care facilities).4
ASSESSMENT:The following evaluation tools are useful for evaluating sleep disturbances:
Sleep Questionnaire / History
Ask about pre-sleep conditions, sleep-wake patterns, sleep-related symptoms, daytime consequences (see figures 1)
At-home sleep log
Document for ≥ 2 weeks, continue tracking during treatment
Psychological screening tests
Check for comorbid psychiatric conditions (e.g., anxiety, depression).
Bed partner interviews
Polysomnography recommended if a breathing or movement disorder is suspected, the diagnosis is uncertain, failed treatment, or violent sleeping habits6
Kierlin L, Olmstead R, Yokomizo M, Nicassio P, Irwin MR. Diagnostic and Statistic Manual criteria for insomnia related impairment in daytime functioning: polysomnographic correlates in older adults. Sleep Medicine. 2012; 13:958-960.
McCrae CS. Late-life comorbid insomnia: diagnosis and treatment. American Journal of Managed Care. 2009; 15(1):S14-S23.
Galimi R. Insomnia in the elderly: an update and future challenges. Gerontology. 2010; 58:231-247.
Morin CM, Benca R. Chronic Insomnia. Lancet. 2012; 379:1129-1141.
Figure 1 from: Schutte-Rodin S, Broch L, Buysse D, Dorsey C, Sateia M. Clinical Guideline for the Evaluation and Management of Chronic Insomnia in Adults. Journal of Clinical Sleep Medicine. 2008; 4(5):487-504.
Author Affiliation: Medical College of Wisconsin, Milwaukee, Wisconsin.
Geriatric Fast Facts are edited by the faculty of the Geriatric Education Teams (GETS) program funded by the Reynolds Foundation, Kathryn Denson, MD, Steven Denson, MD, & Edmund Duthie, MD from the Division of Geriatrics, Medical College of Wisconsin, and are published by the Geriatric Fast Facts Website at the Medical College of Wisconsin. For more information write Kathryn Denson, MD. More information, as well as the complete set of Fast Facts, available at www.mcw.edu/Geriatric-Fast-Facts.htm
Copyright/Referencing Information: Users are free to download and distribute Geriatric Fast Facts for educational purposes only. Citation: Gretchen Wagner, Kathryn Denson, MD, Larry Hook, MD, Elizabeth Nilsson, MD, Dmitriy
Shmaryan, MD November, 2013.
Geriatric Fast Facts, available at www.mcw.edu/Geriatric-Fast-Facts.htm
Disclaimer: Geriatric Fast Facts provide educational information. This information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some Geriatric Fast Facts cite the use of a product in a dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used.