Approach Considerations

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 by electroencephalography (EEG); eye movement by electro-oculography (EOG); chin muscle tension and leg movements by electromyography (EMG); heart rate by electrocardiography (ECG); and blood oxygen saturation levels by 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.

Ferritin levels of less than 50 ng/mL have been found to be present in elderly patients with restless legs syndrome.

Treatment & Management

Subramanian S, Surani S. Sleep disorders in the elderly. Geriatrics. Dec 2007. 62(12):10-32.
Avidan AY. Sleep in the geriatric patient population. Semin Neurol. Mar 2005. 25(1):52-63.
Mahowald MW, Bornemann MA. Sleep Complaints in the geriatric patient. Minn Med. Oct 2007. 90(10):45-7.
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.
Fu Y, Xia Y, Yi H, Xu H, Guan J, Yin S. Meta-analysis of all-cause and cardiovascular mortality in obstructive sleep apnea with or without continuous positive airway pressure treatment. Sleep Breath. 2016 Aug 8. [QxMD MEDLINE Link].
Lee WJ, Peng LN, Liang CK, Chiou ST, Chen LK. Long sleep duration, independent of frailty and chronic Inflammation, was associated with higher mortality: A national population-based study. Geriatr Gerontol Int. 2016 Sep 29. [QxMD MEDLINE Link].
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.
Barry PJ, Gallagher P, Ryan C. Inappropriate prescribing in geriatric patient. Curr Psychiatry Rep. Feb 2008. 10(1):37-43.
Gammack JK. Light therapy for insomnia in older adults. Clin Geritr Med. Feb 2008. 24(1):139-49.
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.
Gooneratne NS. Complementary and alternative medicine for sleep disturbance in older adults. Clin Geriatr Med. Feb 2008. 24(1):121-38.
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.
Webb WB. Age-related changes in sleep. Clin Geriatr Med. 1989 May. 5(2):275-87. [QxMD MEDLINE Link].
Zepelin H, McDonald CS. Age differences in autonomic variables during sleep. J Gerontol. 1987 Mar. 42(2):142-6. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Buratti L, Luzzi S, Petrelli C, Baldinelli S, Viticchi G, Provinciali L, et al. Obstructive Sleep Apnea Syndrome: An Emerging Risk Factor for Dementia. CNS Neurol Disord Drug Targets. 2016. 15 (6):678-82. [QxMD MEDLINE Link].
Sleep apnea increases dementia risk in older women. Harv Womens Health Watch. 2011 Nov. 19 (3):7. [QxMD MEDLINE Link].
Buratti L, Luzzi S, Petrelli C, Baldinelli S, Viticchi G, Provinciali L, et al. Obstructive Sleep Apnea Syndrome: An Emerging Risk Factor for Dementia. CNS Neurol Disord Drug Targets. 2016. 15 (6):678-82. [QxMD MEDLINE Link].
Martin J, Marler M, Shochat T, Ancoli-Israel S. Circadian rhythms of agitation in institutionalized patients with Alzheimer's disease. Chronobiol Int. 2000 May. 17 (3):405-18. [QxMD MEDLINE Link].
Gehrman PR, Martin JL, Shochat T, Nolan S, Corey-Bloom J, Ancoli-Israel S. Sleep-disordered breathing and agitation in institutionalized adults with Alzheimer disease. Am J Geriatr Psychiatry. 2003 Jul-Aug. 11 (4):426-33. [QxMD MEDLINE Link].
Evans LK. Sundown syndrome in institutionalized elderly. J Am Geriatr Soc. 1987 Feb. 35 (2):101-8. [QxMD MEDLINE Link].
Vitiello MV, Bliwise DL, Prinz PN. Sleep in Alzheimer's disease and the sundown syndrome. Neurology. 1992 Jul. 42 (7 Suppl 6):83-93; discussion 93-4. [QxMD MEDLINE Link].
Gallagher-Thompson D, Brooks JO 3rd, Bliwise D, Leader J, Yesavage JA. The relations among caregiver stress, "sundowning" symptoms, and cognitive decline in Alzheimer's disease. J Am Geriatr Soc. 1992 Aug. 40 (8):807-10. [QxMD MEDLINE Link].
Bliwise DL. What is sundowning?. J Am Geriatr Soc. 1994 Sep. 42 (9):1009-11. [QxMD MEDLINE Link].
Scarmeas N, Brandt J, Blacker D, Albert M, Hadjigeorgiou G, Dubois B, et al. Disruptive behavior as a predictor in Alzheimer disease. Arch Neurol. 2007 Dec. 64 (12):1755-61. [QxMD MEDLINE Link].
Wong MM, Brower KJ, Craun EA. Insomnia symptoms and suicidality in the National Comorbidity Survey - Adolescent Supplement. J Psychiatr Res. 2016 Oct. 81:1-8. [QxMD MEDLINE Link].
Ohayon MM, Roth T. Place of chronic insomnia in the course of depressive and anxiety disorders. J Psychiatr Res. 2003 Jan-Feb. 37 (1):9-15. [QxMD MEDLINE Link].
Chemerinski E, Ho BC, Flaum M, Arndt S, Fleming F, Andreasen NC. Insomnia as a predictor for symptom worsening following antipsychotic withdrawal in schizophrenia. Compr Psychiatry. 2002 Sep-Oct. 43 (5):393-6. [QxMD MEDLINE Link].
Bubu OM, Brannick M, Mortimer J, Umasabor-Bubu O, Sebastião YV, Wen Y, et al. Sleep, Cognitive impairment and Alzheimer's disease: A systematic review and meta-analysis. Sleep. 2016 Sep 26. [QxMD MEDLINE Link].
Kamel NS, Gammack JK. Insomnia in the elderly: cause, approach, and treatment. Am J Med. Jun 2006. 119(6):463-9.
Byles JE, Mishra GD, Harris MA. The experience of insomnia among older women. Sleep. Aug 2005. 1:28(8):972-9.
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link]. [Full Text].
Wu JQ, Appleman ER, Salazar RD, Ong JC. Cognitive Behavioral Therapy for Insomnia Comorbid With Psychiatric and Medical Conditions: A Meta-analysis. JAMA Intern Med. 2015 Sep. 175 (9):1461-72. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link]. [Full Text].
Mirsa S, Malow BA. Evaluation of sleep distubances in older adults. Clin Geriatr Med. Feb 2008. 24(1):15-26.
Ancoli-Israel S, Ayalon. Diagnosis and treatment of sleep disorders in older adults. Am J Geriatr Psychiatry. Feb 2006. 14(2):95-103.
[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. [QxMD MEDLINE Link].
Cheng SK, Dizon J. Computerised cognitive behavioural therapy for insomnia: a systematic review and meta-analysis. Psychother Psychosom. 2012. 81(4):206-16. [QxMD MEDLINE Link].
Tariq SH, Pulisetty S. Pharmacotherapy for insomnia. Clin Geriatr Med. Feb 2008. 24(1):93-105.
Blais J, Zolezzi M, Sadowski CA. Treatment Options for Sundowning in Patients With Dementia. Mental Health Clinician. 2014. 4:189-195.
Kim P, Louis C, Muralee S, Tampi RR. Sundowning syndrome in the older patient. Clinical Geriatrics. April 2005. 13(4):32-36.
American Psychiatric Association. American Psychiatric Association Practice Guidelines for the treatment of psychiatric disorders: compendium 2006. 2006.
Gauthier S, Patterson C, Chertkow H, Gordon M, Herrmann N, Rockwood K, et al. Recommendations of the 4th Canadian Consensus Conference on the Diagnosis and Treatment of Dementia (CCCDTD4). Can Geriatr J. 2012 Dec. 15 (4):120-6. [QxMD MEDLINE Link].
de Jonghe A, Korevaar JC, van Munster BC, de Rooij SE. Effectiveness of melatonin treatment on circadian rhythm disturbances in dementia. Are there implications for delirium? A systematic review. Int J Geriatr Psychiatry. 2010 Dec. 25 (12):1201-8. [QxMD MEDLINE Link].
Sanchez Z, Bennett L. An integrative research review (IRR) of pharmacological and non-pharmacological interventions of sundowning syndrome in older adults. J Am Geriatr Soc. 2013.
Eggermont LH, Scherder EJ. Ambulatory but sedentary: impact on cognition and the rest-activity rhythm in nursing home residents with dementia. J Gerontol B Psychol Sci Soc Sci. 2008 Sep. 63 (5):P279-87. [QxMD MEDLINE Link].
Eggermont LH, Blankevoort CG, Scherder EJ. Walking and night-time restlessness in mild-to-moderate dementia: a randomized controlled trial. Age Ageing. 2010 Nov. 39 (6):746-9. [QxMD MEDLINE Link].
Holmes C, Hopkins V, Hensford C, MacLaughlin V, Wilkinson D, Rosenvinge H. Lavender oil as a treatment for agitated behaviour in severe dementia: a placebo controlled study. Int J Geriatr Psychiatry. 2002 Apr. 17 (4):305-8. [QxMD MEDLINE Link].
Raglio A, Bellelli G, Traficante D, Gianotti M, Ubezio MC, Villani D, et al. Efficacy of music therapy in the treatment of behavioral and psychiatric symptoms of dementia. Alzheimer Dis Assoc Disord. 2008 Apr-Jun. 22 (2):158-62. [QxMD MEDLINE Link].
Forbes D, Culum I, Lischka AR, Morgan DG, Peacock S, Forbes J, et al. Light therapy for managing cognitive, sleep, functional, behavioural, or psychiatric disturbances in dementia. Cochrane Database Syst Rev. 2009 Oct 7. CD003946. [QxMD MEDLINE Link].
Boeve BF, Silber MH, Ferman TJ. Current management of sleep disturbances in dementia. Curr Neurol Neurosci Rep. 2002 Mar. 2 (2):169-77. [QxMD MEDLINE Link].
Canevelli M, Valletta M, Trebbastoni A, Sarli G, D'Antonio F, Tariciotti L, et al. Sundowning in Dementia: Clinical Relevance, Pathophysiological Determinants, and Therapeutic Approaches. Front Med (Lausanne). 2016. 3:73. [QxMD MEDLINE Link].
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.
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
McCleery J, Cohen DA, Sharpley AL. Pharmacotherapies for sleep disturbances in Alzheimer's disease. Cochrane Database Syst Rev. 2014 Mar 21. 3:CD009178. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link]. [Full Text].
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. [QxMD MEDLINE Link].
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.
Avidan AY. Sleep changes and dosorders in the elderly patient. Curr Neurol Neurosci Rep. Mar 2002. 2(2):178-85.
Barthlen GM. Sleep disorders. Obstructive sleep apnea syndrome, restless legs syndrome, and insomnia in geriatric patients. Geriatrics. Nov 2002. 57(11):34-9.
Benca RM. Diagnosis and Treatment of Chronic Insomnia: A Review. Psychiatr Serve. 2005. 56:323-343.
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. [QxMD MEDLINE Link].
Buysse DJ. Insomnia, Depression, and Aging. Assessing sleep and mood interactions in older adults. Geriatrics. Feb 2004. 59(2):47-51.
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.
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Gentili A, Edinger JD. Sleep disorders in older people. Aging (Milano). 1999 Jun. 11(3):137-41. [QxMD MEDLINE Link].
Gentili A, Weiner DK, Kuchibhatil M, Edinger JD. Factors that disturb sleep in nursing home residents. Aging (Milano). 1997 Jun. 9(3):207-13. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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.
Marsh G. Sleep problems in the elderly. Psychiatry Consultation-Liaison Psychiatry and Behavioral Medicine. 1993. 2:1-14.
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.
O'Keeffe. Secondary causes of restless leg syndrome in older people. Age Ageing. Jul 2005. 34(4):349-52.
Raji MA, Brady SR. Mirtazapine for treatment of depression and comorbidity in alzheimer disease. Ann Pharmacother. Sep 2001. 35(9):1024-7.
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. [QxMD MEDLINE Link].
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.
Singh H, becker PM. Novel therapeutic usage of low-dose doxepin hydrochloride. Expert Opin Investig Drugs. aug 2007. 16(8):1295-305.
Vitiello MV. Effective treatments for age-related sleep disturbances. Geriatrics. 1999 Nov. 54(11):47-52; quiz 54. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Willcox SM, Himmelstein DU, Woolhandler S. Inappropriate drug prescribing for the community-dwelling elderly. JAMA. 1994 Jul 27. 272(4):292-6. [QxMD MEDLINE Link].
Young T, Skatrud J, Peppard PE. Risk factors for obstructive sleep apnea in adults. JAMA. 2004 Apr 28. 291(16):2013-6. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Zepelin H. Sleep disorders. J Gerontol. 1983 May. 38(3):384. [QxMD MEDLINE Link].
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.
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.

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Author

Glen L Xiong, MD Associate Clinical Professor, Department of Psychiatry and Behavioral Sciences, Department of Internal Medicine, University of California, Davis, School of Medicine; Medical Director, Sacramento County Mental Health Treatment Center

Glen L Xiong, MD is a member of the following medical societies: AMDA - The Society for Post-Acute and Long-Term Care Medicine, American College of Physicians, American Psychiatric Association, Central California Psychiatric Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: SafelyYou, Blue Cross Blue Shield<br/>book co-editor for: Wolter Kluwer, American Psychiatric Publishing Inc.

Coauthor(s)

Ariel B Neikrug, PhD Assistant Professor, Department of Psychiatry and Human Behavior, Director, Behavioral Sleep Medicine Program, University of California, Irvine

Ariel B Neikrug, PhD is a member of the following medical societies: Sleep Research Society

Disclosure: Nothing to disclose.

Olivia Vukcevich, BS Junior Specialist,Department of Psychiatry and Behavioral Sciences, UC Davis Medical Center

Disclosure: Nothing to disclose.

Chief Editor

Ana Hategan, MD, FRCPC Associate Clinical Professor, Department of Psychiatry and Behavioral Neurosciences, Division of Geriatric Psychiatry, McMaster University School of Medicine; Geriatric Psychiatrist, St Joseph's Health Care Hamilton, Canada

Ana Hategan, MD, FRCPC is a member of the following medical societies: Canadian Academy of Geriatric Psychiatry, Canadian Coalition for Seniors' Mental Health, Canadian Psychiatric Association, International Psychogeriatric Association, Ontario Medical Association, Royal College of Physicians and Surgeons of Canada

Disclosure: Book royalties and/or honoraria for articles from American Psychiatric Publishing, Springer, and Current Psychiatry.

Additional Contributors

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.

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.

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

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