I N T E R N A T I O N A L L O N G E V I T Y C E N T E R - U S A Sleep Disorders In Older Adults Harrison G. Bloom, M.D. Director, International Geriatrics Clinical Education and Consultation Service International Longevity Center-USA New York, NY 翻译:唐莉

老年人睡眠障碍 哈里森.布鲁姆医学博士 国际老年医学临床教育中心主任 国际长寿中心，纽约

I N T E R N A T I O N A L L O N G E V I T Y C E N T E R - U S A Consensus Conference to Develop Guidelines for the Assessment and Treatment of Sleep Disorders in Older Adults ILC-USA December 6 & 7, 2007 Made possible by an unrestricted grant from Takeda Pharmaceuticals North America

老年睡眠障碍评估和治疗的共识和指南 2007年12月6~7日

“If sleep doesn’t serve an absolutely vital function it is the biggest mistake that evolution has ever made.”

如果睡眠不能完全恢复人体的活力和机能将是极大的错误，而这种错误在不断发生。

Goal Develop consensus guidelines that are practical and relevant to the primary care practitioner in an ambulatory setting.

目标 形成和初级保健医生共识的医疗开发的实用性与基础护理相关的治疗背景

Guidelines Evidence Based Best Practices

指导思想 以实践为依据

Sleep and Healthy Aging Gallup Survey on Sleep and Healthy Aging October, 2005

睡眠和健康的民意调查 2005年10月

Gallup Survey Objective Document older adults’ awareness and attitudes on a range of issues: Knowledge of the importance of sleep Sleep behaviors and coping mechanisms Attitudes toward sleep and aging

民意调查目的 老年人对睡眠问题的意识和态度： 睡眠的重要性 睡眠行为和应对机制 对于睡眠和衰老的态度

Survey Goal Use survey results to help encourage discussion among healthcare professionals about sleep problems within the aging population.

调查目的 通过调查结果鼓励医疗保健专家关注讨论老年人睡眠障碍

Methodology The Gallup Organization interviewed 1,003 Americans 50 years of age and older via random telephone surveys. Results are nationally representative of all adults age 50 and older.

方法学 盖洛普通过电话随机调查了1003位50岁以上的美国老年人 调查结果能够代表美国50岁以上人群的意见

Older adults recognize the importance of sleep… Summary of Findings: Older adults recognize the importance of sleep…

研究结果摘要： 中老年人意识到睡眠的重要性

睡眠的重要性 大部分老年人相信睡眠对健康非常重要

Sleep Patterns One in two (47%) report they are getting less then seven hours a sleep a night One in three (34%) feel they need more sleep than they are currently getting

睡眠模式 二分之一(47%)的老年人一夜睡眠不足7小时 三分之一(34%)的老年人认为他们需要比现在睡眠时间更长的睡眠

Attitudes Toward Sleep 45% feel they need more sleep today than when they were younger 24% agree that getting more than 9 hours of sleep a night is a sign of laziness

睡眠的态度 45%的人感觉需要比他们年轻时更多的睡眠 24%的人认为睡眠时间超过9个小时是懒惰的表现

Reported use of “sleep aids” One in three (33%) report using at least one “sleep aid” in the past month 18% reported using the respective “sleep aid” every night

辅助睡眠方法的应用 三分之一（33%）的人在过去一个月内至少一次使用过辅助睡眠方法 18%的人每晚使用各种辅助睡眠方法

Respondents reported usage of seven OTC antihistamines or cold meds OTC sleep aids Melatonin Herbal remedies Alcohol Audio tapes Rx meds not prescribed to help with sleep problems

老年人七种常用的辅助睡眠方法 非处方抗组织胺或感冒药 非处方辅助睡眠 褪黑素 草药 酒精 录音带 治疗睡眠障碍的处方和非处方药

Treatment of Sleep Problems One in four (25%) believes she/he has a sleep problem 72% who feel they have a sleep problem have spoken to their healthcare providers More than half (53%) who have spoken with their healthcare providers are not receiving treatment 25% of people who feel they have a sleep problem report taking Rx sleep medication

睡眠障碍的治疗 四分之一（25%）的人认为自己有睡眠障碍 72%感觉自己有睡眠障碍的人已经报告了医生 一半以上（53%）报告过医生的人未得到治疗 25%认为自己有睡眠障碍的人正在服用处方睡眠药

处方睡眠药安全吗?

Most Frequently Cited Safety Concerns Not knowing long-term effects of drug (73%) Becoming addicted (68%) Next-day grogginess (67%) Interactions with other medications (63%) Next-day “hangover” feeling (63%)

最常见的安全隐患 长期药效不详(73%) 成瘾性(68% 次日感觉头昏(67%) 对其他药物的影响(63%) 次日“宿醉”感(63% )

“It ain’t so much what we don’t know that gets us into trouble as what we do know that ain’t so.”

我们遇到的困难不是我们所能预料的

Objective: The objective of this study was to Sleep: A marker of Physical and Mental Health in the Elderly Kathryn J. Reid, et al Objective: The objective of this study was to determine the occurrence and recognition of common sleep-related problems and their relationship to health-related quality-of-life measures in the elderly. Am J Geriatr Psychiatry 14:10,October 2006

目的：这项研究的目的是确定常见睡眠相关问题的发生和鉴别，以及睡眠与健康生活质量的关系。 睡眠：老年人身心健康的标志 目的：这项研究的目的是确定常见睡眠相关问题的发生和鉴别，以及睡眠与健康生活质量的关系。

TABLE 2. Five-Item Sleep Questionnairea 1. Do you feel excessively sleepy during the day? Yes No 2. Do you find yourself falling asleep when you do not want to? Yes No 3. Do you snore frequently and loudly or stop breathing? Yes No 4. If yes to 3, do you feel unrefreshed on awakening? Yes No 5. Do you have difficulty falling asleep, staying asleep, or being able to sleep? Yes No -------------------- aData collection for educational data was initiated after enrollment had begun at the first several project sites (N1,323). For other demographic variables, the full sample size is 1,503. Am J Geriatr Psychiatry 14:10,October 2006

表2.睡眠问卷中的五个问题 1.你感觉白天嗜睡吗？ 2.当你不想睡的时候你会睡着吗？ 3.你频繁和大声打鼾或有呼吸中断吗？ 4.如果第三题你选择是，那么你在醒来的时候会觉得睡眠不解乏吗？ 5.你有入睡困难、易醒吗？

Discussion A positive response to the question about excessive daytime sleepiness best predicted both poor physical and mental health. The results of this study also demonstrates a significant relationship between sleep disturbances with both physical and mental health-related quality-of-life status. Am J Geriatr Psychiatry 14:10,October 2006

讨论 白天过度嗜睡预示体力和精力的减弱 这项研究的结果也证实睡眠与身心健康相关的生活质量有密切关系

Discussion Although the results of the current study indicate that sleep complaints are prevalent in the elderly and are often accompanied by higher rates of mental and physical health problems, primary care professionals are not identifying sleep problems in their patients’ charts. Am J Geriatr Psychiatry 14:10,October 2006

讨论 虽然当前研究结果表明老年人普遍存在睡眠主诉并常伴随身心健康问题，但初级保健专业人员尚不能鉴别患者的睡眠障碍。

Discussion Although only speculation, the low detection rate of sleep disorders in this sample maybe the result of a common belief that sleep problems are part of normal aging and the perception among both patients and physicians that little can be done to improve sleep quantity and quality in the elderly. Am J Geriatr Psychiatry 14:10,October 2006

讨论 虽然只是推测，这个样本中睡眠障碍检出率低可能是由于人们通常认为睡眠障碍是正常衰老的一种表现，患者和医生很少去改善老年人的睡眠时间和质量

Discussion Furthermore, even when recognized, the increasing demands and time constraints in primary care practices require efficient tools to screen for sleep disorders. Results from this study indicate that asking just one question about sleep can be reasonably predictive of poor mental and poor physical health-related quality of life. Am J Geriatr Psychiatry 14:10,October 2006

讨论 此外，甚至公认由于在初级保健实践中需求量的增加和时间所限，需要有效的工具来筛查睡眠障碍。这项研究表明，只要询问一个关于睡眠的问题就能合理的预测出和生活质量相关的身心健康。

Discussion This study indicates that although there has been more than a decade of discussion about the prevalence and low detection rates of sleep problems, little has changed in primary care practice in recognition of sleep problems in the elderly. Am J Geriatr Psychiatry 14:10,October 2006

讨论 这个研究表明虽然睡眠障碍的患病率和低检出率已经讨论了十余年，但在老年人睡眠障碍的初级保健中仍没有改善。

老年睡眠障碍伴随的全身病变 睡眠呼吸暂停 不宁腿综合征 REM睡眠行为 紊乱 阿尔茨海默病 帕金森症 精神病 中风 心脏病 食道反流 糖尿病 心脏病 食道反流 消化道疾病 心脏病 高血压 心脏病 心脏病 高血压 免疫疾病 呼吸道疾病 关节炎 肾病 夜尿 前列腺疾病 Courtesy of P. Zee MD

Impact of Disturbed Sleep in Older Adults Difficulty sustaining attention Slowed response time Difficulty with memory Decreased performance Depression and anxiety (All of the above may all be misinterpreted as dementia) Daytime sleepiness Ancoli-Israel S, Roth T. SLEEP. 1999;22(Suppl 2):S347-S353. Ancoli-Israel. SLEEP. 2000;23:S23-S30. Ancoli-Israel S, Cooke JR. J Am Geriatr Soc. 2005;53:S264-271.

老年人睡眠障碍的影响 注意力难以集中 反映迟钝 记忆力减退 工作能力下降 抑郁和焦虑 （以上症状可能会误以为痴呆） 白天嗜睡

Consequences of Disturbed Sleep Excessive, intrusive daytime sleepiness Increased risk of accidents and falls Impaired mood Impaired vigilance Impaired memory Impaired problem solving Courtesy of M. Vitiello PhD

睡眠障碍的后果 情绪受损过度,间断白天嗜睡 增加意外事故和摔倒的风险 缺乏警觉性 记忆力衰退 解决问题的能力下降

睡眠问题和心脏病 Foley, Ancoli-Israel, Britz, Walsh. J Psychosom Res. 2004;56(5):497-502.

睡眠问题和抑郁症 Foley, Ancoli-Israel, Britz, Walsh. J Psychosom Res. 2004;56(5):497-502.

Percent 老年男性和女性长期睡眠问题的患病率 Men Women Percent Source: Foley, Monjan, Brown et al. SLEEP 18:425-432, 1995

Most Common Drugs Affecting Sleep Alcohol Nicotine Caffeine Television

影响睡眠的最常见因素 酒精 尼古丁 咖啡因 电视

Combining Pharmacologic and CBT-I Approaches No conclusive evidence exists to favor either pharmacologic therapy or CBT-I Pharmacologic treatment provides immediate benefit with risk of side effects CBT-I takes longer to help, but the gains are maintained up to 2 years later with no known side effects or potential for drug interactions The benefits of combined therapeutic approaches are unclear and currently being explored Courtesy of M. Vitiello PhD

药物和行为结合治疗 没有存在有益于药物疗法或CBT确定的迹象 药物治疗收到很快的疗效但有副作用的风险 CBI收到长久疗效，效果会持续，两年来带着未知的或潜在的药物相互作用 综合的治疗疾病的方法和收益还不清楚，目前正在研讨中

2005 – Sleep Conference – Consensus Statements Sleep can be viewed as a new “vital sign” and sleep disturbances are important enough to be routinely addressed by clinicians at most office visits for all patients. For those with mild to moderate cognitive impairment, sleep information should be obtained from both the patient and a knowledgeable caregiver. Poor sleep and/or excessive sleepiness are often associated with poor physical or mental health. Primary sleep disorders such as sleep apnea and restless leg syndrome are common and treatable.

2005——睡眠会议——共识 睡眠问题可以被视为一个新的“生命体征”，睡眠障碍非常重要，医生应当常规记录所有就诊病人的睡眠情况。 对于那些轻中度认知功能障碍者，应该通过患者和护理人员来获得他们的睡眠信息. 睡眠不足和过度嗜睡通常合并身心健康问题。 主要的睡眠障碍，如：睡眠呼吸暂停和不宁腿综合症是常见的和可治疗的。

2005 – Sleep Conference – Consensus Statements Primary care physicians/clinicians need education about the importance and impact of sleep and sleep disorders, and on appropriate treatments and referrals for various disorders. Clinicians often pay too little attention to sleep-related problems and routinely ignore sleep complaints. They are often hesitant to ask their patients about sleep complaints because many clinicians have neither the expertise not time to deal with such complaints. Behavioral/psychological interventions, alone or in combination, have been shown to be very effective in the treatment of insomnia. Examples include cognitive behavioral therapy, stimulus control, and sleep restriction. Light therapy, exercise, and sleep hygiene may be effective as well, although further study is needed to confirm this.

睡眠会议——2005——共识 初级保健医生需要学习睡眠的重要性和睡眠障碍对机体的影响，并要针对各种情况安排适当治疗。 临床医生通常很少注意和睡眠相关的问题，并容易忽视睡眠诉求。由于许多临床医生既没有专业知识又没有时间来处理这些诉求，所以很少询问病人睡眠的情况。 在失眠治疗中单独或联合应用行为/心理干预已经显示出非常有效。这包括：认知行为疗法、刺激控制疗法和睡眠限制疗法。光照治疗、运动和睡眠卫生也可能有效，这还需要进一步研究证实。

2005 – Sleep Conference – Consensus Statements Prescription medications, over-the-counter (OTC) medications and nutraceuticals, other than those approved for sleep, can significantly adversely affect sleep either directly or indirectly. Attention by clinicians to these possible effects is important. Significant numbers of caregivers develop sleep problems themselves, which may or may not be causally related to patient nighttime disturbances. Sleep problems in both patients and caregivers can be treated with psychological/behavioral therapies as well as medications. Sleep disturbances are especially prevalent in long-term care facilities. In general, the environment in such facilities is not conducive to sleep quality or quantity.

2005–睡眠会议–共识 处方药、非处方药和除批准的睡眠药物以外的营养品，能够直接或间接显著改善睡眠。 临床医生关注这些药效十分重要。 值得注意的是许多护理人员自己也出现睡眠问题，这可能是也可能不是病人夜间的骚扰所致。患者和护理人员的睡眠问题既可以以心理/行为疗法治疗，也可以用药物治疗。 睡眠障碍在长期护理单元非常普遍。一般来说，这种环境对睡眠质量或睡眠时间无益。

2005 – Sleep Conference – Consensus Statements The potential benefits and risks associated with daytime napping are controversial. Pharmacologic therapies (prescription and OTC) are widely utilized methods to assist sleep in those with insomnia. New medications with different mechanisms of action from traditionally utilized sleep meds are now approved for both short- and long-term use. It is acceptable to recommend prescription medications, in appropriate patients, for short-term use. It is acceptable to continue prescription medication use over a longer-term period in appropriate patients, for whom the benefits of continued use outweigh the potential risks. Troubled sleep in older individuals is highly related to diminished qualities of life.

2005–睡眠会议–共识 对白天小睡的潜在益处和风险有争议。 药物治疗(处方和非处方)被广泛用于治疗失 眠。与常规使用的睡眠药物作用机理不同的新药现在被批准短期和长期应用。 为有适应症的病人推荐短期应用的处方药是可取的。 有适应症的病人长期持续使用处方药是可取的，持续使用的益处超过可能的风险。 老年人的睡眠紊乱与生活质量减退高度相关。

2006 Sleep Conference Outcomes The primary outcome of the 2006 scientific consensus conference on Sleep and Chronic Disease in Older People, was the decision to create a national coalition of aging, geriatric, and sleep organizations in support of guidelines for sleep in older people. The coalition will develop, endorse, and disseminate a set of comprehensive, evidence, and expert opinion-based guidelines for the diagnosis and management of sleep disorders in older people.

2006睡眠会议成果 2006年老年人睡眠和慢性疾病科学协作会议的主要成果是决定创建一个全国联合会，这个联合会涉及衰老、老年医学和拥护老年人睡眠指导方针。这个联合会将制定、签署和传播一套综合的、有依据的和基于专家观点的老年人睡眠障碍诊断和治疗指南。

The National Coalition for Sleep Disorders in Older People (S-DOP) AARP Alliance for Aging Research American Association for Geriatric Psychiatry American Geriatrics Society AGS Foundation American Medical Directors Association American Society of Consultant Pharmacists Association of Directors of Geriatric Academic Programs Association for Gerontology in Higher Education Gerontological Society of America International Longevity Center National Sleep Foundation Sleep Research Society Disclosure: The creation of the National Coalition for Sleep Disorders in Older People was made possible by a grant from Takeda Pharmaceuticals North America.

老年人睡眠障碍的全国联合会 美国退休者协会 衰老研究联盟 美国老年精神病学协会 美国老年医学会 美国老年医学基金会 美国医学指导协会 美国药剂师顾问协会 老年医学理论规划指导协会 老年医学高等教育协会 美国老年医学 国际长寿中心 国家睡眠基金 睡眠研究协会

“Never go to a doctor whose office plants have died.” -Erma Bombeck

决不去找一个他的办公室里植物已经死亡的（轻视生命的）医生看病。

Key to Designations of Quality and Strength of Evidence Quality of Evidence Level I Evidence for at least one properly designed randomized, controlled trial Level II Evidence from at least one well-designed clinical trial without randomization, from cohort or case-controlled analytic studies, from multiple time-series studies, or from dramatic results in uncontrolled experiments Level lll Evidence from respected authorities, based on clinical experience, descriptive studies, or reports of expert committee American Geriatrics Society 51:5, May 2003m

证据等级分类 证据性质 一级 证据来自至少有一个适当的随机设计的对 照研究 二级 证据来自至少一个非随机、但设计良好的临床试验，来自队列研究或病例对照分析研究，来自多重序列研究或来自非对照实验中令人关注的结果 三级 证据来自权威、基于临床经验、描述性研究或专家委员会

Key to Designations of Quality and Strength of Evidence A Good evidence to support the use of a recommendation; clinicians should do this all the time B Moderate evidence to support the use of a recommendation; clinicians should do this most of the time C Poor evidence to support or reject the use of a recommendation; clinicians may or may not follow the recommendation D Moderate evidence against the use of a recommendation; clinicians should not do this E Good evidence against the use of a recommendation; clinicians should not do this American Geriatrics Society 51:5, May 2003m

证据等级分类 做这个 C 支持或者拒绝使用不利的证据推荐； 临床医师可能或者 可能不跟随 推荐 证据等级 A 支持使用好证据 推荐； 临床医师应该始终做这个 B 支持使用的适中的证据 推荐； 临床医师应该大多数 时间 做这个 C 支持或者拒绝使用不利的证据推荐； 临床医师可能或者 可能不跟随 推荐 D 反对使用适中的证据 推荐； 临床医师不应该这样做 E 反对使用一种推荐的好证据； 临床医师不应该这样做 American Geriatrics Society 51:5, May 2003m 美国老人社会51:5 ， 2003年5月

The ideal is rarely achievable Evidence based guidelines (not just for sleep problems) 84 y.o. woman with hypertension, D.M.,osteoarth, urinary incont + MCI, on multiple medications for these conditions, presents with difficulty falling asleep, frequent awakenings, and daytime fatigue for 3-4 months.

理想 理想是很难实现的 84 岁患有高血压、糖尿病、尿失禁的女性，经多种药物治疗，近3-4个月出现入睡困难，频繁觉醒和白天疲劳。 例证描述（不仅睡眠问题） 84 岁患有高血压、糖尿病、尿失禁的女性，经多种药物治疗，近3-4个月出现入睡困难，频繁觉醒和白天疲劳。

The Ideal continued… Would we assess and treat this person differently from an 84 y.o. women without any of the chronic problems presenting the same way? Obviously, yes. It is clinically, rationally, and intuitively obvious. But, is this based upon evidence?

理想的延续 我们估计并且对待这个84岁妇女没有提出的慢性问题的不同方式？ 显然， 它是合理的并是显而易见的。 但是，可以基于这些证据么？

I N T E R N A T I O N A L L O N G E V I T Y C E N T E R - U S A Restless Legs Syndrome (RLS) Written by: Barbara Phillips, M.D. Presented by: Harrison G. Bloom, M.D.

不宁腿综合症

Restless Legs Syndrome (RLS) Restless legs syndrome (RLS) is a sleep disorder characterized by unpleasant leg sensations that disrupt sleep.

不宁腿综合症 不宁腿综合症是一个以腿部感觉不适引起睡眠片断化的睡眠障碍

RLS Sensations include: Compelling urge to move the lower extremities (most common); creepy crawly, itching, burning, and pain are reported as well. Symptoms of sleep disruptions may lead to a complaint of insomnia or of daytime sleepiness.

不宁腿综合症 症状包括：不由自主的下肢活动（最常见）；蚁走感、瘙痒、烧灼感和疼痛也有报告。 睡眠中断可能导致失眠主诉或白天嗜睡。

RLS The symptoms most commonly involve the lower extremities, but have also been described in the upper extremities and even the trunk. RLS has a circadian pattern, with the intensity of the symptoms worse at night and improving toward the morning.

不宁腿综合症 症状最常累及下肢，但也有是上肢，甚至是 躯干。 不宁腿综合症呈昼夜节律变化，夜间加重， 早晨改善

RLS Symptoms are also classically worse at rest and improve with movement such as walking, rubbing, or stretching. The diagnosis is made by history without the need for a formal sleep study.

不宁腿综合症 症状在休息时加重，活动如散步、按摩或伸屈肢体可缓解。 诊断主要根据病史，而不是正式的睡眠监测。

RLS RLS may be classified as primary or secondary. Primary or idiopathic RLS is more likely to develop at an earlier age, has no known associated or predisposing factors, and likely has a genetic basis. First-and second-degree relatives of patients with idiopathic RLS have a significantly increased risk of developing RLS compared with relatives of matched controls.

不宁腿综合症 不宁腿综合症可以分为原发和继发 原发不宁腿综合症更可能发生在青年，尚不清楚相关或易患因素，可能有遗传基础。 与配对对照组亲属比较，原发性不宁腿综合症病人的第一代和第二代亲属患不宁腿综合症的风险显著增加。

RLS RLS may also be secondary to a variety of medical conditions which have iron deficiency in common. These include iron-deficiency anemia, end-stage renal disease, and pregnancy.

不宁腿综合症 不宁腿综合症也继发于多种疾病，其中与缺铁有着共同之处 这包括缺铁性贫血、肾功能衰竭和妊娠。

RLS The prevalence of RLS symptoms is about 10% in most population-based surveys, and there are consistently higher rates of RLS symptoms in women than in men.

不宁腿综合症 调查显示，大多数人群中不宁腿综合症患病率在10 ％左右，女性多于男性。

RLS The prevalence of RLS symptoms increases with aging for both men and women, at least until the seventh or eighth decade. Some of this age-related increase in prevalence occurs because RLS can develop at any age, but rarely remits. Increasing prevalence of RLS with age may also result from increasing prevalence of secondary causes, such as iron deficiency and renal failure.

不宁腿综合症 不论男女，至少至七十或八十岁，不宁腿综合症患病率随着年龄的增加而增加。 患病率随着年龄而增加的原因是不宁腿综合症可以在任何年龄发生，但很少报告。 不宁腿综合症患病率随着年龄而增加，也可能是因为继发性原因的增多，如缺铁和肾功能衰竭。

RLS The exact pathophysiology of RLS and periodic limb movements is still being worked out, but there appear to be contributions from the spinal cord, peripheral nerves, and central dopamine and narcotic receptors. The impairment of dopamine transport in the substantia nigra due to reduced intracellular iron appears to play a critical role in most patients with this disorder.

不宁腿综合症 不宁腿综合症和周期性肢体运动的确切病理生理学仍在探讨，发病可能与脊髓、周围神经、以及中枢多巴胺和麻醉受体有关。 由于细胞内铁减少导致的黑质纹状体多巴胺通路受损在大多数不宁腿综合症病人的发病中起了关键作用。

RLS A variety of medications, including tricyclic antidepressants, selective serotonin reuptake inhibitors, lithium, and dopamine antagonists (antipsychotics) have been reported to exacerbate RLS.

不宁腿综合症 已经有报告，多种药物包括三环抗抑郁药、选择性5-羟色胺重吸收抑制剂、锂和多巴胺受体拮抗剂（抗精神病药物）可加重不宁腿综合症。

RLS In addition, several social or lifestyle factors appear to contribute to RLS symptoms. These include increasing body mass index, increasing caffeine intake, a sedentary lifestyle, smoking, and earning a lower income.

不宁腿综合症 此外，一些社会或生活方式因素似乎有助于不宁腿综合症的发生 这些因素包括体质指数增加、咖啡因摄入增加、久坐的生活方式、吸烟和收入较低。

RLS The treatment for RLS patients with frequent and/or intense symptoms include both nonpharmacologic and pharmacologic modalities.

不宁腿综合症 有频繁和/或严重症状的病人的治疗包括非药物和药物治疗两种方式。

RLS Nonpharmacologic measures include education, moderate exercise, smoking cessation, alcohol avoidance, caffeine reduction or elimination, and discontinuation of offending medications if it is safe to do so.

不宁腿综合症 非药物措施包括教育、适度的运动、戒烟、避免饮用酒类和咖啡因，并停止可能加重病情的药物 。

RLS Pharmacologic therapies include primarily the dopaminergic agents, although opioids, Benzodiazepines, and anticonvulsants have been used.

不宁腿综合症 虽然阿片类药物、苯二氮卓类、抗癫痫药物已被使用，药理治疗首先应包括多巴胺受体激动剂。

RLS If pharmacologic treatment is required, evidence supports the use of dopaminergic agents, especially the newer dopamine receptor agonists such as ropinirole or pramipexole (both of which are FDA-approved) as first line. These agents have less rebound and augmentation of symptoms than dopamine precursors such as levodopa-carbidopa.

不宁腿综合症 如果需要药物治疗，建议使用多巴胺类药物，特别是最新的多巴胺受体激动剂，如罗匹吡诺或派拉米苏 （二者均经FDA批准）可作为一线治疗药物。 这些药物比多巴胺前体如左旋多巴更少引起症状反弹和加重。

RLS The side effects of these agents include nausea, orthostatic hypertension, sleepiness, headache, and compulsive behaviors. In the older patient, particular consideration should be given to drug interactions and the risk of orthostasis.

不宁腿综合症 这些药物的副作用包括恶心、体位性高血压、嗜睡、头痛和强迫行为。 老年病人应该考虑到药物的相互作用和直立平衡的风险。

RLS: Table 1 Diagnostic Criteria for RLS In Adults: The patient reports an urge to move the legs, usually accompanied or caused by uncomfortable and unpleasant sensations in the legs. B. The urge to move or the unpleasant sensations begins or worsens during periods of rest or inactivity such as lying or sitting.

不宁腿综合症：表1 B. 下肢移动或不适感在休息或静止时出现或恶化，如坐卧时。 成年人不宁腿综合症诊断标准： 病人主诉：渴望不断移动下肢，通常伴有下肢不适感。 B. 下肢移动或不适感在休息或静止时出现或恶化，如坐卧时。

RLS: Table 1, Continued C. The urge to move or the unpleasant sensations are partially or totally relieved by movement, such as walking or stretching, or at least as long as the activity continues. D. The urge to move or the unpleasant sensations are worse, or only occur, in the evening or night. E. The condition is not better explained by another current sleep disorder, medical or neurological disorder, mental disorder, medication use, or substance use disorder.

不宁腿综合症：表1续 c.运动如行走或伸腿，只要是持续活动就可以部分或完全缓解下肢移动或不适感。 D.下肢移动或不适感在晚间加重，或只发生在晚间。 E. 出现的症状不能以其他睡眠疾病、内科或神经科疾病、 精神疾病、使用药物来解释。

Prevalence of Insomnia in the elderly is higher than in younger adults EVIDENCE LEVEL II

老年人的失眠率普遍高于年轻人 二级水平证据

不同年龄失眠患病率 不同年龄失眠患病率 Age Group (years) Mellinger, et al., 1985; Foley, et al., 1995 Age Group (years)

老年人主诉不适症状的百分比（9282人；平均年龄74岁） Foley, et al., Sleep, 1995, 18:452-432

Consequences of Disturbed Sleep Difficulty sustaining attention Slowed response time Difficulty with memory Decreased performance May all be misinterpreted as dementia Ancoli-Israel S, Roth T. Sleep. 1999;22(suppl 2):S347-S353; Ancoli-Israel, 2000, Sleep, 23 (suppl), S23 - S30.

睡眠紊乱的后果 难以集中注意力 反应迟钝 记忆力减退 操作能力下降 可能被误诊为老年痴呆

老年人失眠的后果 摔倒 死亡率增加

Insomnia in the elderly is not a function of age, but rather a function of other factors associated with aging EVIDENCE LEVEL II

老年人失眠不是年龄所致，而是由伴随着衰老的其他因素所引起 二级水平证据

Factors Affecting Ability to Sleep in the Elderly Medical illness Medications/polypharmacy Circadian rhythm disturbances Primary sleep disorders American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC: American Psychiatric Association; 2000:597-661. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC: American Psychiatric Association; 2000:597-661.

影响老年人睡眠的因素 疾病 药物/心理 24小时昼夜节律紊乱 特发性睡眠障碍 美国精神病学协会。精神疾病诊断与分类手册，第四版修订。华盛顿特区： 美国精神病学协会; 2000:597-661

睡眠问题和多种内科疾病 Foley, Ancoli-Israel, Bitz, Walsh, J Psychosom Res. 2004, 56(5):497-502.

Prescription Drugs and Insomnia -blockers Bronchodilators Corticosteroids Decongestants Diuretics Cardiovascular medications Neurological medications Gastrointestinal medications Hauri PJ. Insomnia. Clin Chest Med. 1998;19:157-168. A Special Report: Sleep Disturbance. Boston, MA: Harvard Medical School Health Publications Group; 1999; Ancoli-Israel S, Cooke JR.. J Am Geriatr Soc 2005;53:S264-S271.

处方药和失眠 受体阻滞剂 支气管扩张剂 皮质激素 缩血管药 利尿药 心血管药 神经科药物 消化系统药物

CBT in Elderly CBT (stimulus control, sleep restriction, sleep hygiene and cognitive therapy) vs. temazepam (7.5-30mg) vs. both vs. placebo PSG: pre- and post-treatment subjective report: pre-, post-treatment and F/U 3 active treatments > placebo 3 active treatments all effective at post-treatment (8 weeks) Those treated with CBT maintained clinical gains at F/U (3, 12, 24 mos) Morin CM et al. JAMA. 1999;281:991-999.

老年人行为治疗 24个月行为和认知治疗(控制刺激因素、限制睡眠、睡眠卫生和认知治疗)与羟基安定 (7.5-30mg)或二者联合应用或安慰剂的比较 治疗前后 主观报告：治疗前后和F/U 3治疗>安慰剂 3种治疗都有效(8个星期) 行为和认知治疗可以维持临床效果F/U (3，12)

Behavioral and Cognitive Therapies Behavioral and cognitive-behavioral therapies (CBTs) have demonstrated efficacy in RCTs. Found to be as effective as prescription medications are for brief treatment of chronic insomnia. Moreover, there are indications that the beneficial effects of CBT, in contrast to those produced by medications, may last well beyond the termination of treatment. There is no evidence that such treatment produces adverse effects, but thus far, there has been little, if any, study of this possibility. NIH State of the Science Conference Statement Manifestations and Management of Chronic Insomnia in Adults. Sleep 28(9): 1049-1057, 2005

行为和认知疗法 已经证实行为和认知治疗有效。 发现作为慢性失眠的短期治疗，行为和认知治疗和处方药物同样有效。 此外，与药物治疗相比，行为和认知性治疗有明显益处，疗效可以持续到治疗结束。 到目前为止，还没有证据显示这种治疗有副作用，如果有也很小。

Non-benzodiazepines and melatonin receptor agonists are the most safe and effective drugs currently available EVIDENCE LEVEL I

非苯二氮卓类药物和褪黑素受体激动剂是目前最安全有效的药物 一级证据

已经批准的失眠药品 传统的苯二氮卓类 Zaleplon (Sonata) 扎来普隆 Generic Agent (Trade name) Older Benzodiazepines 传统的苯二氮卓类 Recommended Dose (mg）建议剂量 Half-life Range (h)半衰期范围 Flurazepam HCL盐酸氟西泮 15 or 30 47-100* Quazepam (Doral)夸西泮 7.5 or 15 39-73* Estazolam (ProSom)三唑氮 0.5, 1 or 2 10-24 Temazepam (Restoril)羟基安定 7.5, 15 or 30 3.5-18.4 Triazolam (Halcion)三唑苯二氮 0.125 or 0.25 1.5-5.5 Newer Nonbenzodiazepines最新的安眠药 Eszopiclone Eszopiclone(Lunesta佐匹克隆 1, 2, or 3 6.0 Zolpidem (Ambien)唑吡坦 Zolpidem MR (Ambien MR)唑吡坦缓释制剂 Zaleplon (Sonata) 扎来普隆 MelatoninReceptor Agonists褪黑激素受体激动剂  Ramelteon (Rozerem)雷美替胺 5 or 10 6.25 or 12.5 5, 10 or 20 8 1.4-4.5 2.8-2.9 1.0 2-5 Speaker notes: Evolution of FDA approved hypnotics since 1975(?). Most consistent trends since that time has been the progressive reduction in sedative half life. This reflects emerging understanding that daytime carryover of the sedative effect represents most important side effect for these medications. Half life's of less than 4 hours are associated with reduced risk of residual sedation (Additional reading on comparative pk of hypnotics) The drugs include both older benzos and newer non-benzo hypnotics *Includes active metabolite(s) Consensus Conference. JAMA. 1984;251:2410-2414.; Physicians’ Desk Reference. 1991, 1999 and 2004. FDA Web site. Eszopiclone. www.fda.gov/cder/foi/label/2004/021476lbl.pdf. Accessed 1/25/05.