Resources for the Comprehensive Geriatric Assessment based
Proactive and Personalised Primary Care of the Elderly
Normal sleep is organized into different stages that cycle throughout the night. Polysomnographic studies have classified the sleep stages into rapid-eye-movement (REM) sleep and non-REM sleep
REM sleep (ie, paradoxical desynchronized sleep) is the stage of sleep during which muscle tone decreases markedly.
This stage is associated with bursts of conjugate gaze and dreaming. Relative amounts of REM sleep are maintained until extreme old age, when they show some decline.
Non-REM sleep is subdivided into 4 stages.
Stages 1 and 2 constitute light sleep, and stages 3 and 4 are called deep sleep or slow-wave sleep (SWS).
With aging, an increase in the duration of stage 1 sleep and an increase in the number of shifts into stage 1 sleep occur.
Stages 3 and 4 decrease markedly with age. In extreme old age (>90 years), stages 3 and 4 may disappear completely.
Some studies, however, have found that elderly women tend to have normal or even increased stage 3 sleep, whereas men have normal or reduced stage 3 sleep.
Time in bed
Older individuals spend more time lying in bed at night without attempting to sleep or unsuccessfully trying to sleep. They also use the bed for resting and napping during the day.
Total sleep period
Total sleep period refers to the time from sleep onset to the final awakening from the main sleep period of the day. Total sleep period increases with age because of the increase in the number of awakenings.
Total sleep time
Total sleep time refers to the total sleep period minus the time spent awake during the sleep period. Studies have found the total sleep time to be either reduced or unchanged in the older population.
Sleep latency is the time from the decision to sleep to the onset of sleep. Studies have found considerable variability in individuals. In females, sleep latency has been related to increases in age and hypnotic drug use, which would decrease sleep latency.
Wake after sleep onset
Wake after sleep onset is the time spent awake from sleep onset to final awakening. An increase occurs in the time spent awake after sleep onset in the older population. Webb was able to attribute 38% of nocturnal arousals in a study to physical discomfort (eg, bladder distention, urinary urgency) (Webb WB, 1989).
Pain, restless legs, and dyspnea have also been identified as factors in arousal during sleep.
Sleep efficiency is the ratio of total sleep time to nocturnal time in bed. Most studies have found sleep efficiency to be decreased in the older population.
Nocturnal penile tumescence
Studies have shown that a gradual decline in nocturnal penile tumescence (NPT) during REM sleep occurs with age, even though the duration of REM sleep remains fairly constant until extreme old age.
Primary sleep disorders
Primary sleep disorders are common but up to 50% go under-reported in the general population (Leger D, 2007). The most frequently occurring primary sleep disorders in older adults are insomnia, sleep disordered breathing, restless legs and REM sleep-behaviour disorder (REMSBD).
Insomnia is defined as a difficulty in initiating or maintaining sleep.
It is the most frequent sleep complaint in older age and predicts greater use of health services and hospitalisation (Kaufmann CN, 2013)
Whilst a primary sleep disorder, it is often co-morbid with chronic physical and mental illness. In particular depression has been shown to predict insomnia (Cole MG, 2003) and untreated insomnia can result in depression. Treatment of insomnia should therefore take into account the various possible contributors.
Cognitive behavioural therapy (CBT) is the most effective behavioural treatment for chronic insomnia; benefit may last up to two years after treatment (Morin CM, 1999) and be as effective as pharmacological therapy (NIHSS, 2005).
Older people account for 40% of all hypnotics prescribed and although a variety of drug classes including benzodiazepines, antipsychotics, anticonvulsants, antidepressants and antihistamines have been used to treat insomnia, there is no systematic evidence for efficacy of any class of medication (Koch S, 2006).
Benzodiazepine hypnotics are most commonly used for treatment of insomnia. They are effective in the short term (NIHSS, 2005) and should be considered in combination with behavioural therapy.
'Z-drugs' (zolpidem, zopiclone), thought to be safer hyponotics as they are non-benzodiazepine, have shown a reduction in sleep latency, both polysomnographically and subjectively. However sleep latency shows a significant response to placebo. Chronic use of the `Z-drugs' at low or high dose carries a risk of increased adverse events (Huedo-Medina TB, 2012).
Caution is advised with use of hypnotics as 80% of insomnia in older people is chronic and hypnotics lose effectiveness after weeks of continuous use (Curran HV, 2003).
The risks associated with long-term use of hypnotics outweighs their benefit.
Benzodiapezines must be reviewed and withdrawn gradually when no longer required or effective. Although concerns exist about rebound insomnia, there is little difference in subjective sleep quality in older people tapering off benzodiazepincs compared with those who continue on benzodiazepines (Curran HV, 2003).
Sleep Disordered Breathing
Sleep disordered breathing (SDB) refers to a spectrum of disorders: from snoring to apnoea.
SDB has a higher prevalence in older people, with an increased frequency among those with dementia or living in nursing homes (Young T, 2002).
Increased age, male gender and obesity are the main risk factors for SDB. However other factors including use of sedatives, alcohol consumption, smoking, race and upper airway configuration increase the risk of Sleep Disordered Breathing (SDB) (Young T, 1993).
SDB is associated with impaired cognition (Weaver TE, 2007) and older adults with SDB are more functionally impaired than those with insomnia alone (Goonerathe NS, 2006).
Older adults also have a greater risk of cardiovascular disease (Shahar E, 2001).
Common symptoms of SDB are snoring and excessive daytime somnolence.
Diagnosis is confirmed with overnight oximetry and sleep studies.
Continuous positive airway pressure (CPAP) is a proven treatment for SDB: it reduces apnoea and hypopnoea, improves sleep architecture and cognition, and reduces symptoms and cardiovascular risk (Weaver TE, 2007).
However its effect on mortality has not been defined.
Restless legs syndrome and periodic limb movements in sleep.
Restless legs syndrome (RLS) is characterised by dysaesthesia of the legs resulting in the urge to move. This occurs when relaxed, and is more frequent in the evenings and at night.
Whilst the majority of RLS is idiopathic, it is associated with iron deficiency, uraemia, peripheral neuropathy and radiculopathy. In the former two associations, symptoms abate when the underlying abnormality is corrected. Patients generally present due to disrupted sleep.
Periodic limb movements in sleep (PLMS) may present in a similar manner.
PLMS, also known as nocturnal myoclonus, is characterised by frequent stereotyped movements of the legs, generally extension of the big toe and flexion at the ankle and knee.
It is a symptom associated with RLS, SDB, REMSBD and narcolepsy and is considered pathological when more than five movements occur per hour.
Both RLS and PLMS are more common in older age. RLS has a prevalence of 9-20% in those aged over 70 years and PLMS occurs in up to 86% of older people with sleep disorders (Homyak M, 2004).
A detailed history is vital to diagnose RLS.
The dopamine agonists ropinirole and pramipexole are licensed treatments for RLS.
Other drugs, such as levodopa and anti-convulsants, may be effective albeit a non-licensed indication for these drugs.
Rapid eye movement sleep behaviour disorder
Rapid eye movement sleep behaviour disorder (REMSBD) results from an absence of the normal muscle atonia that is a feature of REM sleep.
Patients with the condition are classically described as "acting out their dreams", including kicking, punching and shouting. The patient is unaware of their actions, which can result in injury to the patient or their bed-partner and often drive the bed partner to move to another bed / bedroom.
As with RLS, REMSBD occurs more frequently in older people, with a greater prevalence amongst older men.
Although the aetiology of REMSBD is unknown, up to 57% are associated with dementia, Parkinson's disease or multiple system atrophy (Olson EJ, 2000).
No specific treatment has been shown to alleviate the symptoms of REMSBD.
Cautious use of low dose clonazepam is more effective and more commonly used, than other options including dopaminergic drugs and SSR1 antidepressmts (Aurora RN, 2010).
Other causes of disordered sleep patterns in geriatric patients include the following:
Chronic pain disorders (eg, osteoarthritis, metastatic diseases) are one of the most common reasons cited by the older population for poor sleep. Osteoarthritis causing joint stiffness at night makes moving during sleep difficult and painful
Left ventricular failure associated with orthopnea and paroxysmal nocturnal dyspnea can lead to frequent awakenings
A Cheyne-Stokes breathing pattern attributable to a cardiac or cerebral cause (treatment of this disorder with respiratory stimulants or nocturnal oxygen therapy can often improve sleep)
Patients with chronic obstructive pulmonary disease (COPD) have nocturnal worsening of hypoxemia, which occurs predominantly during REM sleep
Lower urinary tract symptoms (LUTS), including benign prostatic hypertrophy and detrusor instability, may contribute to poor sleep
Patients with Parkinson disease may experience urinary frequency and difficulty in turning over and getting out of bed, which leads to sleep fragmentation
Gastroesophageal reflux disease (GERD)
Pruritic skin conditions
When evaluating a patient, identify and treat primary sleep disorders, review medications and other contributory medical conditions.
Patient education on age-related changes in sleep and good sleep hygiene may be adequate treatment for many older adults.
If the initial history and physical examination findings do not reveal a serious underlying cause, a trial of improved sleep hygiene is the best initial approach.
The common recommended measures include the following:
Maintain a regular wake-up time
Maintain a regular sleeping time
Decrease or eliminate daytime naps
Exercise daily but not immediately before bedtime
Use the bed only for sleeping or sex
Do not read or watch television in bed
Do not use bedtime as worry time
Avoid heavy meals at bedtime
Limit or eliminate alcohol, caffeine, and nicotine before bedtime
Maintain a routine period of preparation for bed (eg, washing up, brushing teeth)
Control the night-time environment with a comfortable temperature, quietness, and darkness.
Wear comfortable, loose-fitting clothes to bed
If unable to sleep within 30 minutes, get out of bed and perform a soothing activity, such as listening to soft music or reading, but avoid exposure to bright light during these times
Get adequate exposure to bright light during the day
Avoid daytime naps; explaining to the patient that daytime naps decrease night-time sleep is helpful
People who are overweight and habitually snore loudly may be helped by weight loss.
All people who snore loudly should abstain from alcohol or other sedatives before going to bed. They should also take measures to avoid supine sleeping (eg, by taping a tennis ball to the back of their bedclothes).
In the absence of sleep apnea (SA), contributing conditions, such as allergies, nasal pathology, or nasopharyngeal enlargement, should be sought and adequately managed by intranasal corticoid sprays or evaluated by an ear, nose, and throat specialist.
If the sleep problem is secondary to a medical problem, treat the primary problem rather than the sleep problem.
Polysomnography is indicated when primary sleep disorders such as SA or periodic limb movements in sleep (PLMS) are suspected.
Consultation with appropriate specialists may be indicated, depending on the underlying causes of the sleep disorder, such as psychiatric consultation for severe depression and pulmonary or surgical consultation for obstructive sleep apnea. Psychologists may provide cognitive-behavioral therapy for insomnia.
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