eos of Chin Nemoto do even Pree 118. New York Sleep and Sleep Disorders in Older Adults Patricia N. Prinz Medica Research Service, American Lake Veterans Affairs Medical Center, Tacoma. Washington. and Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle. Washington, U.S.A ‘Summary: Complaints of sleep disturbance increase with age. Objective sleep as- ‘sessments using polysomnography reveal sleep impairments (increased wakeful- ness and arousal from sleep: decreased slow wave sleep) even in healthy seniors. Both polysomnographic sleep and subjective sleep worsen in the presence of health impairments related to drug use. pain, cardiovascular disease, diabetes. de- pression, or other emotional disorders. In addition to normal aging and chronic isease, sleep complaints can also result from poor sleep habits, specific occult disorders during sleep, or some combination of these factors. Occult disorders include sleep apnea syndrome, periodic leg movements, and restess legs syn- drome during sleep. Diagnosis and treatment of these and other sleep disorders is discussed. Both pharmacological and nonpharmacological treatments are consid ered, with an emphasis on behavioral and educative treatment approaches. Key Words: Sleep disorders—Sleep complaints—Age—Polysomnography—Treat OF SLEEP DISTURBANCE CREASE WITH AGE Cross sectional studies across a wide variety of pop- ulations have recently been reviewed by Bliwise et al (1992) and Bliwise (1993). These studies have demon- strated that the prevalence of self-reported sleep dis- turbance increases with age (McGhie and Russell 1962; Hammond, 1964; Webb, 1965; Tune, 1969: Zepelin, 1973; Karacan et al., 1976; Bixler et al., 1979; Karacan et al., 1983; Lugaresi et al., 1983; Par- tinen et al,, 1983; Cirignotta et al., 1985; Urponen et al., 1988; Ford and Kamerow, 1989). A typical study. found that the proportion of individuals reporting trouble with sleep often or all the time increases from 9 (ages 20-29 years)-2 % (ages 60-69 years) (Karacan et al,, 1976). Similarly, in another survey, the propor- tion of individuals reporting a current problem with difficulty falling asleep, staying asleep, or awakening, Address correspondence and reprint requests to Dr. P. N. Prinz at Department of Psychiatry and Behavioral Sciences(RP-10}. Un ‘essity of Washington, Seale, Washington 98195, US.A, 139 too early increased from 23 (in 18-30-year-olds)-38% (51-80-year-olds) (Bixler et al., 1979). A third study showed that the prevalence of reported disturbed sleep due to frequent night awakenings increased from 5 (at age 25 years)-25% (at age 65 years) (McGhie and Russell, 1962). Many studies also report that women describe their sleep as more disturbed rel- ative to age-matched men (McGhie and Russell, 1962; Hammond, 1964; Tune, 1969; Karacan et al., 1976; Bixler et al., 1979; Lugaresi et al., 1983; Parti- nen et al., 1983; Cirignotta et al., 1985; Urponen et al,, 1988; Ford and Kamerow, 1989: Spiegel, 1981: Hettaet al., 1985; Kronholm and Hyyppa, 1985; Mel linger et al, 1985; Morgan et al., 1988: Allgulan- der, 1989). These subjective complaints are, in gen- eral, substantiated by polysomnographic assessments showing diminished sleep quality in the aged. Aging is also associated with changes in typical polysomnographic patterns of sleep (Feinberg et al. 1967; Kahn and Fisher 1969; Kahn et al., 1970; Kales 1975; Prinz 1977; Roffwarg et al., 1966). In contrast, to younger individuals, older people spend more time140 PLN. in bed, achieve less time asleep, and are more easily aroused from sleep. These age-related changes, in both sleep and wakefulness, are the result of alter ationsin sleep maintenance and depth—a conclusion supported by the observations that older people are more easily aroused from nighttime sleep by auditory stimuli (Zepelin etal, 1984), suggesting that they may be more sensitive to environmental stimuli, Sleep be comes increasingly fragmented resulting from an in- crease in both number of transient arousals and total amount of time awake through the night, and in a re- duction of time spent in deep non-rapid eye move- ment (REM) (slow wave) sleep. Less striking redue tions in REM (dreaming) sleep and total nighttime sleep also occur. These changes occur even in very healthy screened seniors (Prinz, 1977; Feinberg et al. 1967; Vitielo et al., 1990) and may be due to aging per se (Prinz et al., 1990a). Additional fragmentation ‘of nocturnal sleep may result from such factors as di- minished circadian functioning, sleep-disordered breathing, periodic leg movements of sleep, depressed mood, and medical and psychosocial problems (Prinz etal. 1990a), PHYSICAL HEALTH AND SLEEP DISTURBANCE A major concern the assessment of age-related sleep disturbance is the degree to which observations of poor sleep reflect the normal, nonpathological aging process of the contributions of age-related diseases and chronic health conditions. Only recently has more interest been directed towards the role of medi- cal conditions in the complaint of insomnia in old age. Morgan et al. (1989), for example, reported that the use of medications (excluding hypnotics) for a va- riety of health conditions differentiated between derly good and poor sleepers and noted that the num- ber of physician visits and selfratings of health also distinguished between these groups (Morgan ct al 1988). Gislason and Almqvist (1987) reported that when somatic diseases were controlled for statistics, some types of insomnia complaints showed no age- related increases and, in some cases, even showed d creases with age. Hanson and Ostergren (1987) noted that, among a representative sample of 68-year-old men, more frequent users of the health care system were also more likely to suffer from insomnia. Ford and Kamerow's (1989) recent study showed that when individuals with poor sleep that accompanied physical illness, medication use, or drug/alcohol use were not included in a definition for insomnia, the J.Cha Neneh. Vid 12.8. 21995 PRINZ age-related prevalence and incidence of poor sleep were far less striking than in most previous studies, Prinz et al. (1991) have shown an extraordinarily low prevalence (3.2%) of volunteered sleep complaint ot sleep disorder in a sample of 1,619 elderly individuals, aged > S4 years, who passed a rigorous health screen- ing prior to subjective or objective sleep assessment. This was consistent with the general consensus that specific medical and psychiatric conditions impair sleep (National Institutes of Health, 1990) and un- derlie frank sleep disorders in the elderly (Prinz et al., 1990a). A variety of population-based studies have as- sociated poor sleep with specific conditions, stich as headache (McGhie and Russell, 1962; Lugaresi et al., 1983; Cirignotta et al., 1985; Hetta et al., 1985; Cook et al., 1989), pain (Pilowsky et al., 1985; Mant and Eyland, 1988), nocturia (Morgan, 1987; Mant and Eyland, 1988), bronchitis and asthma (Gislason and Almgvist, 1987; Pilowsky et al., 1985; Janson et al., 1990), menopause (Brugge et al., 1989), cerebrovas- cular disease (Palomaki et al., 1989), cardiovascular symptoms (McGhie and Russell, 1962: Lugaresi et al, 1983; Hetta ct al., 1985; Gislason and Almqvist, 1987; Koskenvuo et al., 1988; Hung et al., 1990; Partinen and Guilleminault, 1990), fibromyalgia and heu- matic disease (Moldofsky et al., 1986; Gislason and Almqvist, 1987; Hyyppa and Kronholm, 1989; Ja- cobsen et al., 1990), diabetes (Hyyppa and Kronholm, 1989; Prinz et al., 1991), depression or other emo- tional problems (Poelstra, 1984; Mellinger et al., 1985; Ford and Kamerow, 1989; Hyyppa and Kron- holm, 1989; Habte-Gabr et al., 1991), and job stress (Estryn-Behar et al., 1990; Mattiasson et al.. 1990) and other psychosocial factors (Habte-Gabr et al., 1991). SLEEP DISORDERS IN CLINICAL PRACTICE Diagnosis of chronic sleep disorders in the elderly may be difficult because the two most common symp- toms—insomnia and excessive daytime sleepiness— may result from normal aging, chronic diseases, poot sleep habits, specific occult disorders, or a combina tion of these factors. Optimal management of a sleep problem depends upon attention to all these factors. Where specific occult disorders, e.g, sleep apnea syn- drome or periodic leg movements during sleep, are suspected, polysomnographic evaluation of sleep may be useful. Polysomnographic evaluation of sleep can Provide objective assessments of insomnia, daytime sleepiness, apnea, leg movements during sleep, orother problems, thereby The descriptions of the sleep disorders below are con- densed from more detailed reviews on this topic (Kryger et al., 1994; Prinz et al., 19902). Jarifying treatment options, NOCTURNAL RESPIRATORY DYSFUNCTION (SLEI APNEA SYNDROME) Nocturnal respiratory dysfunction (sleep apnea’ syndrome) is characterized by the repeated cessation of breathing (apnea) for = 10 s, resulting in multiple episodes of hypoxemia (blood oxygen saturation often < 80%), multiple brief awakenings from sleep, sive daytime sleepiness, and impaired daytime fune- tioning (Guilleminault and Dement, 1988). Sleep ap- nea syndrome usually presents with the symptom of excessive sleepiness, which interferes with normal functioning, The tendency for daytime napping, as ‘measured by the multiple sleep latency test (MSLT), is clearly increased. Often, patients’ bed partners will notice episodes of apnea followed by gasping. Un- treated severe sleep apnea syndrome can compromise cardiac function and lead to death. ‘Apneic episodes are more frequent in men than in women and occur more commonly in older than in younger persons (Bliwise, 1989; Ancoli-Israel et al... 1985; Krieger, 1989). The prevalence of apneic epi- sodes in the elderly population is high; 30-50% of nor- ‘mal older men have = 20 episodes per night. Apneic episodes can be exacerbated by the use of depressant drugs and alcohol (Guilleminault and Dement, 1988; Bliwise, 1989: Ancoli-lsrae! et al., 1985). Snoring, which is associated with obstructive sleep apnea, in- creases in prevalence throughout the adult life span, particularly in men. Furthermore, a number of epide- miologic studies have linked snoring with the devel- opment of sleep apnea, hypertension, and cardiovas- cular disease (Lugaresi et al., 1989; Remmers, 1989; Koskenvuo et al., 1985). The presence of observed apneic episodes, gasping, or choking during sleep, and unexplained right-sided heart failure, even in the absence of snoring, insom- nia, and daytime sleepiness, should alert the clinician to the possibility of a sleep-related breathing disorder that warrants further investigation, Methods of treatment for obstructive sleep apnea include behavior modification (to minimize sleeping on the back), weight loss, avoidance of respiratory-de- pressant drugs (hypnotics and alcohol), use of respira- tory stimulants (such as acetazolamide), nasal contin- uous positive airway pressure. and upper-airway sur- Jal gery (Guilleminault and Dement, 1988; Kryger, 1989), Continuous positive airway pressure is well tol- erated in the majority of adult patients and results in almost immediate consolidation of nighttime sleep, attenuation of daytime sleepiness and fatigue, and im- proved cognitive function. Specific surgical proc: dures to modify the upper airway, such as uvulopal topharyngeoplasty, have been shown, in follow-up studies, to be of limited efficacy. Tracheostomy has Jong been a treatment option in cases of severe apnea. Both surgical procedures have obvious limitations, in- cluding risk of morbidity and mortality. The decision to treat sleep apnea and the choice of the most appro- priate treatment rest upon accurate assessment of the frequency and severity of the sleep-related physiologic disturbances, degree of daytime sleepiness, and im- pairment in cognitive function, There is little evi- dence to support the treatment of mild obstructive sleep apnea in the elderly in the absence of excessive sleepiness, cognitive impairment, or associated ¢: diorespiratory abnormalities. RESTLESS LEG SYNDROME AND PERIODIC LEG MOVEME Two sleep-related neuromuscular dysfunctions can develop in the elderly: restless-leg syndrome, a very strong urge before sleep begins to move one’s legs re- peatedly, which results in an inability to fall asleep; and periodic leg movements during sleep, commonly known as nocturnal myoclonus, a rapid, stereotypic and periodic flexion of the legs and feet associated with repeated awakenings throughout the night (Montplaisir and Godbout, 1989). Some controversy exists over the association between leg movements and sleep disturbance, The incidence of periodic leg ‘movements appears to increase with age and may be related to metabolic, vascular and neurologic factors (Montplaisir and Godbout, 1989), Leg movements often present in conjunction with sleep apnea. Current treatments for these disorders are not ideal. ‘Commonly-used benzodiazepines (clonazepam, tem- azepam) ameliorate repeated arousals from sleep but may have minimal effects on leg movements and may result in daytime sedation, Opioids and L-dopa have also been used with some success (Montplaisir and Godbout, 1989; Roth et al., 1988). SLEEP DISTURBANCE SECONDARY TO MEDICAL ILLNESS ‘A variety of medical illnesses may impair normal sleep; these include arthritic and other pain syn- Neurinhrse, ok 12. No, 2.198142 PLN dromes, and respiratory, cardiac, and neurologic dis- eases (Vitiello and Prinz, 1988; Wooten, 1989). Ap- propriate use of analgesics can help ameliorate sleep disturbances that are secondary to pain syndromes. The elderly often have progressive cardiac or neuro- logic disorders that can affect respiration during sleep. Cardiac failure may be associated with orthopnea and frequent awakenings Treatment itself, of a medical disorder may result in disturbed sleep. Careful attention to the timing and dosage of medications such as diuretics or sympatho- mimetic bronchodilators is a crucial part of the effective treatment of the primary medical disorder. A final factor to consider is the effect of extensive bed rest on the quality of sleep. Longterm confinement to bbed can result in daytime napping and fragmentation of the normal sleep-wake cycle (Winget et al., 1982) ‘The elderly need to be encouraged to remain as active as their health permits. SLEEP DISTURBANCES SECONDARY TO. PSYCHIATRIC ILLNESS Psychiatric illnesses, including depressive reactions to severe or chronic medical illnesses, are common. causes of disturbed sleep in elderly patients. The prev- alence of major depressive disorder in elderly people living in the community is ~2% (Blazer et al., 1987). Substantial impairment in sleep is reported by 50% of this group. The prevalence of major depressive disor- ders among hospitalized elderly persons is substan- tially higher, ranging from 10 to 20% (Koenig et al., 1988) Because sleep disturbance in the depressed patient is usually a function of the psychiatric disorder, ther- apy should be directed at the depression as a whole as, well as the sleep problem itself. The sleep disturbance will remit with successful antidepressant therapy, but such therapy may take several weeks or months to be- come fully effective, and patience is important both for the patient and the physician, Attention to good sleep habits will enhance and speed resolution of the sleep problem. The list below outlines principles for nonpharmacological treatments of insomnia. Use bed and bedroom only for sleep Restrict time in bed Discourage daytime napping and periods of inac- tivity Set carly wake-up time regardless of sleep length or Quality of sleep during the preceding night Consider use of outdoor light exposure J.Chin Neopsiol.Vo 12. 2.1995 Work with patient to understand unfounded be- liefs, unrealistic expectations, and inaccurate at- tributions made regarding the sleep experience Psychotherapy can be used effectively to treat some elderly depressed patients (Gallagher and Thompson, 1982) but is less effective for those with endogenous symptoms such as disrupted slecp. Such patients may also require antidepressant medication and/or other therapeutic interventions. PERSIS| ‘T PSYCHOPHYSIOLOGICAL INSOMNIA Psychophysiologic insomnia results from arousal or anxiety states that interfere with sleep (Hauri, 1989), Also called “learned” or “behavioral” insomnia, this disorder is diagnosed when the insomnia is main- tained by maladaptive learning or sleep-incompatible behaviors in the bedroom, such as excessive problem solving or worrying, negative expectations about poor sleep and tiredness the next day, and poor sleep hab- its. Effective treatments include behavioral therapy to curtail and regularize hours in bed and to modify sleep-incompatible behaviors, biofeedback, and pro- gressive muscle relaxation, always in conjunction with education about good sleep habits (see list above) (Spiclman etal, 1987a; Spielman et al, 1987b; Hauri, 1989). SLEEP DISTURBANCE SECONDARY TO DEMENTING CONDITIONS, AND DELIRIUM Sleep is also disturbed in disorders characterized by dementia. Episodes of nocturnal wandering, delir- ium, or both can occur despite normal daytime fune- tioning. The sleep of patients with Alzheimer’s disease is marked by increased duration and frequency of awakenings, decreased slow-wave and REM sleep, and, in more advanced stages, daytime napping (Prinz et al., 1990b). Similar changes occur in other disorders associated with dementia as well (Prinz et al., 1990b). There is currently no eflective treatment for these de- mentia-related sleep disturbances. Attention to medi- cation side effects, good sleep habits that consolidate nighttime sleep (this may include daytime exercise, light therapy, and discouragement of napping), and making the patient's environment as safe as possible for nighttime forays are useful treatment aids.SLEEP AND SLEEP DISORDERS IN OLDER ADULTS SLEEP DISTURBANCE ASSOCIATED WITH DRUG AND ALCOHOL USE Older patients with sleep disturbances may be tak- ing a variety of medications, often prescribed by sev- eral physicians, as well as over-the-counter drugs. Some of these may cause secondary insomnia or ex- acerbate sleep apnea (Roth et al., 1988; Robinson and Zwillich, 1989; Nicholson et al., 1989). Inquiries about fatigue and daytime sleepiness can help detect underlying drug-induced sleep apnea. Longterm use of sleeping medications or alcohol can induce a drug- related insomnia (Roth et al., 1988). In older persons, ‘drug metabolism may be slowed, and longterm use of hypnotics may lead to excessive daytime sleepiness, impaired memory. and impaired psychomotor fun tioning (Roth et al., 1988; Freedman et al., 1984). Al- though both the use and abuse of alcohol decline with age, unsuspected alcohol abuse or even self-medica~ tion with alcohol as an aid to sleep can also result in impaired sleep. It is important to educate older pa- tients with insomnia about the sleep-impairing effects of longterm use of sedatives and alcohol, good sleep habits, and use of behavioral techniques such as relax- ation and stress reduction in inducing sleep (Hauri, 1989: Freedman et al.. 1984; Mendelson, 1980). timed or excessive use of coffee, tea, oF soft drinks that contain caffeine or other methylxanthines can also lead to disturbed sleep due to the stimulant and diuretic effects of these compounds (Rall, 1985; Kay and Samiuddin, 1988). ‘When assessing a reported sleep disturbance, cially in elderly patients who may be more sensitive to rugs than younger persons (Montamat et al., 1989), it is important to obtain comprehensive information not only about the use of prescribed medications but also about that of over-the-counter medications and social drugs. SLEEP DISTURBANCE RELATED TO CHANGES IN CIRCADIAN RHYTHMS. Rest-activity cycles and other circadian rhythms ‘may change with advancing age in humans and ani- mals (Kahn et al., 1970; Weitzman et al., 1982; De- ment et al., 1985). There is considerable circumstan- tial evidence that damped circadian rhythms are ass ciated with impaired sleep. Increased nocturnal temperatures have been reported in older adults (Vi- tiello et al.. 1986), patients with major depression (Avery etal., 1986). and persons with insomnia (Mon- roe, 1967), all of whom may have disturbed steep. At- 143 tenuation of the rest-activity cycle can also occur in bedridden or sedentary adults, with adverse effects on sleep (Winget et al., 1982; Scheving et al., 1974), a fact that suggests that the declining physical activity of old ‘age may impair sleep. Numerous studies have exam- ined the effects of exercise on sleep quality (Shapiro, 1988). Although the results are far from definitive, ‘many studies suggest that quality of sleep improves with increased physical fitness, particularly aerobic fitness. This evidence suggests that the sleep of the el- derly can be improved by exercise programs. Regular- izing sleep schedules also improves the quality of sleep (Spielman et al., 1987). In addition to disturbances in circadian rhythms, increasing age is also associated with a tendency both to fall asleep and to awaken ear- lier. A recent study has suggested that this “phase ad- vance” of circadian rhythms relative to the 24-h clock can be altered by use of bright light (Czeizler et al., 1989), a concept that needs to be confirmed in large controlled studies. USE OF SEDATIVE HYPNOTICS IN THE AGED Although sedative-hypnotic drugs can be useful for the relief of transient insomnia when used briefly, their longterm use usually results in habituation, loss of efficacy, and drug-induced insomnia. A recent Na~ tional Institutes of Health (NIH) consensus paper on drugs and insomnia urges great restraint in the use of hypnotic agents for anything other than temporary, situational, or intermittent conditions (NIH, 1984). Symptomatic treatment with hypnotic agents may even exacerbate existing sleep disturbances by indui ing a drug-dependency insomnia, resulting in r bound insomnia and nightmares when the drug is dis- continued. In patients with undiagnosed sleep apnea, the use of hypnotic agents can increase the frequency, duration, and severity of apneic episodes. Adverse daytime effects of hypnotic agents include impaired cognition, slowed psychomotor functioning, and in- creased risk of injuries due to falls (NIH, 1984). NONPHARMACOLOGICAL TREATMENTS, A variety of behavioral treatments have proved effective in treating insomnia (Morin, 1993). These include progressive muscle relaxation, biofeedback, stimulus control therapy, and sleep curtailment (Hauri, 1989). In addition, sleep hygiene, chronother- apy, and, even, aspects of cognitive-dynamic therapy are effectively used (Bliwise, 1991). These general J.Chin Neurophysiol Vol 12 No.2, 190514d PN. principles are summarized in the list above (taken from Bliwise, 1991). Stimulus control therapy (Bootzin, 1976) involves nating, worrying) are done elsewhere. Common to both stimulus control procedures and sleep restriction therapy are a curtailment of excessive time in bed, Prohibition on daytime napping, and requirement for a regular bed- and risetimes. These procedures, to- gether with daytime activity and exposure to outdoor sunlight, serve to stabilize and prime the circadian timing system, and, thus optimize sleep. Attention to good sleep hygiene involves careful history of alcohol, tobacco, caffeine, and nonsleep-re- lated medication intake that can affect sleep, making alterations as necessary. Diuretics may be taken ear= lier rather than later in the day to reduce nocturia: tobacco, caffeine, and alcohol intake aRer dinner should be restricted, Other factors that are noncondu- cive to sleep (presleep overstimulation, environmen- tal disturbances at night) should also be addressed. As noted by Bliwise(1991),". . . effectiveness in a nonpharmacological approach to insomnia treatment can be expected only if the therapist engages the pa- tient in the task at hand. Often this involves tackling Patients’ presuppositions about their sleep problem rather than administering a routinized set of proscrip- tions on various behaviors.” SUMMARY In summary, age-related sleep impairment is com- mon, affecting both sleep itself and circadian sleep- wake rhythms. The sequelae of a variety of sleep dis- ‘orders can exacerbate the effects of normal aging. 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