Charles P. Pollak

Sleep problems and institutionalization of the elderly.

This study examined the role of sleep problems in the decisions of families to institutionalize elderly relatives. Previous work on institutionalization of the elderly has given little attention to the contribution of nocturnal, sleep-related problems. Seventy-three primary caregivers of elders recently admitted to a nursing home or psychiatric hospital were asked to identify the problems the elder was having during the night and day and rate the degree to which these influenced their decision to institutionalize the elder. Seventy percent of the caregivers in each sample cited nocturnal problems in their decision to institutionalize, often because their own sleep was disrupted. The most frequent disruptive nocturnal events were micturition, pain, and complaints of sleeplessness. Sleep problems of the elderly contribute heavily to the decision to institutionalize an elder and thus to the social and economic cost of institutional care. They appear to do this largely by interfering with the sleep of caregivers. The nature, prevalence, and treatability of the sleeping problems of both elders and their caregivers need further study. (J Geriatr Psychiatry Neurol 1991;4:204-210).

Sleep problems in the community elderly as predictors of death and nursing home placement

In 1984–85, 1855 elderly residents of an urban community responded to a comprehensive baseline interview that included questions regarding an extensive set of sleep characteristics and problems. During the subsequent 3 1/2 years of follow-up, 16.7% of the respondents died and 3.5% were placed in nursing homes. The predictive significance of each sleep characteristic for mortality and for nursing home placement was determined separately for males and females, using Cox proportional hazards models. Selected demographic and psychosocial variables were also entered into the models. Age, problems with activities of daily living (ADL), self-assessed health, income, cognitive impairment, depression and whether respondents were living alone were controlled for statistically.Of the many variables analyzed, in males insomnia was the strongest predictor of both mortality and nursing home placement. For mortality, the relative hazard associated with insomnia exceeded the hazards associated with age, ADL problems, fair-poor health and low income. For nursing home placement, the hazard associated with insomnia exceeded that associated with cognitive impairment. The relationships of insomnia to mortality and nursing home placement were U-shaped, with a worse outcome if insomnia complaints over the preceding 2 weeks were either prominent (numerous or frequent) or absent. For females, insomnia was a borderline predictor of mortality and did not predict nursing home placement at all. Symptoms of the restless legs syndrome predicted mortality for females in some Cox regression models. Reported sleep duration, symptoms of sleep apnea and frequent use of hypnotic drugs did not predict mortality or nursing home placement in either sex.

Obstructive sleep apnea and death associated with surgical correction of velopharyngeal incompetence

We have observed three children who developed obstructive sleep apnea immediately following construction of pharyngeal flaps designed to improve the speech of these patients with velopharyngeal incompetence. Postoperatively the patients were noted to have repeated episodes during sleep of strong respiratory efforts without airflow. Sleep apnea can be debilitating and lethal, and should be looked for following surgery of the upper airway. Respiratory depressants should be avoided. Airway intubation, revision of the surgery, or tracheostomy may be necessary.

theoretical and Technical Problems in the Measurement of Nocturnal Penile Tumescence for the Differential Diagnosis of Impotence1

&NA; Theoretical and technical problems in using Nocturnal Penile Tumescence (NPT) measurements for the differential diagnosis of impotence are discussed and possible solutions are offered: 1) The basic assumption that NPT measurements can distinguish psychogenic from organic impotence has never been demonstrated in patients shown to be psychogenically and organically impotent independent of the NPT measurements themselves. Studies attempting to do this are necessary to determine definitively the limits of the clinical applicability of this important diagnostic tool. 2) Evidence is presented showing that though a direct observation of one of the patients fullest erections is required for an adequate NPT evaluation, this is not always done. The danger of misdiagnosis if this step is omitted is illustrated with a case report. 3) Disagreements in the literature about NPT criteria for diagnosing psychogenic impotence are discussed and criteria are suggested that are based on demonstrating the intactness of the physiological mechanisms required for erection rather than on values recorded in normal subjects.

Effects of phototherapy on non-seasonal unipolar and bipolar depressive spectrum disorders

In a group of 17 patients with non-SAD depressive disorders we compared the response of bipolar spectrum versus unipolar patients to treatment with light therapy. The main hypothesis was that bipolar spectrum depressed patients would preferentially respond to bright light therapy as compared to unipolar depressed patients. All patients were treated with either 400 or 2500 lux phototherapy for 2 h on seven consecutive days. All outcome measures, which included the SIGH-SAD, CGI, and the Anxiety and Depressive Factors of the SCL-90, showed significant improvement in the bipolar vs. the unipolar spectrum patients. Unexpected this occurred regardless of the intensity of the light. These changes were judged to be quite clinically significant. All patients showing response were noted to have maintained their response at a 3-month follow-up.

Circadian factors during sustained performance: Background and methodology

Cornell University Medical College, Westchester Division, The New York Hospital, White Plains, New York It is well established that there is a complex timekeeping mechanism in the human brain. This mechanism is associated with a variety of physiological and psychological rhythms having a period of about a day, and thus referred to as circadian rhythms. The circadian system has recently been modeled in terms of two underlying oscillators, one much more resistant to changes in routine than the other. These oscillators are considered to be endogenous, that is, internal to the organism, and not reliant for their existence upon changes in the person’s environment or general behavior. They thus continue to run even when the sleep/wake cycle is suspended, as in sustained operations. Thus, by their very nature, sustained operations require the individual to override the inputs that are coming from his or her circadian system (especially the indication that sleep is required). The aim of this paper is to provide a background to the area of circadian rhythms research, including a section on the methodology, so that the impact of the circadian system on sustained operations can be better understood.

Daily sleep reports and circadian rest-activity cycles of elderly community residents with insomnia

Sleep patterns were investigated in 29 insomniacs and 22 controls selected from a large sample of elderly residents of an urban community. According to sleep logs kept for a mean of 14.7 days, insomniacs took longer to fall asleep and stayed awake longer when they woke at night. In 14 insomniacs and 8 controls, wrist movements were monitored with a portable instrument. A circadian rhythm of motor activity was found in both groups, with some notable differences. Insomniacs were more active during periods of bedrest, and their mean daily rest-activity pattern--representing mean activity at equivalent times of day--was flatter. The mean level of activity over the entire experiment was similar in both groups. Insomnia in many elderly persons is thus associated with diffusion of activity over the 24-hr day, leaving bedrest periods only partially filled by rest or sleep.

The sleep lactate infusion: arousal and the panic mechanism.

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Lactate Sensitivity in Sleeping Panic Disorder Patients and Healthy Controls

In spite of a series of careful physiological and neuroendocrine studies of sodium lactate-induced panic attacks in Panic Disorder (PD) patients, the mechanism of panic induction remains poorly understood. To further explore this mechanism, we administered sodium lactate infusions to PD patients and normal controls during sleep, taking advantage of the opportunity that sleep provides for closely monitoring shifts in state of arousal. In previous work (Koenigsberg et al 1987) we reported that sodium lactate but not dextrose-saline infusions, administered during stage 3-4 sleep, induced prompt awakenings in panic disorder (PD) patients.

Impaired nocturnal erections and impotence following transurethral prostatectomy.

A case of impotence with significantly impaired nocturnal penile tumescence (NPT) following transurethral resection of the prostate (TURP) is described. The patient was studied with polysomnographic recording including measurements of NPT for three consecutive nights at nine months after surgery and showed a total absence of full erections. Possible causes of his impotence are discussed. It is concluded that the total clinical picture strongly suggests that the erectile dysfunction was a result of physiologic complications of the surgery. Methodologic problems in past work are discussed, and the need for detailed diagnostic studies is stressed. The sleep studies that should be a part of this comprehensive evaluation are described.