Elsevier

Clinics in Chest Medicine

Volume 28, Issue 4, December 2007, Pages 673-684
Clinics in Chest Medicine

Sleep and Older Patients

https://doi.org/10.1016/j.ccm.2007.07.002Get rights and content

Sleep disturbances are common among older adults. The elderly population reports more symptoms associated with poor sleep initiation and maintenance and increased daytime napping. Sleep problems may be caused by various factors, including medication use, medical and psychiatric illnesses, and primary sleep disorders. The consequences of poor sleep quality may include cognitive impairment, daytime sleepiness, and reduced quality of life. The evaluation and management of these disorders is discussed in this review.

Section snippets

Sleep architecture

The progression of sleep stages throughout the night is predictable and is commonly represented in the form of hypnograms (Fig. 1). Based on poly-somnographic (PSG) data (ie, electro-encephalography [EEG], eye movement, and muscle tone), sleep can be divided into two distinct states, namely, non-rapid eye movement (non-REM) and rapid eye movement (REM) sleep. Non-REM sleep is further subdivided into light sleep, stages 1 and 2, and deep sleep, stage 3 (formerly stages 3 and 4), also known as

Age-related sleep changes

Aging is associated with changes in sleep architecture. Older persons typically have more frequent nighttime arousals, awakenings, and sleep stage shifts [3]. The duration of nighttime awakenings also is increased. Age-related changes include reductions in total sleep time, sleep efficiency (ie, time asleep/time spent in bed), and SWS [4]. There is often a reduction in percentage of REM sleep along with a shortened REM sleep latency and an increase in the duration of the first REM sleep

Aging and circadian rhythms

Aging is associated with dampening of the circadian sleep–wake rhythms [9]. This in turn may result in greater sleepiness during the daytime and reduced nocturnal sleep efficiency. There are concurrent reductions in the amplitude of melatonin secretion and core body temperature. Phase advancement of circadian rhythms is common, leading to greater likelihood of early morning awakenings and excessive sleepiness earlier in the evening [3]. Recent research indicates that reductions in circadian

Causes of sleep disturbance with aging

Several factors could contribute to the greater sleep fragmentation seen with aging. In addition to the dampening of circadian sleep–wake rhythms and decreased homeostatic sleep drive described previously, other factors such as a greater sensitivity to adverse environmental factors (eg, noise) may be important. Sleep problems among older adults are often caused by other primary sleep disorders (such as obstructive sleep apnea, periodic limb movements in sleep, restless legs syndrome [RLS], and

Insomnia

Insomnia is a disorder marked by one or more of the following complaints: difficulty initiating or maintaining sleep, waking too early in the morning, or sleep that is chronically nonrestorative or poor in quality. In addition, these complaints are present despite adequate circumstances and opportunities for sleep, and they result in impairment of daytime function (eg, mood disturbances, attention and memory impairments, or fatigue) [12]. Older adults who have insomnia more often describe

Sleep-disordered breathing

Sleep apnea is characterized by recurrent 10-second airway flow restriction (hypopneas) or obstruction (apneas). These partial or complete upper airway occlusions may cause sleep disruption, frequent arousals from sleep, and oxygen desaturation (Fig. 2). Obstructive sleep apnea is a disorder marked by upper airway obstruction, often at the level of the tongue base or retropalatal space, despite continued respiratory effort. In contrast, central sleep apnea (CSA) is associated with diminished or

Restless legs syndrome and periodic limb movements in sleep

RLS is a diagnosis based on symptoms of unpleasant or uncomfortable leg sensations that are accompanied by an intense urge to move the legs. These symptoms, which are often described as “creepy-crawly sensations,” occur during periods of rest or inactivity, are worse at night, and are either completely relieved or lessened with movement [102]. The underlying mechanisms of RLS are not entirely clear, but iron metabolism and dopaminergic neural functioning seem to be involved [103], [104]. The

Rapid eye movement sleep behavior disorder

REM sleep behavior disorder (RBD) is a parasomnia that is characterized by dream-enacting behaviors during REM sleep resulting from a loss of usual skeletal muscle atonia during this sleep stage [115]. Nocturnal behaviors reported can be violent or aggressive in nature and may include yelling, grabbing, punching, kicking, and running [116]. Sleep-related injury, such as ecchymoses, lacerations, and fractures, to the patient or their bed partner were the presenting complaint in nearly 80% of

Summary

Older patients experience changes in their sleep architecture with aging, with more frequent arousals and a reduction in total sleep time and sleep efficiency. Multiple factors contribute to sleep disturbance with aging, including underlying medical and psychiatric disorders, which should be evaluated for in older patients who have sleep complaints. Sleep-disordered breathing is also common among older patients and may be related to physiologic changes, such as age-related alterations in

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