Clinical and Health Affairs
Sleep Complaints in the Geriatric Patient
By Mark W. Mahowald, M.D., and Michel A. Cramer Bornemann, M.D.
Abstract
Difficulty sleeping is a frequent complaint of elderly patients. But poor sleep is not a normal part of aging. This article discusses the most common sleep problem among older adults—insomnia, its causes, and potential treatments including over-the-counter and prescription medications and behavioral treatments such as relaxation therapy, sleep hygiene, stimulus control, sleep restriction, and cognitive and behavioral therapies.
Older adults frequently complain about having trouble sleeping. However, the commonly held idea that interrupted sleep is a normal and inevitable (albeit undesirable) consequence of aging is being questioned: It is now believed that advanced age alone is not a cause of insomnia. Many elderly people have the ability to get a perfectly good night’s sleep. Complaints about difficulty sleeping are most likely the result of underlying sleep disorders, medical conditions, or medications an individual may be taking.
Nature and Function of Sleep
Although the function of sleep is unknown, there is growing support for the synaptic homeostasis theory, which proposes that learning and experiences that take place during wakefulness result in brain plasticity. Plasticity leads to increased brain volume and energy utilization that would not be sustainable without a periodic “rescaling” of synaptic activity. Sleep is the necessary “off-line” synaptic rescaling period. The importance of normal sleep is underscored by the fact that sleep abnormalities, whatever their cause may be, result in impaired alertness, mood, and performance.
A person’s sleep requirements and preference for going to sleep later or earlier in the day (whether they’re “owls” or “larks”) are genetically determined. Although the average adult requires 7 to 8 hours of sleep a night, the normal range is between 4 hours and 10 to 11 hours. The human biological clock has 2 sleepy periods: the primary period between midnight and 6 a.m. and the secondary one in the afternoon. Reduced alertness in the afternoon is not the result of eating lunch or sitting in a boring lecture or meeting; rather, it is caused by a transient reduction in the alerting signal of the biologic clock. Eating and boredom simply unmask sleepiness.
Age-related Changes in Sleep
Throughout adulthood, the amount of time a person sleeps remains constant, as does the percentage of time spent in rapid eye movement (REM) sleep. The only predictable changes in sleep architecture are a relentless reduction in slow-wave sleep (SWS) (the deepest stages of non-REM sleep) and more frequent arousals and awakenings. It has been suggested that the reduction in SWS is related to a reduced release of growth hormone. Despite the claims of many “natural” anti-aging remedies, there is no evidence that the administration of human growth hormone (HGH) or “naturally occurring analogues” of HGH improves either sleep or daytime functioning in older individuals.
Sometime after middle age, people tend to fall asleep earlier, and the intensity of the sleep phase is reduced. Therefore, waking in the early morning, which is sometimes considered a symptom of depression, may instead be the result of a change in an older person’s biologic clock.
Insomnia in the Elderly
Geriatric patients suffer from the same sleep disorders as their younger counterparts. Conditions that become more prevalent with age include insomnia, central and obstructive sleep apnea, circadian rhythm disturbances, and REM-sleep behavior disorder. This article will focus on insomnia, as it is by far the most common sleep complaint of elderly individuals.
Insomnia affects up to 25% of older adults, and it is more prevalent in postmenopausal women.1 Like pain, insomnia is often a constitutional symptom, and it may be a presenting symptom of numerous medical, psychiatric, and psychological conditions including primary sleep disorders. It is also the reason for a disproportionate number of medical visits. A clear understanding of the probable cause of insomnia will usually lead to effective treatment and a satisfied patient.
Transient insomnia, which can be caused by excitement, pain, medication, stress, grief, environmental noise, jet lag, etc., is a normal part of the human condition. If it persists for several weeks, it is considered short-term insomnia. Insomnia occurring nearly nightly for more than 1 month is considered chronic insomnia. Transient insomnia may develop into chronic conditioned, or learned, insomnia. Insomnia that is not associated with any identifiable underlying condition is considered primary insomnia.
Because chronic insomnia is often a constitutional symptom such as pain, fever, or weight loss, treating it requires a search for its cause. Underlying medical problems should always be suspected in elderly patients who complain of insomnia. These include depression, restless legs syndrome, myocardial infarction, congestive heart failure, angina pectoris, chronic obstructive pulmonary disease, back problems, hip impairment, osteoarthritis, rheumatoid arthritis, and peptic ulcer disease. Medications such as steroids, beta-blockers, decongestants, and stimulating antidepressants also can cause insomnia.
Although depression and anxiety can certainly cause insomnia, there is now overwhelming evidence that insomnia not associated with depression, if untreated, is a major risk factor for the subsequent development of depression.2 Therefore, the relationship between insomnia and depression is often bi-directional.
Evaluation
Most cases of insomnia can be readily diagnosed and managed in the primary care setting. A thorough history and physical examination are critical to the differential diagnosis—particularly in the geriatric population. Subjective records of wake/sleep patterns for 2 or 3 weeks may be of invaluable assistance to the physician. However, analysis of sleep diaries may be insufficient to verify a tentative diagnosis in patients with reported insomnia or suspected wake/sleep cycle abnormalities.
In such cases, definitive objective data may be obtained by actigraphy, a recently developed technique for recording activity during wake and sleep that supplements the subjective sleep log. An actigraph is a small wrist‑mounted device that records activity plotted against time. Movement/nonmovement data are collected over prolonged periods (usually 1 or 2 weeks).
Following data collection, the results are transferred to a personal computer, where software displays activity versus time. The actigraphically recorded rest/activity pattern is correlated with sleep/wake periods, permitting assessment of the true wake/sleep pattern over prolonged periods. Polysomnography is rarely indicated in the evaluation of insomnia unless underlying sleep apnea is suspected or if insomnia is associated with extreme daytime sleepiness.
Treatment
Pharmacological, behavioral, and cognitive therapies can be used to treat insomnia and are often used in combination.
♦ Over-the-Counter Medications
These are limited by the FDA to diphenhydramine (Benadryl) or doxylamine. Although these antihistamines do make people feel sleepy, they have little, if any, objective effect on sleep quality or quantity. Residual daytime hangover may be problematic. The combination of lack of efficacy and side effects suggests that these agents should be avoided for the treatment of insomnia, particularly in the elderly.
♦ Prescription Medications
Benzodiazepines (temazepam, estazolam, triazolam), benzodiazepine receptor agonists (zolpidem, zaleplon, eszopiclone), or melatonin agonists (ramelteon) are the only drugs systematically shown to be safe and effective hypnotic agents. They also are the only FDA-approved agents for the treatment of insomnia. Although the newer nonbenzodiazepine sedative/hypnotic agents are touted as being better-tolerated and having less risk of dependence than the older (and much cheaper) benzodiazepines, the true potential for dependence or abuse of the older agents among patients with insomnia has been wildly overrated.
The choice of agent should be based on matching the pattern of insomnia with the duration of action of the drug. Shorter-acting agents are better for sleep-onset insomnia, longer-acting agents for sleep-maintenance insomnia. Patients receiving any type of sedative/hypnotic should be advised of the possibility of complex behaviors such as eating or operating a motor vehicle arising from the sleep period.
Antidepressant medications such as trazodone or amitryptyline are widely prescribed to treat insomnia. There is no evidence that these agents are effective in treating insomnia that is not associated with depression. The prescribing of potent neuroactive agents such as the atypical antipsychotics for their perceived side effect of somnolence is without scientific basis and should be discouraged.
Sedative hypnotics are absolutely contraindicated for anyone who takes call duty, who may receive a telephone call in the middle of the sleep period, or who is the sole caregiver for a young child.
♦ Behavioral Treatments
Behavioral treatment for insomnia can be quite effective but may be time-consuming. Experienced practitioners are not universally available. A number of approaches have been researched including relaxation therapy, sleep hygiene, stimulus control, sleep restriction, and cognitive and behavioral therapies.
Clinical psychologists who are experienced in the management of insomnia most often use a combination of techniques.
Relaxation Therapy. Relaxation therapy, which includes a variety of techniques (progressive relaxation, abdominal breathing, yoga, guided imagery, hypnosis, biofeedback), may be effective in preparing an individual who is tense or anxious for sleep.
Sleep Hygiene. Sleep hygiene refers to avoiding behaviors such as consuming caffeine or exercising that are likely to disrupt sleep just before going to bed. If such behaviors are apparent, initial intervention should involve specific instructions such as keeping a regular wake/sleep schedule, avoiding naps, and avoiding caffeine after mid afternoon. Although such strategies can be applied to both transient or chronic insomnia, chronic insomnia rarely remits simply with such behavior changes alone.
Stimulus Control. The principle underlying this technique is to strengthen the relationship between bed, bedroom cues, and sleep. Patients should:
- Go to bed only when sleepy.
- Use the bed only for sleep and sex.
- If unable to sleep for 15 minutes, get out of the bed, go to another room and do something relaxing but not something that unconsciously rewards them for being awake in the middle of the night (doing taxes, reconciling the checkbook, doing housework, or studying). Return to the bed only when sleepy. This should be repeated as often as necessary.
- Set the alarm and get up at the same time every morning.
- Do not nap during the day.
Significant sleep deprivation may occur because of repeated trips to another room, and this heightens the drive for sleep. Eventually, the more regular pairing of the stimulus (bed) with the desired response (sleep) reduces insomnia.
Restless Leg Syndrome
One of the most common causes of insomnia is restless legs syndrome (RLS). RLS affects approximately 10% of the population, and its prevalence increases with age. RLS is actually a neurologic sensory-movement disorder that may result in severe sleep onset or sleep maintenance insomnia, hence its presentation as a sleep disorder. The diagnosis of RLS is purely clinical. Formal sleep studies are rarely indicated. Hemoglobin, serum iron, iron saturation, and ferritin determinations should be obtained to look for mild degrees of anemia.
Three classes of medications are effective in the symptomatic treatment of RLS: 1) dopaminergic agents such as L-dopa/carbidopa, pergolide, pramipexole, and ropinirole; 2) benzodiazepines such as clonazepam; and 3) opiates including codeine, propoxyphene, oxycodone, and methadone.
For additional information, see the RLS Foundation website at www.RLS.org. |
Sleep Restriction. Restricting the time in bed available for sleep will increase the pressure to sleep. If the patient reports obtaining 5 hours of sleep nightly but is spending 7 hours in bed, restrict the time in bed to 5 hours. The accumulating sleep deprivation will quickly lead to the patient’s sleeping most of the 5 hours. When that happens, increase the time in bed by 15-minute increments at either end, as long as the patient spends 85% to 90% of time in bed sleeping.
Cognitive and Behavioral Therapies. There is now convincing evidence from several well-designed randomized, controlled trials that a variety of cognitive and behavioral therapy programs are as effective as FDA-approved sleep medications in the short term.3 These programs have been proven safe and effective and do not have the adverse side effects and long-term costs often associated with prescription sedatives. One such approach often employs cognitive restructuring and may include stimulus control and sleep restriction. Recently, Mindfulness-Based Stress Reduction (MBSR), an approach involving meditation and a variety of relaxation techniques, has shown promise for many chronic conditions including insomnia. MBSR is offered at many sites, including the Center for Spirituality and Healing at the University of Minnesota, where it is also under clinical investigative research. Other therapies that are both clinically efficacious and cost-effective have yet to be determined.
Conclusion
A systematic approach to managing insomnia in older individuals will usually result in a specific clinical diagnosis with clear-cut therapeutic implications. Additional information about the diagnosis of and therapies for insomnia can be found at the National Sleep Foundation’s website at www.sleepfoundation.org and the American Academy of Sleep Medicine’s website at www.aasm.org. For the practitioner, employing effective treatment strategies will lead to a satisfied and well-rested patient. MM
Mark Mahowald is director of the Minnesota Regional Sleep Disorders Center at Hennepin County Medical Center and a professor of neurology at the University of Minnesota. Michel A. Cramer Bornemann is co-director of the Minnesota Regional Sleep Disorders Center and an assistant professor of neurology at the University of Minnesota.
References
1. NIH Heart Lung Blood Institute: http://www.nhlbi.nih.gov/about/ncsdrNational Sleep Foundation. “Learn about Women’s Unique Sleep Experiences.” Available at: www.sleepfoundation.org. Accessed September 14, 2007.
2. Brunello N, Armitage R, Fineberg I, et al. Depression and sleep disorders: clinical relevance, economic burden, and pharmacological treatment. Neuropsychobiology. 2000;42(3):107-19.
3. Morin CM, Bootzin RR, Buysse DJ, Edinger JD, Espie CA, Lichstein KL. Psychological and behavioral treatment of insomnia: update of the recent evidence (1998-2004). Sleep. 2006;29(11):1398-414).