Diagnosis and Treatment of Sleep Disorders in Older Adults
Alexandrea Harmell
Sonia Ancoli-Israel
It is a common misconception that sleep-related problems are an inevitable and expected part of the aging process. Although many normal structural and homeostatic changes do take place as one gets older, poor sleep is typically attributed to other factors more prevalent in older adults such as circadian rhythm shifts or medical/psychiatric comorbidities and the medications used to treat them. The complexity and wide variety of contributing causes of sleep disorders in older patients are often challenging for clinicians to address. Additionally, many clinicians do not fully realize the seriousness of sleep-related problems in older people and consequently many sleep complications in older adults are often overlooked or not properly investigated (1).
The focus of this chapter is to present an overview of normal age-related changes in sleep structure and to outline specific sleep disorders commonly reported in the elderly along with the various alternatives used to treat them. This chapter will also highlight special cases that pertain specifically to the older patient such as sleep in long-term care facilities and sleep related changes as a result of neurodegenerative diseases.
NORMAL AGE-RELATED CHANGES IN SLEEP STRUCTURE
Sleep patterns change throughout the life cycle, but by age 60, sleep architecture changes have stabilized (2). Although there is some debate about whether older adults need just as much sleep as younger adults, it is agreed that many older adults have difficulty getting the sleep they need.
The overall differences in sleeping patterns between young and old adults can be partly attributed to changes in sleep structure, homeostatic processes, and circadian rhythms and will be outlined below in more detail.
Structural Changes in Sleep Architecture
There has been a documented change in the distribution of sleep stages with older adults spending more time in the lighter sleep stages (N1 and N2) and less time in deep sleep (N3; slow wave sleep) and dream sleep (REM or R sleep) compared to younger adults. This reduction in slow wave sleep is progressive with advancing age. However, as Ohayon et al. (2) have shown, slow wave sleep is already decreasing in middle-age and by age 60, stabilizes. However, there are more frequent shifts from one sleep stage to another and more transient arousals lasting for only a few seconds, which result in more fragmented sleep and more subjective complaints of poor sleep.
As many as 57% of older adults complain of significant sleep disruption and almost 20% complain of early morning awakening despite wanting to sleep later (3). This decreased sleep time results in insufficient sleep, which has been shown to be associated with negative consequences including impaired immune functioning, depression, hypertension, and increased mortality.
Homeostatic Changes
Homeostatic and circadian changes dramatically affect sleep and wake regulation, and these changes have been documented in the older adult (4). The homeostatic process involves the need or drive to sleep building up throughout the day and then dissipating during sleep. In insomnia, the drive to sleep is weaker than the drive to
stay awake. Sleep maintenance problems may be due to homeostatic mechanisms declining too quickly and the sleep drive only being sufficient in the first part of the night and losing momentum during the second part.
stay awake. Sleep maintenance problems may be due to homeostatic mechanisms declining too quickly and the sleep drive only being sufficient in the first part of the night and losing momentum during the second part.
As mentioned, slow wave sleep declines with age and this decline may also be indicative of reduced sleep drive (5,6). Some studies show that after sleep deprivation and therefore after a buildup of sleep drive, older patients sleep much longer and show more deep sleep delta activity compared to their sleep before sleep deprivation. This is further evidence supporting the notion that older individuals may have a reduced homeostatic drive that interferes with their sleep.
Circadian Rhythm Changes
Another fundamental change that occurs with age is a dampening in the amplitude of circadian rhythms. This disruption may produce changes in body temperature (where minimum temperature occurs much earlier in the nocturnal sleeping period), hormonal levels, urinary electrolytes, and rest/activity profiles.
Several studies have indicated that with age comes a desynchronization of the internal circadian rhythm. For instance, Wever reported that 70% of older subjects and only 20% of younger subjects became desynchronized during “free running” (e.g., not synchronized to environmental time cues and fluctuating on a cycle slightly longer than 24 hours) (7).
Circadian rhythms and oscillations in neurons and hormones throughout a 24-hour cycle are controlled by the suprachiasmatic nucleus (SCN), situated in the anterior part of the hypothalamus. In adults over the age of 80 years, the volume of the SCN decreases by 40% (8). Further evidence for age-related disruptions in circadian rhythmicity comes from animal studies showing that lesioned SCNs result in disrupted circadian rhythms with animals wakeful during the night, sleepy during the day, and napping more during the day (9). This sleep pattern is very similar to that of older patients, thus supporting one theory that age-related decay of the SCN may play a pivotal role in sleep disturbances.
Another hypothesis for major changes in circadian rhythms in older adults has to do with the environment. Deficient zeitgebers, or exogenous cues that synchronize endogenous time-keeping biological clocks, cause circadian rhythms to become disrupted with age (10). Exposure to bright light, the strongest zeitgeber, is reduced in older patients. One study reported that the median amount of time community-dwelling older adults spent in light over 1000 lux was only 4% (11). Older adults also have less exposure to other zeitgebers that entrain the SCN. For instance, it has been widely reported that physical activity helps normalize sleep/wake cycles; therefore, older adults who may be functionally impaired are more likely to have more disturbed sleep.
Sleep and circadian rhythms are also controlled by melatonin, a hormone secreted during darkness from the pineal gland. However, melatonin levels decrease with age in part due to less bright light exposure and a significant decline in the number of beta-adrenergic receptors in the pineal gland (12).
SLEEP DISORDERS
Insomnia
The most common sleep-related complaint in the elderly is insomnia. Insomnia is defined as both persistent difficulties falling and/or staying asleep despite the opportunity for rest, which result in the disruption in one’s ability to carry out daily affairs.
Prevalence of Insomnia
In the general population, the prevalence of insomnia has been estimated to be around 10% to 20%. However, one study of more than 9000 adults aged 65 and older found that 42% reported difficulty falling or staying asleep. In that same sample,
participants with health issues including depression, respiratory symptoms, or who were on medications for various medical problems were considerably more likely to report incidence of insomnia (13). Others have also confirmed this relationship between insomnia and medical illness (14).
participants with health issues including depression, respiratory symptoms, or who were on medications for various medical problems were considerably more likely to report incidence of insomnia (13). Others have also confirmed this relationship between insomnia and medical illness (14).
Consequences of Insomnia
Insufficient sleep at night in the older adult can lead to serious consequences. Low sleep efficiency (ratio of time asleep given time in bed), decreased total sleep time, and increased wake time have all been associated with greater risk of functional disability (15), falling (16), cognitive impairment (particularly problems with memory) (17,18), and mortality (19,20).
Medical and Psychiatric Comorbidities
In the older adult, it is important to recognize that subjective complaints of insomnia are often comorbid with medical and/or psychiatric conditions. In a study of insomnia in older adults, 28% of subjects complained of chronic insomnia, but only 7% of the new cases occurred in the absence of one of these related conditions (13). Patients with chronic medical disease appear particularly prone to sleep disturbances, with studies indicating that 31% of patients with arthritis and 66% of patients with chronic pain report difficulty falling asleep. Eighty-one percent of patients with arthritis, 85% of patients with chronic pain, and 33% of patients with diabetes mellitus report trouble with staying asleep, and 45% of patients with gastroesophageal reflux disease, 50% of patients with congestive heart failure, and 44% of patients with cancer report difficulty both falling and staying asleep (21, 22 and 23).
In a survey of over 1500 community-dwelling older adults, depression, heart disease, bodily pain, and memory problems were all associated with more prevalent symptoms of insomnia. Foley et al. concluded that these results suggest that the sleep complaints common in older adults are often secondary to their comorbidities and not to aging per se (3).
Sleep difficulties are also associated with a number of psychiatric disorders, with depression being strongly linked to insomnia (24). Several studies have confirmed that there is a strong bidirectional relationship between depression and insomnia. Insomnia is a predictor of developing depression 1 to 3 years later (25,26). Most epidemiologic studies show insomnia prevalence is greater in older women than older men (27). Older women with insomnia also seem to be especially susceptible to depression (28, 29 and 30).
The relationship between psychiatric disorders and insomnia is complex. Often when the psychiatric disorder is treated, there are still residual problems with sleep (31). For this reason, the psychiatric problem and the sleep problem should be treated concurrently.
Sleep and Medications
Since older adults have high rates of medical and psychiatric disorders they often take multiple prescription and over-the counter medications. These medications can alter and severely interfere with sleep.
Commonly used medications in older patients, such as beta-blockers, bronchodilators, corticosteroids, decongestants, and diuretics, as well as other cardiovascular, neurological, psychiatric, and gastrointestinal medications, can all adversely affect sleep. Antidepressants, such as selective serotonin reuptake inhibitors (SSRIs) and serotonergic and noradrenergic reuptake inhibitors, are known to have side effects that disrupt sleep and cause insomnia or produce daytime fatigue. Sedating antihistamines commonly taken to relieve colds or allergies, even if over-the-counter, often contain substances like pseudoephedrine or phenylpropanolamine that may induce drowsiness or cause sleeplessness, respectively.
Sometimes, individuals self-medicate and use alcohol to induce sleep. Th is has paradoxical effects because although alcohol may decrease the time required to fall asleep, the second half of the sleep period is often disrupted, leading the individual to wake up in the middle of the night. This sleep disruption can have a dangerous cumulative effect, leading to daytime sleepiness and fatigue.
Sometimes, individuals self-medicate and use alcohol to induce sleep. Th is has paradoxical effects because although alcohol may decrease the time required to fall asleep, the second half of the sleep period is often disrupted, leading the individual to wake up in the middle of the night. This sleep disruption can have a dangerous cumulative effect, leading to daytime sleepiness and fatigue.
Polypharmacy and prescriptions of sedative drugs is increasingly prevalent among older adults (32), often without consideration of its effect on the patient’s sleep. When possible, sedating medications should be administered prior to bedtime, while stimulating medications and diuretics should be taken during the day. In the elderly, the risk of falls, cognitive impairment, and respiratory depression are of particular concern, although recent data suggest that insomnia and disrupted sleep, and not hypnotics, increase the risk of falls (16,33, 34 and 35). Recent studies by Stone and colleagues further support this finding, by demonstrating an increase in risk of falls associated with sleep duration and fragmentation in subjective and objective measures of sleep in older women independent of benzodiazepine use and other risk factors for falls (36,37).
Treatment of Insomnia
As with all sleep disorders, a thorough sleep history is required in order to evaluate and make the diagnosis of insomnia. To best identify precipitating and perpetuating factors related to insomnia, it is helpful to obtain a history about a typical 24-hour day. It is also helpful to have the patient keep a sleep diary to estimate the amount of time it takes to fall asleep, number of awakenings, sleep quality, duration, and timing. Other information about the sleep environment, medical and psychiatric history, and use of alcohol, medications, and caffeine should also be obtained.
In 2005, the NIH State of the Science conference on insomnia concluded that the most effective and safe treatment for insomnia is cognitive-behavioral therapy (CBT) (38). CBT includes both the cognitive component of challenging irrational or distorted beliefs about sleep, and the behavioral component, which includes education on proper sleep hygiene, relaxation techniques, sleep restriction, and stimulus control therapy. In older adults, CBT-I has been shown to be as effective as medications in the short-run and to have better long-term outcomes in the treatment of insomnia (39). Although pharmacological treatments may be of more immediate help, particularly in the acute treatment phase, in order to maintain long-term clinical gains, nonpharmacological or combined approaches may be more effective.
When prescription medications are indicated, the National Institutes of Health (NIH) State of the Science Conference on Insomnia (38)
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