Sleep disorders

Upon completion of this chapter, the reader will be able to:

• Recognize common causes of sleep problems in older people.

• Understand diagnostic testing and appropriate treatments for common sleep disorders in older people.

• Differentiate between sleep complaints that can be managed in primary care versus those requiring referral to a sleep specialist.

CASE 1 Jonathan Chen (Part 1)

Jonathan Chen, a 72-year-old retired, Asian-American engineer, comes to your office for a routine visit. Near the end of his appointment, with prompting from his wife, he states that he is “up all night” and asks you for “something to help me sleep.” He is clearly concerned about his inability to sleep. He reports having sleep problems since his retirement 3 years ago, and notes spending much of his daytime “resting” in order to “catch up on sleep,” which limits the couple’s social activities.

How common are sleep problems in older adults and to what extent do they affect the well-being of older people such as Mr. Chen?

CASE 2 Charles Banker (Part 1)

Charles Banker, a 79-year-old African-American man, arrives 1 hour late for his first appointment in your office, and apologetically explains he fell asleep at home. He reports falling asleep during conversations and card games with friends. He is a retired security guard, and he was fired from a job several years ago for “falling asleep on the job.” He sees a psychiatrist, who is treating him for depression. Mr. Banker wonders whether there is an “energy pill” that will help him stay awake during the day.

What are the potential causes of Mr. Banker’s sleepiness?

Prevalence and impact

Sleep is an essential biological process, and sleep deprivation leads to neurologic, autonomic, and biochemical changes. Older people generally report more nighttime awakenings and more daytime sleeping than younger people. The primary care provider needs to understand common underlying causes of sleep problems, appropriate treatments, and indications for referral to a sleep specialist.

The prevalence of sleep complaints among older adults may be 50% or more.¹ Also, across the life span, women report more problems with insomnia than men. Insomnia is the most common sleep disturbance in the older population, with up to 40% of persons older than age 60 complaining of difficulty falling asleep and/or maintaining sleep, and more than 20% reporting severe insomnia.¹^,² The prevalence of primary sleep disorders, such as sleep apnea and restless leg syndrome (RLS), also increases with age, and the magnitude of sleep problems is higher in long-term care facilities than in community settings.

Sleep disruption in old age is not benign. It can have a significant impact on overall quality of life. In correlational studies, sleep disturbance and sleep disorders have been associated with cognitive impairment, poor health status, low quality of life, and increased mortality.³^,⁴

CASE 1 Jonathan Chen (Part 2)

Mr. Chen’s physical examination reveals mild arthritis in his left knee, for which he takes ibuprofen as needed. He denies pain at night. He does not have hypertension or a history of heart disease. He denies a history of depression, anxiety, or other psychiatric problems. He states that his current mood is “great, except for this sleep thing,” and that he is worried about his son’s job and his grandchildren’s education.

Are Mr. Chen’s sleep complaints age-related?

CASE 2 Charles Banker (Part 2)

Mr. Banker describes his mood as “tired.” He is obese, with a history of hypertension, gastroesophageal reflux, high cholesterol, and diabetes. He takes glipizide, metformin, atenolol, omeprazole, aspirin, and atorvastatin. On physical examination, his blood pressure is 134/76 mmHg; he is 5 feet 8 inches tall and weighs 190 lbs. Heart and lung examination is unremarkable.

Are Mr. Banker’s sleep complaints age-related?

Risk factors and pathophysiology

Human adult sleep is composed of two separate states: rapid eye movement (REM, or stage R) sleep and non-REM (NREM, or stages N1 to N3) sleep. NREM sleep is further divided into three stages, which roughly parallel a “depth of sleep” continuum, including a “light” stage of sleep (stage N1), a stage of sleep where the majority of time asleep is spent (N2), and deep sleep (stage N3). REM sleep is normally characterized by electroencephalogram (EEG) activation, muscle atonia, and rapid eye movements. Normal adults generally progress from NREM stages N1 to N3, then return briefly to lighter sleep (typically stage N2) before entering REM sleep, in a cycle of approximately 90 minutes, which repeats throughout the night.

One of the most notable changes in sleep structure with aging is a decrease in deep (stage N3) sleep. Other common changes with age include taking longer to fall asleep, having decreased sleep efficiency (percentage of time asleep out of time spent in bed), being awake more during the night, waking earlier than desired in the morning, and having more intentional and inadvertent daytime napping.⁵ Age-related neuronal loss in the suprachiasmatic nucleus (SCN) of the hypothalamus and reduced melatonin production by the pineal gland weaken circadian (24-hour) rhythms, contributing to these changes. In addition, a host of other factors often cause or aggravate sleep difficulties.⁶ Box 31-1 lists medical, pharmacologic, psychiatric, and psychosocial factors that commonly contribute to sleep problems in older people. Table 31-1 summarizes age-related changes in specific organ systems and the impact of these changes on sleep.

BOX 31-1 FACTORS THAT INCREASE RISK OF SLEEP PROBLEMS AND SLEEP DISORDERS IN OLDER ADULTS

Medical conditions

Chronic pain (e.g., from arthritis, other rheumatologic disorders, or neuropathy)

Dyspnea of cardiac or pulmonary origin

Gastroesophageal reflux

Obesity

Nocturia and/or incontinence

Neurodegenerative diseases such as Alzheimer’s disease and Parkinson’s disease

Psychiatric disorders

Depression and other mood disorders

Anxiety disorders

Drug or alcohol abuse or dependency

Psychosocial, psychological, and lifestyle factors

Retirement

Bereavement

Poor sleep habits/inadequate sleep hygiene

Daytime sleeping, extended napping

Inaccurate, maladaptive beliefs about sleep changes with advancing age

Medications and nonprescription agents

Benzodiazepines

Antihistamines

Tricyclics and other antidepressants

Antiparkinsonian agents

TABLE 31-1

Impact of Specific Physiologic Changes in Older Adults and Possible Effects on Sleep

System	Changes	Consequences
Circadian rhythms	Phase advance (shift earlier) is normal with aging	Problems maintaining sleep; early morning awakening
Upper airway physiology	More fatty tissue, reduced muscle tone	Obstructive sleep apnea (nighttime awakenings and daytime sleepiness)
Musculoskeletal	Arthritis, other conditions causing chronic pain	Problems with falling asleep and nighttime awakenings
Genitourinary	Increased nighttime urination (e.g., with benign prostatic hyperplasia)	Nighttime awakenings
Menopause	Hot flashes	Nighttime awakenings, night sweats

CASE 1 Jonathan Chen (Part 3)

On further questioning, Mr. Chen reports that he has not been sleeping well for several months. He drinks a glass of wine with dinner, and then later dozes in a chair while watching television. He goes to bed at 10:00 pm most nights, and lies awake thinking about his family as “the hours tick by” until he is able to sleep. He generally awakens at 4:00 am to urinate, and often has trouble falling back to sleep after using the restroom. He and his wife get up at 6:00 am, and he “rests” on the couch after breakfast. He generally exercises in the afternoon, and then rests on the couch while his wife prepares dinner. He does not drink coffee or consume other caffeine. He snores softly on some nights, but his wife has not witnessed loud snoring or periods when he stops breathing while asleep. He denies leg discomfort at night, and his wife has not noticed that he kicks his legs during sleep.

What is your differential diagnosis and what tests should be ordered for Mr. Chen?

CASE 2 Charles Banker (Part 3)

Mr. Banker reports sleeping “off and on” throughout the day and night. He falls asleep in his recliner in the evenings, and then goes to bed around midnight. He falls asleep quickly, but awakens “too many times to count” during the night. He urinates several times during the night, but also awakens for other unknown reasons. He gets out of bed around 4:30 am, and then falls back asleep in his recliner until about 9 am. He reports being told in the past that he snores loudly, although he currently sleeps alone.

What is your differential diagnosis and what tests should be ordered for Mr. Banker?

Differential diagnosis and assessment

Sleep problems are common among older adults,⁷ but older patients often do not spontaneously report problems with sleep to their primary care providers. Because of this, screening for sleep complaints is recommended. This should include asking about satisfaction with sleep, daytime fatigue and sleepiness, and unusual behaviors during sleep (especially snoring, interrupted breathing, and/or leg movements).⁸ Persistent sleep problems require a detailed sleep history from the patient and the bed partner or caregiver, if available. In addition, a “sleep diary,” in which the patient tracks sleep-related behaviors for 1 to 2 weeks, can be informative.

Older adults seldom spontaneously report problems with sleep to their primary care providers; therefore, screening for sleep complaints is recommended.

The initial evaluation of sleep should focus on medical conditions, substance abuse, mental health problems, and medications that may be contributing to sleep complaints (see Box 31-1). Patients should be queried about their usual sleep patterns and events during sleep such as limb movements, respiratory distress, panic attacks, pain, nocturia, shortness of breath, headache, or symptoms of gastroesophageal reflux. Recent stressors and symptoms of depression, anxiety, and other psychiatric disorders need to be identified, and psychosocial factors such as bereavement, loss of social supports, and lifestyle changes (e.g., retirement) should be considered. A mental status examination to identify cognitive impairment is also indicated. A full medication history, including the use of over-the-counter and herbal medications, is essential. The focused physical examination should be based on evidence from the history. For example, reports of nocturia disrupting sleep should lead to evaluation for cardiac, renal, or prostate disease. Prior treatments for sleep-related complaints should be reviewed.

Referral for an overnight sleep study (polysomnography [PSG]) is indicated when evidence suggests a primary sleep disorder, such as sleep-disordered breathing or periodic limb movement disorder (discussed later in the chapter).⁹ PSG is the gold standard for the evaluation of sleep and generally involves spending a night in a sleep laboratory, where physiologic measures are recorded, including an EEG, electrocardiogram (ECG), electrooculogram (EOG), electromyogram (EMG), respiratory effort and airflow, and oxygen saturation. PSGs are performed and interpreted by sleep specialists. Many portable, home monitoring systems are available, particularly to test for sleep-disordered breathing (e.g., sleep apnea).