Sleep Disorders in the Elderly

Calvin Damanik
Significance of Sleep Disorders
Survey of 9000 people > age 65
• No sleep complaints (12%)
• Difficulty initiating/maintaining (43%)
• Nocturnal waking (30%)
• Insomnia (29%)
• Chronic sleep difficulties (>50%)
• Daytime napping (25%)
• Trouble falling asleep (19%)
• Waking too early (19%)
• Waking without feeling rested (13%)
Ancoli-Israel S. JAGS 2005;53:S264-S271.
Significance of Sleep Disorders
 >50% of sedatives are used by people age > 65
 In age 70-100, 19% of patients were taking a sleep
medicine (in one study)
 Disturbed sleep is a strong predictor of ECF placement,
especially in patients with dementia
 Mortality due to common conditions is 2 times higher in
elderly with sleep disorders than in those without.
 Daytime somnolence can interfere with activities and
function
 Sleep disorders negatively impact quality of life
 Sleep disorders can lead to depression and cognitive
impairment
 Normal Physiology - Basics
• Non-REM sleep
– Stage 1: very light, easy to arouse
– Stage 2: most of the night’s sleep
– Stage 3,4: slow wave, deeper sleep
• REM sleep
– EEG similar to stage 1
– Low/absent muscle tone
– Dreaming occurs here
– Greatest cardiac and respiratory instability
 Normal Physiology - Basics
• Sleep Architecture
– REM latency is about 90 minutes (wide
variation)
• Very short in narcolepsy
– REM normally occurs every 90 to 120 minutes
– More stage 3,4 in first half of night, more REM
2nd half
– Brief awakenings (30 sec) common, not
usually remembered
– Brief arousals (3 sec) are normal
 Age-Related Changes
 Non-REM
◦ Less slow wave sleep (stage 3 and 4), may be
entirely absent, easier to awaken
 REM
◦ Shorter REM latency
◦ Decreased REM percentage and duration
 Architecture
◦ Increased overall sleep latency
◦ More awakenings/arousals = less sleep efficiency
◦ Less sleep in 24 hour period*
◦ Reduced sleep latency during day – harder to stay
awake

Espiritu JR. Clin Geriatr Med 2008;24:1-14.

 Age-Related Changes
• Circadian cycle shifted earlier
– Decreased melatonin levels at night
– Decreased modulation of circadian rhythm
between day and night
• More naps during the day (1 hour)
– May have little impact on night-time sleep
– May enhance cognitive and psychomotor
performance due to increase total sleep

Espiritu JR. Clin Geriatr Med 2008;24:1-14.

 Age Related Changes
• Less physiologic flexibility with schedule
changes
• More comorbidities that can interfere with
sleep
• It is hard to know if sleep problems are
more common independent of other
conditions
• The ability to get restorative sleep gets
worse with age, the need for sleep does
not.
 Mechanisms Underlying Sleep Complaints

Vaz Fragoso CA. JAGS 2007;1853-1866.`

 Precipitating Factors
• Declining Health Status
– Nocturia
– Pain (DJD, neuropathy)
– Cardiac Disease
• Angina, CHF, arrhythmia
– Pulmonary Disease
– GER
– Endocrine: thyroid, menopause, DM polyuria
– CKD
 Precipitating Factors
• Medications – impact sleep architecture and
sleep-disordered breathing
– CNS stimulants/depressants
– Diuretics, hypoglycemics
• Neuropsychological Impairments
– Depression, Anxiety
– Cognitive Impairment/Psychosis
• Primary Sleep Disorders
Perpetuating Factors - Psychosocial
• Caregiving
– The work of caregiving
– Associated mental and physical health problems
• Social Isolation
– Poorer sleep hygiene
– Decline in activity
• Bereavement, Widowhood, Retirement
• Loss of zeitgebers* (physical, sensory)
 Primary Sleep Disorders
• Primary Insomnia
– Sleep onset (Initial)
– Sleep maintenance (Middle)
• Sleep disordered breathing
– Obstructive sleep apnea
– Central sleep apnea
– Mixed sleep apnea
• Circadian rhythm disturbances
 Primary Sleep Disorders
• Restless Legs Syndrome
• Periodic Limb Movements of Sleep
• REM Sleep Behavior Disorder

• All primary disorders can be mixed with

other primary and with secondary causes
 Secondary Sleep Disorders
• Underlying conditions that should be
addressed first
• Medical Illness – causing nocturnal
symptoms
• Psychiatric Illness
• Medications
• Social/behavioral
 Secondary Sleep Disorders
• Psychophysiologic Insomnia
(stimulus/response)
• Adjustment Insomnia – recent stressor
• Inadequate Sleep Hygiene
– Lack of schedule (retirement!)
– Sedentary or naps during daytime
– Voluntary sleep deprivation (doctors!)
• Mixed-type insomnia
 Sleep Hygiene
• The bed is for sleeping (and sex) only
• Increase activity, decrease naps
• Avoid late meals
• Avoid caffeine, ETOH, cigarettes
• Environmental control (light, noise, temp)
• Decrease stress
• Establish a routine
 Insomnia - Definition
• Difficulty with initiation, maintenance,
duration, or quality of sleep that results in
the impairment of daytime functioning,
despite adequate opportunity and
circumstances for sleep.
• Can lead to fatigue, mood disturbance,
interpersonal and job problems, and
reduced quality of life.
From DSM-IV
 Insomnia - Definitions
• Sleep latency usually > 30 minutes
• Sleep efficiency < 85%
• Transient: less than 1 week
• Short-term: 1-4 weeks
• Chronic: > 1 month
– May be perpetuated by worrying in bed or
unrealistic expectations of sleep duration
– More common in women, elderly, and chronic
disease (medical and psychiatric)
 Insomnia - Treatment
 Non-pharmacologic therapy
◦ Improvement in 70-80% of patients (though some
studies used psychologists)
◦ Stimulus control therapy – bed for sleeping only, same
wake time daily, 1 small nap only
◦ Sleep restriction therapy – reduce time in bed to
achieve 90% efficiency, gradually increase (up to 6-7
hours)
◦ Relaxation therapy – biofeedback, imagery, meditation,
muscle relaxation
◦ Cognitive therapy – beliefs and attitudes
◦ Sleep hygiene education
Joshi S. Clin Geriatr Med 2008;24:107-119.
 Insomnia - Medications
• Use lowest effective dose
• Use intermittent dosing
• Short term use (< 1 month if possible)
• Gradual discontinuation (rebound)
• Medications with shorter half lives are
preferred to prevent next-day sedation
 Insomnia - Medications
• Short acting medications
– More improvement with sleep latency
– More withdrawal and dependence
• Long acting
– More improvement with sleep duration
– More next day symptoms (sedation, cognitive
impairment, falls)
• Most medications have not been studied
extensively in the elderly or more than 6
months
 Insomnia - Medications
• Benzodiazepines – GABA-A receptors
– Benefits: cheap, improve sleep latency, total sleep
time, number of awakenings, sleep quality
– Disadvantages:
• More next day effects (drowsy, dizzy)
• More dependency/withdrawal
• More rebound symptoms
• More anterograde amnesia (especially with shorter acting
agents)
• Falls and hip fracture risk (long acting)

Tariq SH. Clin Geriatr Med 2008;24:93-105.

 Insomnia - Medications
• Benzodiazepine receptor agonists
– Advantages
• more specific targeting of GABA receptors in the brain – so
less side effects
– Disadvantages
• Not well studied in the elderly (use lower starting doses)
• Not compared against each other
• More expensive ($65-100 per month)
• Dependence/withdrawal still occur
• Still can increase risk of falls and fractures
 Drugs vs No Drugs
– Unclear if cognitive behavioral therapy or medication
therapy is better
◦ Both help
◦ Medications may work more quickly
◦ CBT may have more lasting benefit
– Hard for PCP’s to do cognitive therapy
– Medications not studied more than 6 months

– It is best to attempt education and non-pharmacologic

therapy first, and continue even if medications are used
 Other Treaments for Insomnia
• Bright Light Therapy
– Light -> suprachiasmatic nucleus -> inhibits production of
melatonin by pineal gland
• Threshold between 200-400 lux (normal indoor fluorescent light)
• Treatment uses 2000-10,000 lux
– Cochrane: no trials focused on elderly, but benefit seen with
younger patients
– Dosing, timing, duration, effectiveness not established in the
elderly
– Best evidence for SAD in younger people

Gammack JK. Clin Geriatr Med 2008;24:139-149.

 Sleep-disordered Breathing
• Usually present with daytime somnolence
• Snoring: alone is not usually a problem
• Hypopnea
• Apnea – increased incidence in the elderly,
can be seen in 10-40%
– Obstructive
– Central
– Mixed
 Sleep-disordered Breathing
 Significance, Signs, and Symptoms
◦ Daytime somnolence, effect on function
◦ Decreased cognition, dementia may be worse
◦ CHF, arrythmias, HTN, cor-pulmonale
◦ Polycythemia
◦ Nocturia
◦ Personality changes
◦ Morning headaches
◦ Decreased libido, impotence
◦ May increase mortality
 Sleep-disordered Breathing
• Other Symptoms
– Snoring
– Restless sleep
– Choking/gasping during sleep
– Witnessed apnea
Obstructive Sleep Apnea (OSA)
 Definition: repetitive episodes of uper airway
obstruction with continued movement of
chest and abdominal walls, leads to
desaturations and arousals.
 Risk factors: people with classic symptoms
and:
◦ Male
◦ Large neck circumference (>18 inches)
◦ Obesity
◦ Crowding of oropharynx
 OSA - Diagnosis
• Classic Symptoms and Polysomnography
– EEG (at least 2 channel)
– EMG (muscle activity – chin)
– EOG (eye movements)
– ECG
– Respiratory airflow and effort
– Oxygen saturation
– Snoring intensity and body position
– Reports an “Apnea-Hypopnea Index” - AHI
 OSA - Stages
• Mild: sleepiness when sedentary, little
attention required, not daily, minor
impairment of function
– Mean sat >90 and min sat >85, AHI 6-20
• Moderate: daily sleepiness when minimaly
active and moderate attention required
(driving, meetings, movies)
– Mean sat >90 and min >70, AHI 21-40
 OSA - Stages
• Severe – daily sleepiness during tasks that
require significant attention (driving,
conversation, eating, walking), marked
impairment in function
– Mean sat <90 or min <70, AHI > 40
 OSA - Treatment
• Unclear benefit to treating mild or
minimally symptomatic patients
• Treatment is likely to improve:
– HTN
– CHF
– Daytime function
– Cognition and health-related quality of life
 OSA - Treatment
 Weight loss, avoid supine position (tennis
balls)
 Avoid sedating drugs
 Prescription drugs not helpful
 CPAP/BIPAP – Most efficacious
◦ Compliance issues
 Oral appliance – less effective, use for mild
cases or if CPAP not tolerated
 Surgery – trach, uvuloplasty, bariatric surgery –
not first line, various effectiveness
 Central Sleep Apnea - CSA
 Definition – Periodic complete cessation of
airflow and respiratory effort, followed by
desaturations and arousals.
 Related to chemoreceptors and CO2
physiology.
 Hypercapneic – underlying hypoventilatory
disorders blunts chemoreceptor
responsiveness
 Nonhypercapneic – underlying
hyperventilatory disorder causing periodic
hypocapnea which turns off respiratory drive
 CSA Associated Conditions
• Congestive heart failure
• Prior Stroke and cerebrovascular disease
• Other neurologic disorders – ALS, mucular
dystrophy
• Chronic renal failure
• Hypothyroidism
• Baseline CO2 retainers (COPD,
kyphoscoliosis)
CSA – Diagnosis and Treatment
• Diagnosis – Polysomnography
• Treatment
– CPAP/BIPAP can help
– Nocturnal Oxygen can help (offsets
“overshoot”)
– Consult your local pulmonologist
 Other Sleep Disorders
• Restless Legs Syndrome
• Periodic Limb Movements of Sleep
• REM Sleep Behavior Disorder
• Nocturnal Leg Cramps
• Circadian Rhythm Disturbances
Restless Legs Syndrome (RLS)
Sensorimotor neurologic condition,
possibly caused by abnormal iron
metabolism and dopaminergic dysfunction
– unclear
Compelling urge to move limbs (legs>arms)
◦ Worse at rest
◦ Worse at night
◦ May have dysesthesia or pain
◦ Relieved with movement
◦ Disrupts sleep, alertness, daytime function, QOL
 RLS – Facts
• 5-15% prevalence, increased in the elderly,
more common in women
• Associated features
– FH positive in 60%
– PLMS in 80% (but 30% PLMS pts have RLS)
• Diagnosis
– Classic symptoms
– Responds to trial of therapy
 RLS – Associated Conditions
• Pregnancy • Drugs can exacerbate
• ESRD – Sedating antihistamines
– Metoclopramide
• Fe Deficiency
– Calcium channel blockers
– Check ferritin, iron
– Neuroleptics
• Parkinson’s
– TCA’s
• Radiculopathy – SSRI’s
• Neuropathy – Caffeine
• Rheumatoid arthritis – Nicotine
– ETOH
• DM
• Depression/anxiety
 RLS – Treatment
• Non-pharmacologic
– Avoid caffeine, ETOH, associated medications
– Sleep hygiene
– Bedtime bath
– Mild exercise before bedtime
• Pharmacologic
see handout – most drugs used off label
70-100% effective
 RLS Treatment
 Dopaminergics
◦ Requip/ropinirole and Mirapex/pramipexole– only
FDA approved meds)
◦ Use for daily or intermittent symptoms
◦ First line treatment (most studied)
 Benzos – intermittent use, klonopin is best
choice
 Opioids – daily or intermittent use
 Neurontin – daily use, similar efficacy to
Requip (average dose 800mg)
◦ Neuropsychobiology 2003;48(2):82-6.
 Magnesium, folate have “slight” evidence
Periodic Limb Movements of Sleep
 PLMS: Periodic episodes of repetitive and
highly stereotypc limb movements during
sleep
 34-45% prevalence in the elderly, increases
with age
 Associated with RLS, arousals, difficulty
achieving and maintaining sleep
 Most are asymptomatic
 Unclear significance
 Associated conditions similar to RLS
PLMS – Diagnosis and Treatment
• Diagnosis
– Clinical history and response to treatment
– Polysomnography can be used
• Treatment
– Dopamine agonists
– Benzo’s – decrease arousals but not
movements
– Opioids
REM Sleep Behavior Disorder
• Lack of normally low muscle tone during
REM sleep
• Cause unknown
• Usually male, onset age 50-60
• Act out dreams which can be violent
• Vivid memory of dreams
• Can diagnose with polysomnography
• 1/3 of Patients will develop Parkinson’s
• Treat with benzo (klonopin 90% effective)
 Nocturnal Leg Cramps
• Cause – not known
• Associated factors
– Meds (diuretics, nifedipine, beta agonists,
steroids, morphine, cimetidine, statins,
lithium)
– Conditions (uremia, DM, thyroid, electrolyte
d/o’s)
• Diagnosis – history, check labs
 Nocturnal Leg Cramps
• Treatment
– Review associated factors
– Calf stretching exercises
– Quinine (200-300mg QHS)
• Evidence of moderate benefit
• Toxicity – careful in elderly, kidney/liver disease
– Digoxin interaction
– Hematologic (thrombocytopenia)
– Blindness, arrhythmias, death!