Sleep Disorders across the Life Span

Sleep Disorders across the Life Span Weidong Wang, Xue Yan, and YanJiao Liu, Guang’anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China Ó 2015 Elsevier Ltd. All rights reserved.

Abstract It is estimated that 10% of the population suffer from sleep disorders, which have profound and widespread effects on human health. Although the diagnosis and treatment of sleep disorders is a relatively young discipline, understanding of the diagnosis, pathophysiology, and treatment of sleep disorders is evolving at a rapid pace. There are around 90 distinct sleep disorders in resent research; most are marked by one of these symptoms: excessive daytime sleepiness, difficulty initiating or maintaining sleep, and abnormal events occurring during sleep. The sleep disorders are associated with increased risk of hypertension, diabetes, obesity, coronary heart disease, heart attack, stroke, and depression. This article focuses on incorporating the essential features of common sleep disorders across the life span.

Sleep is a universal phenomenon that occupies almost onethird of human lifetime (Lee-Chiong, 2004). Sleep influences most physiologic processes in the body, and is, in turn, affected by specific circadian, medical, neuropsychiatric, and behavioral disorders, the sleep environment itself, and medication usage (Lee-Chiong, 2004). Sleep disorders are common, and at least 10% of the population suffer from a sleep disorder that is clinically significant and of health importance (Ram et al., 2010). Although the diagnosis and treatment of sleep disorders is a relatively young discipline in medicine and psychopathology dating to the late 1970s, understanding of the diagnosis, pathophysiology, and treatment of sleep disorders is evolving at a rapid pace (Roehrs and Roth, 2004). At present, nearly 90 different sleep disorders are listed in the International Classification of Sleep Disorders (ICSD, Ed 2), which can be divided into eight categories (American Academy of Sleep Medicine, 2005). Sleep disorders vary widely in their complexity, their comorbidities, the risks they represent, and the scope of their manifestations (Colten and Altevogt, 2006). The four major sleep complaints include excessive daytime sleepiness; insomnia; abnormal movements, behaviors, or sensation during sleep; and inability to sleep at the desired time (American Academy of Sleep Medicine, 2005). In addition, sleep problems are associated with health problems, functioning and well-being, work-related indicators, and health care expenditures (Roth et al., 2002). A number of recent studies have demonstrated that individuals with current sleep problems report significantly poorer health, less energy, and worse cognitive functioning than those categorized as having no sleep problem (Roth et al., 2002). The long-term effects of sleep loss and sleep disorders have been associated with a wide range of deleterious health consequences including increased risk of hypertension, diabetes, obesity, coronary heart disease, heart attack, heart failure, stroke, and depression (Colten and Altevogt, 2006). The principles of sleep disorder treatment include first to find the cause of the sleep disturbance and vigorously treat the primary or comorbid conditions causing the sleep disturbance. If the treatment does not resolve the problem, then treatment should be directed at a specific sleep disturbance that may be

70

caused by various neurological and medical diseases (Chokroverty, 2010).

Sleep Patterns Change across the Life Span Sleep architecture changes continuously and considerably with age. From infancy to adulthood, there are marked changes in how sleep is initiated and maintained, the percentage of time spent in each stage of sleep, and overall sleep efficiency. Sleep requirements change dramatically from infancy to old age. A general trend is that sleep efficiency declines with age (Table 1) (Chokroverty, 2010; Colten and Altevogt, 2006). Such changes will be significantly affected by neurological, environmental, and genetic factors as well as comorbid medical or neurological disorders.

Common Sleep Disorders in Children The diagnoses of sleep disorders are often overlooked and underdiagnosed in the pediatric population (Faruqui et al., 2011). Sleep problems in preadolescents have been reported for 10–33% of the population (Fricke-Oerkerman et al., 2007; Ipsiroglu et al., 2002; Meijer et al., 2000). An estimated 40% of adolescents report experiencing some forms of sleep problems, including issues of sleep difficulty, snoring, and sleep apnea (Corbo et al., 2001; Gozal and Pope, 2001; Tarasiu et al., 2007). Sleep disorders in children can be divided into five categories, which are composed of difficulty falling asleep, difficulties with arousal, sleep-related movement disorders, sleep-related breathing disorder, and excessive daytime sleepiness (Carno et al., 2003). Many disorders are included in these categories. There are characteristic symptoms and ages of onset for the different sleep disorders.

Difficulty Falling Asleep Difficulty falling asleep related to the process of going to sleep is called insomnia. Insomnia among children is often reported

International Encyclopedia of the Social & Behavioral Sciences, 2nd edition, Volume 22

http://dx.doi.org/10.1016/B978-0-08-097086-8.21027-1

Sleep Disorders across the Life Span

Table 1

71

Sleep patterns change across the life span

Age group

Average sleep duration

Sleep feature

Newborns

15–16 h per day

1. 2. 3. 4. 5.

Child

11 h per day

Adolescent Adults

9–10 h per day 7.5–8 h per night

Elderly people

7 h per night

Biphasic By 3 months of age, the non-REM (NREM)/REM cycling pattern of adult sleep is established REM sleep constitutes 50% of total sleep time during early infancy Ultradian sleep cycles of REM and NREM sleep states are substantially shorter for infants (50–60 min) Some degree of nighttime waking is normal in young children, particularly during early infancy, when circadian mechanisms are still immature and nighttime feedings a necessity for most infants until about 6 months of age 1. Biphasic 2. REM sleep declining by age 5 years to 20% Monophasic 1. Monophasic 2. Ultradian sleep cycles of REM and NREM sleep states are substantially longer for adults (90–100 min) 1. Biphasic 2. Progressive decrease in slow wave sleep (SWS) and REM 3. Earlier bedtimes and wake times 4. Sleep efficiency continues to decline with age

by caretakers and characterized by bedtime resistance, an inability to sleep independently, or both (Colten and Altevogt, 2006). It can manifest as bedtime resistance, in which a child may cry, repeatedly attempt to leave the room/bed, or engage in other behaviors intended to forestall sleep onset. Delayed sleep onset and issues of sleep anxiety are also common, such as needing a parent in the room to fall asleep, the child signals being afraid to sleep alone and/or to sleep in the dark. In school-aged children, this can be a significant problem and may lead to poor school performance (Colten and Altevogt, 2006; Owens et al., 2000). Children who lack structured bedtime routines or have irregular sleep habits represent a high-risk population. Other influences that may impede settling at bedtime include temperamental characteristics, anxiety, acute illness, medication side effects, and coexisting medical conditions such as attention deficit hyperactivity disorder (ADHD), autism, and other developmental disabilities (Hoban, 2010). Behavioral interventions and establishing good ‘sleep hygiene’ are the preferred method and goal of treatment (Carno et al., 2003; Hoban, 2010). Use of a structured, age-appropriate bedtime routine helps children sleep. In addition, night waking is considered problematic when it is excessively prolonged or frequent for age, or when it is excessively disruptive to other members of the household (Hoban, 2010). Overall, about 20% of children below age 2 years exhibit night waking inducing concern by parents (Hoban, 2010). A variety of predisposing influences may be associated with problematic night waking, some of which relate to expected developmental changes during early childhood. Separation anxiety and cosleeping with a parent are associated with increased risk of arousal and awakening during nighttime sleep (Hoban, 2010; Kryger et al., 2005). Another strong influence of sleep disorder on older schoolage children is the well-recognized tendency toward delayed sleep phase type that develops near adolescence, with a reported prevalence of 7–16% (Reid et al., 2004). Delayed sleep phase syndrome (DSPS), one kind of circadian rhythm sleep

disorder, may be diagnosed when this tendency results in difficulty maintaining school schedule, as well as chronic or recurrent inability of the child to fall asleep and wake up at conventional and socially acceptable times (American Academy of Sleep Medicine, 2005; Anstead, 2000; Carno et al., 2003; Reid et al., 2004). Besides a result of alterations of circadian timing, there is recent evidence that alterations in the homeostatic regulation of sleep may play an important role in the pathophysiology of DSPS (Watanabe et al., 2003). As common in adolescents, habitually later bedtime and waking time on nonschool nights, end to perpetuate or worsen the tendency toward DSPS (Crowley et al., 2007). Treatment includes a gradual change in the child’s sleep time until the desired sleep–wake time is achieved. Both the parents and the child must be committed to the prescribed plan for success (Carno et al., 2003).

Difficulties with Arousals Parasomnias are episodic disturbances of sleep that happen most often in preschool and school-aged children (D’Cruz and Vaughn, 2001). These aberrant arousals are associated with a spectrum of abnormal behavior or physiologic events that occur in association with sleep, specific sleep stages, or sleep– wake transitions and can include night terrors, sleepwalking, sleep talking, and so on (D’Cruz and Vaughn, 2001; Hoban, 2010). During a parasomnia episode, children are difficult to awaken during the event, and if awakened, demonstrate little or no recall for the episode (D’Cruz and Vaughn, 2001). Multiple parasomnias often occur in the same person at different ages. They are more common in boys than in girls, and often found in conjunction with a positive family history (D’Cruz and Vaughn, 2001; Hublin et al., 2001; Lecendreux et al., 2003; Owens et al., 2000). Limited evidence suggests that obstructive sleep apnea (OSA) or restless legs syndrome (RLS) may represent a treatable precipitant of these parasomnias for some children (Guilleminault et al., 2003). Studies have shown a relationship between the child’s stress

72

Sleep Disorders across the Life Span

level and parasomnias such as night terrors, somniloquy, and body rocking (Laberge et al., 2000). Night terrors, sleepwalking, and confusional arousal in children are thought to represent forms of incomplete arousal from non-rapid eye movement (REM) sleep. Exacerbations of non-REM arousal parasomnias are often triggered by sleep deprivation or intercurrent illness. Night terrors and confusional arousal affect up to 17% of children (Laberge et al., 2000) but are most commonly observed in toddlers and preschoolers with no dream association or recollection of the incident. These incidents are accompanied by intense autonomic and motor symptoms, which range from moaning, quiet crying, sitting upright in bed, or screams to extreme agitation (Hoban, 2010; Laberge et al., 2000). Patients appear highly confused and fearful. Episodes can last from only seconds to as long as 1 h, but most typically remit within minutes (Carno et al., 2003; Hoban, 2010). Sleepwalking and sleep talking are more common in school-age children. Sleep talking (somniloquy) is the most frequent parasomnia and can be considered a universal experience (Carno et al., 2003). Although 40% of children exhibit at least one episode of sleepwalking between the ages of 5 and 12 years, frequent sleepwalking affects only 2–3% with a peak prevalence near 10 years of age (Laberge et al., 2000). Episodes of sleepwalking consist of quiet ambulation lasting several minutes, which may include semipurposeful activities such as wandering to some place of the house or urinating in inappropriate locations (Hoban, 2010). Injuries and violent activities have been reported during sleepwalking episodes but generally individuals can negotiate their way around the room (Chokroverty, 2010). Use of scheduled awakenings is often effective for the treatment of the non-REM arousal parasomnias in children whose sleepwalking or night terrors occur at predictable times of the night (Hoban, 2010). For sleepwalking, security of the environment is important. Drug treatment using clonazepam may be effective for children having particularly frequent or severe forms of sleepwalking and night terrors (Remulla et al., 2004). Nightmares during childhood are common, and over half of early school-aged children were affected on an occasional basis but only 3% of children show this disturbance more than once a week (Smedje et al., 1999). Different from night terrors, nightmares arise from REM sleep and are thought to result from awakening during a frightening dream. The child awakens fully, and has recollection of the dream content. Persistent nightmares, which are unexpectedly frequent, prolonged, or violent in content, need especially further attention of potential psychological and medical causes (Hoban, 2010). It may be helpful to teach stress modification techniques based on age, which is also beneficial for sleep talking (Howard and Wong, 2001). Sleep enuresis in children is defined as urinating more than twice a week for children older than 5 years and characterized by recurrent involuntary voiding during sleep at a level that is inappropriate for age (American Academy of Sleep Medicine, 2005). Nocturnal enuresis becomes less common with advanced age, affecting 15% of 3- to 10-year-olds, but only 2% of 13-year-olds (Laberge et al., 2000). It more commonly occurs in boys than in girls. Postulated causes of primary

enuresis include immaturity of arousal mechanisms, reduced functional bladder capacity, and genetic predisposition. Children with frequent enuresis often respond to behaviorally based therapies and conditioning programs (Butler et al., 2007; Lottmann and Alova, 2007). Drug treatment like desmopressin (Ferrara et al., 2008) and imipramine (Neveus et al., 2008) is also effective, which is best used within the context of a comprehensive and closely supervised treatment program.

Sleep-Related Movement Disorders RLS and periodic limb movement disorder (PLMD) are different but related conditions in children and are often comorbid conditions, but either of them may present independently. The RLS criteria in childhood include the adult criteria and additional criteria designed to address the absence or uncertainty of verbal reports (American Academy of Sleep Medicine, 2005). Some children with growing pains may actually have RLS as well (Rajaram et al., 2004). Leg restlessness and growing pains affect 17% and up to 8% of children, respectively (Chervin et al., 2002), but only 2% of children meet diagnostic criteria of RLS (Picchietti et al., 2007). Genetic influences and iron deficiency are suggested as the causes of RLS in the pediatric age group (Muhle et al., 2008; Oner et al., 2007). Childhood PLMD is characterized by excessive periodic limb movements occurring over five times per hour of sleep during polysomnography (PSG), accompanied by clinical complaints of disturbed sleep (American Academy of Sleep Medicine, 2005). The pathophysiology of PLMD is still unknown, but dopaminergic impairment has been implicated (American Academy of Sleep Medicine, 2005). Studies have reported possible association between childhood RLS/PLMD and symptoms of ADHD (Cortese et al., 2005). Treatment options for childhood RLS/PLMD include iron supplementation with low ferritin levels or iron deficiency (Picchietti et al., 2008), or judicious use of dopaminergic agonists (Walters et al., 2000). Sleep-related rhythmic movement disorder (RMD) is characterized by recurrent and well-stereotyped rhythmic behaviors associated with sleep, which is sleep–wake transition parasomnias that involve rhythmic movement of a large muscle group (American Academy of Sleep Medicine, 2005; Hoban, 2003). Body rocking, head or body rolling, and head banging are some common examples. Episodes of rhythmic movement usually last for several minutes and may recur throughout the night (Hoban, 2010). Rhythmic movements may represent self-comforting or a sleepinducing behavior (D’Cruz and Vaughn, 2001). Parents may be unaware of the sleep disturbance unless some sort of noise is involved. Sleep-related rhythmic behaviors are observed in a majority of infants, usually between 8 and 18 months, but disappear around 5 years of age in most children (Dyken and Rodnitzky, 1992). Only 3% of children manifest prominent rhythmic behaviors associated with sleep in early adolescence (Laberge et al., 2000). RMD is a selflimited condition that does not need treatment in most children. But for children exhibiting particularly prolonged

Sleep Disorders across the Life Span

or violent forms of RMD, benzodiazepines, behavioral therapies, or use of padding are suggested (Hoban, 2010).

73

commonly noted in children with mental retardation or cerebral palsy. The episode is characterized by stereotypical tooth grinding and is precipitated by anxiety, stress, and dental disease (Hoban, 2010).

Sleep-Related Breathing Disorder OSA refers to a breathing disorder during sleep that is characterized by either prolonged partial upper airway obstruction (hypopnea) and/or intermittent complete obstruction (apnea) (American Academy of Sleep Medicine, 2005). OSA in children may not present as overtly as in adults and sometimes associated sleep disturbance can be the most obvious symptom and the reason why the child comes to medical attention in the first place (Wiggs, 2003). The prevalence of OSA is approximately 2% in otherwise normal young children (American Academy of Sleep Medicine, 2005). Although OSA can occur in children of any age, it is most common at preschool ages around 2–8 years, a time coincident with tonsils and adenoids being largest relative to the underlying airway (Colten and Altevogt, 2006). Other genetic, neurological, and craniofacial conditions and obesity are associated with increased risk for the development of childhood OSA. The clinical features of OSA in children include snoring, unusual sleeping positions, headache, and daytime sleepiness (American Academy of Sleep Medicine, 2005). Children with OSA have an increased risk for neurocognitive deficits such as behavioral problems, poor learning, and/or ADHD, which result from the lower oxygen levels during the episodes of sleep apnea (Marcus, 2001). Adenotonsillectomy is the most common treatment of childhood OSA. Otherwise, nasal continuous positive airway pressure (CPAP) is an alternative first-line treatment for OSA in children of all ages (O’Donnell et al., 2006). Other treatments are then advised, such as weight loss, use of supplemental oxygen, positional therapy, or more extensive surgery (Hoban, 2010; Schechter, 2002).

Common Sleep Disorders in Adults Sleep disorders have an estimated prevalence of 15–27% in the adult population (Roth et al., 2002). While there are approximately 90 sleep disorders recognized by the medical community (American Academy of Sleep Medicine, 2005), the authors have put together a list of the most common sleep disorders seen in adults as follows. Many people have more than one sleep issue.

Insomnia

Narcolepsy is a neurologic disorder characterized by excessive daytime somnolence, which may be accompanied by cataplexy, sleep paralysis, and hallucinations at sleep onset or offset. It appears commonly during the second decade of life and after the reported onset of puberty (Kotagal, 1996). Onset of narcolepsy can also have a negative impact on school performance. Misdiagnosis of narcolepsy is common in children owing to similar psychiatric disorders and emotional and behavioral changes. Treatment of narcolepsy in children, in most respects, parallels that of adults (Hoban, 2010). However, large-scale clinical trials have not examined the efficacy and safety of drugs to treat narcolepsy in children and adolescents (Colten and Altevogt, 2006).

Insomnia is defined as a repeated difficulty with sleep initiation, duration, consolidation, or quality that occurs despite adequate time and opportunity for sleep and results in some form of daytime impairment (American Academy of Sleep Medicine, 2005). The prevalence in representative population surveys is 10–14% for chronic insomnia and 20–40% for occasional, or less severe, insomnia (Kryger et al., 2005). The precise causes of insomnia are poorly understood but, in general terms, involve a combination of biological, psychological, and social factors (Colten and Altevogt, 2006). Surveys consistently find that the prevalence of insomnia is higher in women and that it increases with age. In addition, insomnia is more prevalent in those with medical illness, substance users, and those with anxiety or depressive disorders (Roehrs and Roth, 2004; Kryger et al., 2005). Among adults, insomnia complaints typically include reported difficulties initiating or maintaining sleep. Concerns about extended periods of nocturnal wakefulness or insufficient amounts of nocturnal sleep usually accompany these complaints. Consequences of insomnia in adults include an increased likelihood of accidents and absenteeism, diminished performance, impaired judgment and social or vocational functioning, polydrug abuse (including alcoholism), increased use of health care resources, reduction in quality of life, and disturbance in interpersonal relationships. It is important and necessary that short-term sleep disturbance be promptly recognized and appropriately treated before learned habits, attitudes, and coping mechanisms incongruous with sleep become established and perpetuate the sleep disturbance. Insomnia is treatable with a variety of behavioral and pharmacological therapies, which may be used alone or in combination. Therapy has to address the predisposing, precipitating, and perpetuating factors of insomnia (Lee-Chiong, 2004).

Bruxism (Tooth Grinding)

Sleep-Disordered Breathing

Bruxism often presents between ages 10 and 20 years, but it may persist throughout life, often leading to secondary problems such as temporomandibular joint dysfunction. It is also

Sleep-disordered breathing (SDB) refers to a spectrum of disorders that feature breathing pauses during sleep. The most common disorder is characterized by obstructive apneas and

Excessive Daytime Sleepiness

74

Sleep Disorders across the Life Span

hypopneas (Kryger et al., 2005). Obstructive sleep apnea syndrome (OSAS) is characterized by repetitive episodes of complete (apnea) or partial (hypopnea) upper airway obstruction occurring during sleep (American Academy of Sleep Medicine, 2005; Kryger et al., 2005). These events often result in loud snoring, blood oxygen saturations, and many and recurrent periods of arousal. They typically recur throughout the evening, at times reaching numbers substantial enough to produce sleep fragmentation and subsequent daytime sleepiness (American Academy of Sleep Medicine, 2005). The diagnosis of OSAS requires detection, by PSG, of at least five or more apneas or hypopneas per hour of sleep (Colten and Altevogt, 2006). OSAS tends to affect mainly middle-aged individuals and is strongly associated with obesity. An estimated 4% of men and 2% of women between the ages of 30 and 60 years in the United States have OSAS (Lee-Chiong, 2004). OSAS increases the risk for hypertension, coronary artery disease, heart failure, arrhythmias, cerebrovascular disease, stroke, glucose intolerance, diabetes, and even mortality (Colten and Altevogt, 2006; Lee-Chiong, 2004). In adults, OSA is most effectively treated with CPAP and weight loss (Kryger et al., 2005). Other options, although less effective, include a variety of dental appliances or surgery (e.g., uvulopalatopharyngoplasty) (Kryger et al., 2005).

a normal sleeping pattern, taking supplements to manage iron deficiencies, and minimizing consumption of alcohol, caffeine, and tobacco (Colten and Altevogt, 2006).

Periodic Limb Movement Disorder PLMD is defined as periodic episodes of repetitive, highly stereotyped limb movements characterized by rhythmic extensions of the big toe, dorsiflexions of the ankle, and occasional flexions of the knee and hip, which cannot be explained by any other sleep disorder. Nonetheless, these stereotypical jerks can partially arouse or awaken the individual, leading to sleep fragmentation and complaints of insomnia or hypersomnolence (American Academy of Sleep Medicine, 2005). It was found to have a population prevalence of 4% in studies of five European countries (Kryger et al., 2005). It is also observed in individuals with narcolepsy, rapid eye movement sleep behavior disorder (RBD), OSA, and hypersomnia (Chokroverty, 2010). PLMD is associated with high rates of depression, memory impairment, attention deficits, oppositional behaviors, and fatigue (American Academy of Sleep Medicine, 2005). Similar to RLS, dopaminergic medications are helpful in alleviating the disorder’s symptoms.

Narcolepsy and Hypersomnia Sleep-Related Movement Disorders Restless Legs Syndrome RLS is a sensorimotor disorder characterized by a strong, nearly irresistible urge to move the legs (American Academy of Sleep Medicine, 2005). It is also associated with paresthesias – uncomfortable feelings – which individuals describe as creeping, crawling, jittery, itchy, aching, or burning feelings. The symptoms are partially or completely relieved by movement. The urge to move and unpleasant sensations worsen during periods of rest or inactivity, especially in the evening and at night, causing most individuals difficulty falling sleep and maintaining sleep (American Academy of Sleep Medicine, 2005). At least 80–90% of RLS patients have periodic limb movement in sleep (PLMS) and may also have periodic limb movement in wakefulness; however, one-third of those with PLMD will have RLS (Chokroverty, 2010; Michaud et al., 2000). The prevalence has been reported at about 5–10% for adult populations but the prevalence of most severe cases is approximately 2.5%, which makes it one of the most common movement disorders and sleep disorders (Chokroverty, 2010; Colten and Altevogt, 2006). In most surveys, the prevalence is greater in women than in men and the disease is chronic and progressive (Chokroverty, 2010). Iron, dopamine, and genetics appear to be primary factors in the pathology of RLS (American Academy of Sleep Medicine, 2005). There are both behavioral and pharmacological treatments for RLS. Four classes of prescription medications are mostly used for the treatment of RLS: dopaminergic agents, benzodiazepines, opioids, or anticonvulsants, in which dopaminergic agents are the primary treatment option for RLS (Colten and Altevogt, 2006). Mild to moderate symptoms can be treated sometimes by lifestyle changes, including maintaining

Narcolepsy and idiopathic hypersomnia are characterized by a clinically significant complaint of excessive daytime sleepiness that is neither explained by a circadian sleep disorder, SDB, or sleep deprivation, nor caused by a medical condition disturbing sleep (American Academy of Sleep Medicine, 2005). Narcolepsy is characterized by narcoleptic sleep attacks (100%), cataplexy (60–70%), sleep paralysis (25–50%), hypnagogic hallucinations (20–40%), disturbed night sleep (70–80%), and automatic behavior (20–40%) (Chokroverty, 2010). In addition to the major manifestations, patients with narcolepsy may also have four important comorbid conditions: sleep apnea, PLMS, RBD, and nocturnal eating disorder (Chokroverty, 2010). Excessive sleepiness may manifest as pervasive drowsiness, frequent napping, and unexpected and overpowering sleep attacks. Repetitive awakenings, automatic or inappropriate behavior, and memory impairment are associated features. It is a lifelong condition but it generally is less severe and may even disappear in old age (Chokroverty, 2010; Lee-Chiong, 2004). It has a population prevalence of 0.03–0.16% of the general population (Lee-Chiong, 2004). Excessive sleepiness in persons with idiopathic hypersomnia, which closely resembles narcolepsy syndrome, manifests as extended major sleep episodes (lasting over 8 h) and prolonged naps (up to 1–2 h) (Lee-Chiong, 2004). The sleep pattern, however, is different from that of narcolepsy. The patient generally sleeps for hours but the sleep is not refreshing. The patient does not give a history of cataplexy, snoring, or repeated awakenings throughout the night. Recurrent hypersomnia can manifest in two forms: hypersomnia only or accompanied by binge eating and hypersexuality (Kleine–Levin syndrome) (Colten and Altevogt, 2006; Lee-Chiong, 2004).

Sleep Disorders across the Life Span

The diagnosis of narcolepsy and hypersomnia is based principally on the multiple sleep latency test, which objectively quantifies daytime sleepiness, or by measuring cerebrospinal fluid hypocretin-1 (Kryger et al., 2005). Secondary cases of narcolepsy or hypersomnia are also common, which can occur in the context of psychiatric disorders, central nervous system tumors, Parkinson’s disease, multiple sclerosis, head trauma, and genetic disorders (Colten and Altevogt, 2006). Treatment for narcolepsy and hypersomnia is symptomatically based. In most cases, pharmacological treatment (such as modafinil or amphetamine-like stimulants) is needed. Behavioral measures are helpful but rarely sufficient (Colten and Altevogt, 2006).

Circadian Rhythm Sleep Disorders Circadian rhythm sleep disorders arise from chronic alterations, disruptions, or misalignment of the circadian clock in relation to environmental cues and the terrestrial light–dark cycle (Colten and Altevogt, 2006). The ICSD 2 designated nine different circadian disorders, and the common primary disorders include delayed sleep phase type, advanced sleep phase type, irregular sleep–wake type, free-running type, shift work type, and jet lag type (American Academy of Sleep Medicine, 2005; Colten and Altevogt, 2006). These conditions often result in complaints of insomnia and excessive sleepiness. In addition to physiological and environmental factors, maladaptive behaviors influence the presentation and severity of the circadian rhythm sleep disorders (American Academy of Sleep Medicine, 2005). These disorders may be comorbid with other neurological or psychiatric disorders, making the diagnosis and treatment difficult (Kryger et al., 2005). Treatment for this disorder requires resynchronizing to a more appropriate phase to the 24-h light–dark cycle. In addition to a structured sleep–wake schedule and good sleep hygiene practices, potential therapies include resetting the circadian pacemaker with bright light, melatonin, or a combination of both (Colten and Altevogt, 2006; Reid et al., 2004).

Parasomnias Parasomnias are undesirable physical, behavioral, or experiential phenomena that occur during entry into sleep, within sleep, or during arousals from sleep (American Academy of Sleep Medicine, 2005). Parasomnias generally manifest as central nervous system activation transmitted into skeletal muscles and the autonomic nervous system channels, often with experiential concomitants, and tend to occur during the transition from one state to another. Parasomnias encompass abnormal sleep-related movements, behaviors, emotions, perceptions, dreaming, and autonomic nervous system functioning, which may result in injuries, sleep disruption, adverse health effects, and psychosocial problems (American Academy of Sleep Medicine, 2005). The ICSD 2 lists 15 items and some of these entities are rare (American Academy of Sleep Medicine, 2005). The common primary sleep parasomnias include disorders of arousal (e.g., confusional

75

arousals, sleepwalking, and sleep terror), RBD, nightmare disorder, sleep enuresis, sleep-related groaning, and eating disorder, most of which are usually common in children (see Section Common Sleep Disorders in Children) (LeeChiong, 2004).

Common Sleep Disorders in Older Adults Sleep disturbances in older adults are often multifactorial. It has been estimated that approximately 50% of older adults complain about difficulty initiating or maintaining sleep (Crowley, 2011; Neikrug and Ancoli-Israel, 2010). However, this higher prevalence of sleep disruption is less a function of age and more a function of other factors that accompany aging, which include the increased presence of medical and psychosocial comorbidities, increased medication use, advances in the endogenous circadian clock, and a higher prevalence of specific sleep disorders (e.g., OSA, PLMS, and RLS) (Bloom et al., 2009). Of major clinical concern is the strong bidirectional relationship between sleep disorders and serious medical problems in older persons (Bloom et al., 2009). Individuals with sleep disorders negatively affect the outcomes of chronic diseases such as hypertension, depression, cardiovascular, and cerebrovascular disease and are associated with increasing mortality and morbidity. Conversely, individuals with any of these diseases are at higher than normal risk of developing sleep problems (Cuellar et al., 2007; Foley et al., 2004; Neikrug and Ancoli-Israel, 2010; Taylor et al., 2007). The most common primary sleep disorders in the elderly include insomnia, SDB, RLS/PLMS, and RBD (Crowley, 2011). Treatment of primary sleep problems can improve the quality of life and daytime functioning of older adults (Neikrug and Ancoli-Israel, 2010).

Insomnia Numerous studies have shown that the prevalence of insomnia is higher in older adults than in younger adults, with estimates as high as approximately 40% in those aged over 65 years (Ancoli-Israel, 2009; Foley et al., 2004; Paudel et al., 2008). The consequences of insomnia in older adults are substantial and include daytime functional impairments, poor health, decreased physical function, falls, cognitive impairment, and mortality (Ancoli-Israel, 2009). Insomnia is often comorbid with medical and psychiatric illness, such as renal disease, nocturia, cerebrovascular disease, gastrointestinal disease, respiratory disorders, chronic pain and arthritis, neurological diseases, menopause cardiovascular disease, anxiety and depression, as well as multiple medications use in the elderly (Neikrug and Ancoli-Israel, 2010). There are also other factors affecting the ability to sleep in older adults including intake of alcohol, caffeine, and nicotine; circadian rhythm disturbances; and primary sleep disorders, such as SDB, RLS, and RBD (Ancoli-Israel, 2009). While medications are traditionally used to treat insomnia, recent studies have shown that behavioral treatments are more effective and, thus, recommended as the first-line treatment option. In some instances, a combined approach may provide for better

76

Sleep Disorders across the Life Span

outcomes (Neikrug and Ancoli-Israel, 2010). It is of utmost importance to make the correct medical and psychiatric diagnoses and treat these problems along with appropriate management of the underlying sleep disturbances in older adults (Ancoli-Israel, 2009).

Sleep-Disordered Breathing SDB is more common in older adults compared to younger adults. Adults 65–90 years of age had a threefold higher prevalence rate than middle-aged adults (Colten and Altevogt, 2006). The prevalence rates of SDB in the elderly were around 55–70% (Bloom et al., 2009; Crowley, 2011; Neikrug and Ancoli-Israel, 2010). Older adults with SDB may also report insomnia, nocturnal confusion, psychomotor function, and daytime cognitive impairment including difficulty with attention and short-term memory loss (Crowley, 2011; Launois et al., 2007). SDB has been associated with nocturia, arterial hypertension, heart failure, atrial fibrillation, diabetes, and stroke, conditions that are more common in the older population (Buchner et al., 2007). Depression has also been found as a common comorbidity in women with SDB (Shepertycky et al., 2005). Older adults are rarely considered candidates for surgery and CPAP is the best approach and first-line treatment for most elderly patients (Bloom et al., 2009; Neikrug and Ancoli-Israel, 2010).

RLS/PLMS PLMS and RLS are both common in the older adult. The prevalence of RLS/PLMS increases significantly with age, which is experienced by up to 15–34% over the age of 60 years (American Academy of Sleep Medicine, 2005; Cuellar et al., 2007; Neikrug and Ancoli-Israel, 2010). Increasing prevalence of RLS with age may also occur in association with the increasing presence of secondary causes in the aging population, such as age-related declines in dopamine receptors, iron deficiency, and renal failure (Bloom et al., 2009; Crowley, 2011). At the spinal level, lumbosacral narrowing has been reported in some older adults with RLS/PLMS, which is consistent with other data suggesting proprioceptive feedback of limb position is important in the initiation and termination of episodes (Crowley, 2011). Other systemic factors have been proposed, including venous insufficiency in the lower limbs, increased parasympathetic nervous system activity, and iron-deficiency anemia. The recommended treatments for RLS/PLMS in elderly is similar with adults as mentioned before in this article.

REM Sleep-Behavior Disorder RBD is an important REM sleep parasomnia commonly seen in elderly individuals, which is characterized by abnormal behaviors emerging and intermittent loss of muscle hypotonia or atonia during REM sleep that cause injury or sleep disruption (American Academy of Sleep Medicine, 2005; Chokroverty, 2010). RBD is a male-predominant disorder

that emerges after the age of 50 years (American Academy of Sleep Medicine, 2005). The prevalence in the elderly population has been reported around 0.5% (American Academy of Sleep Medicine, 2005). It is seen with increasing prevalence in patients with neurological or neurodegenerative disorder, particularly Parkinson’s disease, multiple system atrophy, dementia with Lewy body, narcolepsy, and stroke. PSG demonstrates intermittent loss of REM sleep-associated muscle atonia, with the patient manifesting complex, often violent motor activity associated with dream mentation (Bloom et al., 2009; Chokroverty, 2010). Treatment of RBD involves pharmacologic treatment (e.g., clonazepam and levodopa) and interventions that address environmental safety (Bloom et al., 2009).

Circadian Rhythm Sleep Disorders In the older adult, factors associated with aging are thought to contribute to the desynchronization of rhythms. The circadian pacemaker itself degenerates with age, which results in less robust rhythms (Reid et al., 2004). With age there is also a gradual decrease in rhythm amplitude, which likely contributes to less consistent periods of sleep–wake across the 24-h day (Reid et al., 2004). The endogenous secretion of melatonin at night is also reduced with age, which results in a weaker circadian rhythm. Therefore, the combination of age-related changes in sleep and circadian rhythm regulation paired with decreased levels of light exposure and activity contribute to the development of circadian rhythm-based sleep disorders in older adults (Bloom et al., 2009). The most common clinical consequence of changes in circadian network of old adults is the advanced sleep phase disorder (ASPD). In middle- to older aged adults, the prevalence of ASPD is estimated at 1–7% (Ando et al., 2002; Bloom et al., 2009). This advanced phase results in sleep and wake times that are several hours earlier than conventional and desired times (American Academy of Sleep Medicine, 2005). Older adults, therefore, feel sleepy in the early evening and awaken in the very early morning hours. Sleep during these times is often normal, but out of sync with the environment. A combination of good sleep hygiene practices and methods to delay the timing of sleep and wake times is usually recommended for the treatment of ASPD (Bloom et al., 2009).

Summary Although sleep disorders medicine is a relatively young discipline, the understanding of it is evolving at a rapid rate (Roehrs and Roth, 2004). This evolution is seen in the development of diagnostic systems, pathophysiology understanding, signs and symptoms, and finally in the treatment of sleep disorders and comorbid conditions. Treatment of sleep disorders can result in fewer complications of chronic illnesses, increased quality of life, and lower health care costs. It is important for all practicing physicians to understand the implications of disrupted sleep in different age groups and be able to assess accurately and intervene to improve health outcomes and quality through the life span of human beings.

Sleep Disorders across the Life Span

See also: Occupational Health; Sleep Disorders: Psychiatric Aspects; Sleep and Memory; Sleep: Neural Systems.

Bibliography American Academy of Sleep Medicine, 2005. International classification of sleep disorders. In: Diagnostic and Coding Manual, second ed. Westchester, Illinois. Ancoli-Israel, S., 2009. Sleep and its disorders in aging populations. Sleep Medicine 10, S7–S11. Ando, K., Kripke, D.F., Ancoli-Israel, S., 2002. Delayed and advanced sleep phase symptoms. The Israel Journal of Psychiatry and Related Sciences 39, 11–18. Anstead, M.I., 2000. Pediatric sleep disorders: new developments and evolving understanding. Current Opinion in Pulmonary Medicine 6, 501–506. Bloom, H.G., Ahmed, I., Alessi, C.A., AncoliIsrael, S., Buysse, D.J., Kryger, M.H., et al., 2009. Evidence-based recommendations for the assessment and management of sleep disorders in older persons. Journal of American Geriatrics Society 57 (5), 761–789. Buchner, N.J., Sanner, B.M., Borgel, J., et al., 2007. Continuous positive airway pressure treatment of mild to moderate obstructive sleep apnea reduces cardiovascular risk. American Journal of Respiratory and Critical Care Medicine 176, 1274–1280. Butler, R.J., Holland, P., Gasson, S., et al., 2007. Exploring potential mechanisms in alarm treatment for primary nocturnal enuresis. Scandinavian Journal of Urology 41, 407–413. Carno, M.A., Hoffman, L.A., Carcillo, J.A., Sanders, M.H., 2003. Developmental stages of sleep from birth to adolescence, common childhood sleep disorders: overview and nursing implications. Journal of Pediatric Nursing 18 (4), 274–283. Chervin, R.D., Archbold, K.H., Dillon, J.E., et al., 2002. Associations between symptoms of inattention, hyper-activity, restless legs, and periodic leg movements. Sleep 25, 213–218. Chokroverty, S., 2010. Overview of sleep and sleep disorders. The Indian Journal of Medical Research 131 (2), 126–140. Colten, H.R., Altevogt, B.M., 2006. Sleep Disorders and Sleep Deprivation, first ed. National Academies Press, Washington. Corbo, G., Forastiere, F., Agabiti, N., et al., 2001. Snoring in 9- to 15-year-old children: risk factors and clinical relevance. Pediatrics 108 (5), 1149–1154. Cortese, S., Konofal, E., Lecendreux, M., et al., 2005. Restless legs syndrome and attention-deficit/hyperactivity disorder: a review of the literature. Sleep 28, 1007–1013. Crowley, K., 2011. Sleep and sleep disorders in older adults. Neuropsychology Review 21, 41–53. Crowley, S.J., Acebo, C., Carskadon, M.A., et al., 2007. Sleep, circadian rhythms, and delayed phase in adolescence. Sleep Medicine 8, 602–612. Cuellar, N.G., Rogers, A.E., Hisghman, V., Volpe, S.L., 2007. Assessment and treatment of sleep disorders in the older adult. Geriatric Nursing 28 (4), 254–264. D’Cruz, O., Vaughn, B., 2001. Parasomniasdan update. Seminars in Pediatric Neurology 8, 251–257. Dyken, M.E., Rodnitzky, R., 1992. Periodic, aperiodic and rhythmic disorders of sleep. Neurology 42 (Suppl. 6), 68–74. Faruqui, F., Khubchandani, J., Price, J.H., Bolyard, D., Reddy, R., 2011. Sleep disorders in children: a national assessment of primary care pediatrician practices and perceptions. Pediatrics 128 (3), 539–546. Ferrara, P., Marrone, G., Emmanuele, V., et al., 2008. Homotoxicological remedies versus desmopressin versus placebo in the treatment of enuresis: a randomised, double-blind, controlled trial (see comment). Pediatric Nephrology 23, 269–274. Foley, D., Ancoli-Israel, S., Britz, P., Walsh, J., 2004. Sleep disturbances and chronic disease in older adults: results of the 2003 National Sleep Foundation Sleep in America Survey. Journal of Psychosomatic Research 56, 497–502. Fricke-Oerkerman, L., Pluck, J., Schred, L.M., et al., 2007. Prevalence and course of sleep problems in childhood. Sleep 30 (10), 1371–1377. Gozal, D., Pope Jr., D.W., 2001. Snoring during early childhood and academic performance at ages thirteen to fourteen years. Pediatrics 107 (6), 1394–1399. Guilleminault, C., Palombini, L., Pelayo, R., et al., 2003. Sleepwalking and sleep terrors in prepubertal children: what triggers them? Pediatrics 111, e17–e25. Hoban, T.F., 2003. Rhythmic movement disorder in children. CNS Spectrums 8, 135–138. Hoban, T.F., 2010. Sleep disorders in children. Annals of the New York Academy of Sciences 1184, 1–14.

77

Howard, B., Wong, J., 2001. Sleep disorders. Pediatrics in Review 22, 327–341. Hublin, C., Kaprio, J., Partinen, M., Koskenvu, M., 2001. Parasomnias: co-occurrence and genetics. Psychiatric Genetics 11, 65–70. Ipsiroglu, D.S., Fatemi, A., Werner, I., et al., 2002. Self-reported organic and nonorganic sleep problems in school children aged 11 to 15 years in Vienna. Journal of Adolescent Health 31 (5), 436–442. Kotagal, S., 1996. Narcolepsy in children. Seminars in Pediatric Neurology 3, 36–43. Kryger, M.H., Roth, T., Dement, W.C., 2005. Principles and Practice of Sleep Medicine, fourth ed. Elsevier/Saunders, Philadelphia. Laberge, L., Tremblay, R.E., Vitaro, F., Montplaisir, J., 2000. Development of parasomnias from childhood to early adolescence. Pediatrics 106, 67–74. Launois, S.H., Pepin, J.L., Levy, P., 2007. OSA in the elderly: a specific entity? Sleep Medicine Reviews 11, 83–85. Lecendreux, M., Bassetti, C., Dauvilliers, Y., et al., 2003. HLA and genetic susceptibility to sleepwalking. Molecular Psychiatry 8, 14–117. Lee-Chiong, T.L., 2004. Sleep and sleep disorders: an overview. Medical Clinics of North America 88, 11–14. Lottmann, H.B., Alova, I., 2007. Primary monosymptomatic nocturnal enuresis in children and adolescents. International Journal of Clinical Practice. Supplement 155, 8–16. Marcus, C.L., 2001. Sleep-disordered breathing in children. American Journal of Respiratory and Critical Care Medicine 164, 16–30. Meijer, A.M., Habekothe, H.T., Van Den Wittenboer, G.L., 2000. Time in bed, quality of sleep and school functioning of children. Journal of Sleep Research 9 (2), 145–153. Michaud, M., Chabli, A., Lavigne, G., Montplaisir, J., 2000. Arm restlessness in patients with restless legs syndrome. Movement Disorders 15 (2), 289–293. Muhle, H., Neumann, A., Lohmann-Hedrich, K., et al., 2008. Childhood-onset restless legs syndrome: clinical and genetic features of 22 families. Movement Disorders 23, 1113–1121. Neikrug, A.B., Ancoli-Israel, S., 2010. Sleep disorders in the older adult – a mini review. Gerontology 56, 181–189. Neveus, T., Tullus, K., Neveus, T., Tullus, K., 2008. Tolterodine and imipramine in refractory enuresis; a placebo-controlled crossover study. Pediatric Nephrology 23, 263–267. O’Donnell, A.R., Bjornson, C.L., Bohn, S.G., Kirk, V.G., 2006. Compliance rates in children using noninvasive continuous positive airway pressure. Sleep 29, 651–658. Oner, P., Dirik, E.B., Taner, Y., et al., 2007. Association between low serum ferritin and restless legs syndrome in patients with attention deficit hyperactivity disorder. Tohoku Journal of Experimental Medicine 213, 269–276. Owens, J.A., Spirito, A., McGuinn, M., Nobile, C., 2000. Sleep habits and sleep disturbance in elementary school-aged children. Journal of Developmental and Behavioral Pediatrics 21, 27–36. Paudel, M.L., Taylor, B.C., Diem, S.J., Stone, K.L., Ancoli-Israel, S., Redline, S., et al., 2008. Association between depressive symptoms and sleep disturbances in community-dwelling older men. Journal of the American Geriatrics Society 56 (7), 1228–1235. Picchietti, D., Allen, R.P., Walters, A.S., et al., 2007. Restless legs syndrome: prevalence and impact in children and adolescents–the Peds REST study. Pediatrics 120, 253–266. Picchietti, M.A., Picchietti, D.L., Picchietti, M.A., 2008. Restless legs syndrome and periodic limb movement disorder in children and adolescents. Seminars in Pediatric Neurology 15, 91–99. Rajaram, S.S., Walters, A.S., England, S.J., et al., 2004. Some children with growing pains may actually have restless legs syndrome. Sleep 27, 767–773. Ram, S., Seirawan, H., Kumar, S.K.S., Clark, G.T., 2010. Prevalence and impact of sleep disorders and sleep habits in the United States. Sleep Breath 14, 63–70. Reid, K.J., Chang, A.M., Zee, P.C., 2004. Circadian rhythm sleep disorders. Medical Clinics of North America 88, 631–651. Remulla, A., Guilleminault, C., Remulla, A., Guilleminault, C., 2004. Somnambulism (sleepwalking). Expert Opinion on Pharmacotherapy 5, 2069–2074. Roehrs, T., Roth, T., 2004. Sleep disorders: an overview. Clinical Cornerstone 6 (Suppl. 1C), 6–16. Roth, T., Zammit, G., Kushida, C., Doghramji, K., Mathias, S.D., Wong, J.M., et al., 2002. A new questionnaire to detect sleep disorders. Sleep Medicine 3, 99–108. Schechter, M., 2002. Technical report: diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics 109, 1–20. Shepertycky, M.R., Banno, K., Kryger, M.H., 2005. Differences between men and women in the clinical presentation of patients diagnosed with obstructive sleep apnea syndrome. Sleep 28, 309–314.

78

Sleep Disorders across the Life Span

Smedje, H., Broman, J.E., Hetta, J., et al., 1999. Parents’ reports of disturbed sleep in 5–7-year-old Swedish children. Acta Paediatrica 88, 858–865. Tarasiu, K.A., Greenberg-Dotan, S., Simon-Tuva, T., et al., 2007. Elevated morbidity and health care use in children with obstructive sleep apnea syndrome. American Journal of Respiratory and Critical Care Medicine 175 (1), 55–61. Taylor, D.J., Mallory, L.J., Lichstein, K.L., et al., 2007. Comorbidity of chronic insomnia with medical problems. Sleep 30, 213–218.

Walters, A.S., Mandelbaum, D.E., Lewin, D.S., et al., 2000. Dopaminergic therapy in children with restless legs/periodic limb movements in sleep and ADHD. Dopaminergic Therapy Study Group. Pediatric Neurology 22, 182–186. Watanabe, T., Kajimura, N., Kato, M., Sekimoto, M., Nakajima, T., Hori, T., et al., 2003. Sleep and circadian rhythm disturbances in patients with delayed sleep phase syndrome. Sleep 26 (6), 657–661. Wiggs, L.D., 2003. Paediatric sleep disorders: the need for multidiscipline. The need for multidisciplinary sleep clinics. International Congress Series 1254, 185–190.