Geriatric Sleep Disorder Clinical Presentation

Updated: Oct 14, 2016
  • Author: Glen L Xiong, MD; Chief Editor: Ana Hategan, MD, FRCPC  more...
  • Print
Presentation

History

Evaluation of sleep disorder in elderly patients begins with a complete sleep history. The assessment of includes a detailed multidisciplinary approach. Sleep-related problems in the elderly include hypersomnia, disorientation, delirium, impaired intellect, decreased cognition, psychomotor complaints, increased accidents, and falls. [29] In the geriatric population, the most frequent complaints are problems initiating or maintaining sleep. [30]

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; intake of caffeine, alcohol, drugs, or food before bedtime; and the 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, such as 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? (assessment of excessive daytime somnolence)
  • Do you snore, gasp for breath, stop breathing, or wake up confused? (differentiation of periodic limb movements in sleep [PLMS] from obstructive sleep apnea [OSA])
  • Do you have a morning headache? (OSA)
  • 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.

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), impulse control and access to firearms. If the patients has suicidal thoughts, the chart should document that the patient does not have an immediate plan or that he/she was referred for psychiatric hospitalization. [31]

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.

If the patient has homicidal ideation, refer the patient immediately for psychiatric hospitalization.

Next:

Physical Examination

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). 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.

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. Examples of items to assess in the Mental Status Examination are listed below.

  • 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
  • Homicidal ideation: May or may not be present
  • 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 the patient to read a sentence (eg, "Close your eyes."); this part of the Mental Status Examination evaluates the patient's ability to sequence
  • Memory: For remote memory, ask the patient, What was the name of your first grade teacher? For recent memory, ask the patient, What did you eat for dinner last night? For immediate memory, ask the patient to repeat 3 words: pen, chair, flag. Then, tell the patient to remember these words, and after 5 minutes, have the patient repeat the words.
  • Delusions: Any type possible (eg, paranoid, thought insertion or withdrawal, grandiose, bizarre)
  • Hallucinations: Any type possible (most common is auditory, least common is gustatory)
  • Insight: Range varies
  • Judgment: Range varies
Previous