Elder Care Interprofessional Provider Sheets

Sleep in Older Adults

Joan L. Shaver, PhD, RN, FAAN, Dean, College of Nursing, University of Arizona

September 2016

TIPS FOR DEALING WITH SLEEP DISORDERS IN OLDER ADULTS
  • When an older adult reports problems with sleep, consider depression as a possible contributor.
  • Also consider the possibility that medications are causing or aggravating a patient's insomnia.
  • For treatment of chronic insomnia, use cognitive behavioral therapies (Table 1) with only short-term, intermittent use of sedative-hypnotic medications.
  • Always consider sleep-related breathing disorders, movement disorders, and rapid eye movement disorders as possible contributors to a patient's insomnia or daytime sleepiness.

As we age, sleep becomes less consolidated, which people experience as frequent awakenings and perceptions of sleep loss or inadequacy.  At least half of older adults report poor or worsened sleep. 

The Daily Sleep/Wake Cycle

The daily sleep/wake cycle is governed by three interacting processes: (1) sleep drive, (2) circadian rhythm, and (3) environmental and behavioral factors (Figure). With aging, sleep drive weakens due to changes in neurochemical receptor sensitivity. Various circadian rhythms, most importantly levels of melatonin and its sensitivity to the light-dark cycle, also change with aging. Indeed, many older adults experience a 'phase advance' of the sleep/wake rhythm, with earlier positioning of the night sleep period within the 24-hour light/dark cycle, leading to earlier bedtimes and arise times (the phase advance can be normalized using an early evening dose of bright-light therapy). Decreased sensitivity to the light/dark cycle can be further aggravated by environmental factors, such as increased time spent indoors with less exposure to adequate bright light as well as with artificial light (especially blue spectrum) from electronic devices. 

The Nighttime Sleep Cycle

Each night's sleep is characterized by recurring cycles lasting roughly 90 minutes each, which on polysomnogram reveal the sequential stages of a cycle from awake to transitional, light, deep, and rapid-eye-movement (REM) sleep. Observed changes with aging include more light sleep, less deep-stage and REM sleep, and a gradual reduction in total sleep time each night. 

When individuals report waking at approximately 1-2 hour intervals, they are probably waking between sleep cycles. If return to sleep is relatively rapid, sleep cycles likely are being completed with little overall sleep loss or effect on daytime function. In otherwise healthy older adults, simply explaining this normal phenomenon can help alleviate undue anxiety about poor sleep. 

On the other hand, when individuals truly have inadequate sleep, they can experience impaired physical performance (e.g., slower reaction times), poor cognitive performance (e.g., impaired memory), and a propensity to fall. Indeed, poor sleep efficiency and decreased total sleep time have been associated with higher risk of death, even after controlling for other factors.

Sleep in Chronic Disease

Chronic health conditions produce a myriad of disease changes which, along with the many medications prescribed, can induce insomnia - the inability to fall or stay asleep or get restful sleep. Chronic insomnia can be primary (i.e., occurring in the absence of a clear causative condition), but more frequently poor sleep emerges secondary to stress or chronic disorders such as arthritis, chronic pain, diabetes, heart failure, cancer, chronic lung disease, stroke, Parkinson's disease, or dementia. 

Insomnia is also strongly associated with depression. Indeed, there is growing evidence that insomnia is prodromal to depression and depression predicts insomnia. Therefore, reports of chronic insomnia should trigger an evaluation for symptoms of depression. Alternatively, depressive mood states should raise concern about the possibility of poor sleep. 

Many medications used to manage common chronic diseases can affect sleep and contribute to insomnia. These include nervous system stimulants, antihypertensives, respiratory medications, chemotherapy, decongestants, steroid hormones, and many psychotropic medications. Prescribe medications with stimulating or activating effects earlier in the day, and sedating medications near bedtime.

Treating Insomnia

Long-term use of benzodiazepines is not generally recommended as it poses risks to patients, especially older adults. Comparatively, short-term use of non-benzodiazepine hypnotics, such as eszopiclone, ramelteon, zaleplon, and zolpidem has fewer side effects, while other medications, such as over-the-counter products containing diphenhydramine or other antihistamines, should be avoided in older adults. Instead, insomnia in older adults can be managed initially with the aforementioned non-benzodiazepine hypnotics, and then longer term with cognitive behavioral therapies (Table 1).

Table 1. Cognitive Behavioral Therapies for Insomnia

Cognitive

  • Discuss sleep expectations, misconceptions and sleep-promoting behaviors

Behavioral - the 4 Rs
Regularize sleep-wake pattern 
  • No daytime napping
  • Restrict time in bed to current sleep duration; gradually lengthen time in bed
  • Arise at consistent time
Ritualize cues for sleeping 
  • Quiet, dark environment 
  • Lie down only when sleepy
  • If not asleep in 20 min, get up
  • Use bedroom only for sleep and sex
Relaxation techniques 
  • Comfortable posture
  • Clear the mind - concentrate on breathing or scenery
  • Use biofeedback, deep relaxation
Resist sleep interference (sleep hygiene) 
  • Avoid heavy meals before bed
  • Avoid heavy exercise 2-3 hours before bed
  • Avoid tobacco, alcohol, caffeine

Important Sleep-related Disorders

Adding to risk of sleep disturbance with aging are the sleep-related conditions of sleep-disordered breathing; sleep-related movement disorders (restless leg syndrome and periodic limb movements); and rapid eye movement sleep-behavior disorder (Table 2). A key manifestation to these disorders is excessive daytime sleepiness (EDS), most often seen as unintentional napping. As part of a sleep history, assessing for EDS is warranted. Symptoms of these disorders should trigger in-depth assessment and possible referral to a sleep center.

Table 2. Important Sleep-Related Disorders

Disorder
Key Clinical Considerations
Sleep-Disordered Breathing (Snoring, Sleep Apnea)
  • Complete sleep history - especially snoring, unintentional daytime dozing, excessive daytime sleepiness
  • Bed partner testimony
  • Risk factors: male, obesity, use of sedatives, alcohol, smoking, thick neck (men), narrow upper airway (women), family history
  • Confirm with overnight polysomnography
Restless Legs Syndrome
  • Discomfort in legs (crawling sensation), urge to move
  • Most prominent at rest, in relaxed state, during inactivity, usually evening or night
Periodic Limb Movements in Sleep
  • Clusters of repetitive limb movements during sleep - can cause arousal
  • Bed partner testimony
  • Confirmed by overnight monitoring
Rapid Eye Movement Sleep Behavior Disorder
  • Absence of usual muscle atonia during REM
  • Gross movements occur during sleep, e.g., running, kicking, yelling, punching (complex motor movements while dreaming)
  • Can be dangerous or injurious
  • Confirmed by monitoring intermittent muscle tone and movements during REM sleep

References and Resources

  • Duffy JF, Zitting KM. Chinoy ED. Aging and circadian rhythms. Sleep Med Clin. 2015; 10(4), 423-434. 
  • Zdanys KF, Steffens DC. Sleep disturbances in the elderly. Psychiatr Clin North Am. 2015; 38(4): 723-741.