eMedicine Specialties > Psychiatry > Geriatric

Sleep Disorder, Geriatric

Author: 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
Coauthor(s): Subir Vij, MD, MPH, Assistant Professor, Department of Medicine, Eastern Virginia Medical School; Medical Director, Portsmouth Community Health Center; Angela Gentili, MD, Director of Geriatrics Fellowship Program, Associate Professor, Department of Internal Medicine, Virginia Commonwealth University Health System and McGuire Veterans Affairs Medical Center
Contributor Information and Disclosures

Updated: Aug 3, 2009

Introduction

Background

Sleep disorders are commonly underdiagnosed and a significant source of concern in the geriatric population.¹  Several diverse factors may contribute to sleep disturbances in a large proportion of the elderly. These contributing factors include changes associated with aging, such as retirement, health problems, death of spouse/family members, as well as changes in circadian rythym.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 (including excessive daytime sedation, physical, psychological, cognitive problems affecting overall health of the patient⁴ ), sleep disorders have been implicated with an increased mortality rate. Unfortunately, the number of medications increases with age, which in itself can lead to more morbidity, mortality, side effects such as falls⁵ , cognitive impairment, financial stressors, and even sleep disturbances.⁶ Treating insomnia in the elderly can improve the overall health of the patient, but care must be taken when medications are used in this particular population.¹

Treatments for sleep disorders include over-the-counter and prescription medications, behavioral treatments, relaxation techniques, sleep hygiene, sleep restriction, light therapy⁷ , cognitive behavioral therapies^3,8 , valerian, Tai Chi, yoga, meditation, acupuncture, and acupressure⁹ .

See Medscape's Insomnia and Sleep Health Resource Center.

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 age increase in adults and hypnotic drug use, which would decrease sleep latency.
• 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.¹⁰

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. More than 50% of elderly people have insomnia.¹¹ 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). Sleep apnea 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.

In a study of sleep-disordered breathing (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 sleep-disordered breathing. In addition, different forms of sleep-disordered breathing were associated with the different types of arrhythmias.

Polysomnography in 2,911 participants showed that the odds of atrial fibrillation (P=0.01) and of complex ventricular ectopy (P <.001) 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 (odds ratio [OR], 2.69; 95% CI, 1.61-4.47) than with complex ventricular ectopy (OR, 1.27; 95% CI, 0.97-1.66). In contrast, obstructive sleep apnea and hypoxia was associated with complex ventricular ectopy; participants in the highest hypoxia category had an increased odds of CVE (OR, 1.62; 95% CI, 1.23-2.14) compared with the lowest quartile. The results suggest that different sleep-related stresses may contribute to atrial and ventricular arrhythmogenesis in older men.¹²

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.¹³

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

History

Evaluation begins with a complete sleep history. The assessment of this patient includes a detailed multidisciplinary approach. Sleep problems in the elderly include hypersomnia, disorientation, delirium, impaired intellect, decreased cognition, psychomotor complaints, increase accidents, falls, and financial issues.¹⁴ In the geriatric population, the most frequent complaints are problems initiating or maintaining sleep.¹⁵

• 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 periodic limb movements in sleep [PLMS] from sleep apnea [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 sleep apnea [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.

Obtain a complete medical history, and perform a complete mental status examination, physical examination, and neurologic examination to assist with the evaluation and rule out other disease processes.

Although the mental status examination varies for each patient, examples of items to assess are listed below. Because of the variability of the presentation of the disorder, any or all symptoms of insomnia or other sleep disorders may manifest depending on the presenting subtype.

• Appearance - Ranges from well-groomed to disheveled
• Eye contact - Appropriate, increased, or decreased
• Facial expression - Neutral, angry, euphoric, sad
• Motor - Possible psychomotor agitation or retardation
• Cooperativeness - May cooperate or may be uncooperative
• Mood - Euthymic, depressed, or manic
• Affect - Ranges from appropriate to flat
• Speech - Ranges from poverty to flight of ideas or pressured
• Suicidal ideation - May or may not be present. Remember that individuals with this disorder have a lifetime risk for suicide, which is significant. Inquiring about suicidal ideation at each visit is always important. In addition, the interviewer should inquire about past acts of self-harm or violence. Ask the following types of questions when determining suicidal ideation or intent. "Do you have any thoughts of wanting to harm or kill yourself?" "Do you have any thoughts that you would be better off dead?" If the reply is positive for these thoughts, inquire about specific plans, suicide notes, family history (anniversary reaction), and impulse control. Also, ask how the patient views suicide to determine if a suicidal gesture or act is ego-syntonic or ego-dystonic. Next, determine if the patient will contract for safety. 
• Homicidal ideation - May or may not be present. Inquiring about homicidal ideation or intent during each patient interview is also important. Ask the following types of questions to help determine homicidal ideation or intent. "Do you have any thoughts of wanting to hurt anyone?" "Do you have any feelings or thoughts that you wish someone were dead?" If the reply to one of these questions is positive, ask the patient if he or she has any specific plans to injure someone and how he or she plans to control these feelings if they occur again.
• Orientation - To elicit responses concerning orientation (ie, person, place, time, situation), ask the patient questions, as follows. "What is your full name?" "Do you know where you are?" "What is the month, date, year, day of the week, and time?" "Do you know why you are here?"
• Consciousness - Levels of consciousness are determined by the interviewer and are rated as (1) coma, characterized by unresponsiveness; (2) stuporous, characterized by response to pain; (3) lethargic, characterized by drowsiness; and (4) alert, characterized by full awareness.
• Concentration and attention - Ask the patient to subtract 7 from 100, then to repeat the task from that response. This is known as serial 7s. Next, ask the patient to spell the word world forward and backward.
• Reading and writing - Ask the patient to write a simple sentence (noun/verb). Then, ask patient to read a sentence (eg, "Close your eyes."). The part of the Mental Status Examination evaluates the patient's ability to sequence.
• Memory - To evaluate a patient's memory, have him or her respond to the following prompts. For remote memory, "What was the name of your first grade teacher?" For recent memory, "What did you eat for dinner last night?" For immediate memory, "Repeat these 3 words: pen, chair, flag." Tell the patient to remember these words. Then, after 5 minutes, have the patient repeat the words.
• Delusions - Any type possible (eg, paranoid, thought insertion or withdrawal, grandiose, bizarre, to name a few)
• Hallucinations - Any type possible (most common is auditory, least common is gustatory)
• Insight - Range varies
• Judgment - Range

Causes

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 > 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.

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