Introduction
Several physical and psychological changes
are known to occur with normal ageing; however,
adjustment to changes insleep quantity and quality can
is a common complaint among patients of all ages,
research suggests that older adults are particularly
age of > 65 yr found that 42 per cent of participants
Follow up assessment 3 yr later revealed that 15 per
at baseline had disturbed sleep, suggesting an annual
incidence rate of approximately 5 per cent
1
changes insleep architecture are to be expected with
increasing age, age itself does not result in disturbed
Sleep disordersinthe elderly
*
*,**
*
San Diego State University/University of California, San Diego Joint Doctoral Program in Clinical Psychology
&
**
Department of Psychiatry, University of California, San Diego, California, USA
Nearly half of older adults report difculty initiating and maintaining sleep. With age, several
changes occur that can place one at risk for sleep disturbance including increased prevalence of
medical conditions, increased medication use, age-related changes in various circadian rhythms, and
environmental and lifestyle changes. Although sleep complaints are common among all age groups,
older adults have increased prevalence of many primary sleepdisorders including sleep-disordered
breathing, periodic limb movements in sleep, restless legs syndrome, rapid eye movement (REM)
sleep behaviour disorder, insomnia, and circadian rhythm disturbances. The present review discusses
age-related changes insleep architecture, aetiology, presentation, and treatment of sleepdisorders
prevalent among theelderly and other factors relevant to ageing that are likely to affect sleep quality
and quantity.
Key words
with age, often as a result of the other factors associated
with aging
2
disorders that are more prevalent among older adults
Ageing and sleep
Both subjective and objective measures of sleep
Subjectively, older adults report waking up at earlier
times, increased sleep onset latency, time spent in bed,
nighttime awakenings, and napping, and decreased
measurement tools such as polysomnography (PSG),
studies have been able to support subjective reports of
Review Article
Sleep consists of 2 main phases: rapid eye
younger adults found that older adults spent less time
suggested that with increasing age, time spent in lighter
3
are already detectable in young and middle aged
wave sleep linearly decreased at a rate of approximately
sleep becomes more fragmented as we age, such that
there are more frequent sleep stage shifts, arousals, and
time spent in bed), which indeed, continues to decrease
3
sleep time decreased an average of 27 min per decade
from midlife until the eight decade
4
changes insleep architecture, increased risk for sleep
disorders, circadian rhythm shifts, medical and/or
psychiatric conditions, and medication use (and
likely a combination of these factors) as possible
Considering the impact that sleep disturbance can have
on health, it is important to pay special attention to
Sleep disordersinthe elderly
Primary sleep disorders
Primary sleepdisorders are distinguished from
other sleepdisordersin that these are not other
mental disorders, medical conditions, medications,
sleep disorders frequently seen in older adults: sleep
disordered breathing (SDB), restless legs syndrome
(i
of breathing disorders ranging from benign snoring to
complete cessation of respiration (apnoeas) and/or partial
throughout the night, resulting in repeated arousals from
of apnoea and hypopnoeas per hour of sleep is called the
5
6
daytime somnolence) were 4 per cent for men and 2 per
cent for women
7
elderly people living independently
other factors associated with risk for developing
SDB include use of sedating medications, alcohol
consumption, family history, race, smoking, and upper
SDB are snoring and excessive daytime sleepiness
insomnia, nocturnal confusion, and daytime cognitive
Snoring is caused by airway collapse and often
plays a role inthe breathing cessation during an apnoeic
cent of those who snore also have SDB
not everyone who snores has SDB and vice versa;
however, snoring is associated with increased risk of
result of sleep fragmentation from repeated nighttime
take frequent unintentional naps or fall asleep during
activities such as reading, watching television, having
2
Patients with SDB are also at greater risk for a
cardiovascular consequences such as hypertension,
cardiac arrhythmias, congestive heart failure, stroke,
adults, the severity of SDP was associated with
increased risk for developing coronary artery disease,
congestive heart failure, ischemic disease, and stroke
6
et al
in attentional tasks, immediate and delayed recall of
both verbal and visual stimuli, executive functioning,
et al
11
found that dementia
severity ratings were positively associated with SDB
severely demented had more severe SDB compared to
may be partially explained by evidence suggesting
that patients with many progressive dementias such
experience neurodegeneration in areas of the brainstem
responsible for respiration regulation and other
is similar to that seen in younger adults and whether
it should be treated
12
cardiac disease, hypertension, nocturia, cognitive
dysfunction, or severe SDB, treatment should be
considered
13
conducting a complete sleep history focusing on
and psychiatric history should be reviewed in order
to gain information regarding medical conditions,
an overnight sleep recording should be conducted to
While several treatments exist for SDB, continuous
months have demonstrated improvement in cognitive
performance such as psychomotor speed, executive
prescribing treatment for older adults with SDB,
it is important that clinicians not assume that old
colleagues
14
compliance was depression, suggesting that treating
depression concurrently with SDB might lead to
improved compliance
14
SDB treatments such as oral appliances are available;
however, these have not been shown to be as effective
consider weight loss, smoking cessation, and abstinence
Finally, elderly patients with SBD should also avoid
respiratory depressants and may increase the number
Restless legs syndrome(RLS) / Periodic limb movements
in sleep (PLMS)
dysesthesia inthe legs which is usually described as
“pins and needles” or a “creepy and crawly” sensation
dysesthesia usually occurs when the patient is in a
about twice as prevalent among women compared to
men
15
causing brief arousal and/or awakening occurring
which shows patients having at least 5 kicks per hour of
among older adults compared to younger adults, with
approximately 45 per cent prevalence among older
adults
16
been questioned as many patients with repetitive leg
complain of uncomfortable leg sensations throughout
and may have even moved into a separate bed due to the
anaemia, uraemia, and peripheral neuropathy prior to
not clearly understood, some research speculates that
these disorders may result from dysregulation of the
dopaminergic system due to the therapeutic effects of
posit that these disorders may be associated with iron
homeostatic dysregulation because patients often
present with reduced ferritin levels inthe cerebrospinal
17
dopamine agonists, which are effective at reducing leg
ropinirole and pramipexole have been approved by
Rapid eye movement (REM) sleep behaviour disorder
likely the result of intermittent lack of the skeletal
walking, speaking, eating, and can also be violent
is most prevalent among older adult males
and monoamine oxidase inhibitors, and withdrawal
from alcohol or sedatives
other hand, has been associated with narcolepsy and
other idiopathic neurodegenerative disorders such as
eliminate abnormal motor behaviour in approximately
report the side effect of residual sleepiness due to the
21
hygiene education is also recommended for patients
techniques include making the bedroom environment
safer by removing potentially dangerous heavy or
breakable objects, using heavy curtains on bedroom
windows, keeping doors locked at night, and sleeping
Insomnia
22
maintaining sleep throughout the night), early morning
returning to sleep), and psychophysiologic insomnia
from maladaptive cognitions and/or behaviours), the
most common among older adults being maintenance
transient (lasting only a few days before or during a
during an extended period of stress or adjustment),
or chronic (enduring several months or years after a
People from all age groups with chronic sleep
problematic in older adults as it puts them at greater
risk for falls, cognitive impairment, poor physical
functioning and mortality, even after controlling for
medication use
to decreased quality of life and increased symptoms of
anxiety and depression
27
psychiatric illnesses, medication use, circadian rhythm
et al
found
insomnia, only 7 per cent of the cases were in isolation
ageing alone does not cause sleep disruption, but rather
the conditions that often accompany ageing result in
found a positive relationship between the amount of
sleep complaints and the medical conditions, such
as cardiac disease, pulmonary disease, stroke and
conditions increased, so did the likelihood of having
of older adults, heart disease, diabetes mellitus, and
respiratory disease measured at baseline were all
measured at a 3 yr follow up assessment
conditions such as arthritis, diabetes, chronic pain
patients is extremely prominent and is also one of the
nine diagnostic criteria for depression
supports a bidirectional relationship between depression
and insomnia, such that mood disturbance can result
in disturbed sleep and insomnia can place one at
risk for developing depression
31
or loss of a loved one, may experience depression
colleagues
31
, found that the presence of insomnia at
baseline was predictive of developing depression 1
found similar results
32
33
found that 65 per cent of depressed patients, 61
per cent of patients with panic disorder and 44 per cent
Certain medications are also known to affect
relevant considering the number of elderly patients
bronchodilators, corticosteroids, decongestants, diuretics,
stimulating antidepressants, and other cardiovascular,
When possible, clinicians should advise patients to
modify their medication schedule such that stimulating
medications and diuretics are taken earlier inthe day and
Pharmacological intervention is the most common
antihistamines, antidepressants, antipsychotics, and
concluded that there is no systematic evidence that
antihistamine, antidepressant, antipsychotic, and
anticonvulsant treatment is effective for insomnia and
therefore are not recommended for the elderly
34
receptor agonists;
e.g
agonists (
e.g
adults
is cognitive behavioural therapy
34
of insomnia often involves teaching sleep hygiene
techniques in combination with other behavioural
treatments to counteract poor sleep habits and cognitive
therapy to counteract maladaptive or dysfunctional
be aware that sleep hygiene education alone is not as
effective as cognitive behavioural therapy for insomnia
Table. Sleep hygiene tips
Spend more time outside, without sunglasses, especially late
control is that insomnia results from maladaptive
can only return to bed when he/she feels adequately
patients are instructed that they can stay in bed for 15
min longer than the time of actual sleep they report each
improves each week, the amount of time allowed in
colleagues
active treatment was more effective than the placebo in
maintained clinical gains better than those who were
37
similar techniques inthe primary care setting
For some patients, combining pharmacological and
behavioural treatment may be a more effective regimen
for treating insomnia as medications can provide acute
Circadian rhythm disturbances
rhythms entrained to a 24 h cycle that control many
physiological functions, can also contribute to sleep
cycle, are controlled by the superchiasmatic nucleus
controls the internal circadian pacemaker, which is
cues includ
melatonin decreases with age resulting in decreased
rhythm disturbance
41
circadian rhythms due to decreased responsiveness to
external cues
42
the amplitude of the circadian rhythm may decrease
43
advancement may be a result of changes in core body
temperature cycle, decreased light exposure, and may
cause patients to become sleepy early inthe evening
sleepy, they would be able to get an adequate amount
societal norms to stay up later inthe evening, despite
begin sleepy and despite continuing to wake up too
Presenting complaints of those with circadian
rhythm disturbances can be similar to those with
differentiate between the two diagnoses because
disturbance is effectively treated with bright light
rhythms and can also shift core body temperature and
in improving sleep continuity among healthy and
44,45
Sleep and menopause
is one of the hallmark symptoms of menopause, with
menopause reporting sleep complaints compared to
approximately 15 per cent of the general population
46
in menopausal women is associated with vasomotor
46
injected intravenously, has direct sedative qualities
47
increased arousals
47
somewhat more complex, however, evidence suggests
that estrogen is associated with increased sleep time
and decreased sleep latency, nighttime awakenings, and
arousals
temperature regulation of the body, decreased estrogen
and thus increased arousals
46
menopausal women with insomnia have lower levels
related symptoms, should be carefully considered and
the risks (
i.e., increased risk of incident cancer, and
i.e., reduced
menopausal symptoms, decreased risk for osteoporotic
fractures) associated with this line of treatment should
be weighed
et al
51
examined the effects of
postmenopausal women with one group receiving
sleep problems compared to women inthe placebo
Summary
changes insleep quality and quantity can be the most
experience normal changes insleep architecture and
that accompany ageing which are associated with
morbidities are used, the prevalence of insomnia is
very low in healthy older adults
52
treatments for the various sleep disturbances that older
a comprehensive sleep history and, when appropriate,
sleep studies should be conducted in order to be
psychiatric history, and lifestyle and environmental
factors should be carefully considered while choosing
the chance for improvement in quality of life and
Acknowledgment
References
Sleep 18 :
Am J Geriatr Psychiatry
14
to old age in healthy individuals: Developing normative sleep
Sleep 27
JAMA
284
Sleep14
et al
Arch Intern Med 162
N Engl J Med 328
Am J
Geriatr Psychiatry 11
Sleep medicine
J Psychosom Res
54
J Am Geriatr Soc 39
should age be the determining factor inthe treatment decision
matrix?
Sleep Med Rev 11
Ann Intern Med 134
et al
Am J Geriatr Psychiatry 14 :
Arch Intern
Med 160
Sleep 14
Sleep 28
Isr J Psychiatry
Relat Sci 39
Sleep Med Rev 1
Cleve
Clin J Med 57
et al
Clin Neurosci 55
Sleep 23
et al
Arch Intern Med 168 :
et al
J Gerontol: Med Sci 61
J
Am Geriatr Soc 56
Bauer DC,
et alk of
J Am Geriatr Soc
57
et al
J Gerontol A Biol
Sci Med Sci 55
Sleep
22
J Psychosom Res
56
Diagnostic and statistical
manual of mental disorders, 4
th
et al
Sleep 17
et al
Behav Sleep Med 4
insomnia inthe general population?
J Psychosomatic Res
51
Sleep 28
et al
Sleep
28
Sleep Med 6
Clin Ther15
Sleep Med 7
JAMA
281
et al
J Clin Sleep Med
2
Exp Gerontol 36
Brain Res 342
Curr Opin Psychiatry
9
J Biol Rhythms10 :
et al
Sleep Med 1
J Clin Sleep Med 1
Sleep 22
Clin Ther 19 :
melatonin secretion in perimenopausal women: correlation
J Pineal Res
28
women after receiving hormone therapy: results from the
JAMA 287
et al
combined hormone replacement therapy: randomised
BMJ 337
with illness in older adults: clinical research informed by and
J Psychosom Res
53
Reprint requests
u
.
Sleep disorders in the elderly
Primary sleep disorders
Primary sleep disorders are distinguished from
other sleep disorders in that these are not other. report difculty initiating and maintaining sleep. With age, several
changes occur that can place one at risk for sleep disturbance including increased prevalence