Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Geriatric Sleep Disorder

  • Author: Angela Gentili, MD; Chief Editor: Iqbal Ahmed, MBBS, FRCPsych(UK)  more...
 
Updated: Jun 09, 2016
 

Background

Sleep disorders are commonly underdiagnosed and are a significant source of concern in the geriatric population.[1] Several diverse factors may contribute to sleep disturbances in a large percentage of the elderly population, including retirement, health problems, death of spouse/family members, and changes in circadian rhythm.[2] 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 not considered a normal part of aging.[3, 4]

In addition to affecting quality of life—because of excessive daytime sleepiness, as well as physical, psychological, and cognitive problems[4] —sleep disorders have been implicated with increased mortality. In addition, the number of medications used tends to increase with age, which in itself can lead to increased morbidity, mortality, and side effects such as falls,[5] cognitive impairment, and even sleep disturbances.[6]

When a person experiences significant and prolonged sleep disturbance, they will generally contact their primary care provider for an evaluation. This evaluation may consist of a medical history review, concomitant medications, physical examination, lab work, and a Mental Status Examination. If the provider is unable to determine the underlying causality of the sleep disturbance, referral to a psychiatrist or sleep specialist may be necessary. At this point, a more in-depth examination is performed to rule out other potential contributing factors and to reach a diagnosis. Determining the causality of the sleep disturbance is imperative to be able to educate patients and caregivers about treatment alternatives.

Treating insomnia in the elderly can improve overall health, but care must be taken when medications are used in this particular population.[1] Treatments for insomnia include over-the-counter and prescription medications, behavioral treatments, relaxation techniques, sleep hygiene, sleep restriction, light therapy,[7] cognitive-behavioral therapies,[3, 8] valerian, tai chi, yoga, meditation, acupuncture, and acupressure.There is even an FDA-approved bedside device for insomnia that cools and pumps fluid to a forehead pad that is worn throughout the night. The device helps reduce latency to stage 1 and stage 2 sleep.[60]

Next

Pathophysiology

Normal sleep is organized into different stages that cycle throughout the night. Polysomnographic studies have classified the sleep stages into rapid-eye-movement (REM) sleep and non-REM sleep

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 is subdivided into 4 stages. Stages 1 and 2 constitute light sleep, and stages 3 and 4 are called deep sleep or [#OLE_LINK1]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; in extreme old age (>90 years), 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.

Definitions

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

Total sleep period 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

Total sleep time 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.

Sleep latency

Sleep latency 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 increases in age and hypnotic drug use, which would decrease sleep latency.

Wake after sleep onset

Wake after sleep onset 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).[10] Pain, restless legs, and dyspnea have also been identified as factors in arousal during sleep.

Sleep efficiency

Sleep efficiency 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

Studies have shown that a gradual decline in nocturnal penile tumescence (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.[11]

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 persons have been observed to be more easily aroused from sleep by auditory stimuli, suggesting increased sensitivity to environmental stimuli.

Previous
Next

Etiology

Sleep apnea and periodic limb movements in sleep

Two primary sleep disorders that increase with age are sleep apnea (SA) and periodic limb movements in sleep (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 more than 5 apneas per hour) was 28% in men and 20% in women.[12] They also found that among a random sample of patients in a medical ward, the prevalence of SA was higher (33%).[12] 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 patient from sleep. In 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.

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 used. An attempt should be made to manage the underlying condition before initiating treatment for sleep.

A patient who is depressed may experience an increase in sleep latency, a decrease in REM latency, prolonged initial rapid-eye-movement (REM) sleep, an increase in nighttime wakefulness, a decrease in slow-wave sleep (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.

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 take 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, and appetite suppressants.

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.

Other causes

Other causes of sleep disorders in geriatric patients include the following:

  • 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 (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
  • Gastroesophageal reflux disease (GERD)
  • Constipation
  • Pruritic skin conditions
Previous
Next

Epidemiology

More than 50% of elderly people have insomnia.[13] 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.

Older women are more likely to experience insomnia than older men. In a large epidemiologic study of people older than 70 years, 35% of women reported moderate to severe insomnia, compared to only 13% of men.[14] 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.

Previous
Next

Prognosis

In addition to affecting quality of life, sleep disorders have been associated with increased mortality. Two primary sleep disorders that increase with age are sleep apnea (SA) and periodic limb movements in sleep (PLMS). Sleep apnea can result in daytime hypersomnolence, systemic hypertension, cardiac arrhythmias, cor pulmonale, and sudden death. In a random sample of 427 older volunteers, 45% had PLMS, and they reported dissatisfaction with sleep, sleeping alone, and kicking at night. Yaffe et al suggested that older women with sleep-disordered breathing (SDB), characterized by recurrent arousals from sleep and intermittent hypoxemia, have an increased risk of developing cognitive impairment.[15]

In a study of SDB and nocturnal cardiac arrhythmias in older men, Mehra et al found that the likelihood of atrial fibrillation or complex ventricular ectopy (CVE) increased along with the severity of SDB. In addition, different forms of SDB were associated with the different types of arrhythmias.[16]

Polysomnography in 2,911 participants showed that the odds of atrial fibrillation and of complex ventricular ectopy increased with increasing quartiles of the respiratory disturbance index (a major index including all apneas and hypopneas). Central sleep apnea was more strongly associated with atrial fibrillation than with complex ventricular ectopy. In contrast, obstructive sleep apnea and hypoxia were associated with complex ventricular ectopy; participants in the highest hypoxia category had an increased odds of CVE compared with those in the lowest quartile. The results suggest that different sleep-related stresses may contribute to atrial and ventricular arrhythmogenesis in older men.[16]

Previous
Next

Patient Education

Individuals should be made aware that obtaining 8 hours of sleep per night is not crucial. Sleep needs are individualized. Although one person may need 9 hours of sleep, another person may need only 5 hours. Also, the amount of sleep required may change with age. If a significant change in amount of sleep occurs but there are no disturbances in daily functioning, there shouldn't be a cause for worry. When significant disturbances in daily functioning have occurred, it is important to identify the cause of the sleep disturbance and discuss available treatment options.

A variety of treatment options are available for insomnia and do not necessarily include the use of prescription medications. However, if prescription medications are warranted, there are many to choose from. Certain medications should be avoided in the elderly population (see Medication).

Experts suggest stimulus control, which means using the bed for only sleep and sex. If people are used to reading or watching television in bed, they are encouraged to leave the bedroom and engage in a relaxing activity elsewhere until they are sleepy and ready to return to bed.

Teaching patients muscle-relaxation techniques to reduce tension and promote sleep is also useful. Regardless of the underlying causes of insomnia, general habits should be practiced for good sleep.

Patients should be instructed to go to bed at the same time, wake up at the same time, and avoid daytime napping, caffeine, heavy meals, nicotine, alcohol, and exercise at bedtime. Sedentary elderly persons should be encouraged to start a daily exercise program in the morning, as moderate training (60 min/d) has been shown to improve sleep quality.[17] Another useful tool is to turn the bedroom into an environment that is quiet, dark, and cool and ultimately promotes sleep.

The Web sites below provide further education on insomnia. These sites have information on signs and symptoms, causality, preventive measures, complications, treatments, and even current enrollment in clinical trials for insomnia.

Previous
 
 
Contributor Information and Disclosures
Author

Angela Gentili, MD Director of Geriatric Medicine Fellowship Program, Professor of Internal Medicine, Division of Geriatric Medicine, Virginia Commonwealth University Health System and McGuire Veterans Affairs Medical Center, Richmond, VA

Angela Gentili, MD is a member of the following medical societies: Virginia Geriatrics Society, American Geriatrics Society

Disclosure: Nothing to disclose.

Coauthor(s)

Guy E Brannon, MD Associate Clinical Professor of Psychiatry, Louisiana State University Health Sciences Center; Director, Adult Psychiatry Unit, Chemical Dependency Unit, Clinical Research, Brentwood Behavior Health Company

Disclosure: Received income in an amount equal to or greater than $250 from: Sunovion; Forest.

Chief Editor

Iqbal Ahmed, MBBS, FRCPsych(UK) Faculty, Department of Psychiatry, Tripler Army Medical Center; Clinical Professor of Psychiatry, Uniformed Services University of the Health Sciences; Clinical Professor of Psychiatry, Clinical Professor of Geriatric Medicine, University of Hawaii, John A Burns School of Medicine

Iqbal Ahmed, MBBS, FRCPsych(UK) is a member of the following medical societies: Academy of Psychosomatic Medicine, American Neuropsychiatric Association, American Society of Clinical Psychopharmacology, Royal College of Psychiatrists, American Association for Geriatric Psychiatry, American Psychiatric Association

Disclosure: Nothing to disclose.

Acknowledgements

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

References
  1. Subramanian S, Surani S. Sleep disorders in the elderly. Geriatrics. Dec 2007. 62(12):10-32.

  2. Avidan AY. Sleep in the geriatric patient population. Semin Neurol. Mar 2005. 25(1):52-63.

  3. Mahowald MW, Bornemann MA. Sleep Complaints in the geriatric patient. Minn Med. Oct 2007. 90(10):45-7.

  4. Cole C, Richards K. Sleep disruption in older adults. Harmful and by no means inevitable, it should br assessed for and treated. Am J Nurs. May 2007. 107(5):40-9.

  5. Latimer Hill E, Cummings RG, Lewis R, Carrington S, Le Couteur DG. Sleep disturbance and falls in older people. J Ger A bio Sci Med. Jan 2007. 62(1):62-6.

  6. Barry PJ, Gallagher P, Ryan C. Inappropriate prescribing in geriatric patient. Curr Psychiatry Rep. Feb 2008. 10(1):37-43.

  7. Gammack JK. Light therapy for insomnia in older adults. Clin Geritr Med. Feb 2008. 24(1):139-49.

  8. Rybarczyk B, Lopez M, Benson R, Alsten C, Stepanski E. Efficacy of two behavioral treatment progrmas for comorbid geriatric insomnia. Psychol Aging. Jun 2002. 17(2):288-98.

  9. Gooneratne NS. Complementary and alternative medicine for sleep disturbance in older adults. Clin Geriatr Med. Feb 2008. 24(1):121-38.

  10. Webb WB. Age-related changes in sleep. Clin Geriatr Med. 1989 May. 5(2):275-87. [Medline].

  11. Zepelin H, McDonald CS. Age differences in autonomic variables during sleep. J Gerontol. 1987 Mar. 42(2):142-6. [Medline].

  12. Martin J, Shochat T, Ancoli-Israel S. Assessment and treatment of sleep disturbances in older adults. Clin Psychol Rev. 2000 Aug. 20(6):783-805. [Medline].

  13. Kamel NS, Gammack JK. Insomnia in the elderly: cause, approach, and treatment. Am J Med. Jun 2006. 119(6):463-9.

  14. Byles JE, Mishra GD, Harris MA. The experience of insomnia among older women. Sleep. Aug 2005. 1:28(8):972-9.

  15. Yaffe K, Laffan AM, Harrison SL, et al. Sleep-disordered breathing, hypoxia, and risk of mild cognitive impairment and dementia in older women. JAMA. 2011 Aug 10. 306(6):613-9. [Medline].

  16. Mehra R, Stone KL, Varosy PD, Hoffman AR, Marcus GM, Blackwell T, et al. Nocturnal Arrhythmias across a spectrum of obstructive and central sleep-disordered breathing in older men: outcomes of sleep disorders in older men (MrOS sleep) study. Arch Intern Med. 2009 Jun 22. 169(12):1147-55. [Medline]. [Full Text].

  17. Lira FS, Pimentel GD, Santos RV, et al. Exercise training improves sleep pattern and metabolic profile in elderly people in a time-dependent manner. Lipids Health Dis. 2011 Jul 6. 10:1-6. [Medline]. [Full Text].

  18. Mirsa S, Malow BA. Evaluation of sleep distubances in older adults. Clin Geriatr Med. Feb 2008. 24(1):15-26.

  19. Ancoli-Israel S, Ayalon. Diagnosis and treatment of sleep disorders in older adults. Am J Geriatr Psychiatry. Feb 2006. 14(2):95-103.

  20. Cheng SK, Dizon J. Computerised cognitive behavioural therapy for insomnia: a systematic review and meta-analysis. Psychother Psychosom. 2012. 81(4):206-16. [Medline].

  21. Tariq SH, Pulisetty S. Pharmacotherapy for insomnia. Clin Geriatr Med. Feb 2008. 24(1):93-105.

  22. The American Geriatrics Society 2012 Beers Criteria Update Expert Panel. American Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. American Geriatrics Society. Available at http://www.americangeriatrics.org/files/documents/beers/2012BeersCriteria_JAGS.pdf. Accessed: May 21, 2012.

  23. Beland SG, Preville M, Dubois MF, et al. Benzodiazepine use and quality of sleep in the community-dwelling elderly population. Aging Ment Health. 2010 Sep. 14(7):843-50. [Medline].

  24. Béland SG, Préville M, Dubois MF, et al. The association between length of benzodiazepine use and sleep quality in older population. Int J Geriatr Psychiatry. 2011 Sep. 26(9):908-15. [Medline].

  25. Lankford A, Rogowski R, Essink B, Ludington E, Heith Durrence H, Roth T. Efficacy and safety of doxepin 6 mg in a four-week outpatient trial of elderly adults with chronic primary insomnia. Sleep Med. 2012 Feb. 13(2):133-8. [Medline].

  26. Krystal AD, Durrence HH, Scharf M, Jochelson P, Rogowski R, Ludington E, et al. Efficacy and Safety of Doxepin 1 mg and 3 mg in a 12-week Sleep Laboratory and Outpatient Trial of Elderly Subjects with Chronic Primary Insomnia. Sleep. 2010 Nov. 33(11):1553-61. [Medline]. [Full Text].

  27. 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. 1999 Jul. 47(7):784-91. [Medline].

  28. Ancoli-Istael S. Sleep disorders in older adults. A primary care guide to assessing 4 common sleep problems in geriatric patients. Geriactrics. Jan 2004. 59(1):37-40.

  29. Avidan AY. Sleep changes and dosorders in the elderly patient. Curr Neurol Neurosci Rep. Mar 2002. 2(2):178-85.

  30. Barthlen GM. Sleep disorders. Obstructive sleep apnea syndrome, restless legs syndrome, and insomnia in geriatric patients. Geriatrics. Nov 2002. 57(11):34-9.

  31. Benca RM. Diagnosis and Treatment of Chronic Insomnia: A Review. Psychiatr Serve. 2005. 56:323-343.

  32. Boot BP, Boeve BF, Roberts RO, Ferman TJ, Geda YE, Pankratz VS. Probable rapid eye movement sleep behavior disorder increases risk for mild cognitive impairment and Parkinson disease: a population-based study. Ann Neurol. 2012 Jan. 71(1):49-56. [Medline].

  33. Buysse DJ. Insomnia, Depression, and Aging. Assessing sleep and mood interactions in older adults. Geriatrics. Feb 2004. 59(2):47-51.

  34. Cotroneo A, Gareri P, Lacava R, Cabodi S. Use of zolpidem in over 75-year-old patients with sleep disorders and comorbidities. Arch Gerontol Geriatr Suppl. 2004. 9:93-6.

  35. 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. 2000 Aug. 68(4):586-93. [Medline].

  36. 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].

  37. Gentili A, Edinger JD. Sleep disorders in older people. Aging (Milano). 1999 Jun. 11(3):137-41. [Medline].

  38. Gentili A, Weiner DK, Kuchibhatil M, Edinger JD. Factors that disturb sleep in nursing home residents. Aging (Milano). 1997 Jun. 9(3):207-13. [Medline].

  39. 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. 2000 May 15. 47(10):921-7. [Medline].

  40. Koo BB, Blackwell T, Ancoli-Israel S, Stone KL, Stefanick ML, Redline S. Association of incident cardiovascular disease with periodic limb movements during sleep in older men: outcomes of sleep disorders in older men (MrOS) study. Osteoporotic Fractures in Men (MrOS) Study Group. Circulation. 2011 Sep 13. 124(11):1223-31. [Medline].

  41. Kryger M, Monjan A, Bliwise D, Ancoli_Israel S. Sleep, health, and aging. Bridging the gap between science and clinical practice. Geriactrics. Jan 2004. 59(1):24-6,29-30.

  42. Marsh G. Sleep problems in the elderly. Psychiatry Consultation-Liaison Psychiatry and Behavioral Medicine. 1993. 2:1-14.

  43. Mazza M, Della Marca G, De Risio S, Mennuni GF, Mazza S. Sleep disorders in the elderly. Clin Ter. Sep 2004. 155(9):391-4.

  44. O'Keeffe. Secondary causes of restless leg syndrome in older people. Age Ageing. Jul 2005. 34(4):349-52.

  45. Raji MA, Brady SR. Mirtazapine for treatment of depression and comorbidity in alzheimer disease. Ann Pharmacother. Sep 2001. 35(9):1024-7.

  46. Rechtschaffen A, Bergmann BM, Gilliland MA, Bauer K. Effects of method, duration, and sleep stage on rebounds from sleep deprivation in the rat. Sleep. 1999 Feb 1. 22(1):11-31. [Medline].

  47. Shimazaki M, Martin JL. Do herbal agents have a place in the treatment of sleep problems in log-term care?. J Am Med Dir Assoc. May 2007. 8(4):248 - 52.

  48. Singh H, becker PM. Novel therapeutic usage of low-dose doxepin hydrochloride. Expert Opin Investig Drugs. aug 2007. 16(8):1295-305.

  49. Vitiello MV. Effective treatments for age-related sleep disturbances. Geriatrics. 1999 Nov. 54(11):47-52; quiz 54. [Medline].

  50. Weaver EM, Kapur V, Yueh B. Polysomnography vs self-reported measures in patients with sleep apnea. Arch Otolaryngol Head Neck Surg. 2004 Apr. 130(4):453-8. [Medline].

  51. Willcox SM, Himmelstein DU, Woolhandler S. Inappropriate drug prescribing for the community-dwelling elderly. JAMA. 1994 Jul 27. 272(4):292-6. [Medline].

  52. Young T, Skatrud J, Peppard PE. Risk factors for obstructive sleep apnea in adults. JAMA. 2004 Apr 28. 291(16):2013-6. [Medline].

  53. 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. 1998 Sep. 53(5):M391-4. [Medline].

  54. Zepelin H. Sleep disorders. J Gerontol. 1983 May. 38(3):384. [Medline].

  55. Berry SD, Lee Y, Cai S, Dore DD. Nonbenzodiazepine sleep medication use and hip fractures in nursing home residents. JAMA Intern Med. 2013 May 13. 173(9):754-61. [Medline].

  56. FDA Drug Safety Communication: FDA warns of next-day impairment with sleep aid Lunesta (eszoplicone) and lowers recommended dose. May 15, 2014. www.fda.gov. Available at http://www.fda.gov/downloads/Drugs/DrugSafety/UCM397277.pdf. Accessed: 6/4/2014.

  57. FDA Drug Safety Communication: FDA approves new label changes and dosing for zolpidem products and a recommendation to avoid driving the day after using Ambien CR. May 14, 2013. www.fda.gov. Available at http://www.fda.gov/Drugs/DrugSafety/ucm352085.htm. Accessed: 6/4/14.

  58. [Guideline] Nakajima GA, Wenger NS. Quality indicators for the care of depression in vulnerable elders. J Am Geriatr Soc. 2007 Oct. 55 Suppl 2:S302-11. [Medline].

  59. McCleery J, Cohen DA, Sharpley AL. Pharmacotherapies for sleep disturbances in Alzheimer's disease. Cochrane Database Syst Rev. 2014 Mar 21. 3:CD009178. [Medline].

  60. Anderson, P. FDA Approves New Device for Insomnia. Medscape Medical News. Available at http://www.medscape.com/viewarticle/864509. June 8, 2016; Accessed: June 9, 2016.

 
Previous
Next
 
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.