AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

Sleep disorders are common and significant complaints of older people. A large proportion of older people are at risk for sleep disturbances, which may be caused by many factors such as physical illness or symptoms, increased use of medications, changes in social patterns, retirement, death of a spouse or loved one, and changes in circadian rhythm. Changes in sleep patterns may be part of the normal aging process; however, many of these disturbances may be related to pathological processes that are associated with aging. In addition to affecting quality of life, sleep disorders have been implicated with excess mortality.

Pathophysiology

Normal sleep is organized into different stages that cycle throughout the night. Polysomnographic studies have classified the sleep stages into the following categories:

• Rapid eye movement sleep
  • Rapid eye movement (REM) sleep (ie, paradoxical desynchronized sleep) is the stage of sleep during which muscle tone decreases markedly; this stage is associated with bursts of conjugate gaze and dreaming.
  • Relative amounts of REM sleep are maintained until extreme old age, when they show some decline.
• Non-REM sleep
  • Non-REM sleep is subdivided into 4 stages. Stages 1 and 2 constitute light sleep; stages 3 and 4 are called deep sleep or slow-wave sleep (SWS).
  • With aging, an increase in the duration of stage 1 sleep and an increase in the number of shifts into stage 1 sleep occur.
  • Stages 3 and 4 decrease markedly with age, and, in extreme old age (>90 y), stages 3 and 4 may disappear completely. Some studies, however, have found that elderly women tend to have normal or even increased stage 3 sleep, whereas men have normal or reduced stage 3 sleep.

The following definitions are provided:

• Time in bed: Older individuals spend more time lying in bed at night without attempting to sleep or unsuccessfully trying to sleep. They also use the bed for resting and napping during the day.
• Total sleep period: This refers to the time from sleep onset to the final awakening from the main sleep period of the day. Total sleep period increases with age because of the increase in the number of awakenings.
• Total sleep time: This refers to the total sleep period minus the time spent awake during the sleep period. Studies have found the total sleep time to be either reduced or unchanged in the older population compared with younger age groups.
• Sleep latency: This is the time from the decision to sleep to the onset of sleep. Studies have found considerable variability in individuals. In females, sleep latency has been related to both age and hypnotic drug use.
• Wake after sleep onset: This is the time spent awake from sleep onset to final awakening. An increase occurs in the time spent awake after sleep onset in the older population. Webb was able to attribute 38% of nocturnal arousals in a study to physical discomfort (eg, bladder distention, urinary urgency). Pain, restless legs, and dyspnea have also been identified as factors in arousal during sleep.
• Sleep efficiency: This is the ratio of total sleep time to nocturnal time in bed. Most studies have found sleep efficiency to be decreased in the older population.
• Nocturnal penile tumescence (NPT): Studies show that a gradual decline in NPT during REM sleep occurs with age, even though the duration of REM sleep remains fairly constant until extreme old age.
• Other changes: Few data describe cardiovascular changes during sleep in the older population. Zepelin found that auditory awakening thresholds from stage 4 sleep were significantly lower during the first night's sleep in a sleep laboratory in older men than in younger men.

Older people spend more time in bed to get the same amount of sleep they obtained when they were younger; however, the total sleep time, at most, is only slightly decreased, with an increase in nocturnal awakenings and daytime napping. They often report having earlier bedtimes and an increased sleep latency (time to fall asleep), but excessive daytime somnolence is not part of normal aging. Older subjects have been observed to be more easily aroused from sleep by auditory stimuli, suggesting increased sensitivity to environmental stimuli.

Frequency

United States

Sleep disturbance or insomnia is the third most common patient complaint, ranking behind headaches and the common cold. Approximately 15% of the adult population in the United States has insomnia of significant enough severity to seek medical attention. Of the US population, 1.7% receive a hypnotic prescription annually, and another 0.8% purchase nonprescription sleep aids. Fifty million Americans occasionally take some form of sleep medication.

Mortality/Morbidity

In addition to affecting the quality of life, sleep disorders have been implicated with excess mortality. Two primary sleep disorders that increase with age are sleep apnea (SA) and periodic limb movements in sleep (PLMS). SA can result in daytime hypersomnolence, systemic hypertension, cardiac arrhythmias, cor pulmonale, and sudden death. Among a random sample of 427 older volunteers, 45% had PLMS, and they each reported dissatisfaction with sleep, sleeping alone, and kicking at night.

Sex

Older women are more likely to experience insomnia than older men. In a large epidemiological study of people older than 70 years, 35% of women reported moderate-to-severe insomnia, compared to only 13% of men.

Age

More than one half of people older than 64 years who live at home and two thirds of people older than 64 years who reside in a long-term care facility are estimated to have some form of sleep disturbance.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

Evaluation begins with a complete sleep history.

• Whenever possible, interview the bed partner because he or she often notices problems with the patient's sleep of which the patient is unaware.
• A good sleep history includes questions relating to typical sleep at night; daytime functioning; presence of medical conditions; caffeine, alcohol, drug, and food intake before bedtime; and the patient's history of psychiatric and mood disorders.
• The following questions may also be considered:
• • Do you go to bed at the same time every night?
  • How long does it take to fall asleep? (sleep latency)
  • Do you use the bed for other purposes like watching television and reading?
  • How many times do you wake up every night?
  • Are your sleep patterns the same during weekdays and weekends?
  • Are your waking times irregular?
  • What do you do when you wake up at night?
  • What is the estimated time spent sleeping at night?
  • Do you take naps in the daytime?
  • Do you fall asleep while reading, watching television, talking to friends, or driving? (assesses excessive daytime somnolence)
  • Do you snore, gasp for breath, stop breathing, or wake up confused? (differentiates PLMS from SA)
  • Do you have a morning headache? (SA)
  • Do you kick repetitively at night? (PLMS)
• These data help determine the sleep pattern of the patient, the severity of the disorder, and the possible causes leading to sleep disturbances. They also help differentiate between SA and PLMS.
• Having the patient maintain a sleep diary for several weeks before arriving for assessment is advisable. This provides a reliable perspective about the patient's condition for the clinician, and the patient learns more about his or her sleeping patterns.

Physical

Physical examination and the Mental Status Examination may give clues to the causes of sleep disturbance (eg, obesity with resulting obstructive SA, depression). These are further discussed below in Causes. In addition, potential complications of sleep disorders, such as hypertension from obstructive SA, may also be discovered.

Causes

Two primary sleep disorders that increase with age are SA and PLMS.

SA is the lack of breathing during sleep, and it can be obstructive (upper airway occlusion), central (primary neurologic disease), or mixed. People with SA may experience waking with gasping, confused wandering in the night, and thrashing during sleep.

Because waking resolves obstructive apnea, avoid sedatives and hypnotics in these patients because such agents can further relax the pharynx dilators, thereby worsening the apnea. Martin et al found that among healthy older adults living in community settings, the prevalence of SA (defined by > 5 apneas per h) was 28% in men and 20% in women.

Martin et al also found that among a random sample of patients in a medical ward, the prevalence of SA was higher (33%). This may be because of the high incidence of congestive heart failure (CHF) in this group. Significantly, many elderly inpatients are prescribed hypnotics, which can exacerbate SA. SA occurs in 42% of people with dementia who live in nursing homes and correlates with cognitive function.

An interaction between SA and the cognitive deterioration of dementia is likely, which could be exacerbated with the use of hypnotics and other CNS depressants. SA can result in daytime hypersomnolence, systemic hypertension, cardiac arrhythmias, cor pulmonale, and sudden death.

PLMS or nocturnal myoclonus is repetitive, unilateral, or bilateral stereotyped leg jerks that arouse the subject from sleep.

Among a random sample of 427 older volunteers, 45% had PLMS; this statistic correlated with dissatisfaction with sleep, sleeping alone, and kicking at night. The incidence of nocturnal myoclonus increases with age, and the likelihood of an associated sleep-wake complaint is related to the absolute number and intensity of the leg movements.

• Medical disorders
• • Chronic pain disorders (eg, osteoarthritis, metastatic diseases) are one of the most common reasons cited by the older population for poor sleep. Osteoarthritis, causing joint stiffness at night, makes moving during sleep difficult and painful.
  • Left ventricular failure associated with orthopnea and paroxysmal nocturnal dyspnea can lead to frequent awakenings.
  • A Cheyne-Stokes breathing pattern attributable to a cardiac or cerebral cause and treatment of this disorder with respiratory stimulants or nocturnal oxygen therapy can often improve sleep.
  • Patients with chronic obstructive pulmonary disease (COPD) have nocturnal worsening of hypoxemia, which occurs predominantly during REM sleep.
  • Lower urinary tract symptoms (LUTS), including benign prostatic hypertrophy and detrusor instability, may contribute to poor sleep.
  • Patients with Parkinson disease may experience urinary frequency and difficulty in turning over and getting out of bed, which leads to sleep fragmentation.
  • Tachyarrhythmias may contribute to poor sleep.
  • Gastroesophageal reflux disease (GERD) may contribute to poor sleep.
  • Constipation may contribute to poor sleep.
  • Pruritic skin conditions may contribute to poor sleep.
• Psychiatric disorders
• • Psychiatric illnesses such as dementia and depression often result in insomnia. Of elderly patients with major depressive disorders, 50% report substantial sleep impairment. Clinical tools such as the Mini–Mental State Examination (MMSE) and/or Geriatric Depression Scale (GDS) should be administered to these patients. Management of the underlying condition should be tried before initiating treatment for sleep.
  • A patient who is depressed may experience an increase in sleep latency, a decrease in REM latency, prolonged initial REM sleep, an increase in nighttime wakefulness, a decrease in SWS, and early morning awakening.
  • Patients with dementia, especially those with Alzheimer disease, have lower sleep efficiency; an increase in the length of stage 1 sleep; a decrease in stage 3, stage 4, and REM sleep; more sleep disruptions and awakenings; episodes of nocturnal wandering; and an increase in daytime napping. Currently, no effective therapy for dementia-related sleep disorders exists.
  • Personality and affective disorders can lead to poor sleep or subjective complaints of poor sleep. This can further manifest as early-morning wakefulness, a reduction of stage 4 sleep, and short REM latency, which is more pronounced in the older population. Bipolar disorders, schizophrenia, posttraumatic stress disorder (PTSD), and anxiety disorders can result in difficulty initiating and/or maintaining sleep.
• Medications
• • Older patients consume an average of 5-9 daily medications, some of which can interfere with sleep and wakefulness.
  • Sedative antidepressants (eg, amitriptyline) and sedative neuroleptics (eg, chlorpromazine, clozapine) can cause impaired performance and daytime drowsiness.
  • Avoid amitriptyline in older people because of the anticholinergic effects and possible confusion.
  • Beta-blockers, especially lipophilic compounds (eg, metoprolol, propranolol), can cause difficulty falling asleep, an increased number of awakenings, and vivid dreams.
  • The chronic use of sedative-hypnotics often confounds normal sleep-wake functioning because of drug withdrawal effects or daytime drowsiness.
  • The xanthines theophylline and caffeine are stimulants that increase wakefulness while they decrease SWS and total sleep time. The effect of caffeine can last as long as 8-14 hours and may be more pronounced in older patients because of decreased caffeine clearance with decreased liver function. Furthermore, caffeine is present in many over-the-counter medications, including analgesics, cold or allergy remedies, appetite suppressants, and tonics used for fatigue, anorexia, and debility.
  • Nicotine is also a stimulant and affects sleep in a manner similar to that of caffeine. Several studies have shown that people of all ages who smoke have more sleep disturbances than people who do not smoke, primarily difficulty falling asleep and decreased sleep duration.

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to be Considered

Psychiatric disorders

• Anxiety disorder
• Bipolar disorder
• Schizophrenia
• Posttraumatic stress disorder

• Parkinsonism
• Dementia
• Delirium

• Sleep apnea
• Chronic obstructive pulmonary disease
• Sleep-related asthma

• Gastroesophageal reflux disease
• Coronary artery disease
• Pain and nocturia

• Restless leg syndrome
• Periodic limb movements in sleep
• Nocturnal leg cramps

Circadian rhythm sleep disorders

Many abnormalities of the sleep-wake cycle manifest as sleep-wake disorders. These conditions include the following:

• Jet lag: A study performed on airline pilots operating on transmeridian routes found that the older the pilot, the greater the cumulative sleep loss.
• Acute and chronic shift-work insomnia
• Delayed sleep-phase syndromes
• Advanced sleep-phase syndromes
• Non–24-hour circadian rhythms
• Disorganized circadian rhythms

Psychophysiological insomnia

This is associated with acute emotional conflicts or reactions and is transient in nature. If it is associated with frustration to fall asleep, thereby resulting in arousal, it can be persistent in nature.

Environmental sleep disorders

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Tests

• After a detailed history, a clinician may find it necessary to refer the patient to a sleep disorders center for evaluation of SA.
• • A full-night polysomnogram records brain waves, using electroencephalography (EEG); eye movement, using electrooculography (EOG); chin muscle tension and leg movements, using electromyography (EMG); heart rate, using ECG; and blood oxygen saturation levels, using pulse oximetry.
  • Portable recorders are also used as screening tools. These devices are placed on patients in the afternoon, and patients are then sent home to sleep on their beds at night. These systems are more convenient and less expensive than a laboratory polysomnogram.
  • If a polysomnogram cannot be obtained, proceed with extreme caution.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical Care

• The geriatric population is the largest group of people who use hypnotic drugs. People older than 60 years receive 33% of all hypnotic prescriptions, although they comprise only 14% of the population. The use of sedative-hypnotics by the elderly population has been associated with falls, hip fractures, and daytime carryover symptoms. When evaluating a patient, exclude primary sleep disorders and review medications and other contributory medical conditions.
• Patient education on age-related changes in sleep and good sleep hygiene may be adequate treatment for many older adults. If the initial history and physical examination findings do not reveal a serious underlying cause, a trial of improved sleep hygiene is the best initial approach. The common recommended measures include the following:
• • Maintain a regular wake-up time.
  • Maintain a regular sleeping time.
  • Decrease or eliminate daytime naps.
  • Exercise daily but not immediately before bedtime.
  • Use the bed only for sleeping or sex.
  • Do not read or watch television in bed.
  • Do not use bedtime as worry time.
  • Avoid heavy meals at bedtime.
  • Limit or eliminate alcohol, caffeine, and nicotine before bedtime.
  • Maintain a routine period of preparation for bed (eg, washing up, brushing).
  • Control the nighttime environment with comfortable temperature, quietness, and darkness.
  • Wear comfortable, loose-fitting clothes to bed.
  • If unable to sleep within 30 minutes, get out of bed and perform a soothing activity, such as listening to soft music or reading, but avoid exposure to bright light during these times.
  • Get adequate exposure to bright light during the day.
  • Avoid daytime naps. Explaining to the patient that daytime naps decrease nighttime sleep is helpful.
• People who are overweight and habitually snore loudly may be helped by weight loss. All people who snore loudly should abstain from alcohol or other sedatives before going to bed. They should also take measures to avoid supine sleeping (eg, by taping a tennis ball to the back of their bedclothes).
• In the absence of SA, contributing conditions, such as allergies, nasal pathology, or nasopharyngeal enlargement, should be sought and adequately managed by intranasal corticoid sprays or evaluated by an ear, nose, and throat specialist.
• If the sleep problem is secondary to some medical problem, then treat the primary problem rather than the sleep problem.
• Polysomnography is indicated when primary sleep disorders such as SA or PLMS are suspected.

Consultations

Consultation with appropriate specialists may be indicated, depending on the underlying causes of the sleep disorder, eg, psychiatric consultation for severe depression, pulmonary or surgical consultation for obstructive SA.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

The goal of pharmacotherapy is to reduce insomnia. Usually, treatment is on a short-term basis while any underlying cause of the insomnia is treated.

Drug Category: Hypnotics/benzodiazepines

According to the 1990 National Institutes of Health (NIH) consensus statement, hypnotics should be used on a limited short-term period and should only be used for older adults with transient insomnia because of increased hypnotic-related adverse effects. Avoid over-the-counter hypnotics (eg, diphenhydramine) because they have strong anticholinergic effects.

Barbiturates also are not indicated for insomnia, and psychiatric consultation may become necessary for patients receiving barbiturates for many years. The advantage of chloral hydrate is its rapid onset and rapid metabolism, although whether it is safe and well tolerated in the older population is unclear. Barbiturates are effective only for short-term use, losing much of their effectiveness after 2 weeks of administration. They are not used for insomnia in the elderly.

Benzodiazepines remain the most commonly prescribed agents for sleep. The major advantages of the benzodiazepines (short and intermediate acting) are their relative safety in overdose, lower addiction risk, and weak interaction with other drugs. They should be used for a maximum of 2-3 weeks, or, if used longer, they should be used for only 2-3 nights per week. Because continued use results in increasing tolerance and increasing dose, care must be taken to avoid dependence. While the short- and intermediate-acting benzodiazepines are less likely to be associated with falls and hips fractures than the barbiturates and the longer-acting benzodiazepines, they are still a risk factor for falls in the elderly population.

Benzodiazepines are also more likely to produce the most pronounced rebound and withdrawal symptoms after discontinuation of the drug. Tapering the dosage can reduce rebound insomnia after discontinuation of these agents. Do not use long-acting agents (eg, flurazepam) in the older population because of the long half-life (2-8 d) and the tendency to accumulate over several days or weeks. These drugs are associated with daytime sedation, lethargy, ataxia, falls, and cognitive and psychomotor impairment.

Drug Category: Antidepressants

Sedating antidepressants (eg, trazodone, nefazodone), in low doses, can also be prescribed at bedtime for insomnia. Indicated for use when patient has a previous history of substance abuse. As with other antidepressants, little scientific evidence supports efficacy in the treatment of insomnia without associated depression, but clinical studies report usefulness in chronic insomnia.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Deterrence/Prevention:

• Sleep disorders in older patients can arise from multiple and diverse factors.
• Older patients with either short or long sleep duration need thorough evaluation. A careful review of sleep history and sleep hygiene, a comprehensive history of drug use, reports from spouse, sleep logs, and education regarding age-related sleep change should be integral parts of the evaluation of sleep disturbance.
• Use hypnotics with extreme caution and only for transient sleep disturbances.
• The most common primary sleep disorders in older people are SA, PLMS, or both.
• In summary, physicians must reevaluate the approach to treating the widespread sleep complaints of the older population.

Patient Education:

• Educating the partner and family of the patient regarding proper sleep hygiene is vital for the success in the management of this problem
• For excellent patient education resources, visit eMedicine's Mental Health and Behavior Center and Sleep Disorders Center. Also, see eMedicine's patient education articles Sleep Disorders and Aging, Insomnia, REM Sleep Behavior Disorder, Understanding Insomnia Medications, Periodic Limb Movement Disorder, and Sleeplessness and Circadian Rhythm Disorder.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• Failure to diagnose SA and PLMS

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

• Alessi CA, Yoon EJ, Schnelle JF, et al. A randomized trial of a combined physical activity and environmental intervention in nursing home residents: do sleep and agitation improve?. J Am Geriatr Soc. Jul 1999;47(7):784-91. [Medline].
• Edinger JD, Fins AI, Glenn DM, et al. Insomnia and the eye of the beholder: are there clinical markers of objective sleep disturbances among adults with and without insomnia complaints?. J Consult Clin Psychol. Aug 2000;68(4):586-93. [Medline].
• Friedman L, Benson K, Noda A, et al. An actigraphic comparison of sleep restriction and sleep hygiene treatments for insomnia in older adults. J Geriatr Psychiatry Neurol. 2000;13(1):17-27. [Medline].
• Gentili A, Weiner DK, Kuchibhatil M, Edinger JD. Factors that disturb sleep in nursing home residents. Aging (Milano). Jun 1997;9(3):207-13. [Medline].
• Gentili A, Edinger JD. Sleep disorders in older people. Aging (Milano). Jun 1999;11(3):137-41. [Medline].
• Jean-Louis G, Kripke DF, Ancoli-Israel S, et al. Sleep duration, illumination, and activity patterns in a population sample: effects of gender and ethnicity. Biol Psychiatry. May 15 2000;47(10):921-7. [Medline].
• Marsh G. Sleep problems in the elderly. Psychiatry Consultation-Liaison Psychiatry and Behavioral Medicine. 1993;2:1-14.
• Martin J, Shochat T, Ancoli-Israel S. Assessment and treatment of sleep disturbances in older adults. Clin Psychol Rev. Aug 2000;20(6):783-805. [Medline].
• Rechtschaffen A, Bergmann BM, Gilliland MA, Bauer K. Effects of method, duration, and sleep stage on rebounds from sleep deprivation in the rat. Sleep. Feb 1 1999;22(1):11-31. [Medline].
• Vitiello MV. Effective treatments for age-related sleep disturbances. Geriatrics. Nov 1999;54(11):47-52; quiz 54. [Medline].
• Weaver EM, Kapur V, Yueh B. Polysomnography vs self-reported measures in patients with sleep apnea. Arch Otolaryngol Head Neck Surg. Apr 2004;130(4):453-8. [Medline].
• Webb WB. Age-related changes in sleep. Clin Geriatr Med. May 1989;5(2):275-87. [Medline].
• Willcox SM, Himmelstein DU, Woolhandler S. Inappropriate drug prescribing for the community-dwelling elderly. JAMA. Jul 27 1994;272(4):292-6. [Medline].
• Young T, Skatrud J, Peppard PE. Risk factors for obstructive sleep apnea in adults. JAMA. Apr 28 2004;291(16):2013-6. [Medline].
• Youngstedt SD, Kripke DF, Klauber MR, et al. Periodic leg movements during sleep and sleep disturbances in elders. J Gerontol A Biol Sci Med Sci. Sep 1998;53(5):M391-4. [Medline].
• Zepelin H, McDonald CS. Age differences in autonomic variables during sleep. J Gerontol. Mar 1987;42(2):142-6. [Medline].
• Zepelin H. Sleep disorders. J Gerontol. May 1983;38(3):384. [Medline].

Article Last Updated: Aug 4, 2005