Rest Disorders in Long-Term Care

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Rest Disorders in Long-Term Care Thomas Magnuson, M.D. Aide Professor Division of Geriatric Psychiatry UNMC

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To Get Your Nursing CEUs After this program go to . Your program ID number for the July 12 th program is 10CE028. Directions are on the site. **All addresses about proceeding with instruction credit and installment can be coordinated towards the College of Nursing at UNMC.** Heidi Kaschke Program Associate, Continuing Nursing Education 402-559-7487

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Objectives Discuss the reasons for rest disturbance in long haul mind Identify non-pharmacologic intercessions conceivable to cure rest disturbance Assess pharmacologic mediations for rest disturbance

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Impact Significant issue Many inhabitants with rest issues half of the elderly have rest issues 65% in Los Angeles region ALFs Effect Cognition Physical wellbeing Mood Quality of life Staff spirit

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Well Elderly Spend additional time in bed to get a similar measure of rest Total rest time just somewhat diminished from when more youthful Increase in evening renewals and daytime snoozing Earlier sleep times Increased time to nod off More effortlessly excited by sound Daytime lethargy not a portion of typical maturing

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Long-Term Care More regularly self-report rest issues More serious self-report Asleep at extremely inconvenient times, even mealtimes Wake and rest discontinuity Wakefullness hindered by brief rest Leads to outrageous rest wake interruption Distributed over the whole day Rarely alert or sleeping for quite a long time

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Effects of Poor Sleep Variety of issues Irritability Poor fixation Decreased memory Lessened response time Poorer execution on errands Community staying elderly More falls Increased mortality

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Case 78-year-old deranged female Up during the evening, boisterous and problematic Sleeps a great part of the day No exercises CAD, HTN, melancholy, hypothyroidism, h/o bosom growth, joint pain, GERD, clogging, incontinence ASA, APAP, sertraline, synthroid, esomeprazole, metoprolol, furosemide, senna, MOM, oxybutynin, donepezil, memantine, hydrocodone/APAP

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First Questions How much would they say they are dozing? Generally nobody truly knows Up around evening time… dozing pill Up in the day… stimulant Shifts need to converse with each other Sleep is inadequately recorded When are they resting? Daytime? Evening time? Both?

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First Intervention Sleep diagram Daily Every hour, on the hour Not 4:01, only 4 :00 24 hours a day For a week Good broad thought Usually is around 9-11 hours a day

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Causes Primary rest issue Medical conditions Psychiatric issue Medications/polypharmacy Circadian beat issues Environment Noise and light during the evening Low daytime light Behavioral Physical dormancy More time in bed

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Primary Sleep Disorders Sleep confused breathing (SDB) Restless Leg Syndrome (RLS) Periodic Limb Movement Disorder (PLMD) REM rest conduct issue (RBD)

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Sleep Disordered Breathing (SDB) Airflow intruded on Obesity regular cause Apnea/hypopnea 10 second scenes 15 times a hour Low oxygen to cerebrum Disrupts rest LTC inhabitants 50-66% have in any event gentle SDB Treatment is CPAP Air powers aviation route open

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Restless Leg Syndrome (RLS) Uncomfortable feeling in legs Relieved by moving legs Worse later in the day Falling snoozing is hard Symptoms go ahead and decline with age Possible reason for engine eagerness and meandering Treatment ropinerole (Requip) and pramipexole (Mirapex)

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Periodic Limb Movement Disorder (PLMD) Legs kick, yank amid evening rest Easier to recognize on the off chance that one has snoozing accomplice Causes rest fracture Treatment Much as RLS ropinerole (Requip) pramipexole (Mirapex)

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REM Sleep Behavior Disorder (RBD) Usually CNS engine is incapacitated in REM Except for breathing Act out dreams Prominent in more seasoned men, certain dementias Safety is an issue Treatment clonazepam (Klonopin) Secure the earth

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Case Workup Sleep graph Broken up Averages 9.4 hours a day Range 4-13 hours a day Lab, restorative tests Oxygen immersion unremarkable TSH typical CBC, BMP ordinary

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Medications Near sleep time Lung medicines/bronchodilators caffeine, albuterol Stimulants methylphenidate (Ritalin) Daytime sedation Antihistamines promethazine (Phenergan) Anticholinergics diphenhydramine (Benedryl) Sedating antidepressants nortriptyline, mirtazapine (Remeron) under 30mg/d

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Medical Conditions Common Pain Parasthesias Nighttime hack Dyspnea GERD Incontinence or successive evening time pee Neurodegenerative issue Parkinson's ailment, e.g.

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Dementia Common rest issues More rest disturbance Lower rest productivity More light rest Less profound rest Less REM Sundowning

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Circadian Rhythm Body's example of rest/wake Elderly Blunted in sufficiency Less time in every rest/wake cycle Shifted in time More daytime sluggishness, evening time arousals Less steady in LTC than in the community May connect with level of dementia Decreases survival in LTC

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Circadian Rhythm Exerts much impact on the planning of rest Weak CR or reset CR may firmly impact rest issues How to attempt and settle Exposure to brilliant light in the daytime Regular booked introduction Physical action less essential than light Bright in the day, dim during the evening

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Case Medical conditions GERD Well controlled, no proof of evening time indigestion No nourishment for 60 minutes before sleep time Pain No grievances on routine APAP Signs of compounded agony not present Incontinence Oblivious during the evening Toileting just before sleep time

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Case Medical conditions Mood Stable manifestations Hypothyroidism TSH ordinary Primary rest issue Oxygenation typical No prominent developments conscious or snoozing that look like RLS or PLMD No odd or abnormal evening time conduct Dementia Pattern of rest issue sounds natural

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Case Medications hydrocodone/APAP (Vicodin) Pain controlled well on APAP Not utilized as a part of for a short time sertraline (Zoloft) Not a quieting energizer Could give at evening oxybutynin (Ditropan) Anticholinergic, antihistaminergic Can pick a less concerning specialist L-thyroxine (Synthroid) Only if underused

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Night in LTC Many rest issues in the earth Shared rooms Frequent commotion and light intrusions Extended, daily premise Most clamor brought on by laborers Doing individual considerations Room level light Suppresses melatonin Disrupts rest Changes CR

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Treatment Nonpharmacologic Timed light presentation More ready directly after presentation More dynamic in the day Mixed results Lower commotion and light levels Hard to change the earth

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Treatment Mixed approach Daytime light introduction Increased physical action Bedtime routine Less time in bed Minimize evening time interruption Results Lessened daytime sedation More social vitality More physically dynamic Hard to change evening commotion and light levels

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Treatment Pharmacologic treatment Hypnotics zolpidem (Ambien) zaleplon (Sonata) ramelteon (Rozerem) Adverse occasions Dizziness Drowsiness Falls Not useful Don't provide for somebody dozing 13 hours a day Psychological reliance

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Treatment Pharmacologic Benzodiazepines alprazolam (Xanax) lorazepam (Ativan) clonazepam (Klonopin) Adverse occasions Falls Confusion Sedation Dependency

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Treatment Pharmacologic Sedating antidepressants Tricyclics Nortriptyline Amitriptyline Trazodone Mirtazapine Adverse occasions Daytime sedation Falls, orthostasis Confusion, bladder maintenance, clogging, tachycardia

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Treatment Melatonin Hormone Mixed results Bad thought Antipsychotics Alcohol Caffeine Exercise preceding sleep time

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Case No uproarious flat mate No standard renewals Environment is loud Often sitting in seat close front entryway Falls snoozing in her room Rarely goes outside

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Case Likely dementia related Timed light treatment Take outside to sit in the sun Discontinue prn opiate Changed oxybutynin Allowed coordinated rests to cutoff time in bed Made unbending sleep time routine Dark during the evening, splendid in the daytime No dozing pill

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Objectives Discuss reasons for rest interruption in long haul mind Identify non-pharmacologic intercessions conceivable to cure rest interruption Assess pharmacologic mediations for rest interruption