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Changes to circadian rhythm and sleep cycles have been observed in aging, but do not necessarily result in subjective sleep disturbance.
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Behavioral factors contribute to poor sleep and when addressed may improve sleep quality in older adults.
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Psychiatric, cognitive, and medical disorders often present with disturbed sleep in the elderly.
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First-line treatment of sleep disorders in the elderly is nonpharmacologic.
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When nonpharmacological treatment approaches are unsuccessful, pharmacologic treatments
Sleep Disturbances in the Elderly
Section snippets
Key points
Sleep changes with aging
As individuals age, their overall sleep efficiency decreases.4 Circadian rhythms become “phase-advanced,” such that wake time is earlier in relation to the nadir of circadian temperature fluctuation, although early awakening may not be solely attributable to phase advancement.5, 6 Other changes include increased sleep latency, increased nighttime arousals, reductions in rapid eye movement (REM) sleep, and decreased stages 3 and 4 sleep (“deep,” non-REM, slow-wave sleep characterized by delta
Insomnia
According to the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, insomnia is defined as reported dissatisfaction with sleep quantity or quality and associated with difficulty with sleep initiation, maintenance, or early-morning awakening and that causes clinically significant distress or impairment, occurs at least 3 nights per week for 3 months, occurs despite adequate opportunity for sleep, and is not better explained by another disorder or substance abuse.9 Older adults
Alcohol
It has long been established that consumption of alcohol before sleep affects sleep stages on polysomnography (PSG).22 Alcohol intake before bed decreases sleep-onset latency, but increases arousals during the second half of the night in a dose-dependent manner.23 Consumption of alcohol in the elderly before bed may have a particular negative impact on the quality of sleep. Chronic alcohol abuse in older men is associated with increased hypoxemia overnight.24 This effect is sustained among
Mood
Mood disorders are common in the elderly, with an estimated 11% of older adults suffering from either major or minor depression.46 A bidirectional relationship between sleep and mood disorders has been reported in elderly individuals, such that poor sleep has been linked to the development of depression, and poor sleep is a common presenting symptom of depression.47, 48 In the elderly, this relationship can be confounded by comorbid medical illness for which poor sleep may also be an associated
Sleep and neurocognitive disorders
In the elderly, poor sleep may contribute to cognitive symptoms, and conversely different types of dementia may present with associated sleep disturbances. Studies suggest that sleep duration, sleep fragmentation, sleep-disordered breathing, and hypoxemia may contribute to cognitive impairment.66, 67 Mild cognitive impairment has been associated with difficulty initiating sleep, difficulty maintaining sleep, and early morning awakening.68 Among forms of dementia, two with notable sleep
Delirium
Among the critically ill, amplitude and phase of circadian rhythm may be disrupted.82 Delirium in particular is characterized by disrupted sleep-wake cycles,83 and disruption of sleep-wake cycles may also predispose patients to develop delirium.84 In an acute hospital setting there are many factors that may contribute to the disruption of sleep-wake cycle, including persistent dim lighting in intensive care units,85 lack of daylight,86 noise,87 medication administration, automatic blood
Medications affecting sleep
In addition to medical and psychiatric illnesses, medications used to treat these disorders may also disrupt sleep. A list of such medications commonly used in the elderly are included in Box 1. Acetylcholinesterase inhibitors are used for cognitive enhancement in patients with AD. A common adverse effect of this therapeutic class is vivid dreams or nightmares, which may be related to shortened REM latency,114, 115, 116 increased REM density,115, 116 and increased time spent in REM sleep.117
Nonpharmacologic treatment approaches
Given risk of side effects and polypharmacy with medication management in the elderly population, nonpharmacologic treatment approaches are the first-line approach for treatment of sleep disorders. Both nonpharmacologic and pharmacologic approaches to treatment of sleep disorders are summarized in Table 1.
Melatonin
In the elderly population, melatonin has been demonstrated to decrease sleep latency, awakenings per night, and movements per night.130 Melatonin is considered second-line treatment for REM sleep behavior disorder after clonazepam.131 There is evidence that use of melatonin in patients with a diagnosis of dementia may also improve sundowning behavior.77 The current recommendation for treatment of sleep disorders in the elderly with melatonin is to use the lowest possible dose of the
Amyloid Beta and Circadian Rhythm
Understanding sleep disorders in the elderly may give insight into pathogenesis of late-life diseases. As an example, there may be a link between the development of amyloid beta plaques (a well-established pathologic finding in AD) and a disruption of circadian rhythms. Briefly, some studies in animal models as well as in humans have suggested that there is a diurnal variation in the concentration of amyloid beta protein levels as measured in brain interstitial fluid and cerebrospinal fluid.146
Summary
Sleep disorders in the elderly pose unique challenges for diagnosis and treatment. The elderly are at high risk for the development of sleep disorders given their propensity for changes in sleep architecture in combination with medical, psychiatric, cognitive, behavioral, and environmental factors. A thorough assessment of these components provides the physician with data to guide treatment, often by addressing the underlying problem. Management of sleep disorders is complicated by the risk of
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Effects of auricular acupressure on sleep and pain in elderly people who have osteoarthritis and live in nursing homes: A randomized, single-blind, placebo-controlled trial
2023, ExploreCitation Excerpt :In normal sleep, N2 accounts for about 50% of the NREM sleep38. In elderly people living in nursing homes, however, aging and changes in the living environment affect their normal sleep patterns, resulting in decreased N2 and increased awakening during sleep, which cause sleep disturbances39. In particular, sleep disorders in the elderly may have a negative impact on their health status by increasing the risk of high blood pressure, cardiovascular diseases, cerebral infarction, and diabetes due to decreased N2 and N340.
Sleep disorders and dementia
2021, Sex and Gender Differences in Alzheimer’s DiseaseSelf-reported sleep problems and their relationship to life and living of Māori and non-Māori in advanced age
2020, Sleep HealthCitation Excerpt :These and similar such relationships have been reported elsewhere and are indicative of the complex ecology of sleep and the many extrinsic as well as intrinsic and mediating factors which can affect it.17,18 In the original LiLACS NZ W1 sleep analyses, participants who reported that they had a sleep problem when they were younger were 2.67 times more likely to report a problem at the time of survey completion (when they were in their early 80s, CI = 1.25-5.72, P < .0516) This supports previous research indicating that problematic sleep tends to become a persistent issue, warranting early intervention to avoid adverse health outcomes.1,10 Recent research from cross-sectional and longitudinal studies has found that reporting exceptionally short or long sleep duration has implications for poorer health, quality of life, and mortality.19,20
Disclosures: None (K.F. Zdanys); Financial from the American Psychiatric Press for the American Psychiatric Press Textbook of Geriatric Psychiatry, Fifth Edition, 2015; Consultant to Janssen R&D (D.C. Steffens).