Self Treatment of Insomnia in Self Treatment of Insomnia in the Elderlythe Elderly
Ashdin Tavaria M.D., Nalaka S. Gooneratne M.D., Ashdin Tavaria M.D., Nalaka S. Gooneratne M.D., Clara Kwan M.D., Nirav Patel M.D., Clara Kwan M.D., Nirav Patel M.D.,
Lavanya Madhusudan, Kathy C. Richards, Ph.D. Lavanya Madhusudan, Kathy C. Richards, Ph.D. May 18, 2010May 18, 2010
AcknowledgementAcknowledgement
Supported by:Supported by:– The Hartford FoundationThe Hartford Foundation– Penn Center of ExcellencePenn Center of Excellence– National Institute of HealthNational Institute of Health
Introduction
Sleep disorders are common in the elderly, with up to 57% of older adults complaining of difficulties with their sleep1
Prevalence of Insomnia by AgePrevalence of Insomnia by Age
0
10
20
30
40
15-24 25-34 35-44 45-54 55-64 >65Age Group
Perc
ent
Male Female
-Ohayon, J Psychiat Res 1997
IntroductionIntroduction
Sleep disorders can be associated with an Sleep disorders can be associated with an increased risk of increased risk of – Driving accidents Driving accidents 2-42-4 – Cardiovascular mortality Cardiovascular mortality 55
– FallsFalls66
– DepressionDepression77
– Cognitive deficits Cognitive deficits 88
Insomnia-associated MortalityInsomnia-associated Mortality
Nursing home study of 272 patientsNursing home study of 272 patients
2 year follow-up2 year follow-up
Adjusted for ADLs, age, genderAdjusted for ADLs, age, gender
Manabe et al., Gerontology 2000Manabe et al., Gerontology 2000
0
0.5
1
1.5
2
2.5
3
Nighttimeinsomnia
Daytimesleepiness
Earlyawakening
Sleep-onsetdelay
Mort
alit
y H
azard
Ratio
Insomnia-associated Cognitive Impairment: Insomnia-associated Cognitive Impairment: ResultsResults
EPESE dataset, 3 year follow-up, n=6,444EPESE dataset, 3 year follow-up, n=6,444
Adjusted for demographic and health factorsAdjusted for demographic and health factors
00.5
11.5
22.5
33.5
4
Non-depressed,
IncidentInsomnia
Non-depressed,
ChronicInsomnia
Depressed,no insomnia
at f/u
Depressed,Incident
Insomnia
Depressed,ChronicInsomnia
Ad
just
ed
OR
for
Co
gn
itive
D
ecl
ine
Cricco et al., JAGS 2001
IntroductionIntroduction
Despite the significant prevalence of sleep Despite the significant prevalence of sleep disorders, many older adults do not seek disorders, many older adults do not seek evaluation or treatment of their sleep evaluation or treatment of their sleep problemsproblems
Instead engage in a number of self-Instead engage in a number of self-treatment activities treatment activities 9, 109, 10
Study MethodsStudy Methods
Purpose of this study was to explore Purpose of this study was to explore – Different types of self-treatment strategiesDifferent types of self-treatment strategies– Determine their perceived efficacy Determine their perceived efficacy
Study MethodsStudy Methods
Cross-sectional survey study consisting of Cross-sectional survey study consisting of a mailed questionnairea mailed questionnaire
Adults over the age of 65 recruited from Adults over the age of 65 recruited from the greater Philadelphia areathe greater Philadelphia area
Penn Partners in Healthy Living Program Penn Partners in Healthy Living Program Data Base which is an elder outreach Data Base which is an elder outreach program affiliated with the University of program affiliated with the University of Pennsylvania Health SystemPennsylvania Health System
ResultsResults
A total of 242 study questionnaires were A total of 242 study questionnaires were completedcompletedAverage of 4.8 treatments used per study Average of 4.8 treatments used per study participant (SD 2.9, range 0-13)participant (SD 2.9, range 0-13)Correlation between the number of treatments Correlation between the number of treatments attempted and the PSQI sleep quality score attempted and the PSQI sleep quality score (r=0.37, p<0.0001) (r=0.37, p<0.0001) – Suggested that study participants who had worse Suggested that study participants who had worse
sleep quality had attempted more sleep treatments.sleep quality had attempted more sleep treatments.
ResultsResults
Bar graph showing the number of treatments used by subjects
ResultsResultsActivityActivity PercentPercent
Sleep HygieneSleep Hygiene
““Listened to radio, music or watched TV”Listened to radio, music or watched TV” 66.466.4
““Read a book, newspaper, magazine”Read a book, newspaper, magazine” 56.256.2
““Took a nap the next day”Took a nap the next day” 44.044.0
““Did not nap the next day”Did not nap the next day” 35.035.0
““Had a snack”Had a snack” 34.134.1
““Drank other liquids (tea, coffee, milk, etc.)”Drank other liquids (tea, coffee, milk, etc.)” 32.632.6
““Drank a beer, wine or other alcohol”Drank a beer, wine or other alcohol” 13.013.0
““Spoke to someone on the telephone”Spoke to someone on the telephone” 8.28.2
““Smoked a cigarette”Smoked a cigarette” 4.24.2
EnvironmentEnvironment
““Adjusted temperature of the room, adjusted Adjusted temperature of the room, adjusted blankets or clothing”blankets or clothing” 47.047.0
““Went to a different room to sleep”Went to a different room to sleep” 15.615.6
““Wear ear plugs”Wear ear plugs” 1.41.4
ResultsResults
MedicationsMedications PercentPercent
““Took a pain medicine”Took a pain medicine” 40.140.1
““Took an over-the-counter sleeping pill (Tylenol PM, etc.)”Took an over-the-counter sleeping pill (Tylenol PM, etc.)” 30.630.6
““Took a prescription sleeping pill (Valium, Ativan, Sonata, Took a prescription sleeping pill (Valium, Ativan, Sonata, etc.)”etc.)” 22.122.1
Alternative TherapiesAlternative Therapies
““Did relaxation exercise, hypnosis, meditated”Did relaxation exercise, hypnosis, meditated” 15.315.3
““Took a vitamins or herb”Took a vitamins or herb” 11.011.0
““Took melatonin”Took melatonin” 10.610.6
““Went for acupuncture treatment”Went for acupuncture treatment” 1.91.9
OtherOther
““Had a hot bath or massage”Had a hot bath or massage” 29.629.6
““Went for a walk or exercised (jogging, swimming, etc.)”Went for a walk or exercised (jogging, swimming, etc.)” 18.618.6
Efficacy of Different Types of Efficacy of Different Types of Self-treatment StrategiesSelf-treatment Strategies
Value
0 0.5 1 1.5 2 2.5 3
Bath/massage Alcohol
Spoke to someone OTC sleep med
Took a nap the next day Took medicine for pain
Read Radio or TV
Change room temperature Change room
Prescription sleeping medicine
Value
Efficacy of Different Types of Efficacy of Different Types of Self-treatment StrategiesSelf-treatment Strategies
ResultsResultsPrescription sleeping pills were felt to be Prescription sleeping pills were felt to be the most effective treatment option (2.5) the most effective treatment option (2.5) Ear plugs (1.0) were felt to be the least Ear plugs (1.0) were felt to be the least effective effective Prescription medications had a perceived Prescription medications had a perceived efficacy that was significantly larger than efficacy that was significantly larger than the other methods (p-value = 0.0024)the other methods (p-value = 0.0024)
ResultsResults
In our study, most commonly used interventions In our study, most commonly used interventions were watching TV or listening to the radio, or were watching TV or listening to the radio, or readingreadingPain medications were the most commonly used Pain medications were the most commonly used form of medication highlighting the impact of form of medication highlighting the impact of pain as a contributing factor to insomnia in the pain as a contributing factor to insomnia in the elderlyelderlyOf particular concern, nearly half of all subjects Of particular concern, nearly half of all subjects who used alcohol or over-the-counter sleeping who used alcohol or over-the-counter sleeping aids had not told this to their health care aids had not told this to their health care providerprovider
ResultsResults
Women are more likely to engage in broad Women are more likely to engage in broad range of activities to improve their sleep range of activities to improve their sleep when compared to menwhen compared to men
Caucasians tended to rely on Caucasians tended to rely on pharmacotherapy while African Americans pharmacotherapy while African Americans tended to use social toolstended to use social tools
DiscussionDiscussion
Wide array of treatment options used by Wide array of treatment options used by elders for the management of their elders for the management of their insomnia insomnia
High usage rates of several treatments High usage rates of several treatments highlights the importance of inquiring highlights the importance of inquiring about the broad range of treatment about the broad range of treatment choices made by older adults as they seek choices made by older adults as they seek to address their sleep complaintsto address their sleep complaints
DiscussionDiscussion
Some elderly patients are trying up to 13 Some elderly patients are trying up to 13 different treatmentsdifferent treatments
DiscussionDiscussion
Response rate may be affected by Response rate may be affected by participants may have become participants may have become discouraged by the end and chosen not to discouraged by the end and chosen not to fill out additional questionnairefill out additional questionnairePatients may have underreported Patients may have underreported negatively viewed activities or treatments negatively viewed activities or treatments such as alcohol, smoking, or even such as alcohol, smoking, or even medicationsmedications
DiscussionDiscussion
Self treatment can be dangerous Self treatment can be dangerous
Patients are unaware of the interplay Patients are unaware of the interplay between aging and physiology, chronic between aging and physiology, chronic diseases and drugsdiseases and drugs
Polypharmacy can result in adverse drug-Polypharmacy can result in adverse drug-drug interactions which can lead to drug interactions which can lead to confusion, falls, and incontinenceconfusion, falls, and incontinence– Over-the-counter sleep aidsOver-the-counter sleep aids
DiscussionDiscussion
As Healthcare providers we must be As Healthcare providers we must be asking our patients about their sleep asking our patients about their sleep patterns patterns
If they are having disturbances we must If they are having disturbances we must ask what if any self-treatment activities ask what if any self-treatment activities they are engaging inthey are engaging in
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