Journal of Gerontology: MEDICAL SCIENCES

1997, Vol. 52A, No. 4, MI89-MI9I

Copyright 1997 by The Gemntological Society of America

MINI-REVIEW

Sleep Disorders and Aging:

Understanding the Causes
Michael V. Vitiello

S many as 40% of the elderly population complain

L about sleep problems. Studies sampling from a wide
variety of populations have consistently demonstrated that
older people are disproportionately dissatisfied with their
sleep; these studies have also noted disproportionate use of
sedative medications among the aged (e.g., 1,2,3).
Significant sleep disturbance can lead to daytime sleepiness
and fatigue and impaired daytime function; it can seriously
compromise the quality of life of many elderly individuals
and cause them to seek professional health care.
The sleep disturbances of elderly people arise from a
multitude of causes and create a complex problem. There
are three major considerations regarding sleep disorders
and aging: (a) the recognition of the multifactorial nature
of sleep disorders in the elderly; (b) the need to, wherever
possible, treat the primary problem rather than the symptom of sleep disturbance; and (c) the importance of taking a
very conservative approach to prescription of hypnotics for
sleep complaints.

The Multifactorial Nature of Sleep Disturbance in Aging

Sleep disturbance in elderly people is the result of: (a)
changes in sleep that accompany the aging process, per se;
(b) medical and psychiatric conditions and their treatments
and psychosocial factors that result in secondary sleep disturbance; (c) primary sleep disorders, some of which can
themselves be age-related; and (d) poor sleep hygiene. A
given sleep complaint can be and often is based on any
combination of these factors. It is also important to recognize that whether an older individual complains is also dependent on their subjective appraisal of their own sleep
quality.
Age-Related Sleep Change
The subjective complaints of the elderly have clear objective bases when their sleep is examined in the laboratory. Polysomnographic studies consistently show that
older individuals spend more time in bed, spend less time
asleep, take more time to fall asleep, awaken more often
and for longer periods of time, and have less efficient sleep.
Also, they spend less time in slow wave (SWS) and rapid

eye movement (REM) sleep and are more prone to napping

compared to younger individuals (2,4).
It is important to remember that considerable portions of
these changes are age-related and are not the result of any
medical or psychiatric pathologies, primary sleep disorders,
or poor sleep hygiene. That is, even extremely healthy,
carefully screened, noncomplaining aged adults manifest
the changes in sleep quality mentioned above.
Sleep Disturbance Secondary to Physical
and Mental Illness
The role of physical and mental health in the reported
sleep disturbances of elderly persons has begun to be better
appreciated (5). While it is clear that sleep is severely disturbed by numerous diseases that increase in prevalence
with advancing age, e.g., dementia (6,7), a number of studies have recently demonstrated that when medical and psychological health factors, such as the presence of significant systemic diseases, pain syndromes or major life event
stresses, are controlled for then the prevalence and incidence of sleep complaint in aged samples are considerably
less than most previous studies have reported (8).
A recent epidemiologic study has elegantly demonstrated
that the bulk of incident insomnias that developed in a
large elderly sample over three years were associated with
incident medical or psychosocial burden (1,9). Further, initial report of insomnia coupled with improved health over
the three-year period was associated with resolution of insomnia (10). This ongoing study clearly demonstrates the
logical causal relationship between health and sleep quality
and argues against insomnia being the result of aging, per
se. Another consideration that needs to be appreciated in
this context is that medical treatment of an illness ranging
from bedrest to medications can also impact sleep quality
adversely (2,4,5,11).
Primary Sleep Disorders
The sleep of the elderly can also be impaired as a direct
result of primary sleep disorders, some of which themselves may be age-related. Sleep-related breathing disturbance (SRBD or sleep apnea) and periodic leg movement
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Departments of Psychiatry and Behavioral Sciences, Psychology, and Biobehavioral Nursing

and Health Care Systems, University of Washington, Seattle.

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VITIELLO

during sleep (PLMS or nocturnal myoclonus) are two such

primary sleep disorders for which there is clear evidence of
increasing prevalence with age (8,12).
However, the clinical implications of these observations
are unclear. The presence of mild or even moderate amounts
of SRBD in the absence of symptoms such as excessive
daytime sleepiness and impaired daytime function is not
necessarily clinically significant (8,12,13). Similarly, older
individuals can experience significant nocturnal myoclonic
activity and be apparently free of morbidity. The true impact of these disorders in the aged population has yet to be
clearly delineated. Finally, it needs to be remembered that
an older individual can also have a primary sleep disorder
that is not age-related (e.g., psychophysiological insomnia
or narcolepsy).

Use of Sedative-Hypnotics
There is often the temptation to prescribe a sedative when
faced with an older person complaining of poor sleep quality (3). In 1985 over 20 million benzodiazapine prescriptions were written, representing a 38% increase from 1980
levels (15). A disproportionate number of these prescriptions
were written for elderly patients, with persons above 60 receiving 66% more sedative prescriptions than persons 40 to
59. Further, older women were 1.7 times more likely to
receive a sedative prescription compared to older men.

Circadian Rhythms and Melatonin

There is considerable evidence that at least some of the
sleep disturbance seen with advancing age may be the result of ontogenetic changes in the physiological systems
that generate and regulate circadian rhythms (19). That is,
disturbed sleep in the elderly is at least partially the result
of breakdowns in the body's circadian rhythms. Based on
the premise that sleep quality will improve, considerable
research has focused on assessing interventions which may
reverse these circadian changes. The circadian melatonin
rhythm has been demonstrated to interact with the timing
and quality of sleep, and exhibits diminished amplitude and
advanced phase (occurring earlier in reference to clock
time) with advancing age (19). Melatonin is available over
the counter and its exaggerated potential to treat sleep disturbance has received considerable attention in the media.
Melatonin's potential efficacy in this context has been
preliminarily demonstrated in a recent series of studies (2022). Melatonin may ultimately prove to be efficacious but is
likely to be limited in usefulness to those elderly who are
"melatonin-deficient." Indeed, in older individuals with relatively robust melatonin rhythms it may prove counterproductive, interfering with endogenous melatonin secretion.
Further, the potential side effects from regular melatonin
supplementation are unexplored, and its currently available
preparations are far from optimal in dosage, quality control,
and speed of release. It is likely that appropriate melatonin
preparations will ultimately prove useful in improvirig
sleep quality in a subset of older insomniacs. At the present
time such preparations are not available.
Summary and Conclusion
The sleep disturbances disproportionately reported by the
elderly are multifactorial in their origins and must be taken
seriously. Even optimally healthy, noncomplaining elderly
people have sleep patterns that are significantly disturbed
relative to healthy younger subjects. In this regard, the unrealistic but understandable expectation of many elderly

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The Roles of Sleep Hygiene and Subjective Appraisal

Even given all of the factors discussed above, the sleep
quality of older individuals can be further compromised by
a multitude of other factors. These factors may be collectively described as poor sleep hygiene, which includes, but
is not limited to: an individual's chosen sleep schedule;
daytime napping; their bedroom environment, including
bed, acoustics, lighting, and bed partner; dietary habits
(e.g., "tea and toast" syndrome); lack of regular exercise
and exposure to daylight; inappropriate use of caffeine, alcohol, or medications; and inappropriate use of the bedroom environment (e.g., using bedtime as "worry time").
These factors all have the potential to affect sleep adversely. Improving an individual's sleep hygiene can aid in
optimizing their sleep quality (5,14). Quite often, education
about normal age-related sleep changes coupled with specific advice regarding sleep hygiene can effectively treat a
sleep complaint not based on a specific pathology.
The last layer of complexity concerning sleep disturbance in the elderly is that of subjective appraisal of sleep
quality. One individual may judge normal age-related sleep
change in the absence of other disturbing factors to be a
possibly annoying but minimal problem, while another
might view it as severe and report a sleep complaint. Conversely, another patient with age-related change, primary
and secondary disorders, and poor sleep hygiene all contributing to severely disturbed sleep that could be improved
might view the sleep disturbance as simply "part of
growing old" and not volunteer a complaint. Sensitivity to
an individual's appraisal of their problem is crucial as it can
strongly influence whether or not a patient is likely to report a significant sleep disturbance and it may affect their
adherence to treatment.

While sedatives can be useful for relief of transient insomnia, several recent studies have demonstrated the limited efficacy of chronic sedative use in older populations
(e.g., 3,16). Tolerance frequently develops, and symptomatic treatment with hypnotics may even exacerbate existing sleep disturbances by inducing a drug dependency insomnia with rebound insomnia and nightmares when the
drug is discontinued. Occult sleep apnea can also be exacerbated. Adverse daytime effects can include impaired cognition, slowed psychomotor functioning, and increased
likelihood of injuries due to falls. A recent epidemiological
study further calls into question the chronic use of sedatives
demonstrating that patients with insomnia who make use of
psychotropic medication reported comparable satisfaction
about their sleep quality compared with patients with insomnia not taking psychotropics (3).
Two recent NIH Consensus Conferences advocate great
restraint in the use of sedative-hypnotics for other than temporary, situational, or intermittent conditions, and even then
for extremely limited periods, at the smallest effective dose,
with frequent "drug holidays" (17,18).

SLEEP DISORDERS AND AGING

ACKNOWLEDGMENTS

This review was supported by Public Health Service Grants K02MH01158, RO1-MH45186, RO1-MH53575, RO1-AG-10943, RO1AG12915, R37-MH33688, MO1-RR37, and the Department of Veterans
Affairs. The author wishes to thank Sharon Roloff for her assistance in
preparation of the manuscript.
Address correspondence to Dr. Michael V. Vitiello, Department of
Psychiatry and Behavioral Sciences, Box 356560, University of Washington, Seattle, WA 98195-6560. E-mail: [email protected]
REFERENCES

1. Foley DJ, Monjan AA, Brown SL, Simonsick EM, Wallace RB,
Blazer DG. Sleep complaints among elderly persons: an epidemiologic study of three communities. Sleep 1995; 18:425-32.
2. Vitiello MV, Prinz PN. Sleep disturbances in the elderly. In: Albert
ML, Knoefel JE, eds. Clinical neurology of aging, 2nd ed. New York:
Oxford University Press, 1994:637-50.
3. Ohayon MM, Caulet M. Insomnia and psychotropic drug consumption. Prog Neuropsychopharmacol Biol Psychiatry 1995;19:421-31.
4. Vitiello MV, Prinz PN. Sleep and sleep disorders in normal aging. In:
Thorpy MJ, ed. Handbook of sleep disorders, neurological diseases
and therapy. New York: Dekker, 1990:139-51.

5. Prinz PN, Vitiello MV, Raskind MA, Thorpy MJ. Sleep disorders and
aging. N Engl J Med 1990;323:520-6.
6. Vitiello MV, Poceta JS, Prinz PN. Sleep in Alzheimer's disease and
other dementing disorders. Can J Psychol 1991 ;45:221-39.
7. Vitiello MV, Bliwise DL, Prinz PN. Sleep in Alzheimer's disease and
the sundown syndrome. In: Culebras A, ed. The neurology of sleep.
Neurology 1992;42:Suppl 6:83-94.
8. Bliwise DL.Sleep in normal aging and dementia. Sleep 1993; 16:
40-81.
9. Monjan A, Foley D. Incidence of chronic insomnia associated with
medical and psychosocial factors: an epidemiologic study among
older persons. Sleep Res 1996;25:108.
10. Monjan A. Personal communication, February 1997.
11. Winget C, Vernikos-Denellis J, Cronin S, Leach CS, Rambaut PC,
Mack PB. Orcadian rhythm asyncrony in man during hypokinesis. J
ApplPhysiol 1982;33:640-3.
12. Bliwise DL, Kryger MH, Roth T, Dement WC: Normal aging. In:
Bliwise DL, Kryger MH, Roth T, Dement WC, eds. Principles and
practice of sleep medicine, 2nd ed. Philadelphia: WB Saunders,
1994:26-39.
13. Ancoli-Israel S, Coy T. Are breathing disturbances in elderly equivalent to sleep apnea syndrome? Sleep 1994; 17:77-83.
14. Zarcone VP. Sleep hygiene. In: Bliwise DL, Kryger MH, Roth T,
Dement WC, eds. Principles and practice of sleep medicine, 2nd ed.
Philadelphia: WB Saunders, 1994:542-6.
15. Baum C, Kennedy DL, Knapp DE, Faich GA. Drug utilization in the
U.S.1985: Seventh annual review. Rockville, MD: Food and Drug
Administration, Center for Drugs and Biologies, 1986.
16. Alessi CA, Schnelle JF, Traub S, Ouslander JG. Psychotropic medications in incontinent nursing home residents: association with sleep
and bed mobility. J Am Geriatr Soc 1995;43:788-92.
17. National Institute on Aging. National Institutes of Health Consensus
Development Conference Summary: Drugs and insomnia. Washington, DC: U.S. Government Printing Office, 1984.
18. National Institute on Aging. National Institutes of Health Consensus
Development Conference: The treatment of sleep disorders of older
people. Washington, DC: U.S. Government Printing Office, 1990.
19. Myers BL, Badia P. Changes in circadian rhythms and sleep quality
with aging: mechanisms and interventions. Neurosci Biobehav Rev
1995; 19:553-71.
20. Haimov I, Laudon M, Zisapel N, et al. Sleep disorders and melatonin
rhythms in elderly people. Br Med J 1994;309:167.
21. Garfinkel D, Laudon M, Nof D, Zisapel N: Improvement of sleep
quality in elderly people by controlled-release melatonin. Lancet
1995;346:541-4.
22. Haimov I, Lavie P, Laudon M, Herer P, Vigder C, Zisapel N:
Melatonin replacement therapy of elderly insomniacs. Sleep 1995;
18:598-603.
23. American Sleep Disorders Association, 604 2nd St. SW, Rochester,
MN 55909, 507(287-6006).
Received January 7, 1997
Accepted March 17, 1997

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that they should sleep for as long and as soundly as they did
when they were young needs to be recognized and addressed. It is important to distinguish these age-related
sleep disturbances from those originating in pathological
processes such as sleep disorders secondary to medical and
psychosocial burden, primary sleep disorders, and poor
sleep hygiene. Finally, whether or not an individual chooses
to view their sleep disturbance, regardless of its cause, as a
problem deserving of complaint and makes an effort to seek
treatment is moderated by that individual's appraisal of
their sleep disturbance and its implications.
In conclusion, sleep disorders in older patients can arise
from multiple and diverse causes. Because many sleep disorders are secondary, comprehensive and accurate diagnosis and specific cause-based treatments are essential. A
careful review of sleep history, sleep hygiene, and education regarding age-related sleep change should be integral
parts of any evaluation of a sleep disturbance. When appropriate, referral to the growing number of specialized sleep
disorders centers and clinics should be considered (23).
Hypnotics should be used with extreme caution and only
for transient or situational sleep disturbances, as their
chronic use is at best questionable and potentially harmful.

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