Managing Sleep Issues and Stroke Recovery in Elderly Patients

Elderly stroke, drowsiness, and reversed sleep-wake cycle?

Hello Doctor: My grandmother is 84 years old and had a stroke nearly a year ago, resulting in right-sided paralysis and aphasia.
She is currently only taking medication prescribed by her cardiologist and resides in a care facility.
During the Lunar New Year, when we brought her home, we noticed that she has been excessively drowsy.
When called, she opens her eyes briefly but quickly falls back asleep, seemingly unable to control her alertness.
After inquiring with the facility, we learned that she sometimes does not sleep at night and has a reversed day-night cycle.
Should we schedule a follow-up appointment with her neurologist? Would medication be helpful in this situation, or would you recommend consulting another specialty?

Yun, 30~39 year old female. Ask Date: 2024/02/17

Dr. Jiang Junyi reply Neurology

Dear Ms.
Yun,
You mentioned that "the institution informed us that grandma sometimes does not sleep at night and has a reversed day-night cycle." This issue needs to be considered from multiple perspectives.
For sleep disturbances and reversed day-night cycles, it is recommended to implement non-pharmacological approaches for adjustment.
Non-pharmacological strategies include:
1.
Treating daily activities such as meals, bathroom visits, bathing, and brushing teeth as important events to schedule.
Ensure there are rest periods between activities and adjust flexibly based on daily conditions.
2.
Organizing daytime activities, such as daily walks and sun exposure, encouraging the elderly to participate in activities at long-term care centers to reduce daytime sleeping opportunities while simultaneously slowing the decline of physical and cognitive functions.
3.
Establishing a bedtime routine, such as consistently brushing teeth, using the bathroom, listening to soothing music, or having a five-minute massage before sleep.
Regarding pharmacological options, there are various medications used to aid sleep in clinical practice:
1.
For insomnia due to depression following a stroke, antidepressants can be used to assist with sleep.
2.
For insomnia due to musculoskeletal pain following a stroke, muscle relaxants and analgesics can be utilized.
3.
For insomnia due to cognitive dysfunction or delirium following a stroke, antipsychotic medications may be appropriate.
4.
For insomnia due to sleep apnea following a stroke, continuous positive airway pressure (CPAP) devices can be employed.
5.
For insomnia due to limb movements during sleep following a stroke, benzodiazepines (BZD) may be prescribed.
Treatment for insomnia may include both pharmacological and behavioral modifications.
Current medications are generally safer than those used in the past, and the use of sleep medications requires ongoing adjustments.
It is crucial to avoid falls due to medication use and to prevent daytime drowsiness caused by these medications.
However, older adults metabolize medications more slowly, so it is advisable to consult a specialist familiar with geriatric pharmacotherapy when addressing insomnia.
I hope that through treatment, we can identify the physiological and psychological issues causing insomnia and improve the sleep and quality of life for the elderly.
I recommend accompanying grandma to consult a neurologist to discuss further treatment and management (such as controlling risk factors, rehabilitation plans post-stroke, etc.).
Wishing you and grandma good health, safety, and happiness.
Thank you for your inquiry, and feel free to discuss further.
Sincerely,
Dr.
Jiang Junyi

Reply Date: 2024/02/17

More Info

Managing sleep issues in elderly patients, particularly those recovering from a stroke, is a multifaceted challenge that requires careful consideration of both medical and behavioral interventions. In the case of your grandmother, who is 84 years old and has experienced significant health challenges following a stroke, her symptoms of excessive daytime sleepiness and disrupted sleep patterns warrant a thorough evaluation.

Importance of Follow-Up with a Neurologist
Given your grandmother's history of stroke, it is crucial to follow up with a neurologist. Stroke can lead to various complications, including cognitive impairments and changes in sleep patterns. The excessive daytime sleepiness she is experiencing could be a result of several factors, including post-stroke fatigue, medication side effects, or even the development of sleep disorders such as sleep apnea or restless leg syndrome. A neurologist can help assess her cognitive function and determine if there are underlying neurological issues contributing to her sleep disturbances.

Behavioral Interventions
Before considering medication, implementing non-pharmacological strategies can be beneficial. Here are some recommendations:
1. Structured Daily Routine: Establishing a consistent daily schedule can help regulate her sleep-wake cycle. This includes setting regular times for meals, activities, and bedtime. Engaging her in daytime activities, such as light exercise or social interactions, can also promote alertness during the day and improve nighttime sleep.

2. Environmental Adjustments: Creating a conducive sleep environment is essential. Ensure her sleeping area is dark, quiet, and comfortable. Limiting exposure to screens and bright lights in the evening can help signal to her body that it is time to wind down.

3. Sleep Hygiene Practices: Encourage practices such as a calming bedtime routine. This could include activities like reading, listening to soft music, or gentle stretching. Avoiding caffeine and heavy meals close to bedtime can also improve sleep quality.

Pharmacological Considerations
If behavioral interventions do not yield significant improvements, it may be necessary to consider pharmacological options. However, medication should be approached cautiously in elderly patients due to the risk of side effects and interactions with other medications. Here are some potential options:
1. Antidepressants: If her sleep issues are linked to underlying depression or anxiety, certain antidepressants can help improve sleep quality.

2. Sleep Aids: Medications such as melatonin or low-dose benzodiazepines may be considered, but they should be prescribed and monitored by a healthcare professional familiar with geriatric pharmacology.

3. Addressing Underlying Conditions: If sleep apnea or other sleep disorders are suspected, a sleep study may be warranted. Treatment for sleep apnea, such as continuous positive airway pressure (CPAP) therapy, can significantly improve sleep quality and overall health.

Multidisciplinary Approach
In addition to consulting a neurologist, involving other specialists may be beneficial. A geriatrician can provide comprehensive care tailored to the unique needs of elderly patients, while a sleep specialist can conduct further evaluations and recommend targeted treatments for sleep disorders.

Conclusion
In summary, your grandmother's symptoms of excessive daytime sleepiness and disrupted sleep patterns following her stroke are concerning and should be addressed through a combination of medical evaluation and behavioral interventions. Regular follow-up with a neurologist is essential to monitor her cognitive function and overall recovery. Implementing structured daily routines and sleep hygiene practices can help improve her sleep quality. If necessary, pharmacological treatments should be considered under the guidance of a healthcare professional experienced in geriatric care. By taking a comprehensive approach, you can help enhance your grandmother's quality of life and support her recovery journey.

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