eMedicine Specialties > Psychiatry > Geriatric

Sleep Disorder, Geriatric

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
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

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.

Differential Diagnoses

Other Problems to Be Considered

Psychiatric disorders

• Anxiety disorder
• Bipolar disorder
• Schizophrenia
• Posttraumatic stress disorder
• Depression
• Morning headaches

• Parkinsonism
• Dementia
• Delirium

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

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

• Restless legs 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

Laboratory Studies

Ferritin levels of less than 50 ng/mL were present in elderly patients with restless legs syndrome.

Other Tests

After a detailed history, a clinician may find it necessary to refer the patient to a sleep disorders center for evaluation of sleep apnea.

• 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.

Treatment

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 sleep apnea.

Medication

The first priority should be to determine the underlying cause of the sleep disorder, rather than just treat insomnia symptomatically. Usually, treatment on a short-term basis together with sleep hygiene is appropriate for transient insomnia, for example, second to bereavement or acute hospitalization. Insomnia in this population is treated with antidepressants, benzodiazepines, nonbenzodiazepines, melatonin agonist, and herbals. Medications, if used, should be started with low dose and monitored for side effects.¹⁶

In March of 2007, the FDA requested that the manufacturers of 13 sedative-hypnotic medications (such as, temazepam, flurazepam, triazolam, estazolam, zolpidem, zalepon, eszoplicone, quazepam, ramelton, butabarbitol, and secobarbitol) change their labeling to include stronger language about the risks of severe allergic reactions and complex sleep-related behaviors (eg, driving, making telephone calls, eating, having sex while not fully awake).

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 older patients.

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 older 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.

Newer nonbenzodiazepines hypnotics like zolpidem, zaleplon, and eszoplicone do not cause rebound insomnia or withdrawal symptoms at discontinuation. Eszoplicone is approved for prolonged use.

Triazolam (Halcion)

Depresses all levels of CNS (eg, limbic and reticular formation), possibly by increasing activity of GABA. Rapidly absorbed and eliminated and may cause rebound insomnia, anterograde amnesia, and confusion, especially in elderly individuals.

Dosing

Adult

Older patient: 0.125 mg PO hs; use 0.25 mg only in patients who are exceptional and do not respond to a trial of lower dose; not to exceed 0.25 mg/d

Pediatric

Not established

Interactions

Increased toxicity of benzodiazepines in CNS with coadministration of phenothiazines, barbiturates, alcohol

Contraindications

Documented hypersensitivity; narrow-angle glaucoma; untreated obstructive SA; history of substance abuse

Precautions

Pregnancy

X - Contraindicated; benefit does not outweigh risk

Precautions

Caution and close monitoring needed in hepatic disease, low albumin levels, renal or pulmonary disease; causes residual daytime sedation, impairs cognition, and increases risk of falls, especially in older people; caution with other CNS depressants

Zolpidem (Ambien)

Structurally dissimilar to benzodiazepines but similar in activity with the exception of having reduced effects on skeletal muscle and seizure threshold. Advantage of no rebound insomnia or anxiety at discontinuation. At recommended doses, it is as effective as triazolam. Adverse CNS effects (eg, nightmares, agitation, drowsiness) noted in 10% of patients. As with benzodiazepine hypnotics, is approved only for short-term use (3-4 wk maximum) and, if used longer, for only 2-3 nights/wk.

Dosing

Adult

5 mg PO hs; not to exceed 10 mg

Pediatric

Not established

Interactions

Increases toxicity of alcohol and CNS depressants

Contraindications

Documented hypersensitivity; breastfeeding

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Monitor elderly people for impaired cognitive or motor performance

Zaleplon (Sonata)

Short-acting pyrazolopyrimidine hypnotic with full agonistic activity on central benzodiazepine receptors (B21 type). At small doses, it is an affective sleep inducer with limited risk of disturbance in morning performance. Like zolpidem, zaleplon is particularly suitable for treatment of initial insomnia and does not cause rebound insomnia and withdrawal symptoms at discontinuation. Approved only for short-term use (3-4 wk maximum), and, if used longer, limit use to only 2-3 nights/wk.

Dosing

Adult

5 mg PO hs

Pediatric

Not established

Interactions

Cimetidine significantly increases levels

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Failure of insomnia to remit after 7-10 d of treatment may indicate need for evaluation of a primary psychiatric or medical illness; reevaluate patient if needs to be taken for >2-3 wk (not to prescribe in quantities exceeding a 1-mo supply); caution in patients exhibiting signs or symptoms of depression

Eszopiclone (Lunesta)

Nonbenzodiazepine hypnotic pyrrolopyrazine derivative of the cyclopyrrolone class. The precise mechanism of action is unknown but is believed to interact with GABA-receptor at binding domains close to or allosterically coupled to benzodiazepine receptors. Indicated for insomnia to decrease sleep latency and improve sleep maintenance. Short half-life of 6 h. Higher doses (ie, 2 mg for elderly adults and 3 mg for nonelderly adults) are more effective for sleep maintenance, whereas lower doses (ie, 1 mg for elderly adults and 2 mg for nonelderly adults) are suitable for difficulty in falling asleep.

Dosing

Adult

Nonelderly adults: 2 mg PO hs; may increase to 3 mg PO hs prn
Elderly adults: 1 mg PO hs initially; not to exceed 2 mg PO hs
Severe hepatic impairment: Do not exceed 2 mg PO hs

Pediatric

<18 years: Not established
>18 years: Administer as in adults

Interactions

CYP3A4 and CYP2E1 substrate; potent CYP3A4 inhibitors (eg, ketoconazole, itraconazole, clarithromycin, nefazodone, ritonavir, nelfinavir) increase AUC, C_max, and t_1/2 and therefore potential toxicity (decrease dose); potent CYP3A4 inducers (eg, rifampicin) increase clearance; coadministration with alcohol or other CNS depressants may increase effect and toxicity (decrease dose); coadministration with olanzapine may decrease DSST scores; sleep onset may be delayed if taken with or immediately after a high-fat or heavy meal

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

May cause dyspepsia, headache, or coldlike symptoms; rare adverse effects associated with hypnotics include short-term amnesia, confusion, agitation, hallucinations, worsened depression, or suicidal thoughts; high doses (ie, 6-12 mg) produce euphoric effects similar to those of diazepam 20 mg; anxiety, abnormal dreams, nausea, and upset stomach may occur within 48 h after discontinuing; alertness may be affected the following day; use caution while operating machinery or driving a car

Lorazepam (Ativan)

Sedative hypnotic with short onset of effects and relatively long half-life. By increasing the action of GABA, which is a major inhibitory neurotransmitter in the brain, may depress all levels of CNS, including limbic and reticular formation. Helpful for sleep maintenance insomnia and should be taken 30 min before bedtime. Causes less withdrawal and rebound than short-acting benzodiazepines but may cause more daytime sedation.

Dosing

Adult

0.5-1 mg PO hs

Pediatric

Not established

Interactions

Toxicity of benzodiazepines in CNS increases when used concurrently with alcohol, phenothiazines, barbiturates

Contraindications

Documented hypersensitivity; preexisting CNS depression, hypotension, and narrow-angle glaucoma

Precautions

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution in renal or hepatic impairment, myasthenia gravis, organic brain syndrome, or Parkinson disease;
like all benzodiazepines, danger of abuse and physical dependence; avoid abrupt cessation

Temazepam (Restoril)

Depresses all levels of CNS (eg, limbic and reticular formation), possibly by increasing activity of GABA. Intermediate-acting agent that is helpful for sleep-maintenance insomnia. If patients also have difficulty falling asleep, agent should be taken 30 min before bedtime. Causes less withdrawal and rebound than short-acting benzodiazepines but may cause more daytime sedation.

Dosing

Adult

15 mg PO hs

Pediatric

Not established

Interactions

Increased toxicity of benzodiazepines in CNS with coadministration of phenothiazines, barbiturates, alcohol

Contraindications

Documented hypersensitivity; narrow-angle glaucoma; untreated obstructive SA; history of substance abuse; severe uncontrolled pain

Precautions

Pregnancy

X - Contraindicated; benefit does not outweigh risk

Precautions

Caution with other CNS depressants, low albumin levels, or hepatic disease (may increase toxicity);
like all benzodiazepines, danger of abuse, addiction, and physical dependence; avoid abrupt cessation

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 and their use in patients with insomnia but without depression is not FDA approved and should be considered off label use.  

Doxepin (Adapin, Sinequan)

Increases concentration of serotonin and norepinephrine in the CNS by inhibiting their reuptake by presynaptic neuronal membrane. These effects are associated with a decrease in symptoms of depression.

Dosing

Adult

30-150 mg/d PO hs or 2-3 divided doses; gradually increase dose to 300 mg/d prn

Pediatric

<12 years: Not recommended
>12 years: 25-50 mg/d PO hs or bid/tid and increase gradually to 100 mg/d

Interactions

Decreases antihypertensive effects of clonidine but increases effects of sympathomimetics and benzodiazepines; effects of desipramine increase with phenytoin, carbamazepine, and barbiturates

Contraindications

Documented hypersensitivity; urinary retention; acute recovery phase following myocardial infarction; glaucoma

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution in cardiovascular disease, conduction disturbances, seizure disorders, urinary retention, hyperthyroidism and patients receiving thyroid replacement

Mirtazapine (Remeron)

Exhibits both noradrenergic and serotonergic activity. In cases of depression associated with severe insomnia and anxiety, shown to be superior to other SSRI drugs.

Dosing

Adult

15 mg PO hs initially; may increase by 15 mg increments q1-2wk, not to exceed 45 mg hs

Pediatric

Not established

Interactions

May increase effect of CNS depressants; concurrent administration with MAOI may trigger hypertensive crisis

Contraindications

Documented hypersensitivity; MAOI within 14 d

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

May cause drowsiness; discontinue use if patient develops sore throat, fever, or other signs of infection; suicide ideation is inherent in depression and may persist until significant remission occurs; severe neutropenia reported in clinical trials

Trazodone (Desyrel)

Antagonist at the 5-HT2 receptor and minimally inhibits the reuptake of 5-HT. Has negligible affinity for cholinergic and histaminergic receptors. Not associated with tolerance or withdrawal effects. Associated orthostatic hypotension can be minimized by administration with food. Limited data exist regarding efficacy in patients who are not depressed, and the FDA does not approve it as a hypnotic.

Dosing

Adult

50 mg PO hs

Pediatric

Not established

Interactions

May enhance response to alcohol, barbiturates, and other CNS depressants; cimetidine significantly increases levels of trazodone; serotonin syndrome may occur when used with other serotonergic agents, such as buspirone, meperidine, tramadol, dextromethorphan, triptans, mirtazapine, nefazodone, SSRIs, but especially with MAOIs

Contraindications

Documented hypersensitivity; MAOIs use within 14 d of initiating treatment

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Hypotension has occurred, including orthostatic hypotension and syncope; may produce drowsiness, dizziness, or blurred vision; patients taking this medication should be cautious while driving or performing other tasks requiring alertness, coordination, or dexterity; caution in cardiac disease, cerebrovascular disease, or seizures; discontinue therapy and reevaluate if priapism occurs

Nefazodone (Serzone)

Antagonist at the 5-HT2 receptor and inhibits the reuptake of 5-HT. Has negligible affinity for cholinergic and histaminergic receptors.

Dosing

Adult

50 mg PO hs

Pediatric

Not established

Interactions

Increases effects of digoxin, carbamazepine, triazolam, alprazolam, and protease inhibitors through its effect of inhibiting CYP450 3A4 enzyme; serotonin syndrome may occur when used with other serotonergic agents, such as buspirone, meperidine, tramadol, dextromethorphan, triptans, mirtazapine, SSRIs, but especially with MAOIs

Contraindications

Documented hypersensitivity; MAOIs use within 14 d of initiating treatment

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in cardiac disease, cerebrovascular disease, or seizures

Melatonin agonists

These agents may promote sleep. Ramelteon does not cause rebound insomnia or withdrawal symptoms at discontinuation. It is approved for prolonged use.

Ramelteon (Rozerem)

Melatonin receptor agonist with high selectivity for human melatonin MT₁ and MT₂ receptors. MT₁ and MT₂ are thought to promote sleep and be involved in maintaining circadian rhythm and normal sleep-wake cycle. Indicated for insomnia characterized by difficulty with sleep onset.

Dosing

Adult

8 mg PO 30 min before bedtime on empty stomach

Pediatric

Not established

Interactions

Major substrate of cytochrome P450 CYP1A2 and minor substrate of CYP2C and CYP3A4; strong CYP1A2 inhibitors (eg, fluvoxamine) increase AUC up to 190-fold and C_max 70-fold; strong CYP inducers (eg, rifampin) decrease total exposure by mean of 80%; strong CYP3A4 inhibitors (eg, ketoconazole) and strong CYP2C9 inhibitors (eg, fluconazole) may increase serum levels

Contraindications

Documented hypersensitivity; strong cytochrome P450 CYP1A2 inhibitors (eg, fluvoxamine); severe hepatic impairment

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

May affect reproductive hormones in adults (eg, decreased testosterone levels, increased prolactin levels), further study required to determine safety in prepubescent and pubescent children; caution with mild hepatic impairment; adverse effects leading to discontinuation in clinical trials included: dizziness, nausea, fatigue, headache, and worsening insomnia

Follow-up

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 sleep apnea, periodic limb movements in sleep, or both.
• In summary, clinicians must reevaluate the approach to treating the widespread sleep complaints of the older population.

Patient Education

Health professionals must continually educate themselves on the topic of sleep disorders in the geriatric population so they can properly educate the patients and caregivers about insomnia. With the aid of clinical studies and various forms of research, a wealth of new information on insomnia is available. These data inform health professionals about the different types of insomnia, available treatments, and good sleep practices. However, if this information is not utilized, it will be a huge disservice to the elderly patient population.

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.

Individuals should be made aware that obtaining 8 hours of sleep a night is not crucial. Sleep needs are individualized. Although one person may need 10 hours of sleep, another person may only need 5 hours. The amount of sleep we require tends to change with age. If a significant change in amount of sleep occurs, yet there are no disturbances in daily functioning, there shouldn't be a cause for worry. When significant disturbance in daily functioning has occurred, it is time to educate the patient about available treatment options. 

Today, a variety of options are available that 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 section for further information). If medication is not preferred, healthcare professionals can educate patients about other alternatives.
 
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 muscular 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. Another useful tool is to turn the bedroom into an environment that is quiet, dark, cool, and one that ultimately promotes sleep.

Please visit the following Web sites for further education on insomnia. These sites have information on signs and symptoms, causality, preventive measures, complications, treatments, and even current enrolling clinical trials for insomnia.

• Institute of Mental Health, Insomnia
• American Academy of Sleep Medicine, sleepeducation.com
• Holisticonline.com, Insomnia
• ClinicalTrials.gov, Insomnia: Behavioral Treatments

For other 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

Medicolegal Pitfalls

Failure to diagnose sleep apnea and periodic limb movements in sleep

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Keywords

sleep disturbances, sleep problems, sleep changes, sleep disorders, insomnia, sleep apnea, SA, hypersomnolence, sleep latency, sleep efficiency, periodic limb-movement disorder, PLMD, periodic limb-movement syndrome, periodic limb movement syndrome, periodic limb movements in sleep, PLMS, nocturnal myoclonus, rapid eye movement, REM, non-REM, paradoxical desynchronized sleep, slow-wave sleep, SWS, conjugate gaze, dreams, dreaming, nocturnal penile tumescence, NPT, electrooculography, EOG, circadian rhythms

Contributor Information and Disclosures

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
Guy E Brannon, MD is a member of the following medical societies: American Medical Association, American Medical Writers Association, American Psychiatric Association, American Society of Addiction Medicine, Association of Clinical Research Professionals, Louisiana State Medical Society, and Southern Medical Association
Disclosure: AstraZeneca Honoraria Speaking and teaching; Takeda Honoraria Speaking and teaching; Wyeth Honoraria Speaking and teaching; Janssen Honoraria Speaking and teaching; Pfizer Honoraria Speaking and teaching

Coauthor(s)

Subir Vij, MD, MPH, Assistant Professor, Department of Medicine, Eastern Virginia Medical School; Medical Director, Portsmouth Community Health Center
Subir Vij, MD, MPH is a member of the following medical societies: American College of Physician Executives, American College of Physicians, and American Medical Association
Disclosure: Nothing to disclose.

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
Angela Gentili, MD is a member of the following medical societies: American Geriatrics Society
Disclosure: Nothing to disclose.

Medical Editor

Sarah C Aronson, MD, Associate Professor, Departments of Psychiatry and Medicine, Case Western Reserve School of Medicine/University Hospitals of Cleveland
Sarah C Aronson, MD is a member of the following medical societies: American Academy of Family Physicians, American Medical Association, and American Psychiatric Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Iqbal Ahmed, MBBS, Professor, Department of Psychiatry, John A Burns School of Medicine, University of Hawaii
Iqbal Ahmed, MBBS is a member of the following medical societies: Academy of Psychosomatic Medicine, American Association for Geriatric Psychiatry, American Neuropsychiatric Association, and American Psychiatric Association
Disclosure: Nothing to disclose.

CME Editor

Harold H Harsch, MD, Program Director of Geropsychiatry, Department of Geriatrics/Gerontology, Associate Professor, Department of Psychiatry and Department of Medicine, Froedtert Hospital, Medical College of Wisconsin
Harold H Harsch, MD is a member of the following medical societies: American Psychiatric Association
Disclosure: lilly Honoraria Speaking and teaching; Forest Labs Honoraria Speaking and teaching; AstraZeneca Honoraria Speaking and teaching; Pfizer Grant/research funds Speaking and teaching; Northstar Grant/research funds Research; Novartis Grant/research funds research; Pfizer  Speaking and teaching; Sanofi-avetis Grant/research funds research; Otsuke Grant/research funds reseach; GlaxoSmithKline Grant/research funds research

Chief Editor

Stephen Soreff, MD, President of Education Initiatives, Nottingham, NH; Faculty, Metropolitan College of Boston University, Boston, MA
Stephen Soreff, MD is a member of the following medical societies: American College of Mental Health Administration and American Psychosomatic Society
Disclosure: Nothing to disclose.

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