Acute and Emergent Events in Sleep of Older Adults
- DOI:
- 10.1093/med/9780195377835.003.0015
Introduction
Approximately 50% of older adults complain of difficulty sleeping. Although a number of normal, age-related changes in sleep occur, problems with sleep are not an inevitable part of aging, as many of these complaints are related to specific sleep disorders, circadian rhythm changes, medical or psychiatric comorbidities, or the medications administered to treat these illnesses. Sleep complaints reach a pathological level as older adults begin to experience deterioration of function during their period of normal wakefulness, manifested as excessive sleepiness, concentration deficits, mood changes, or the emergence of bizarre or dangerous behavior during sleep. This chapter reviews the acute and emergent events, including the assessment, diagnosis, treatment, and special issues of sleep disorders in the elderly.
Age-related changes in sleep
Elderly patients report a variety of difficulties with sleep, including sleeping less despite spending more time in bed, taking longer to fall asleep, more nighttime awakenings, lower sleep efficiency (defined as the ratio of total sleep time to time in bed), waking up earlier than they would like in the morning, and voluntary as well as unintentional naps compared with younger adults. Research has verified these subjective complaints objectively with polysomnography. A meta-analysis that included more than 3,000 healthy subjects identified age-related changes in polysomnographic parameters. Sleep architecture changes significantly with aging, including an increase in the lighter stages of sleep (stages 1 and 2) at the expense of the deeper stages (slow wave sleep).1 These changes, however, begin in middle age and by age 60 they stabilize. Natural physiological changes in circadian rhythms result in many older adults going to bed earlier and waking up earlier than desired. In sum, the sleep of elderly patients is more fragmented, with an increase in the number of awakenings, arousals, shifts in sleep stage, and advancing circadian rhythm, all of which result in deterioration of sleep quality and lower sleep efficiency.
The ability to sleep at night also diminishes, often resulting in inadequate sleep. Insufficient sleep should not be considered a benign condition, as it is associated with significant morbidity and increased mortality. A lack of adequate sleep has been associated with compromised immune functioning,2 hypertension,3 depression,4 diminished alertness,5 and poorer physical functioning.6 Sleep problems in the elderly may be especially hazardous as troubles with sleep are associated with an increased risk of falls and difficulty with ambulation, balance, and vision, even after controlling for medication use.7,8
Cognitive deficits, specifically in the areas of attention, short-term memory, response times, and performance level, can be due to chronic sleep difficulties at any age and may be especially problematic for elderly persons who are most vulnerable—that is, those with underlying cognitive dysfunction at baseline. Sleep difficulties in the elderly are also associated with an increased mortality risk, as lower sleep efficiency (<80%) has been reported to almost double the risk of all-cause mortality.9 While these changes may explain an elderly patient’s complaints about sleep, they are not associated with aging per se, but rather are most often associated with other diagnoses that must be considered, including the presence of specific sleep disorders, circadian rhythm disturbances, and medical and psychiatric comorbidities.
Sleep disorders in older adults
Sleep-disordered breathing
One of the most common sleep disorders in older adults is sleep-disordered breathing (SDB). SDB is characterized by respiratory events, including hypopneas (partial respiration) and/or apneas (complete cessation of respiration), during sleep. These respiratory events occur repeatedly over the course of the night, with each respiratory event lasting a minimum of 10 seconds. The number of apneas and hypopneas per hour of sleep is called the apnea/hypopnea index or AHI (sometimes incorrectly called the respiratory disturbance index). Clinical diagnosis of SDB is traditionally given when a patient has an AHI of 10 to 15. Cessations in breathing in SDB lead to repeated arousals from sleep, as well as to reductions in blood oxygen levels over the course of the night, which result in nighttime hypoxemia.
SDB is more common in older adults than younger adults, with most longitudinal and cross-sectional studies showing that the prevalence increases or stabilizes with age.10,11 While the reported prevalence of SDB among middle-aged adults is approximately 9% to 24%,12 it has been reported to be 45% to 62% in adults over the age of 60 years.10 A longitudinal study9 showed that the prevalence of SDB did not increase with age and changed only with associated increases in body mass index. Conversely, other studies have shown an increasing prevalence of SDB with increasing age (60 to 90 years).13,14 The Sleep Heart Health Study15 reported increasing rates with increasing age only for subjects with an AHI of at least 15. Risk factors for SDB in the elderly include increasing age, gender, family history/genetic factors, race, smoking, craniofacial anatomy, and obesity.16 The use of sedating medications and alcohol consumption may also increase a patient’s risk.
Clinicians often recognize SDB only when the patient receives treatment for another condition, such as hypertension, myocardial infraction, congestive heart failure, stroke, or diabetes. The patient’s only complaints may be excessive daytime sleepiness or snoring. Excessive daytime sleepiness often results from recurrent nighttime arousals and sleep fragmentation and is manifested as falling asleep at inappropriate times during the day and/or unintentional napping. Excessive daytime sleepiness can lead to social and occupational difficulties and cognitive dysfunction, which may be of particular importance for patients with underlying cognitive impairment at baseline.17 Several less common presentations of SDB can also be found in the elderly, including complaints of insomnia, nocturnal confusion, and daytime cognitive impairment such as short-term memory loss and poor concentration.
Undiagnosed or untreated SDB is associated with considerable morbidity (e.g., hypertension, cardiac arrhythmias, congestive heart failure, myocardial infarction, and stroke); however, the exact relationship between SDB and these various morbid conditions in the elderly remains unknown. Using a case–control design, Gupta18 found that postoperative complications occurred at a higher rate (39%) in patients with obstructive sleep apnea (OSA) than in a group of matched controls (18%). The study concluded that OSA is a risk factor for increased perioperative morbidity, longer hospital stays, and adverse postoperative outcomes in older adults undergoing hip- or knee-replacement surgery. Also, severe SDB (AHI > 30)19 and milder SDB (AHI 10 to 20) with excessive sleepiness20 have negative effects on cognitive performance in non-demented elderly patients, including decreased attention, poor recall, slowed response time, and trouble completing executive tasks.
Accurate evaluation of elderly patients with suspected SDB requires a complete sleep history focused on the symptoms of SDB, the existence of other sleep disorders, and sleep-related habits in the presence of a bed partner or caregiver when possible. A thorough review of the patient’s current and past medical and psychiatric history should also be completed, with particular attention paid to SDB-associated medical conditions, medications, the use of alcohol, and evidence of cognitive dysfunction. An overnight sleep recording should be performed to confirm the diagnosis. Obtaining an overnight sleep study in an elderly patient may present some unique challenges, including difficulties with transportation, resistance to spending the night in an unfamiliar environment, and trouble understanding complicated instructions. Anticipating some of these potential difficulties and involving the patient’s bed partner or caregiver may help to resolve some of these issues.
Treatments for SDB include weight loss, positional therapy, and the use of a continuous positive airway pressure (CPAP) device. While compliance with CPAP is low in all populations, Ancoli-Israel et al showed that even patients with mild to moderate Alzheimer’s disease and sleep apnea used their CPAP for an average of 5 hours a night.21 Physicians therefore should not hesitate to treat CPAP based on age.
Periodic limb movements in sleep and restless leg syndrome
Periodic limb movements in sleep (PLMS) is a motor disorder commonly found in elderly patients that is characterized by clusters of repetitive leg jerks or kicks during sleep. These leg movements typically occur every 20 to 40 seconds and recur throughout the night. The etiology of PLMS is unknown. As each jerk or kick may result in an arousal or brief awakening, patients with PLMS have fragmented and disrupted sleep and therefore may present with complaints of EDS or unrefreshing sleep. Patients may or may not be aware of the leg kicks and may subjectively interpret the disrupted sleep that results as insomnia and instead complain of difficulty falling or staying asleep. The patient’s bed partner may be bothered by the repetitive movements and can be helpful during the patient’s assessment.
The diagnosis of periodic limb movement disorder (PLMD) requires an overnight polysomnograph showing a calculated periodic limb movement index (PLMI; the number of limb movements per hour of sleep) of at least 15 in adults associated with clinical sleep disturbance or a complaint of daytime fatigue. PLMS occurs in 5% of healthy 30- to 50-year-olds, but the prevalence rises to rates of 40% to 45% of the population, equally among men and women, over the age of 65.22,23 Although the prevalence does increase with age, research shows that the severity of PLMS remains stable and does not worsen with increasing age.24 There is some controversy in the field on the clinical significance of PLMS. If the patient is not complaining, then the repetitive limb movements may be of no consequence.
Restless legs syndrome (RLS) is a condition strongly associated and often comorbid with PLMS that affects 2.5% to 15% of the population.25 This disorder is characterized by leg dysesthesia that occurs during rest or inactivity, such as lying or sitting. Patients typically describe an uncomfortable sensation in their legs accompanied by the impulse to move. The uncomfortable leg sensations tend to begin or worsen during the evening or at night and are somewhat or entirely relieved by movement, such as walking or stretching. A variety of expressive and often colorful terms may be used to convey the unpleasant sensation that patients experience, including creepy-crawly, pins and needles, crazy legs, ants crawling, or pain. Like PLMS, the etiology of RLS is also unknown, although it is associated with iron deficiency states (including pregnancy), uremia, peripheral neuropathy, and radiculopathy.
The prevalence of RLS increases significantly with age, with rates in older adults reported to range from 9% to 20%, and women are affected twice as often as men.26,27 RLS in older adults is often more severe and debilitating.28 While the diagnosis of PLMS requires polysomnography, patients with RLS can be diagnosed on the basis of history alone. Patients with suspected RLS should also have evaluations of serum ferritin and percent iron saturation, as low-normal ferritin levels (<45 to 50 µg/L) are associated with increased severity and risk of recurrence of RLS, particularly in older adults.29,30
In the United States, FDA-approved pharmacologic interventions include the dopamine agonists pramipexole and ropinirole.31,32 Nonpharmacologic interventions include counseling patients to avoid caffeine, nicotine, and alcohol, which have been shown to aggravate symptoms.
Circadian rhythm sleep disorders
Circadian rhythms are 24-hour biologic rhythms, such as core body temperature and the sleep–wake cycle, controlled by an internal pacemaker located in the suprachiasmatic nucleus of the anterior hypothalamus. These rhythms are synchronized to the 24-hour day by external zeitgebers (i.e., time-givers or cues) such as light and activity and by internal rhythms such as body temperature and melatonin secretion. If one of the various contributors to the circadian rhythm becomes uncoupled or desynchronized from other rhythms, then circadian rhythm sleep disorders (CRSDs) may develop.
In the elderly, a number of factors associated with aging likely contribute to the desynchronization of rhythms. The circadian pacemaker itself degenerates with age, resulting in less robust rhythms, and there is a gradual decrease in the amplitude of the rhythm, which may lead to less consistent periods of sleep–wake across the 24-hour day.33 The endogenous secretion of melatonin at night is reduced with age, which may result in a weaker circadian rhythm. In addition, older adults may no longer have the same response to external zeitgebers and/or are exposed to fewer of them, such as the light–dark cycle. Studies suggest that in general, older adults spend little time exposed to bright light, averaging from about 30 minutes of bright exposure for Alzheimer’s disease patients living at home to zero minutes for nursing home patients.34,35
The most common circadian shift seen in the elderly is advanced sleep phase, which is characterized by a shift or advance in the sleep–wake cycle and is manifested as habitual (and involuntary) sleep and wake times that are several hours earlier than societal norms. Patients with an advanced sleep phase feel sleepy in the early evening, timed with the drop in body temperature, and awaken in the very early morning. Sleep itself is normal, but delays in sleep onset related to obligations or societal behavior often result in an insufficient amount of time in bed and thus insufficient sleep, as the advanced phase still results in awakenings in the early morning regardless of what time the individual went to sleep. The insufficient time in bed and insufficient sleep then can result in excessive sleepiness during the day. If patients ignore their rhythm (i.e., sleepiness) in the early evening or inadvertently fall asleep watching television, when they finally get into bed, they may experience difficulty falling asleep and subsequently complain of sleep-onset insomnia, typically coupled with early morning awakening.
An advanced sleep phase is related to a combination of factors, including decreased light exposure, that subsequently causes changes in the core body temperature cycle. There may also be a genetic predisposition.36 The prevalence of the advanced sleep phase disorders is approximately 1% in younger adults, and although the prevalence of an advanced rhythm appears to increase with age, the exact rate of an advanced sleep phase disorder has not yet been established in older adults. Patients may learn to function with the advance in their sleep–wake cycle and therefore not present to their clinician for evaluation. Elderly patients who do present to clinicians may report trouble falling asleep or maintaining sleep, similar to patients with sleep-onset insomnia or depression.
To recognize patients with advanced sleep phase, a careful and detailed sleep history along with a 1- to 2-week patient-completed sleep diary should be obtained. Activity monitoring with wrist actigraphy, which records the patient’s underlying circadian activity rhythm and allows for an objective examination of the patient’s sleep–wake cycle, can also be useful in making the diagnosis.
As some advancement of the circadian rhythm is a common and expected development in older age, patients should be educated that advancing circadian rhythms is not a medical disorder and does not necessarily need to be treated. Treatment depends on the extent of the discomfort the circadian disturbance has on the day-to-day life of the individual patient. Patients often complain that their waking hours are no longer consistent with societal norms, causing them to be awake (or asleep) when those around them are not. If the patient complains that circadian disturbances are interfering with functioning, treatments known to strengthen and entrain the sleep–wake cycle are the most appropriate therapies for shifting the circadian rhythm.
The most common treatment for circadian rhythm shifts is bright light therapy, as light is the strongest cue for circadian entrainment. Evening light exposure has been found to delay circadian rhythms and strengthen the sleep–wake cycle in both healthy community-living older subjects as well as in nursing home patients.37 Patients with advanced rhythms should spend more time outdoors during the late afternoon or early evening and avoid bright light in the morning hours. In addition, a regular sleep schedule helps to promote a stronger sleep–wake cycle.
Insomnia
Insomnia is defined as difficulty initiating or maintaining sleep, or nonrestorative sleep that results in daytime consequences and dysfunction.38 Sleep requirements and patterns change throughout life, but sleep problems in the elderly are not a normal part of aging. Many elderly patients report that they are unable to stay asleep throughout the night and/or wake up in the early morning and are unable to fall back to sleep. Precipitants to insomnia in the elderly include medical illness, hospitalization, changes in the sleep environment, medication, or psychological stressors such as the death of a loved one. Behavioral negative conditioning can occur during transient periods of induced insomnia, which does not resolve after causative factors are eliminated. Behavioral negative conditioning involves pairing the bed and bedroom with feelings of anxiety and worry as bedtime approaches, thus perpetuating insomnia.
In the older adult, it is important to recognize that subjective complaints of insomnia are often comorbid with medical and/or psychiatric conditions. In a study of insomnia in older adults, 28% of subjects complained of chronic insomnia, but only 7% of the new cases occurred in the absence of one of these related conditions.39 Patients with chronic medical disease appear particularly prone to sleep disturbances, with studies indicating that 31% of patients with arthritis and 66% of patients with chronic pain report diffi-culty falling asleep. Eighty-one percent of patients with arthritis, 85% of patients with chronic pain, and 33% of patients with diabetes mellitus report trouble with staying asleep, and 45% of patients with gastroesophageal reflux disease, 50% of patients with congestive heart failure, and 44% of patients with cancer report difficulty both falling and staying asleep.40–44 Sleep difficulties are also associated with a number of psychiatric disorders, with depression being strongly linked to insomnia.45,46 Insomnia is a predictor of developing depression 1 to 3 years later.47,48 Most epidemiologic studies show that the insomnia prevalence is greater in older women than older men.49 Older women with insomnia also seem to be especially susceptible to depression.50–52
Given the number of factors that can contribute to insomnia, it is not surprising that the prevalence of insomnia in older adults is relatively high. In a study of more than 9,000 older adults (>65 years of age), 42% reported difficulty both falling and staying asleep, and 28% reported trouble falling asleep.39 While the sleep complaints had resolved in 15% of the study’s population 3 years later, the incidence of new sleep complaints was 5%.53 Chronic insomnia becomes more prevalent with increasing age.54 Notably, a study of more than 13,000 participants aged 45 to 69 years reported that when medical/psychiatric illnesses, medications, and other confounders that are believed to contribute or cause trouble with sleep were controlled for, the prevalence of insomnia did not increase with increasing age.55 These data suggest that it is not aging that results in poor sleep, but rather the factors associated with aging.
Sleep problems and medical illness
Older individuals often suffer from multiple medical problems. Painful conditions prevalent among older adults, such as osteoarthritis, neuropathy, pulmonary conditions, neurological deficits, and nocturia due to an enlarged prostate, all can lead to difficulty with sleep initiation and maintenance. While pain can worsen sleep quality, inadequate sleep can also intensify pain. In 2003 the National Sleep Foundation conducted a telephone survey of 1,506 adults aged 65 years and over. Those with more medical conditions, including cardiac and pulmonary disease and depression, reported significantly more sleep complaints.56 The relationship between medical conditions and sleep is considered bidirectional, where health issues put the elderly at risk for sleep disturbance, and sleep disruption may be a risk factor for future health problems.
When assessing and treating sleep disturbance in the elderly, the patient’s medical history should also be considered. Likewise, sleep quality should be assessed in elderly persons with any type of illness.
Sleep problems and medications
Medications used to treat these various underlying medical problems can also cause disruptions in sleep. Beta-blockers, bronchodilators, corticosteroids, decongestants, and diuretics as well as other cardiovascular, neurologic, psychiatric, and gastrointestinal medications can all cause sleep disturbances. Medications such as sedative–hypnotics, antihistamines, antidepressants (amitriptyline, doxepin, trazodone, mirtazapine), and dopamine agonists can all contribute to excessive daytime sleepiness, which could contribute to sleep-onset insomnia or exacerbate or maintain existing sleep problems. Polypharmacy and prescriptions of sedative drugs are increasingly prevalent among older adults,57 often without consideration of the drugs’ effects on the patient’s sleep. Whenever feasible, sedating medications should be administered prior to bedtime, while stimulating medications and diuretics should be taken during the day. In the elderly, falls, cognitive impairment, and respiratory depression are of particular concern, although recent data suggest that insomnia and disrupted sleep, and not hypnotics, increase the risk of falls.6,58–60 Recent studies by Stone et al further support this finding by demonstrating an increase in the risk of falls associated with sleep duration and fragmentation in subjective8 and objective measures of sleep61 in older women independent of benzodiazepine use and other risk factors for falls.
Treatment of insomnia
As with other sleep disorders, a thorough sleep history is necessary for evaluation and diagnosis of insomnia. While obtaining the sleep history it can be useful to have a patient report a typical 24-hour day to identify precipitating and perpetuating factors related to insomnia. It is recommended that the patient track sleep prospectively using a sleep diary to identify the amount of time it takes to fall asleep, number of awakenings, sleep quality, duration, and timing. Other information about the sleep environment; medical and psychiatric history; and use of alcohol, medications, and caffeine should also be obtained.
Cognitive–behavioral therapy for insomnia (CBT-I) includes some combination of challenging irrational or distorted beliefs about sleep, education on proper sleep hygiene, relaxation techniques, sleep restriction, and stimulus control therapy. In older adults, CBT-I has been shown to be as effective as medications in the short run and to have better long-term outcomes in the treatment of insomnia.62 The NIH 2005 State of the Science conference on insomnia concluded that CBT-I was an efficacious treatment for insomnia.63 Although pharmacological treatments may be of more immediate help, particularly in the acute treatment phase, in order to maintain long-term clinical gains, non-pharmacological or combined approaches may be more effective. Given the frailty of elderly and nursing home populations and the likelihood of adverse effects in these groups, clinicians should be cautious in using sleep-promoting medications and should consider non-pharmacological interventions as a first line of treatment.
When prescription medications are indicated, the treatment of choice should be one of the newer benzodiazepine receptor agonists or melatonin receptor agonists. The NIH State of the Science Conference on Insomnia63 concluded that the newer non-benzodiazepines are safer and more effective than the older ones (i.e., eszopiclone, zaleplon, and zolpidem). Since the conference, two new sleeping aids have also been approved, ramelteon and zolpidem MR. All five of these hypnotics have been shown to be safe and effective in older adults with insomnia.64–72
Other sleeping aids are often prescribed and used off-label. These include antidepressants, antipsychotics, anticonvulsants, and diphenhydramine. While all have some sedating properties, the NIH State of the Science Conference on Insomnia concluded that the risks of these medications outweigh the benefits and they did not recommend their use for the treatment of insomnia.63
Acute and emergent events in old age related to sleep–wake disturbances
The consequences of poor sleep in older adults are substantial and include poor health, decreased physical function, difficulty with ambulation, balance, and vision, falls, cognitive impairment, and mortality. Poor physical function, particularly falls, is of great concern in older populations. Several studies have examined the relationship between poor sleep and physical function and falls. In the Outcomes of Sleep Disorders in Older Men Study (MrOS Sleep Study, as part of the Osteoporotic Fractures in Men Study), sleep fragmentation and hypoxia were shown to be associated with poorer physical function in over 3,000 older men.73 In the same study, sleep disturbances, including poor self-reported sleep quality, lower sleep efficiency, prolonged sleep onset latency, and the presence of SDB, were all inde-pendently associated with greater frailty.74 Similar results were found in a large cohort of older women.6 In yet another study of frailty in 374 older adults, daytime sleepiness resulting from disturbed sleep was associated with frailty.75
Of even greater concern is the association of poor sleep and falls, after controlling for comorbidities and medication use, including benzodiazepine use. Avidan et al examined data from the Minimum Data Set (MDS) of 34,163 nursing home patients and found that untreated insomnia and hypnotic-treated nonresponsive insomnia were both associated with a greater risk of falls (55% and 32% greater risk, respectively), while hypnotic use alone was not associated with a greater risk of falls.76 A cross-sectional survey study of 300 older adults in Australia reported that falls were associated with poor sleep quality (odds ratio [OR] 4.5), number of nocturnal awakenings (OR 2.5), use of diuretics (OR 2.1), pain and depressive symptoms, poor health (OR 2.1), vision impairment (OR 2.3), and use of walking aids (OR 4.4), but not with use of benzodiazepines.59
The association between poor sleep and falls was confirmed in the largest objective study to date, the Study of Osteoporotic Fractures. The investigators collected a mean of 5 days of actigraphy data from over 3,000 community-dwelling women aged 70 and older (mean age 84 years) who were followed for self-reported falls and fractures for 1 year. Information on falls was gathered tri-annually by postcard with greater than 98% response rate. After adjustment for race, age, body mass index, medical conditions, depression, cognitive function, exercise, activities of daily living, antidepressant use, and benzodiazepine use, results showed a 30% to 40% increased risk of falls with short sleep duration, poor sleep efficiency, and increased napping.7,61,77 These results suggest that studies are needed to examine whether treating sleep disturbances will result in decreases in accidents, falls, and fractures and longer survival rates.
Sleep in institutionalized elderly patients
Institutionalized elderly persons experience extremely fragmented sleep.78 Because the sleep of older adults is lighter, it may be more easily disrupted in hospitals and other long-term care facilities. Middelkoop et al79 reported that patients living in nursing homes had poorer sleep quality, more disturbed sleep onset, more phase-advanced sleep periods, and higher use of sedative–hypnotics when compared with older adults living in the community or in assisted living environments. Studies have shown that for older adults living in nursing homes, not a single hour in a 24-hour day was spent fully awake or fully asleep.78,80,81 Environmental factors in hospitals and nursing homes may also contribute to the reduced sleep quality. Schnelle et al82 showed that both ambient light and nighttime noise contributed significantly to sleep disruption in nursing home patients. This study also found that patients living in nursing homes where nighttime noise and light were kept to a minimum had better sleep. Changes in sleep hygiene and the sleep environments of nursing home patients may greatly improve sleep quality in this population. One study showed that nursing home patients were exposed to less than 10 minutes of bright light per day, and those with more light exposure had fewer sleep disruptions.83 Coping strategies, such as adjusting the thermostat to a cooler temperature, reducing lighting, and organizing nursing care in a way to minimize interruptions in sleep at night, and providing significant daytime light exposure, increasing activity and exercise, and decreasing naps during the day will help both patients and nursing home staff reduce the nighttime disturbances in the sleeping environment, while promoting stronger and more defined sleep–wake cycles. If adjustments to the facility environment are not possible, patients can be given earplugs and a mask. In addition, asking the patient what his or her usual bedtime is and encouraging him or her to begin preparing for sleep 30 minutes ahead of time or practicing routine bedtime rituals (e.g., bathing, prayer, quiet reading, listening to music, drinking warm milk) can assist in inducing sleep.
Sleep and neurodegenerative disorders
The sleep of older adults living in nursing homes is known to be extremely disturbed, particularly in those suffering from neurodegenerative disorders such as Alzheimer’s, Parkinson’s, and Huntington’s disease, and some forms of dementia. There is considerable evidence that dementia affects sleep differently from the normal aging process.84 Persons with dementia may be more susceptible to sleep disorders because disease processes cause permanent damage to brain areas regulating sleep. In general, patients with dementia have disturbed sleep at night, and laboratory sleep studies of demented patients have shown increased sleep onset latency, nighttime awakenings and daytime napping, and decreased sleep efficiency, total sleep time, and slow wave sleep.85 Furthermore, the severity of dementia appears to be associated with the severity of the sleep disruption.81 Due to sleep architecture changes, patients with dementia may have excessive daytime sleepiness, nighttime wandering, confusion, and agitation (sundowning). Volicer et al86 showed that Alzheimer’s disease causes disturbance of circadian rhythms, and sundowning is related to a phase delay of body temperature caused by Alzheimer’s disease.
Unfortunately, in standards of care for people with dementia, sleep often goes unmentioned. For many caregivers, disrupted sleep—both their own and that of the people they care for—is the primary reason for placement of the person with dementia in a long-term care facility. Therefore, addressing issues related to sleep and circadian disturbances in community-dwelling demented elderly is especially important, as it may postpone institutionalization.
It may be difficult to determine the exact nature of the sleep disturbance in patients with dementia, although caregivers can be a valuable source of information. The same causes of sleep disruption in the non-demented older adult will also be found in the patient with dementia. Pain from medical illnesses, medications, circadian rhythm changes, and depression are all potential causes of sleep disturbances in this population. It is also important to inquire about treatable primary sleep disorders such as SDB, RLS, or PLMS. Depending on the severity of the dementia, overnight sleep studies may not be feasible, and therefore actigraphy may serve as a useful method to assess sleep and circadian rhythms in these patients.87
Summary
Despite the increased prevalence of certain sleep disorders and changes that occur in both sleep architecture and circadian rhythms in the elderly, poor and/or disrupted sleep is not an inevitable part of growing older. Complaints about sleep in older adults are more often due to specific sleep disorders, changes in circadian rhythms, medication use, or comorbid medical and/or psychiatric conditions. Clinicians caring for older patients should be educated about the normal and the pathologic changes in sleep in this population. As with younger patients, sleep complaints in older patients should be evaluated with a thorough sleep history and often an overnight sleep study. The appropriate diagnosis or identification of specific, often reversible or correctable factors contributing to an elderly patient’s sleep complaint can result in significant improvements in quality of life, daytime functioning, and reductions in acute and emergent events such as falls and accidents.
Supported by NIA AG08415, NIH M01 RR00827, and the Department of Veterans Affairs Center of Excellence for Stress and Mental Health (CESAMH).
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