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Sleep disturbances are associated with many poor health outcomes in older adults, including increased risk for falls, cognitive decline, and all-cause mortality.
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Insomnia is often related to underlying medical, psychiatric, or environmental factors. A thorough medical and psychiatric history and an understanding of sleep environment and psychosocial stressors are essential when evaluating sleep disturbances.
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Many medications can cause or contribute to insomnia and other sleep disorders. It is
Insomnia and Other Sleep Disorders in Older Adults
Section snippets
Key points
Age-related changes in sleep and circadian rhythms
Developmental changes in sleep occur throughout the lifespan, and older adults experience normal, age-related changes in sleep and circadian rhythms.19 Sleep architecture refers to the classification of sleep into different stages, as measured by brain wave patterns, eye movements, and muscle tone.20 Sleep consists of three non-REM stages known as N1, N2, and N3 and REM sleep.20,21 Compared with younger persons, older adults spend more time in N1 and N2, the “shallow” stages of sleep in which
Insomnia disorder
Insomnia is the most prevalent sleep disorder, and symptom burden increases with age, particularly for women.15,34 Although insomnia can manifest as a primary disorder, it is frequently comorbid and multifactorial in origin (Box 2).35 “Comorbid insomnia” refers to insomnia that is directly related to an underlying medical, psychiatric, or environmental cause.36 A thorough medical and psychiatric history and an understanding of sleep environment and psychosocial stressors are essential when
Medical Comorbidities
The more comorbidities an older adult has, the more likely he or she is to report a sleep complaint.37 Common medical conditions strongly associated with insomnia and reduced sleep quality include heart disease, cancer, hypertension, neurodegenerative disorders, respiratory disease (including OSA), urinary issues, diabetes, chronic pain, and gastrointestinal disorders.38, 39, 40 When evaluating a sleep concern, clinicians should screen for shortness of breath, somatic pain, nocturia,
Taking a Sleep History
The evaluation of the older patient with sleep difficulties begins with gathering a thorough sleep, psychiatric, and medical history and should incorporate collateral information from a bed partner or caretaker if possible. A sleep history should identify chief sleep complaints, which commonly include one or more of the following: inability to fall asleep, inability to stay asleep, waking too early, poor sleep quality, too little sleep, work or lifestyle interfering with sleep, or inability to
Non-Pharmacological Interventions
Given the increased potential for adverse medication side effects in older adults, non-pharmacological interventions for insomnia are first line.61 Behavioral approaches target thoughts, feelings, and behaviors that cause, perpetuate, and exacerbate poor sleep. They include sleep hygiene education (SHE), SRT, stimulus control therapy (SCT), relaxation techniques (RT), cognitive therapy (CT), and CBT-I. All have demonstrated sustained efficacy for older adults, including those with medical and
General Principles
If non-pharmacological interventions for insomnia are not sufficiently effective, pharmacologic options may be considered. Although several medications are commonly prescribed for insomnia in the general population, particular care must be taken when selecting one for the aging adult.
The American Academy of Sleep Medicine (AASM) Clinical Practice Guideline for pharmacologic treatment of insomnia published in 2017 is used by many providers as a guide for insomnia treatment in adults.71 Although
Other noteworthy sleep disorders in the aging adult
It is important to recognize that insomnia in older adults can co-occur with and obfuscate the diagnosis of other sleep disorders. Moreover, patients with overlapping sleep disorders typically do not improve unless all conditions are addressed.
Summary
Insomnia and other sleep disorders are prevalent in older adults and are associated with distress and negative health outcomes. A thorough sleep history and review of medical and psychiatric history, medication list, and collateral history from bed partners or caregivers are crucial to effective diagnosis and treatment planning. Non-pharmacological treatment of insomnia, particularly CBT-I, should be implemented first whenever possible. Some pharmacologic treatments for insomnia are effective
Disclosure
Drs Z.L. Cohen, P.M. Eigenberger, M.L. Conroy, and K.M. Wilkins do not have any disclosures to report. Dr K.M. Sharkey receives royalties from Wolters Kluwer for an article on Advanced Sleep-Wake Phase Disorder.
References (110)
- et al.
Diagnosis and treatment of sleep disorders in older adults
Am J Geriatr Psychiatry
(2006) Epidemiology of insomnia: what we know and what we still need to learn
Sleep Med Rev
(2002)- et al.
Sleep in the aging population
Sleep Med Clin
(2017) - et al.
Connections between sleep and cognition in older adults
Lancet Neurol
(2014) - et al.
Insomnia in the elderly: cause, approach, and treatment
Am J Med
(2006) - et al.
Sleep and older patients
Clin Chest Med
(2007) Rapid-eye-movement sleep behaviour disorder and neurodegenerative diseases
Lancet Neurol
(2006)- et al.
Chapter 2 - normal human sleep: an overview
National Sleep Foundation's sleep time duration recommendations: methodology and results summary
Sleep Health
(2015)- et al.
Sleep complaints cosegregate with illness in older adults: Clinical research informed by and informing epidemiological studies of sleep
J Psychosom Res
(2002)
Comorbid Insomnia: Reciprocal Relationships and Medication Management
Sleep Med Clin
(2010)
Sleep disturbances and chronic disease in older adults: results of the 2003 National Sleep Foundation Sleep in America Survey
J Psychosom Res
(2004)
Sleep: a novel mechanistic pathway, biomarker, and treatment target in the pathology of Alzheimer's disease?
Trends Neurosci
(2016)
Effects of melatonin and bright light administration on motor and sensory symptoms of RLS
Sleep Med
(2010)
Effect of levothyroxine on prolonged nocturnal sleep time and excessive daytime somnolence in patients with idiopathic hypersomnia
Sleep Med
(2011)
Drug-Induced Insomnia and Excessive Sleepiness
Sleep Med Clin
(2018)
Sleep disturbances and psychiatric disorders associated with posttraumatic stress disorder in the general population
Compr Psychiatry
(2000)
A systematic review of manic and depressive prodromes
J Affect Disord
(2003)
Sleep disturbances in bereavement: a systematic review
Sleep Med Rev
(2020)
Quantitative criteria for insomnia
Behav Res Ther
(2003)
The Pittsburgh Sleep Quality Index: a new instrument for psychiatric practice and research
Psychiatry Res
(1989)
STOP-Bang Questionnaire: A Practical Approach to Screen for Obstructive Sleep Apnea
Chest
(2016)
Cognitive behavioral therapy in persons with comorbid insomnia: A meta-analysis
Sleep Med Rev
(2015)
Anticholinergic drug burden and delirium: a systematic review
J Am Med Dir Assoc
(2021)
Effects of suvorexant on sleep architecture and power spectral profile in patients with insomnia: analysis of pooled phase 3 data
Sleep Med
(2016)
Suvorexant in elderly patients with insomnia: pooled analyses of data from phase iii randomized controlled clinical trials
Am J Geriatr Psychiatry
(2017)
Lemborexant vs suvorexant for insomnia: a systematic review and network meta-analysis
J Psychiatr Res
(2020)
Ramelteon for the treatment of insomnia in adults: a systematic review and meta-analysis
Sleep Med
(2014)
Effects of ramelteon on patient-reported sleep latency in older adults with chronic insomnia
Sleep Med
(2006)
The efficacy of melatonin and melatonin agonists in insomnia - an umbrella review
J Psychiatr Res
(2020)
Sleep disordered breathing in the elderly
Am J Med
(2011)
Sleep complaints in community-living older persons: a multifactorial geriatric syndrome
J Am Geriatr Soc
(2007)
Sleep perception in non-insomniac healthy elderly: a 3-year longitudinal study
Rejuvenation Res
(2014)
Perceived racial discrimination and risk of insomnia among middle-aged and elderly Black women
Sleep
(2020)
Sleep in the elderly: normal variations and common sleep disorders
Harv Rev Psychiatry
(2008)
Healthy older adults' sleep predicts all-cause mortality at 4 to 19 years of follow-up
Psychosom Med
(2003)
Insomnia and daytime sleepiness are risk factors for depressive symptoms in the elderly
Sleep
(2011)
Sleep loss and hypertension: a systematic review
Curr Pharm Des
(2013)
Insomnia and the risk of acute myocardial infarction: a population study
Circulation
(2011)
World population ageing 2020: highlights
(2021)
A portrait of obstructive sleep apnea risk factors in 27,210 middle-aged and older adults in the Canadian Longitudinal Study on Aging
Sci Rep
(2022)
Meta-analysis of quantitative sleep parameters from childhood to old age in healthy individuals: developing normative sleep values across the human lifespan
Sleep
(2004)
The AASM manual for the scoring of sleep and associated events: rules, terminology, and technical specification
(2007)
Sleep classification according to AASM and Rechtschaffen & Kales: effects on sleep scoring parameters
Sleep
(2009)
The REM sleep-memory consolidation hypothesis
Science
(2001)
Sleep Disturbances and Frailty Status in Older Community-Dwelling Men
J Am Geriatr Soc
(2009)
Poor sleep and risk of falls in community-dwelling older adults: a systematic review
J Appl Gerontol
(2018)
Sleep disorders in the older adult - a mini-review
Gerontology
(2010)
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