Sleep disorders are defined as different problems that cause functionality and distress due to the quality, timing and the amount of sleep ( Parekh, 2019 ). The most common sleep disorders are insomnia, narcolepsy and restless leg syndrome. The therapeutic alternatives in managing these conditions rely on different variables with age being one of them. This paper will look at the implications of prescription drugs while treating elderly patients.
Insomnia is the dissatisfaction of the quality or amount of sleep which then results in social and occupational impairment as well as clinical distress. Symptoms of insomnia are difficulty initiating sleep and difficulty maintaining sleep ( Parekh, 2019 ). Benzodiazepines therapy should be issued based on the action onset and duration of action desired by the patient since they develop rapid tolerance to the effects of the drugs. Due to this, long term use is not recommended. The use of BZDs should be discouraged for elderly patients as the side effects (psychomotor retardation, memory impairment) bear the risk for cognitive impairment, delirium, falling and fractures. Non- Benzodiazepines (non-BZDs) were created as an alternative to counter the effects of BZDs. Zolpidem and Zaleplon have short initiation time but also have a short half-life and are less suitable for patients with sleep retention. However, these also bear considerable fall risk for elderly patients ( Esse, & Serna, 2015 ). Alternatively, Ramelteon may be used in the treatment of chromic insomnia to help with sleep onset, as it does not affect patient balance. The recommendation for countering these risks is adopting the cognitive behavioral therapy or fall prevention strategies. These interventions feature an exercise program after a multifactorial fall risk assessment.
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Narcolepsy is a sleep disorder that induces sleep due to malfunction in the primary brain. Its main characteristic is cataplexy. Other characteristics include attaining REM sleep without the other stages, sleep paralysis and daytime sleepiness ( Arcangelo, & Pet, 2017 ). The use of psychostimulants as Modafinil and Armodafinil to promote wakefulness is the main drug therapy for narcolepsy. These drugs have a lower abuse rate and report mild and transient side effects like headaches, nausea and anxiety. For the elderly patients, oral clearance is reduced significantly (up to 50%). Similarly, liver damage has the potential to reduce the drug clearance and double serum concentrations. The use of amphetamines has also been explored in improving alertness by increasing dopamine levels ( Medications | Narcolepsy., 2019 ). Elderly patients have to be precautionary about this alternative since amphetamines affect the blood pressure and heart rate. These would be detrimental to people with heart conditions and hypertension, and the prevalence of these increase with age.
Periodic limb movement disorder is characterized by phases of very repetitive and stereotypic limb movement, only when sleeping. Restless leg syndrome is characterized by a strong need to move the legs coupled with paresthesias and dysesthesias than increase in the evening. The use of dopamine agonists, like pramipexole and ropinirole, is used due to their minimal side effects ( Hornyak, &Trenkwalder, 2004 ). Benzodiazepines are taken concurrently with these dopamine agonists if the sole agent treatment has failed. BZDs can, however, cause cognitive impairment in elderly patients. Another alternative for ineffective dopamine therapy is the use of anticonvulsants. Gabapentin is used to treat patients who experience RLS discomfort as pain, and it is issued in low dosages as hypersomnia side effects hamper improvement. The use of opioid treatment is a last resort in cases of severe RLS or PLMD that cannot be managed by other treatment alternatives. Elderly patients may have reduced renal function that increases their risk of drug accumulation, which means opioid therapy increases their risk of respiratory depression or overdose ( Wu, 2019 ). If this option is explored, then checking the patient’s glomerular filtration rate is necessary to determine safe dosing.
References
Parekh, R. (2019). What Are Sleep Disorders?. Retrieved from https://www.psychiatry.org/patients-families/sleep-disorders/what-are-sleep-disorders
Esse, T., & Serna, O. (2015). Nonbenzodiazepine Hypnotics and Their Association With Fall Risk and Fractures in the Elderly. US Pharm , 5 , 15.
Medications | Narcolepsy. (2019). Retrieved from http://healthysleep.med.harvard.edu/narcolepsy/treating-narcolepsy/medications
Arcangelo, V. P., & Peterson, A. M. (Eds.). (2017). Pharmacotherapeutics for advanced practice: a practical approach (Vol. 536). Lippincott Williams & Wilkins.
Hornyak, M., & Trenkwalder, C. (2004). Restless legs syndrome and periodic limb movement disorder in the elderly. Journal of psychosomatic research , 56 (5), 543-548.
Wu, V. (2019). Special Considerations for Opioid Use in Elderly Patients With Chronic Pain. Retrieved from https://www.uspharmacist.com/article/special-considerations-for-opioid-use-in-elderly-patients-with-chronic-pain
