SLEEP DISORDERS IN THE
ELDERLY POPULATION
Joseph Cherian DO,
Geriatric Fellow at UCI
OBJECTIVES
Understanding normal sleep physiology
and age related changes
Recognize and diagnose various sleep
disorders and their Prevention
Management and treatment in the
inpatient setting
BACKGROUND
Poor sleep affects up to 50%
in the adult population
More common in elderly
women than men
Up to 57% of noninstitutionalized elderly have
problems with chronic
insomnia
IMPACT OF SLEEP DISORDERS
Trouble
falling
asleep /
waking up
too early
Nocturnal
awakening
Day time
napping
Poor day
time
function
...CAN LEAD TO
“OTC sleep aids”
/ “PM”
medications
Sedative
use or
sleep
medicine
•Diphenhydramine
•Tylenol PM
•Advil PM
Worse
daytime
function/
sedated
ETOH /
wine
Affects quality
of life, and
iADLs
Increased
mortality, risk for
falls, depression
and cognitive
impairment
NORMAL SLEEP PHYSIOLOGY
“Sleep
architecture”
•NREM-REM lasts about 100min (first
half) then 90-120min (latter half).
•NREM: REM changes between first half
vs latter half of the night
•Stage 3 and 4 during first half of night
NORMAL SLEEP CHANGES IN
AGING
Increased…
Increased
sleep latency
at bedtime
More day time
naps
More
awakenings
Alterations in…
Decreased…
NREM: REM proportion;
Less melatonin at
bedtime
Decreased stage 3 and 4
Less overall sleep
Circadian cycle
Sleep phases tend to
“advance”
Less flexible with
schedule changes
Less rested after
waking up
PREDISPOSING FACTORS TO SLEEP
DISORDERS
Pain, respiratory issues, nocturia.
Comorbidities that prevent patient
from resting flat like CHF, GERD
Medications like stimulants, diuretics
anxiety, social isolation,
Insomnia is a common complaint in • Depression,
psychosis, epilepsy, movement disorders,
many other disease processes:
and neurodegenerative conditions
SLEEP DISORDER CLASSIFICATIONS
Primary
sleep
disorders
• Primary insomnia
• Sleep disordered
breathing
• Circadian disorders
• Restless Leg Syndrome
• Periodic limb
movements of sleep
• REM sleep behavior
disorder
• 2° to an underlying medical,
psychiatric, social or
behavioral cause.
Secondary
sleep disorder • ..or inadequate sleep hygiene
+/- Mixed
type insomnia
• A mixed presentation of both
PRIMARY SLEEP DISORDERS
Primary insomnia: sleep onset, sleep maintenance issue
Sleep disordered breathing: OSA, central sleep apnea, mixed sleep apnea
Circadian disorders
Restless Leg Syndrome
Periodic limb movements of sleep
REM sleep behavior disorder
EVALUATION
Assess baseline
daily function,
routine from
partner or
caregiver,
consider a sleep
diary
Assess impact
during the day
Assess nature of
the problem
(excess daytime
sleep vs early
awakening vs
initiation /
maintenance),
look for a
secondary cause
as well
Formal sleep
testing:
•Indications for
polysomnography
•Diagnoses related
to sleep disordered
breathing, or CPAP
titration,
•Suspected
Narcolepsy or REM
Sleep movement
disorder,
•Periodic limb
movement disorder
INSOMNIA
“It is a group of disorders
defined by difficulty in:
falling asleep (initiation),
staying asleep
(maintenance), waking too
early (duration), or feeling
unrefreshed in the morning
(quality of sleep) which
results in an impact during
the day despite adequate
opportunity and
circumstances for sleep.”
• Presenting symptoms
• Fatigue, mood disturbances, interpersonal and job problems,
reduced quality of life.
• Terminology: Transient if <1wk, short
term if < 4 weeks, chronic >1 month
Effective in about
70% patients.
Sleep hygiene
education
CBT- beliefs and
attitudes – most
lasting benefit
NON-PHARMACOLOGIC
MANAGEMENT OF INSOMNIA
Stimulus control
therapy- reinforce
same routine for
bedtime, limit bed
activity to sleep,
limit napping.
Sleep restriction
therapy- avoiding
going to bed
early
Relaxation therapy
– meditation,
biofeedback,
imagery
MEDICATIONS FOR INSOMNIA
Most medications have limited
studies in elderly
A retrospective study looking from
2001 to 2010 noted increase in
prescribing benzos to 85+, than in
those aged 65 to 84.
Gradual discontinuation to
prevent rebound when tapering
Benzodiazepines, non-benzodiazepines
and antidepressants pose a risk of harm:
increased risk of falls, confusion,
rebound insomnia, tolerance (to
treatment effects), and withdrawal
symptoms on discontinuation
• SA benzodiazepines assoc. with falls at night
• ++ Pronounced withdrawal and rebound
syndromes (dose dependent)
• LA benzodiazepines should not be given in the
elderly (Flurazepam) (cognitive impairment, falls,
sedation)
NONBENZODIAZEPINES ( Z-DRUGS)
Evidence is limited in older adults who have significant comorbidities
• Newer data suggest fall rates similar to benzos;
Zolpidem (Ambien) : Short ½ life 2.6 hrs (sleep onset insomnia)
• Less rebound symptoms when discontinued.
• Still has risk for falls, anterograde amnesia, driving impairment (FDA warning)
• Avoid higher doses
Zaleplon (Sonata) :Very Short ½ life 1 hr (sleep onset insomnia)
• Has been studied for short-term use in older adults with insomnia,
• Still at risk for falls, can cause occasional HA and dizziness;
• Not approved for long term use.
• Taken immediately just before bed / if unable to fall asleep.
Eszopiclone (Lunesta): Medium ½ life 5-7 hrs (sleep maintenance insomnia),
• Increases total sleep time > sleep onset.
• Risk for falls, taste change, headache,+ evidence for next day effects (driving) in elderly- lower dose
OTHER PHARMACOLOGICAL
AGENTS
Suvorexant
• First dual orexin receptor antagonist approved for treatment of insomnia
• Role in elderly ? unknown
Ramelteon – melatonin receptor agonist
• Small reduction in sleep latency; increases total sleep time
• Approved for chronic use.
• No significant rebound or withdrawal effects with discontinuation.
Melatonin (0.1 -10mg)
• Has been shown to be effective in the management of chronic insomnia (deficiency associated
with insomnia, happens more often in elderly)
OTHER PHARMACOLOGICAL
AGENTS
Sedating antidepressants – (sleep maintenance)
• Limited evidence, but used for decades
• Use should be limited to pts with sleep issues who have psychiatric conditions.
• Avoid routine use in older adults without serious psychiatric illness, avoid TCA
due to anticholinergic SE .
• Low doses of Doxepin (3-6 mg)
• Low dose Trazodone (25–100mg)
• helps improve Slow-wave sleep (during stages 3 and 4)
• Low dose Mirtazapine (7.5–30mg)
• increases duration of Slow-wave sleep as well, helps sleep efficiency
SLEEP DISORDERED BREATHING
CSA (central sleep apnea)
OSA (central sleep apnea)
• Defined as “periodic complete
cessation of airflow and respiratory
effort followed by desaturation and
arousals”
• Common in older adults
• Respiratory effort is absent because
of CNS or cardiac dysfunction
• Diagnosed with Polysomnography
• Treatment of CSA
• CPAP
• -continued breathing effort but inadequate
ventilation.
• Elder adults have a subtle presentation in the
elderly but can be lead to cognitive
impairment, frailty and mortality
• Increased risk for OSA in edentulous patients
• Occurs in 20% of older adults (2x)
• Patients with normal BMI and unremarkable
physical exam (Normal neck circumference
and BMI) does not exclude OSA
• Diagnosis: Symptoms + Polysomnography
• Treatment of OSA: CPAP
AVOID sedating drugs in patients with sleep related breathing disorders
CIRCADIAN RHYTHM DISORDERS
Circadian disorder:
•Often misdiagnosed as insomnia
•Easy to find among other sleep
complaints,
•presentation may have behavior
and psychological issues.
Diagnosis:
•Sleep log
•Wrist actigraphy
Non- pharmacological therapies :
highly effective
•Behavioral treatment: most effective.
•Lifestyle changes(chronotherapy),
Photo therapy
•Managing expectations in patients
with chronic medical or psychiatric
conditions is difficult
•It requires continuous patient
participation, insight, and lifestyle
change.
•Some patients with dementia and
nursing-home residents have
extremely irregular sleep-wake
cycles,
•They tend to have advanced sleep
phase, they may respond to
evening exposure to bright light
•or vice-versa in delayed sleep
phase, with timed morning bright
light and/or evening melatonin
RESTLESS LEG SYNDROME
Symptoms
• uncontrollable urge to
move one’s legs at
night due to an
unpleasant sensation
• while awake
• worsens with inactivity
• improves with
movement
• It tends to have
circadian patternworse in evenings.
Associated
conditions
• RLS should be
considered in
dementia patients
who have signs such as
rubbing or massaging
of legs, increased
motor activity
• PLMS occurs in most
(80%–90%) patients
with RLS
• Associated with
anemia, or renal or
neurologic disease
• Screen for iron
deficiency
Causes
Treatment
• Some classes of
medications like
antiemetics,
antipsychotics, SSRIs,
tricyclic
antidepressants, and
diphenhydramine can
worsen RLS
• More common in older
adults and women,
• Pharmacologic
• dopaminergic agents
are the initial agent
of choice,
pramipexole or
ropinirole one hour
before bed time, with
Gabapentin being
an effective
alternative
• May also consider
carbidopa-levodopa
for PRN use
• Non pharmacologic
• Avoid offending
agent and address
sleep hygiene,
caffeine and alcohol
intake
PERIODIC LIMB MOVEMENTS OF SLEEP
(VS. PLMD)
Symptoms
Diagnosis
Treatment
•condition of repetitive,
stereotypical leg
movements
•occur in non-REM sleep
•Most are asymptomatic
and do not tend to cause
sleep disruption
•PLMD can cause sleep
disruption or day-time
fatigue however.
•Associated with increasing
age (up to 45%
prevalence)
•PLMD requires
polysomnography to be
diagnosed
•Dopaminergic agents are
the initial agent of choice
for PLMD with coexisting RLS
but not isolated PLMD
REM SLEEP BEHAVIOR DISORDER
Presenting symptoms: Vigorous sleep behaviors from vivid dreams; may present with
self injury or injured bed partner
Common in older men, can be familial
Transient RBD has been associated with toxic metabolic abnormalities, and
•Drugs (TCA, MAOi, fluoxetine, venlafaxine, cholinesterase inhibitors)
•Alcohol withdrawal or intoxication
About a 1/3rd of patients develop synucleinopathies (PD, DLB, multisystem
atrophy)
•REM sleep disorder predates several years
Diagnosis
•Polysomnography
INPATIENT AND LTC MANAGEMENT
Insomnia in the inpatient
setting:
•Multiple causes, usually transient
•The need for sleep is greater in the hospital than in outpatient
•Increased risk of delirium
Non-pharmacologic
interventions to prevent
delirium-
•Need improvement in adherence
•difficult to adhere to in the acute setting
No Benadryl
Resume CPAP use-
•leads to delirium, urinary retention, risk of cognitive impairment
•Sleep apnea is a common comorbidity in hospitalized adults,
INPATIENT AND LTC MANAGEMENT
In the nursing
home:
•Patients tend to sleep more during the day- increased risk for depression and functional
decline.
•Some prospective studies have shown that decreased daytime sleeping in patients after they
have been discharged were noted to have a improvement in cognitive function
•Hurdles to lessen sleep disturbances include:
•Appropriate light exposure to light
•Debility or inactivity or daytime naps
•surrounding noise
•Night time sleep disturbances were associated with poor physical function in older veterans in
an ADHC program.
•No indication to use sedative-hypnotics
PREVENTION: SLEEP HYGIENE
Limit external
stimulation
Medications
Addressing reversible
causes
Promote sleep in hospitals
• HELP model : multifactorial approach
• Non-pharmacologic sleep protocol
PREVENTION: SLEEP HYGIENE
• Unnecessary
awakenings
Limit external • stress, late meals,
cigarettes, alcohol,
stimulation
• caffeine close to bed
time
• noise
Medications
•Avoid Benadryl, diuretics
•Non-pharmacologic
sleep hygiene program,
•Nighttime sleep protocol
Addressing reversible
causes
• Encourage: activity,
routine, using bed primarily
for sleep,
• Timing for light exposure
• Limit naps
Promote sleep in hospitals
• HELP model : multifactorial approach
• Non-pharmacologic sleep protocol
THANK YOU
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