sleep problems in the elderly (2023)

Restful sleep requires both adequate total sleep duration and sleep that is synchronized with a person's circadian rhythm. Sleep management issues in older patients often include difficulty falling asleep, less time in deeper sleep phases, early morning awakenings, and shorter total sleep time. Poor sleep habits like irregular bedtimes and daytime naps can lead to insomnia. Caffeine, alcohol, and some medications can also interfere with sleep. Primary sleep disorders are more common in older people than younger people. Restless legs syndrome and intermittent limb movement disorders can disrupt sleep and respond to low doses of antiparkinsonian drugs as well as other drugs. Sleep apnea can cause excessive daytime sleepiness. Assessing sleep problems in older adults involves a thorough assessment of poor sleep habits and other factors that may contribute to sleep problems. Formal sleep studies may be required when a primary sleep disorder is suspected or significant daytime dysfunction is identified. After careful consideration, therapy with a benzodiazepine receptor agonist may be indicated.

Complaints about insomnia are common among older people. In a National Institute on Aging study of more than 9,000 people age 65 and older, more than half of the men and women reported at least one chronic sleep disorder.¹Typical symptoms of sleep problems in older people include difficulty falling asleep and staying asleep, waking up early, and excessive daytime sleepiness.

A variety of processes can affect sleep and alertness in the elderly.^2,3These include acute and chronic illnesses, drug effects, mental disorders, primary sleep disorders, social changes, poor sleep habits, and changes in circadian rhythms. Sleep and wakefulness problems can be exacerbated by improper treatment by the patient, family members, doctors, or other caregivers.

The consequences of chronic sleep problems can be significant. Lack of sleep or chronic use of tranquilizers can lead to falls and accidents.^4,5Disordered breathing during sleep can have serious effects on the circulatory system, lungs and central nervous system. There is evidence of a strong link between sleep apnea and high blood pressure.^6–8Severe sleep disorders often result in people with dementia being placed in a nursing home. For all these reasons, sleep problems in elderly patients need to be properly assessed and treated.

The physiological need for sleep is controlled by two main factors: the total amount of sleep and the circadian rhythm of sleepiness and wakefulness. For optimal alertness during the day, people need about eight hours of sleep every 24 hours on average. Lack of sleep leads to increased drowsiness and can lead to cognitive decline.

Under normal circumstances, the circadian rhythm promotes a circadian cycle of nocturnal sleep and daytime alertness. There is also often a physiological drop in alertness in the afternoon, which can lead to napping. It is now known that exposure to light strongly influences the human circadian rhythm.

Normal sleep goes through a series of phases during each sleep period. REM (rapid eye movement) sleep accounts for 15 to 25 percent of all sleep and is associated with dreaming and increased instability in heart rate, blood pressure, and breathing. Non-REM sleep is divided into four stages of increasing depth. The deepest non-REM sleep usually occurs at the beginning of the night. REM sleep episodes occur in cycles of about 90 minutes and the duration of each episode tends to increase throughout the night. As seen in...illustration 1Older people have more fragmented sleep and shorter durations of sleep stages 3 and 4 than young adults.

Several generalizations can be made about age and sleep characteristics. Compared to younger people, older people tend to sleep less at night. However, it cannot be assumed that older people need less sleep. In older people, waking up occurs more frequently, and waking up at night as well. The effect of this pattern can lead to increased daytime sleepiness. In general, the sleep-wake cycle in the elderly can be fragmented, with nocturnal sleep and daytime wakefulness interrupted by naps. The deeper stages of non-REM sleep are often limited or absent in older people; However, REM sleep is usually preserved. Although a slight deterioration in sleep quality may be normal with age, an elderly patient's complaint of significant disturbance of nocturnal sleep or impaired daytime functioning due to excessive sleepiness should be evaluated.

Another common age-related change in sleep involves the circadian rhythm of the typical sleep period. Although there are exceptions, older people tend to go to bed earlier at night and wake up earlier in the morning. Getting up early is a common complaint of older people. Some people get annoyed when they spontaneously wake up at 4:30 in the morning. M. instead of 6:30 a.m. M. These people can experience sleep deprivation and excessive daytime sleepiness if nocturnal sleep is initiated early enough.

Afternoon naps can make the problem worse by reducing the desire to fall asleep at the usual time, delaying sleep onset and further shortening the duration of the night's sleep.

In older people, the development of a "night owl pattern," with a bedtime delay into the early hours of the morning, is less common, but sometimes dramatic. This sleep-wake cycle may have been tolerated in younger working years, when the bright morning light signals were stronger and the regularity of sleep-wake hours was greater. After retirement, however, these signals become weaker and the sleep-wake cycle can be delayed by several hours. These patients may complain of a day-night reversal, in which sleep begins at dawn and lasts until mid-afternoon.

There are many factors to consider when assessing sleep-related disorders in elderly patients, as many problems can contribute to sleep deprivation.(Table 1). Nocturnal insomnia and excessive daytime sleepiness should not be viewed as isolated symptoms. It is important to have a complete sleep history over the entire 24-hour day to examine all the factors that can influence sleep and wakefulness.(Table 2). Asking the patient to keep a sleep diary of all sleep over a period of several weeks can be helpful in identifying the patient's sleep patterns. In addition to assessing the timing and regularity of bedtime, falling asleep, nocturnal awakenings, and daytime naps, other important features of the assessment are the total duration of habitual sleep over a 24-hour period and the predictability of the longest uninterrupted sleep periods.

Treatment to correct inappropriate sleep-wake times, or to increase total sleep time when it is insufficient, can significantly improve or even solve a patient's sleep problem. A thorough investigation of a complaint of insufficient or excessive daytime sleepiness includes consideration of other potential issues that may be contributing to sleep disorders, such as: B. Poor sleeping habits, medical conditions, medications and mental disorders.

Poor sleeping habits are a very common cause of insomnia. Irregular sleep and wake patterns related to lifestyle or work demands can interfere with the circadian system's ability to effectively time sleep and wakefulness. Caffeine consumption can have worrying effects over many hours. Consuming caffeinated beverages in the afternoon can interfere with your sleep at night. While drinking alcohol at night initially has a sedative effect, it prevents deeper sleep and increases the frequency of awakenings in the second half of the night. Excessive wakefulness before bedtime can cause the patient to develop increased restlessness, which intensifies each night.

Acute and chronic medical conditions such as arthritis, enlarged prostate, cardiovascular, gastrointestinal, and pulmonary disorders can cause sleep problems. Pain and discomfort can delay sleep and shorten sleep duration. Disorders of the sleep-wake cycle can be associated with neurodegenerative diseases, especially Alzheimer's disease.

Many drugs can have a stimulating effect and therefore cause sleep disturbances. These include certain antidepressants (particularly selective serotonin reuptake inhibitors), decongestants, bronchodilators, certain antihypertensives, and corticosteroids. As expected, nighttime use of diuretics can result in patients having to repeatedly wake up and go to the bathroom. In patients reporting excessive daytime sleepiness, the possible sedative effects of medications (particularly long-acting sedatives abused as sleep aids) should also be considered.

The stress of acute symptoms of a mental disorder can promote sleep disorders. A classic example is insomnia combined with major depression. The tendency towards hyperarousal and early morning awakenings in older people can be significantly increased in the presence of depression. Also, psychological manifestations of various life changes that older people often experience contribute to the deterioration of sleep quality. Physical limitations, the loss of loved ones, and leaving the family home to live in a more supervised environment are important factors.

Several primary sleep disorders are associated with age. Primary sleep disorders can delay falling asleep, cause multiple awakenings, and promote excessive daytime sleepiness.(Tisch 3). Wandering behavior and states of confusion can occur, particularly in patients with dementia. In rare cases, sleep patterns can result in serious injury to the patient or partner in bed.

Restless legs syndrome is characterized by severe discomfort, especially in the legs, at night when the person is resting.⁹This is akathisia, which is often described as a “tingling sensation”. The patient feels a strong urge to move their legs or to get up and walk around to relieve the discomfort. Restless Legs Syndrome can significantly interfere with falling asleep.

Periodic limb movement disorders, another primary sleep disorder, may accompany or occur independently of restless legs syndrome. This idiopathic disorder is characterized by episodes of stereotyped, rhythmic movements, most commonly in the legs, although other muscle groups, including the arms, may be affected in severe cases. These episodes are often perceived by the patient's bed partner as kicks occurring in cycles of 20 to 40 seconds. Hundreds of limb movements may occur in one night, but the patient is usually not awakened. However, they can lead to many short wakes, disrupting sleep patterns and shortening the time spent in the deeper stages of sleep. Delayed falling asleep associated with restless legs syndrome and sleep disruptions caused by periodic limb movements lead to daytime sleepiness. Restless legs syndrome is primarily a clinical diagnosis. Based on information from the bed partner, periodic limb mobility disorders can be suspected. If needed, the diagnosis can be confirmed by electromyography of limb muscle function during nighttime monitoring in a sleep laboratory.⁹Risk factors for both diseases are advanced age, kidney failure and iron deficiency (serum ferritin below 50 ng per ml). Up to a third of older people have measurable periodic leg movements during sleep; However, only relatively high event rates and high rates of associated arousal should be considered clinically significant. The level of distress reported by the patient should influence treatment decisions.

Soaking the legs and feet in a warm bath or regular exercise relieves restless legs syndrome in some patients. The most appropriate first-line pharmacological treatment for restless legs syndrome and intermittent limb movement disorders is carbidopa-levodopa (Sinemet) and other dopaminergic agents. Co-morbidities such as low iron may also need to be adjusted to ensure an appropriate response. Carbidopa-levodopa (in a 25-100 mg formulation) can be started with a dose of half a tablet at bedtime. The dose can be increased by half a tablet every three to four days, up to a maximum of two tablets per day. As with the use of carbidopa levodopa in the treatment of Parkinson's disease, a potential problem with this agent is the development of what is known as augmentation, where agitation begins earlier in the evening or afternoon.

Pergolide (Permax), starting with a very low dose, e.g. B. 0.05 mg two hours before bedtime and gradually increased to 0.5 mg, has also been used successfully to treat restless legs syndrome and periodic limb mobility disorder. In some cases, a dose of a benzodiazepine or a low-potency opioid such as codeine or oxycodone (rooxycodone) before bedtime can help. Other drugs being tested to treat restless legs syndrome include bromocriptine (Parlodel), carbamazepine (Tegretol), clonidine (Catapres), and clonazepam (Klonopin). Patients can seek information and support from organizations such as the Restless Legs Syndrome Foundation (website:http://www.rls.org).

Sleep apnea often results in repeated episodes of brief awakenings, which the patient is often unaware of, and can result in prolonged awakenings from sleep.^10,11The patient may report insomnia, but more often notices excessive daytime sleepiness. Hundreds of apnea episodes can occur in one night. Frequent sleep interruptions and repeated drops in oxygen saturation in the blood can lead to a significant deterioration in alertness and performance during the day. Sleep can interfere with everyday activities like driving, which can have dangerous consequences. Patients suspected of having sleep apnea are seen in a sleep laboratory, where electroencephalogram, blood oxygen saturation, airflow, and chest and abdominal ventilation can be followed to confirm the diagnosis.

Apnea episodes usually result from partial or complete obstruction of the airway (obstructive sleep apnea) or, more rarely, from a reduction in the drive to breathe (central sleep apnea). Risk factors for sleep apnea include male gender and obesity (particularly a heavy neck). Sleep apnea can be associated with hypothyroidism, neurodegenerative diseases, and cardiovascular disease. The main clinical symptom of sleep apnea is a history of loud, excessive snoring, interrupted by pauses, followed by wheezing. Observations by the patient's bed partner or another family member can provide important information to the doctor. In obese patients with sleep apnea, weight loss is often beneficial. However, the basis of therapy is continuous positive airway pressure during sleep, which is achieved by the patient wearing a well-fitting nasal mask. Snoring can often be eliminated with surgery, but apnea may not. Effective sleep apnea control can lead to more sound sleep at night and dramatic improvements in daytime alertness and performance.

A rare REM behavior disorder is most common in older people. Behind this disorder is the disinhibition of a process that normally prevents the transmission of muscle activity during sleep. The patient may squirm in bed, sometimes falling or jumping out of bed, and sustain serious injury. Treatment with a long-acting benzodiazepine, such as clonazepam, at bedtime often provides effective control of this disorder.

Since many factors influence the sleep-wake cycle, treatment should be individualized based on the patient's specific symptoms and assessment.¹²However, several generalizations are possible. Implementing good sleep habits and daily physical activity should help create an environment conducive to restful sleep.(Table 4). While poor sleep habits aren't responsible for insomnia, eliminating these habits can minimize their lasting effects.

Daily exercise and daylight can help strengthen the circadian cycle. These interventions have the greatest potential for improving sleep quality in older people. For patients who go to bed early and complain of early awakening, exposure to bright light at night for 30 to 60 minutes may be beneficial.¹³Minimizing exposure to light in the bedroom at dawn can also help. For people with delayed sleep onset and difficulty waking up in the late morning, regular early morning exposure to bright light can help shift their sleep-wake cycle to an earlier time of falling asleep and waking up during the night. Melatonin appears to help alter the sleep phase, but more research is needed to elucidate its use in treating insomnia and time zone shifting.

Many people who suffer from insomnia experience excessive anxiety from failed sleep attempts and respond well to behavioral approaches. As bedtime hyperactivity progresses, it may help the patient to spend less time in bed trying to fall asleep. This can help reduce the patient's anxiety about not being able to fall asleep. Patients may be advised not to go to bed until they feel they can easily fall asleep. Prolonged wakefulness in bed (eg, more than 30 minutes) should be avoided to minimize further escalation of hyperarousal. In addition, patients should schedule relaxing evening activities before bedtime.

Select patients may benefit from the temporary use of hypnotics.^14,15Over-the-counter antihistamines should be used with caution in the elderly because of their relatively long duration of action and anticholinergic effects, which can cause confusion, constipation, and urinary retention. Low-dose sedating antidepressants are particularly useful in patients with depressive symptoms. The duration of sedation and other potential side effects should be considered.

When considering hypnotics, a short-acting benzodiazepine receptor agonist would be the first choice. In general, a low dose and short-term use is recommended. Intermittent dosing has advantages. With occasional use, possible withdrawal symptoms are minimized. Instructions can be given to patients, e.g. For example, the advice not to take a sleeping pill more than two nights a week. On particularly difficult nights, the availability of a sleeping pill can calm the patient. This reassurance is likely to reduce the patient's anxiety on off-medication nights.

While potentially helpful in relieving insomnia, sleeping pills should not be viewed as the ultimate solution to sleep problems. They should be used in a limited manner, after assessment of the patient's symptoms and in the context of good sleep habits.

Consultation with a sleep specialist should be considered in patients with significant daytime sleepiness, as this symptom can be dangerous. You can also consult a sleep disorder specialist for tips on how to deal with chronic insomnia and sleep-related behavioral disorders. Formal sleep studies are appropriate when a primary sleep disorder is suspected.

You can find a lot of information on the subject of sleep and sleep disorders from various national organizations on the Internet. Helpful websites include the American Sleep Disorders Association (http://www.asda.org), National Sleep Foundation (http://www.sleepfoundation.org) y sleep home pages (http://bisleep.medsch.ucla.edu).