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Week 3: Sleep - Coggle Diagram

- - - - :three: Occurs at least 3 nights per week for at least 3 months
        
        occurs despite adequate opportunities for sleep
        
        Short-term :arrow_right: less than 3 months
        
        Chronic :arrow_right: more than 3 months
      - :four: Not caused by other disorders or substances
  - - - intended for short-term use (1-2 weeks)
        
        after that => :arrow_up: potential for tolerance or dependance
      - Examples
        
        melatonin
        
        effective with no withdrawal effects or rebound insomnia
        
        small treatment effects
        
        sedating antidepressants
        
        mainly prescribed hypnotics (sleeping pills)
        
        Side Effects
        
        impaired cognitive functioning
        
        :arrow_up: risk of falls (salient)
        
        parasomnia-like symptoms like sleep walking & sleep eating (salient)
        
        daytime sleepiness
        
        Even for newer BRA drugs designed to :arrow_down: negative side effects
        
        benzodiazepine receptor agents
        
        zalepon effective for 3-6 mth usage
        
        unfavourable benefit-risk ratio for :older_man::skin-tone-3:
        
        small to moderate magnitude of improvements
    - - 80% success rate post-treatment
      - multifaceted treatment approach required
        
        CBT-I
        
        cognitive and behavioural treatments
        
        Cognitive Therapy
        
        Sleep restrictions
        
        matching time spent in bed
        to actual sleeping time
        
        Relaxation therapy
        
        Stimulus control
        
        Sleep Hygiene
        
        Benefits
        
        regarded by national agencies as firstline treatment for chronic insomnia before pharmacological
        
        substantial efficacy for primary/comorbid insomnia with moderate-large effect sizes
        
        Older adults with insomnia => significant improvement in insomnia symptoms
  - - - :arrow_up: wake time associated with cognitive complaints as early as 2 years and as late as 28 years
      - Sleep duration changes of ≥ 2 hours in middle-aged adults linked with :arrow_down: cognitive performance
    - - self-reported insomnia associated with :arrow_up: cognitive decline
    - - no associations between insomnia and cognitive performance
      - did not analyze all insomnia subcomponents or objective measures of sleep quality/quantity
    - - 1.5-fold risk of dementia dev in :older_man::skin-tone-3: with insomnia
    - - impairments in executive function, working memory, attention, episodic memory, cognitive complaints
      - both long and short sleep duration
      - long sleep duration (≥ 10hrs) linked to :arrow_down: cognitive performance in :older_man::skin-tone-3:
        
        also correlated with other medical conditions and overall poor health
      - :arrow_down: associations in :older_man::skin-tone-3: controlling for demographics & health related variables
  - - - 24hr psychobiological disorder because etiology related to
        
        neurobiological substrate alterations
        
        maladaptive behaviours and cognitions
        
        psychosocial stress
      - evidence supports hypothesis for younger adults but not older adults
        
        late-life insomnia characterised by commorbid insomnia
        
        competing factors with hyperarousal in insomnia experience
    - - Poverty & :arrow_down: educational attainment related to :arrow_up: sleep disturbance & insomnia complaints
      - may relate to insomnia through
        
        :arrow_down: social support
        
        food insecurity
        
        unhealthy lifestyle
    - - insomnia symptoms & complaints despite chronic use of hypnotic meds for treatment
        
        related to maintenance of chronic insomnia.
      - :older_man::skin-tone-3: seeking insomnia treatment likely to receive hypnotic medications as first-line treatment
        
        :arrow_up: risk of developing hypnotic-dependent insomnia
      - withdrawal attempts from hypnotic
        
        insomnia temporarily worsens
        
        incentivizes continued use of hypnotics in :older_man::skin-tone-3: despite :arrow_down: efficacy
  - - - Precipitating
        
        Perpetuating
        
        :arrow_up: time spent in bed
        
        excessive napping
        
        loss of daytime structure
        
        short-term behaviors/cognitions that seem to be logical solutions to :arrow_down: sleep disruption
        
        may create :arrow_up: sleep pattern variability, non-sleep-promoting environment, unrealistic expectations of sleep in long-term
        
        stimulating substances to help wakefulness
        
        sedative substances to fall asleep
        
        stressful life events (retirement, bereavement)
        
        vary in content, duration, quality
        
        event that introduces transient sleep disruption
      - Impaired plasticity
      - Family history
      - Hyperarousal
      - Personality factors
  - - - ranges from 9% to 44%
        
        higher estimates when diagnosed without considering daytime impairments or insomnia duration & frequency
        
        :arrow_up: frequency in :womens: and gap widens in older adulthood
    - - 13.7% of adults report ≥ 1 sleep problem
      - 69.4% :arrow_right: sleep interruptions at night
      - 48.9% :arrow_right: difficulties falling asleep
      - 22.3% :arrow_right: early morning awakening
      - 11.4% :arrow_right: all 3 problems
- - - - :arrow_down: dramatically throughout childhood
      - :arrow_down: steadily during adulthood
      - Stabilises after age 60
      - :arrow_up: percentage in infants
    - - Young adults
        
        SWS activity highest in 1st NREM cycle
        
        :arrow_down: with subsequent sleep cycles
        
        bound to homeostatic drive regulation
        
        :arrow_up: activity in response to time spent awake
      - Older adults
        
        :arrow_down: amplitude and density of SWS with maximal reduction in frontal lobe
        
        Changes in homeostatic drive regulation
        
        Smaller decrease in SWS throughout night with sleep
        
        Smaller increase in SWS with prolonged wakefulness
    - - transient bursts of waxing and waning oscillations in the 11Hz to 16Hz
      - commonly found in NREM Stage 2 but also in SWS
      - Older adults :older_man:
        
        Significant :arrow_down: in spindle density with largest reductions in frontal regions
        
        :arrow_down: spindle activity associated with impairments in hippocampal memory
        
        :arrow_down: amplitude & duration of sleep spindles
      - last 0.5 to 2 seconds
      - role in various learning paradigms
        
        consolidating memory of word-pair associations
        
        procedural memory tasks
    - - nREM (1, 2, 3) => REM
  - - - plateaus after 60
      - 10 to 14 hours in children
      - 6.5 to 8.5 hours in 20 to 35 yr olds
      - 5 to 7 hours in
        35 to 60 yr olds
      - Reasons
        
        longer sleep onset latency
        
        :arrow_up: wake time after sleep onset (WASO)
        
        :arrow_up: sleep fragmentation
        
        early morning awakening
    - - Statistics
        
        50% of unplanned naps in older people
        
        Reported by 10% of 55-64 yr olds and 25% of 75-84 yr olds
        
        25% of older people experience EDS that regularly impairs daytime activity
        
        EDS may be related to :arrow_up: sleep fragmentation
        
        related to comorbid conditions (sleep disorders, medical disorders & depression)
      - :arrow_down: in sleep duration offset by :arrow_up: in daytime napping
  - - - Timezone changes
      - Vision loss
      - Reduction of daytime
    - - earlier sleep and wake times
    - - :arrow_up: deterioration in clock gene expression in peripheral tissues
      - :arrow_down: ability of the suprachiasmatic nucleus (SCN) to entrain and regulate peripheral clocks
  - - - Lighter
        
        :arrow_down: deep sleep (stage N3) & :arrow_up: light sleep (stages N1 & N2)
        
        sleep architecture shifts occur before 60 then plateau
      - More disrupted
        
        :arrow_up: difficulty falling back asleep
        
        :arrow_up: awakenings
        
        longer time to fall asleep
        
        continues till late older adulthood (≥90)
    - - Biopsychosocial
      - Age-related changes in multiple neurobiological substrates (eg. cortisol, serotonin, growth hormone)
- - - - psychomotor retardation
      - mood disorders and dementia
      - memory and attention difficulties
    - - :arrow_up: economic burden & :arrow_down: overall quality of life
      - stress for family and caregivers
      - :arrow_up: risk of injury from falls & unsafe driving
- - - - FDA approved hypnotics
        
        benzodiazepine receptor agonists: zolpidem and eszopiclone
      - Off-label agents
        
        sedating antidepressants:
        trazodone, mirtazapine
        
        sedating antipsychotics: quetiapine
      - 1st-gen antihistamines
        
        antagonism of H1 receptors
        
        has anticholinergic effects
    - - Stats
        
        :older_man::skin-tone-3: have nearly 5x :arrow_up: risk of unwanted cognitive and psychomotor effects from hypnotics relative to placebo
        
        antidepressants, anxiolytic medications, sedative hypnotics most common potentially inappropriate medications in community-dwelling elderly patients
      - age-related changes in drug metabolism and clearance
      - Tolerance development
      - RIsk of cognitive impairment
      - Dementia
        
        Anticholinergic meds
        
        dementia risks :arrow_up:in heavy past users and recent users
        
        risk may persist despite discontinuation.
        
        often used to manage poor sleep and depression (prodromal phase)
        
        suggests indirect association of anticholinergic meds and dementia
        
        :arrow_up: risk for nonhypnotic and nonantidepressant anticholinergic meds
        
        :arrow_down: likelihood that dementia risk related to only sleep problems
        
        showed 10-yr cumulative dose response rs with dementia dev
        
        Zolpidem
        
        :arrow_up: risk for short-term cognitive effects
        
        conflicting results linking it to dementia
  - - - Psychotropic drugs
        
        affects neurotransmitter systems involved in sleep-wake cycle
        
        drug that affects persons mental state
        
        antidepressants
        
        unintended insomnia or sedation
        
        :arrow_up: limb/eye movements that disrupt sleep
        
        REM sleep supression
- - - - Problems initiating
        and maintaining sleep
      - poor sleep quality
      - EDS
      - may begin decades before dementia onset
    - - sleep problems may not only occur as a result of dementia but also contribute to it
      - Dementia Patients
        
        treating sleep problems linked with improvement in above problems
        
        :arrow_down: sleep associated with :arrow_down: cognitive function, behavioral & psychological symptoms
- - - - most apparent in the concurrent development of sleep disturbances, cognitive changes, and histopathological changes in dementia patients
      - important to diagnose & treat sleep problems particularly in middle-aged population
      - may slow or arrest pathologic cognitive changes in later life.