Sleep in Older Adults
Mirnova Ceïde, MD
Assistant Professor of Psychiatry and Medicine
Albert Einstein College of Medicine/
Montefiore Medical Center
April 6, 2015
Learning Objectives
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Describe the prevalence of sleep disorders in the population.
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Describe the effects of factors such as age, race/ethnicity,
medical and mental illnesses on sleep.
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Illustrate normal sleep changes which occur in aging.
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Discuss diagnosis and treatment of common disorders in the
elderly.
Sleep in America
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4/10 Americans describe themselves as “great sleepers.”
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43% of American’s report rarely or never getting a good
night’s sleep.
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95% of Americans utilize an electronic device one hour prior
to sleep.
Sleepfoundation .org
Changes in Sleep In the
population
Population Estimates of Sleep Duration
Kripke et al. 1979
8 hrs
Sleep Habit Gallup Poll 1979
8hrs
Schoenborn et al. 1986
7.5 hrs
Sleep Habit Gallup Poll 1995
7 hrs
Sleep in America Poll 1998
6.6 hrs
Jean-Louis et al. 1999
6.5 hrs
Sleep in America Poll 2008
6.5 hrs
Kripke et la. 2002
Selected Groups
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Certain groups have been identified as vulnerable to poor
sleep:
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Older adults : higher prevalence of insomnia and medical
comorbidities.
Gender: Women are more likely to report insomnia symptoms.
Variable
Women
Men
Lack of Sleep
24%
19%
Difficulty Initiating Sleep
26%
17%
Difficulty Maintaining Sleep
35%
28%
Early Morning Awakening
24%
19%
Sleepfoundation .org, Sleep in America Poll 2001, Hale et al. 2009
Selected Groups
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Other vulnerable groups:
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Hispanics and Blacks:
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poor sleep hygiene
higher prevalence of sleep symptoms
higher prevalence of sleep apnea
less adherent to sleep study referrals
Psychiatric illness particularly mood disorders, dementia,
substance abuse.
Medical illness: particularly GERD, pulmonary, metabolic
syndrome, Parkinson’s disease, stroke and incontinence.
Occupational: Night shift and rotating shift workers.
Sleepfoundation..org, Baldwin et al. 2010, Hayes 2009, Jean Louis et al.
2008, Nunes et al. 2008, Loredo et al 2010. Ruiter et al. 2011, Ohayon et al.
2010,, Ceide et al. 2012
Outcomes of Poor Sleep
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Short term Hazards:
• Excessive daytime sleepiness
• Mood: depressive symptoms, relapse of chronic
psychiatric illness
• Nutrition: snacking, consumption of energy dense food,
delayed gastric emptying
• Metabolic: increased postprandial glucose and
decrease metabolic rate, increased ghrelin and
decreased leptin
• Immune: increased cytokines such as IL-6
• Vascular: endothelial dysfunction
Chaput et al. 2010, Buxton et al 2012, Heffner er al. 2012, Taheri
et al. 2004, Kim et al. 2011
Outcomes of Poor Sleep
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Long term hazards:
• Obesity
• DM II
• Hypercholesterolemia
• Hypertension
• Mortality (in the elderly)
Kohatsu et al. 2012, Zizi et al. 2012, Knutson et al. 2009, Kripke et
al. 2002, Gangwisch et al 2008, Vgontzas et al. 2010
Stages of Sleep
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5% Stage 1 is the beginning of the sleep cycle, and is a
relatively light stage of sleep. Slow theta waves
50% Stage 2 is the second stage of sleep; body temp
decrease and breathing rate slows. Sleep spindles and K
complexes.
15-25% Stage 3 and 4 or NREM is a transitional period
between light sleep and a very deep sleep; blood pressure
dips by 10%. Delta waves.
25% REM sleep is characterized by eye movement,
increased respiration rate, increased brain activity and
dreaming.
Normal Changes with
Aging
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Increased awakenings and arousals
Decreased REM sleep
Decreased slow wave sleep
Increased stage shifts
Fewer “cycles”
Reduced sleep efficiency
Circadian control of
sleep
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Circadian rhythm mediated by the CLOCK system in the
suprachiasmatic nucleus (SCN) in the hypothalamus
The SCN releases amino acids in response to light via
retinal projections.
Changes are mediated by NO and Glutamate
SCN CLOCK system regulates transcription of nuclear
glucocorticoid receptors in the brain and peripheral
tissues.
Ding et al 1994, Kino et al 2007
Normal Changes with
Aging
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Age is associated with decreased electrical, hormonal
and gene – expression activity of SCN cells.
Decrease in pineal gland function and decreased
circulating melatonin.
Gender specific changes in post menopausal women.
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Women experience a more significant decline in melatonin
Decreased photoreception due to pupillary miosis and
impaired crystalline lens light transmission.
Impaired pineal innervation/interconnection between the
SCN and the pineal gland.
SCN degeneration.
Phase advancement
Costa et al 2013
Insomnia
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Definition:
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Prolonged sleep latency, difficulties in maintaining sleep, early
morning awakening and/or the experience of non-restorative
sleep.
Cause marked distress or significant impairment.
Subtypes include: psychophysiological, sleep- state
misperception, and idiopathic insomnia
Prevalence:10 to 30 %:
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2:1 ratio women to men
higher in older adults
Bastien et al. 2011
Bastien 2011
Insomnia
Fundamentals of Good Sleep Hygiene
What to do
What not to do
-Use your bed for sleep and
sexual activities
-In general, refrain from napping
and going to sleep too early
(phase advance syndrome)
-Make the quality of your sleep a
priority
-Before bedtime avoid heavy
eating, consumption of caffeine
or alcohol, smoking, exercise
-Develop and maintain bedtime -While you try to fall asleep,
“rituals” that make going to sleep avoid thinking of life issues,
familiar
problem solving, etc.
Gellis et al. 2009, Wolkove et al. 2010
Insomnia
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Exercise:
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Light Therapy:
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Promotes both sleep onset and sleep consolidation
Elderly benefit from even minimal exercise
Also benefits cardiovascular status, bone density, joints and balance
Moderately bright light (1000 lux) or more improves subjective alertness,
mood, and sleep quality
Morning bright light promotes normal sleep in phase delay
Evening bright light promotes sleep in phase advance
Bright light resynchronizes circadian rhythm
Napping:
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Lower diastolic blood pressure, Improves mood, Decreases subjective
sleepiness, Improved performance
Also associated with increased mortality
Wolkove et al. 2010
Insomnia
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Cognitive Behavioral Therapy:
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Cognitive principles of insomnia
Treatment targets include:
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Unrealistic sleep expectations
Misconceptions about the causes of insomnia
Distorted perception of insomnia consequences
Faulty beliefs about sleep promoting practices
Other sleep disturbing thoughts
Efficacy:
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In RCT, CBT and CBT/Med are better than meds alone.
Improved attitudes and beliefs about sleep are associated with
better sleep at 24 months.
Belanger et al. 2006, Bluestein et al. 2011,
Morin et al 2011
Insomnia
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Pharmacotherapy:
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Melatonin
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Melatonin levels decline with age
Lower in elderly insomniacs than age matched controls
Some studies show improvement in sleep quality
Not FDA improved, studies have looks as doses from 3mg to 6mg.
Melatonin Receptor Agonist
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Ramelteon; prolonged-release melatonin, agomelatine and
tasimelteon
FDA approved sleep onset insomnia, with studies specifically in the
elderly
Half life 1-2.5 hrs
Clinical dose 8mg
No tolerance in 12 months studies, no withdrawal symptoms
Adverse effects: somnolence, fatigue, dizziness, nausea
Raehrs et a l 2012, Bastien et al 2011, Laudon et al. 2014
Insomnia
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Benzodiazepines:
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No adverse effects on COPD and SDA
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May develop tolerance, may experience withdrawal(
including seizures
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Short term use associated with sedation, poor recall,
psychomotor slowing.
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Longer term use associated with Alzheimer’s disease
Bastien et al 2011, , Pomara et al 1998, Pomara et al. 2015, Gage et al.
2014
Insomnia
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Non Benzo Benzodiazepine Receptor Agonists
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GABAa complex, higher affinity for alpha 1
Zolpidem:5mg, 10mg
Zaleplon: 5mg, 10 mg
Eszopiclone: 1mg -3mg
Less tolerance and rebound
Amnestic parasomnias
Equivocal risk for falls compared to insomnia
Antidepressants:
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Mirtazapine, Trazodone, Doxepine
Orthostatic Hypotension
Anticholinergic, Antihistamine side effects
Equivalent fall risks
Roehrs et al 2012, Bastien et al 2011
Sleep apnea
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Apnea: cessation of breathing >10 sec
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Obstrucitve: if effort
Central: wiithout effort
Hypopnea: reduction in breathing ( 50% of airflow +O2
desaturations)
AHI: Apnea + Hypopnea Index
Obstructive Sleep Apnea/Hypopnea Syndrome:
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AHI=5 or more respiratory event per hour of sleep
AHI=15 or more moderate toe severe sleep apnea.
Sleep Apnea
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Evaluation
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Clinical history: snoring, excessive daytime sleepiness, witnessed
apneas, weight gain, impotence
Physical findings: BMI >30, Hypertension, Neck Circumference
>=17 in
Polysomnography: AHI >5
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1/3 elderly patients have AHI >5
Morbidity and Mortality increased with increasing AHI
Treatment: CPAP
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Surgery is less favorable over the age of 50 years old
Weight loss and smoking cessation are mandatory
Compliance may be problematic
Jean Louis et al. 2008
Sleep Apnea
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Prevalence: men 14%, women 5%
Untreated:
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Car Accidents/ Work Accidents
Cardiovascular disease
Hypertension
Diabetes
Metabolic Syndrome
Andrews et al 2004, Jean Louis et al 2008
Periodic Limb Movement
Disorder
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Sleep disorder where the person moves limbs involuntarily
during sleep.
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Associated with Restless leg syndrome
Half of people with ESRD
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Diagnosed on PSG:
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3 periods of atleast 30 movements during the night, lasting a
few minutes to an hour or more, followed by partial arousal
and awakening.
Ancoli-Israel et al. 2008
Restless Leg Syndrome
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Disorder of dysethesia in legs which often occurs when the
person is inactive which includes nighttime
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Prevalence increases with age, about 45%.
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More common in women.
50% of patients with ESRD
Diagnosis:
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NIH criteria: an urge to move limbs with or without sensations,
improvement with activity, worsening at rest, worsening in the
evening or night.
Ancoli-Israel et al. 2008
PLMD/RLS
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Associated conditions:
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ESRD
Neuropathies and myelopathies
Pregnancy
Anemia (iron deficiency)
Chronic renal failure
Folate / B12 deficiency
Medications (tricyclics, SSRI’s, caffeine)
Obesity
Hypothyroidism
PLMD/RLS
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Treatment:
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Nonpharmacologic
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Mental alerting actions
Avoidance of certain meds: ie. Antidepressants, antipsychotics,
antihistamines and alcohol, nicotine, caffeine
Exercise
Pneumatic compression, heating pads
Daily HD for uremic patients
Pharmacologic
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Dopamine agonist : pramipexole, ropinirole
Gabapentin
Opioids: particularly methadone
Benzodiazepine: diazepam
Anticonvulsants: carbamazepine
Einollahi et al. 2014, Ancoli-Israel et al. 2008
REM Sleep Behavior
Disorder (RBD)
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Diagnostic Criteria
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Presence of REM sleep without atonia
Atleast 1 of the following:
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Absence of epileptiform activity, not another sleep
disorders
Strongly associated with neurodegenerative illnesses like
PD or LBD, MSA
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Sleep related injurious behavior
Abnormal REM sleep behaviors on PSG.
40-80% of people with RBD develop PD in 5 to 15 years.
Prevalence: most common in males over 50 years old.
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General population 0.5%
People 70-89 years old 8.9%
Coeytaux et al 2013
REM Sleep Behavior
Disorder (RBD)
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Treatment
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Reduce injury, remove hazards
No FDA approved treatments
First line pharmacotherapy:
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Melatonin 3mg to 15mg qhs
Clonazepam 0.25to 2mg qhs
Or both
Coeytaux et al 2013
Dementia
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Sleep changes in Alzheimer’s Dementia include:
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Reduction in fast sleep spindles
Deterioration of rest/ activity cycle in moderate dementia
Multiple night time awakening
Frequent daytime napping
May have increased overall sleep in more severe dementia
Rauchs et al 2008, Gehrman et al 2005, Fetveit et al. 2006
Dementia
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Sleep disturbance is one of the main causes for institutionalization of people with
dementia.
Often comorbid with other neuropsychiatric symptoms.
Nonpharmacological:
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Increase activity during the day to improve the rest/activity cycle.
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Exercise, HHA, day program
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Bright light therapy in the evening may ameliorate sleep-wake cycle disturbance
Pharmacological:
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Melatonin: decease sundowning and may slow cognitive decline.
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Antidepressants, if accompanied by depressive symptoms
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Hypnotics such as non benzo benzodiazepine receptor agonist or rarely
benzodiazepines.
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Monitor for fall risk and delirium
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Antipsychotics may be used if accompanied by psychotic symptoms and
agitation.
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Avoid anticholinergic agents.
Lin et al 2013, Wolkove et al. 2010, Hatfield et al. 2004
Case
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60 years old divorced Black woman reporting poor sleep
and depressed mood.
Description of symptoms; onset, sleep maintenance or
early morning awakens.
Get collateral from a partner.
Clarify mood symptoms and any psychiatric history. Ask
about mania
Sleep hygiene
Diet
Sleep environment
Any recent trauma or stressors
Case
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Review of systems: SOB, chest pain, claudication
Medications (diuretics, stimulants)
Past medical history: metabolic syndrome, ESRD,
Parkinson’s, Dementia
Consider sleep study if high risk
First line treatment if insomnia
First line treatment if dementia
Thank you
Questions?
mceide@montefiore.org