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Sleep Disorders in the Elderly
Module one
Brenda K. Keller, MD
Assistant Professor
Geriatrics & Gerontology
University of Nebraska Medical Center
PROCESS
Series of 3 modules and questions on
1. Diagnosis and impact of Sleep Disorders
2. Non-pharmacological treatment insomnia
3. Pharmacological treatments insomnia
Step #1 Power point module with voice overlay
Step #2 Case-based question and answer
Step #3 Proceed to additional modules or take a
break
Module 1 Objectives
Sleep disorders in the elderly
person
• Epidemiology
• Review changes in the sleep cycle with
aging
• Impact of insomnia
• Evaluation of Insomnia
Epidemiology
• 20-40% of older Americans experience
insomnia at least a few nights per month
• Insomnia may be:
– Difficulty falling asleep 18.1%
– Difficulty staying asleep 18.6%
– Not feeling restored by sleep 30.9%
Rockwood et al J Am Geriatr Soc 2001; 49:639-41
Normal Sleep Pattern
After sleep onset:
• Sleep usually progresses through NREM
stages 1 to 4 within 45 to 60 min. Slowwave sleep (NREM stages 3 and 4)
predominates in the first third of the night
and comprises 15 to 25% of total nocturnal
sleep time in young adults.
• The first REM sleep episode usually
occurs in the second hour of sleep.
Changes in sleep with age
• Light sleep (Stages 1 and 2) increases with age
=More awakenings
• Deep sleep (Stages 3 and 4) decreases from
~25% down to 3% of total sleep time
• The depth of slow-wave sleep, as measured by
the arousal threshold to auditory stimulation, also
decreases with age.
– In the otherwise healthy older person, slow-wave sleep
may be completely absent, particularly in males.
• Decreased amount of REM sleep
• Sleep quality and efficiency is 70-80% of younger
subjects.
• Loss of neurons in the suprachiasmatic nucleus
with advanced age may account for the age
related circadian phase shift
Circadian Rhythm
Disturbances
• 24 hr. physiological rhythms
– Affect hormones
– Core body temperature
– Sleep/wake cycle
• In aging the sleep/wake cycle advances
due to change in the core body temp, and
decreased light exposure
Circadian Rhythm Changes
Sleepy, go to bed
wake up
Standard phase
6:00p 7:00 8:00 9:00 10:00 11:00 MN 1:00 2:00 3:00 4:00 5:00 6:00a 7:00 8:00 9:00
Sleepy
Advanced phase
go to bed
wake up
Decline in hours slept by age
8
7
6
5
4
Hours Sleep
3
2
1
0
30
40
50
60
70
80
Impact of Disrupted Sleep
• Difficulty staying awake during the
day
• Impaired attention
• Slowed response time
• Impaired memory and concentration
• Decreased performance
• Mortality due to common causes of death
is 2 x higher in older people with sleep
disorders than those who sleep well.
Evaluation
• Sleep history
–
–
–
–
–
–
Timing of insomnia
Sleep schedule
Sleep environment
Sleep habits
Daytime effects
Symptoms of other
sleep disorders
• Medical history– Social History
• Stressors
• ETOH/Caffeine use
– Medication review
• Psychiatric history
– Depression
– Mania
– Psychosis
Sleep Disordered Breathing
• Recurrent hypopnea and apnea episodes
during sleep leading to repeated arousals
from sleep, and hypoxemia
– Prevalence Men > Women
– Associated with HTN, cardiac and pulmonary
dx.
• Main Sx is: snoring, pauses in respiration
and excessive daytime sleepiness.
• Treatment- CPAP, weight loss, use of
dental/mechanical devices, & surgery
Periodic Limb Movements of
Sleep
• Clusters of repeated leg jerking during
sleep
• Dx made when PLMI is >5.
• Prevalence 45% in elderly population
• No gender difference.
Treatment:
• Avoid alcohol, caffeine and TCA’s
• Dopaminergic agents:
Levodopa/carbidopa, pergolide,
pramipexole, ropinirole, gabapentin
Restless Leg Syndrome
• Dysesthesia in the legs, usually creepy
crawling sensation or pins and needles
• Only relieved with movement
• Sensations often occur when pt is in a
restful relaxed state.
• High association with PLMS
• Treatment with dopaminergic
agents.
Summary
• Epidemiology
• Review changes in the sleep cycle with
aging
• Impact of insomnia
• Evaluation of Insomnia
Post-test question 1
• An 83-year-old woman who resides in a longterm-care facility complains of chronic insomnia.
She is bedridden and is legally blind secondary
to diabetes mellitus. Which of the following agerelated changes most likely contributes to this
patient’s sleep disturbance?
A. A reduction in total sleep time
B. A reduction in melatonin secretion
C. A reduction in the percentage of stage 3 and 4
sleep
D. An increase in the percentage of rapid eye
movement (REM) sleep
E. A breakdown in the segregation of sleep and
wakefulness
Used with permission from: Murphy JB, et. Al. Case Based Geriatrics Review: 500 Questions and
Critiques from the Geriatric Review Syllabus. AGS 2002 New York, NY.
Correct Answer: E. A breakdown in the
segregation of sleep and wakefulness
Feedback
A fundamental change occurs in the circadian physiology of older
adults. Decreased nocturnal sleep, the tendency to nap, and
daytime sleepiness suggest that the segregation of sleep and
wakefulness in the light–dark cycle breaks down with age.
Moreover, older adults exhibit a “flattened” (ie, less prominent day–
night demarcation) circadian rhythm with respect to basal body
temperature and cortisol production. This patient, who is blind and
bedridden, likely has relatively few social and environmental cues to
indicate day or night. Thus, she may sleep randomly during a 24hour period and experience nighttime awakenings or insomnia. Total
sleep time decreases only moderately between the third and ninth
decade, and older persons generally are able to maintain normal
sleep patterns. Compared with a younger individual, an older
person’s sleep is less efficient, with substantial reduction in deep
(stages 3 and 4) sleep, as well as a tendency to experience more
awakenings because of environmental noise or temperature change.
• The relative percentage of REM sleep changes
little with age, although the temporal distribution
does “flatten” (ie, more uniform percentage of
REM sleep in both halves of the night). Agerelated changes in both REM and deep sleep
may contribute to this patient’s sleep
disturbance, but these factors are not clinically
significant. Although circulating levels of
melatonin decrease with advancing age, the
biologic and clinical implications of this change
are not clear. In this patient, a relative deficiency
of melatonin is not sufficient to explain the
clinical presentation.
Post-test question 2
• A 78-year-old man presents with complaints of restless
sleep at night and daytime fatigue and sleepiness. These
problems have been worsening over the past 5 years.
He describes social detachment and vivid nightmares
about his experiences during World War II. His wife
confirms the restless sleep and recently decided to sleep
in a separate bedroom because of his loud snoring and
occasional tendency to hit her unknowingly during sleep.
Which of the following represents the best diagnostic
approach?
A. Obtain a detailed 2-week sleep diary.
B. Obtain a measurement of serum melatonin and growth
hormone levels.
C. Obtain neuropsychologic testing.
D. Obtain a psychiatric evaluation.
E. Obtain a sleep laboratory (polysomnographic) study.
Correct Answer: E. Obtain a sleep laboratory
(polysomnographic) study.
• This case involves clinical features that are not unusual in sleep
disorders of older persons and suggests a multifactorial disturbance
in the sleep-wake cycle. The diagnosis in this case is directed
toward the disorder that would have the most significant impact,
including medical morbidity, and the treatment that would
significantly enhance quality of life. The primary diagnosis for any
patient who complains of daytime sleepiness is sleep apnea
syndrome. This primary sleep disorder is characterized by daytime
sleepiness and loud snoring. It is caused by repetitive apneas (often
hundreds of times during a night’s sleep) brought about by collapse
of upper-airway muscles, leading to partial or total obstruction. The
loud snoring results from inspiratory efforts to overcome the
obstruction and leads to arousals necessary for restoration of airway
muscle tonus. Sleep apnea syndrome is associated with significant
medical morbidity, including systemic hypertension, congestive heart
failure, and cognitive dysfunction.
• Risk factors for sleep apnea, present in this case, include male sex,
advanced age, history of loud snoring, and significant daytime
sleepiness. Because of poor correlations between clinical
complaints and objective measures of sleep apnea, the clinician is
advised to maintain a low threshold for referring patients to a sleep
evaluation center to assess sleep apnea syndrome. The clinical
history also suggests a diagnosis of restless legs syndrome or
periodic limb movements (PLM) disorder, or both. Sleep laboratory
(polysomnographic) testing should be obtained for this patient in
order to document the presence and extent of myoclonic activity in
the lower extremities during sleep as well as the association of
arousal during sleep. The history of the patient’s wife sleeping in
another room to avoid being hit by her husband raises the clinical
suspicion that this patient may be suffering from a parasomnia, such
as sleepwalking or rapid-eye movement (REM) sleep behavior
disorder. In the latter condition, the normal muscle atonia of REM
sleep is absent, allowing patients to engage in dream-enacting
behavior.
• Not uncommonly, patients with PLM disorder will intermittently kick
their bed partners; this results from larger involuntary limb
movements associated with the PLM disorder. In this patient, a
former war experience with recurrent traumatic dreams also should
prompt consideration of the diagnosis of posttraumatic stress
disorder. Patients with this disorder are known to have a greater
frequency of PLM disorder as well as a greater frequency of dream
and acting behaviors related to the traumatic experience. The use of
a sleep diary may be helpful in assessment of cases where it is
suspected that poor sleep habits (that is, poor sleep hygiene) or
other clinical factors are operating to disrupt sleep. Psychiatric
evaluation and neuropsychologic testing are most often useful
where prominent psychiatric symptoms are present; these
approaches may also be helpful following a sleep laboratory
evaluation in order to assess comorbid psychiatric conditions. The
measurement of serum levels of growth hormone, melatonin, or
other hormonal factors known to facilitate normal sleep is of no
value in this case.
End
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