Sleep disturbances in aging

Advances in Cell Aging and Gerontology

Sleep disturbances in aging Marci M. Loisellea, Melanie K. Meansa,b and Jack D. Edingera,b,* a

Duke University Medical Center, Durham, NC, USA Department of Veterans Affairs Medical Center, Durham, NC, USA *Correspondence address: J. D. Edinger, VA Medical Center, 508 Fulton Street, Durham, NC 27705, USA. Tel: þ 1-919-286-0411; fax: þ 1-919-416-5832. E-mail address: [email protected] b

Contents 1. Introduction 2. Normal sleep and the effects of the aging process 2.1. Age-related sleep and circadian changes 2.2. Gender differences in sleep and aging 2.3. Nocturia 3. Epidemiology 3.1. Prevalence 3.2. Risk factors 3.3. Morbidity 3.4. Mortality 4. Common sleep disorders in older age groups: nature and etiology 4.1. Sleep-disordered breathing (SDB) 4.2. Primary insomnia 4.3. Circadian rhythm disorders 4.4. Sleep-related movement disorders 4.5. Secondary sleep disturbances 5. Assessment and diagnosis of sleep problems in older adults 5.1. Clinical interview 5.2. Psychological assessment 5.3. Sleep logs 5.4. Actigraphy 5.5. Polysomnography (PSG) 5.6. Multiple sleep latency test (MSLT) 6. Treatment of sleep disturbances in older adults 6.1. Sleep-disordered breathing 6.2. Positive pressure devices 6.3. Primary insomnia 6.4. Secondary insomnia

Advances in Cell Aging and Gerontology, vol. 17, 33–60 ß Published by Elsevier B.V. DOI: 10.1016/S1566-3124(05)17002-3

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6.5. Circadian rhythm disorders 6.6. Sleep-related movement disorders 6.7. Sleep in institutionalized older adults 7. Summary

1. Introduction For a variety of reasons, aging is accompanied by an increasing susceptibility to sleep disturbances. Normal age-related changes in the human sleep system increase the propensity for developing sleep problems in late life. With advancing age comes increased risks of medical illnesses, psychiatric problems, and polypharmacy, all of which may adversely impact sleep. Multiple life changes including retirement from long-term employment, chronic medical illness, loss of a loved one, and reduced social contacts may dramatically alter the rest-activity cycle of the older individual. This chapter begins with a discussion of age-related sleep changes. Subsequently, epidemiology of sleep disturbances in older adults is presented, followed by a review of sleep disorders commonly found in this age group. Finally, assessment, diagnosis, and treatment of sleep disorders are reviewed, with a focus on issues relevant to older adults. 2. Normal sleep and the effects of the aging process Human sleep patterns reflect characteristic changes in brain wave activity that can be quantified via electroencephalography (EEG) and categorized into two distinct brain states: non-rapid eye movement (NREM) sleep and rapid eye movement (REM) sleep. The NREM sleep consists of stages 1, 2, 3, and 4, reflecting a continuum of lighter to deeper sleep. Stage 1 is a transitional period of light sleep that occurs when falling asleep. Stage 2 comprises the largest portion of sleep throughout the night. Together, stages 3 and 4 represent ‘‘deep sleep,’’ during which slow wave EEG activity dominates. The REM sleep is distinguished by vivid dream activity, rapid eye movements, muscle atonia, and an EEG pattern that resembles wakefulness. Adults typically cycle through deepening stages of NREM sleep followed by an episode of REM sleep every 90–120 min throughout the night. Greater amounts of deep sleep (stages 3 and 4) occur in the first half of the night, with increased REM sleep in the latter half. Although the exact functions of sleep are unknown, sufficient amounts of both NREM and REM sleep are necessary for full restorative benefit (Morin, 1993). 2.1. Age-related sleep and circadian changes Aging is associated with reliable changes in sleep/wake architecture that are believed to reflect neuronal degeneration in brain mechanisms responsible for sleep

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% of sleep period

100% 80%

Wake

60%

Stage 1 40%

REM Stage 2

20% 0% 16-19

Stages 3 & 4 20-29

30-39

40-49

50-59

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70-79

Age

Fig. 1. Objective sleep changes with aging. Data reported in Williams et al. (1974).

physiology (Prinz et al., 1990). As depicted in Fig. 1, older adults have increased light sleep (stages 1 and 2) and corresponding reductions in deep sleep (Williams et al., 1974). Compared to younger adults, older adults take longer to fall asleep and spend more time awake during the night; their sleep is characterized by frequent arousals and stage shifts reflecting sleep fragmentation (Morgan, 2000; Floyd, 2002). Although they spend longer periods of time in bed, they experience less overall sleep time. In addition, age-related changes in breathing and ventilatory responses may predispose older adults to sleep-disordered breathing (SDB) (Janssens et al., 2000). Older adults also experience changes in their endogenous circadian rhythms thought to be the result of deterioration of the suprachiasmatic nucleus in the hypothalamus (Bliwise, 2000b; Van Someren, 2000). These changes are characterized by a ‘‘flattening’’ of the circadian amplitude and a weakening of circadian entrainment (Monk, 1989). Consequently, older adults are more sensitive to disturbances in circadian timing and thus more susceptible to jet lag and shift work disorders (Monk, 1989; Morgan, 2000). Age-related circadian changes cause a forward shift in the sleep phase, associated with earlier bed and rising times. This advanced sleep phase in part may explain the complaint of early morning awakening common in this population. From the above discussion, it is clear that age-related sleep changes result in a deterioration of the nighttime sleep pattern. It is important to note, however, that the process of aging does not guarantee the development of a sleep problem. Most older adults experience the aforementioned age-related sleep and circadian changes, whereas not all older adults complain of sleep disturbance. Thus, it appears that sleep changes due to normal aging are predisposing but not sufficient for the development of sleep problems. 2.2. Gender differences in sleep and aging Men have greater difficulty maintaining sleep with more wake time during the night, more light sleep, and a higher incidence of primary sleep pathologies than do

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women (Gottlieb, 1990; Floyd, 2002). Despite these differences, women are more likely to report sleep problems and to use sleep medications (Bliwise, 2000b). Studies also suggest that circadian phase advances are greater in women than in men (Bliwise, 2000b). Furthermore, menopause affects sleep patterns via hormonal mechanisms and is commonly associated with complaints of insomnia, sleep disruption, and fatigue (Moe, 1999). 2.3. Nocturia Nocturia, the need to urinate multiple times during the night with a consequent disruption of sleep, increases significantly with age and is very common in older adults. By age 60, over half of all individuals experience nocturia, and this problem increases to at least 80% of 80-year-olds (Donahue and Lowenthal, 1997; Jennum, 2002). Causes of nocturia include excessive nighttime urine production, reduced bladder capacity, prostate problems, or other underlying medical conditions (Jennum, 2002). In some cases, nocturia may be a result of untreated SDB (Bliwise, 2000b; Russo-Magno et al., 2001). Whatever its etiology, nocturia is a common cause of sleep maintenance complaints in older adults (Bliwise, 2000b). 3. Epidemiology 3.1. Prevalence Complaints about sleep disturbances and associated waking symptoms are relatively prevalent in society at large and are particularly common among older adults. More than half of community-dwelling adults over the age of 65 report chronic sleep difficulties (Prinz et al., 1990; Foley et al., 1995). Close to 50% of this age group report insomnia symptoms such as difficulty initiating sleep, difficulty sustaining sleep, waking too early in the morning, or feeling unrefreshed upon awakening (Ganguli et al., 1996; Babar et al., 2000; Ohayon et al., 2001; Ohayon and Vecchierini, 2002). Moreover, roughly 5% of the older adult population experience the onset of such sleep symptoms each year, and once present, such symptoms tend to persist over time (Ganguli et al., 1996; Foley et al., 1999). In addition, complaints of excessive daytime fatigue and sleepiness resulting from nocturnal sleep disturbances are also relatively common in aged populations. In fact, between 8 and 25% of all adults 65 and older complain of daytime sleepiness that disrupts normal diurnal functioning (Ganguli et al., 1996; Hays et al., 1996; Foley et al., 2001). Given these nocturnal and diurnal complaints, it is not surprising that various common sleep disorders are especially prevalent in older age groups. For example, a greater proportion of middle-aged and elderly adults meet formal criteria for an insomnia diagnosis than do younger age groups (Ohayon and Vecchierini, 2002). Likewise, sleep apnea, characterized by SDB and associated daytime sleepiness, is present in as many as 24% of community-dwelling, 33% of acutely hospitalized, and 42% institutionalized individuals over 65 years of age (Ancoli-Israel, 1989;

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Ancoli-Israel et al., 1991b). Restless legs syndrome and periodic limb movements are common sleep-related movement disorders that respectively occur in 28% (Clark, 2001) and 45% (Ancoli-Israel et al., 1991a) of the aged population. Finally, disorders involving unusual sleep-related events such as dangerous dream enactments or motor paralysis upon awakening also show relative propensities to occur in older adults (Wing et al., 1999; Mahowald and Schenck, 2000). 3.2. Risk factors Since subjective sleep/wake complaints and various sleep disorders are relatively prevalent among older adults, it is tempting to conclude that age operates as an independent risk factor for sleep/wake pathology. However, aging itself is often accompanied by marked changes in vocational status, social activity, health, and lifestyle in general (Bliwise, 2000b; Krystal et al., in press). Each of these agerelated factors may have a powerful influence on sleep/wake functioning independent of the aging process alone. As such, age, per se, may not represent a specific risk factor for either sleep complaints or specific sleep disorders. Rather, age may only serve as a proxy for other factors that more directly enhance risk for such conditions. Clearly, complaints of insomnia and daytime somnolence are strongly influenced by various age-related risk factors. Declining health status often accompanies aging and appears to operate as an independent risk factor for sleep/wake dysfunction. Indeed, a variety of studies have shown that perceptions of poor health as well as medical conditions such as angina, respiratory disorders, arthritis, chronic pain, visual impairment, and nocturia all enhance risk for both nighttime sleep disturbance and daytime sleepiness in older age groups (Blazer et al., 1995; Foley et al., 1995; Newman et al., 1997; Maggi et al., 1998; Whitney et al., 1998; Roberts et al., 1999; Bliwise, 2000b; Zizi et al., 2002; Byles et al., 2003). Additionally, various studies have shown that the presence of psychiatric disorders and depression in particular enhance risks for sleep/wake complaints in aged samples (Blazer et al., 1995; Morgan and Clarke, 1997; Newman et al., 1997; Schechtman et al., 1997; Maggi et al., 1998; Whitney et al., 1998; Roberts et al., 1999; Byles et al., 2003). Furthermore, somatic and mental disorders seemingly account for a substantial proportion of the increased sleep/wake dysfunction among older adults as compared to younger age groups. In fact, when community-dwelling older adults are thoroughly screened to exclude those with sleep-disruptive medical and psychiatric conditions, fewer than 4% report significant sleep-related difficulties (Vitiello et al., 2002). However, even healthy older adults may be subject to certain age-related risk factors that enhance their chances of suffering sleep/wake difficulties. In particular, psychosocial and behavioral changes that accompany aging may have significant effects on sleep/wake functioning. Death of a spouse leading to extended bereavement has been noted as a common cause of sleep difficulty in older populations (Hall et al., 1997). Many older adults face a reduction in their social and physical activities after retiring from long-term employment. Such individuals

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often incur disturbance as a result of their limited physical and social activity (Ohayon et al., 2001). Furthermore, the loss of a daily schedule accompanying retirement often results in excessive free time for older adults. Those who attempt to fill some of this time by spending excessive time in bed or taking daytime naps often develop sleep difficulties as a result of these poor sleep hygiene practices (Ohayon et al., 1996). 3.3. Morbidity Considerable morbidity accompanies the sleep/wake disturbances in older adults. Within this population, those who suffer from persistent insomnia typically report reduced physical functioning, reduced energy for activities, and a global reduction in their quality of life in general (Schubert et al., 2002). Perhaps as a result of such changes, those older adults with insomnia have a greater risk for depression than do their counterparts without sleep/wake complaints (Roberts et al., 1999). Nocturnal sleep difficulties also represent a safety concern for older adults in that those with insomnia are at increased risk for falls and hip fracture both as a function of the sleep disturbance alone as well as due to sedating medications they take to remedy these difficulties (Brassington et al., 2000; Byles et al., 2003; Cumming and Le Couteur, 2003). In addition, nocturnal sleep difficulties have been linked to the subsequent cognitive decline of older adults (Cricco et al., 2001; Jelicic et al., 2002). In turn, sleep difficulties among demented community-dwelling older adults rank high among the leading reasons for their nursing home placement (Pollak et al., 1990). Like insomnia, daytime sleepiness may contribute to considerable morbidity in older age groups. Complaints of daytime sleepiness have been linked to a reduction in productivity, vigilance, activity level, and general functional status in those aged 65 and older (Gooneratne et al., 2003). As is the case with insomnia, daytime sleepiness seemingly operates as an independent risk factor for cognitive decline in older adults (Foley et al., 2001; Ohayon and Vecchierini, 2002). Excessive daytime sleepiness has also been linked to increased risk for cardiovascular events such as myocardial infarction and congestive heart failure (Newman et al., 2000). However, it should be noted that excessive daytime sleepiness is a common symptom of SDB (Foley et al., 2003), a primary sleep disorder recognized as contributing to hypertension and cardiovascular disease in older adults (Nieto et al., 2000; Wang et al., 2002). Hence, the link between daytime sleepiness and cardiovascular disease seen in older age groups is likely mediated by occult SDB. 3.4. Mortality A very limited number of studies have examined the effects of insomnia and its treatment on risk for mortality among older adults. One study (Pollak et al., 1990) that statistically controlled for other risk factors showed ‘‘severe’’ insomnia among men was related to increased risk for mortality during a 3-year follow-up period. In a more recent study (Manabe et al., 2000), insomnia was found to be a significant

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risk factor for mortality among older, chronically institutionalized patients. By contrast, three similarly well-controlled studies (Morgan and Clarke, 1997; Althuis et al., 1998; Kripke et al., 2002) failed to demonstrate a significant relationship between the presence/absence or frequency of insomnia and subsequent mortality over 4 to 6-year follow-up periods. However, one (Morgan and Clarke, 1997) of these studies did find that mortality risk was significantly related to incident insomnia during the follow-up period. Another longitudinal study (Rumble and Morgan, 1992) showed that mortality risk over a 6-year follow-up period was significantly elevated in older adults who used medications other than traditional hypnotics to aid their sleep. Yet, given the inconsistent findings of these various studies, it remains questionable whether insomnia per se enhances mortality risk. A similar statement can be made about mortality risk associated with daytime sleepiness. Whereas several survey studies (Ganguli et al., 1996; Hays et al., 1996; Newman et al., 2000) of community-dwelling older adults in the U.S. showed a link between daytime sleepiness and mortality, a recent survey study (Rockwood et al., 2001) conducted in Canada failed to show that daytime sleepiness enhances mortality risk. However, when daytime sleepiness reflects underlying SDB, this symptom should be considered seriously, since sleep apnea syndromes do appear to enhance mortality risk among older age groups (Lavie et al., 1995; Ancoli-Israel et al., 2003b).

4. Common sleep disorders in older age groups: nature and etiology Sleep disturbances in older adults are often multifactorial in nature. Contributing factors may include age-related changes in sleep architecture, medical and psychiatric conditions, medication and substance use, primary sleep disorders, psychosocial factors, and poor sleep hygiene (Vitiello, 1997). Common primary sleep disturbances in this age group include SDB, insomnia, circadian rhythm disorders, and sleep-related movement disorders. Secondary sleep disturbances, which are the result of or aggravated by a medical disorder, psychiatric disorder, medication use, and/or substance use, are also commonly seen in older age groups.

4.1. Sleep-disordered breathing (SDB) Studies show that SDB (see Chapter 6) encompasses a variety of nocturnal breathing disorders that disrupt the sleep pattern and typically cause excessive daytime sleepiness. Sleep apnea is the most common form of SDB. It is characterized by episodes of nocturnal breathing cessation (apnea) occurring repeatedly and is associated with a reduction in oxygen level and brief arousals from sleep. Apnea can be the result of upper airway collapse (obstructive sleep apnea), complete cessation of respiratory effort due to a depressed central nervous system drive (central sleep apnea), or a combination of the two (mixed sleep apnea).

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This SDB’s increased prevalence in older adults is due to multiple factors. The incidence of SDB is higher in patients with neurological disorders, cardiac conditions, cerebrovascular disease, and severe metabolic disorders, all of which are more prevalent in older adults (Janssens et al., 2000). Snoring and obesity, both risk factors for SDB, increase in prevalence through age 70 (Bliwise, 2000b; Janssens et al., 2000). Although SDB is more common in men, postmenopausal women are at an increased risk compared to their premenopausal counterparts (Moe, 1999). 4.2. Primary insomnia Primary insomnia is a multifaceted disorder characterized by difficulty initiating or maintaining sleep, unwanted early morning awakenings, and/or unrefreshing sleep with associated daytime impairment. It may be precipitated by an identifiable event but persists when maladaptive habits and conditioned environmental cues perpetuate sleep disruption after the precipitating event is no longer present (Morin and Edinger, 2003). A comprehensive model of the development and maintenance of insomnia is helpful in understanding the etiology of this problem (Spielman and Glovinsky, 1997). According to this model, predisposing factors increase the likelihood of insomnia developing, but are not sufficient in and of themselves to trigger the insomnia. For example, individuals who have an innate propensity toward physiological or cognitive arousal or feelings of anxiety or depression may have a lower threshold for the development of insomnia. However, insomnia typically develops after precipitating factor(s) temporally and proximally cause an acute sleep disturbance. Insomnia may be precipitated by a variety of events, conditions, or circumstances, such as stress, environmental factors (e.g., nocturnal light or noise, sleeping away from home), changes to the sleep/wake cycle (e.g., shiftwork, jet lag), medical or psychiatric illnesses, or ingestion of sleep-disrupting substances (e.g., caffeine, stimulants, alcohol). As precipitating factors resolve (either fully or partially), insomnia assumes a chronic status with perpetuating factors maintaining sleep disruption. These factors include behavioral and conditioning factors such as poor sleep habits and are found to be as relevant in older adults as they are for their younger counterparts (Bliwise, 1993). 4.3. Circadian rhythm disorders Individuals with circadian rhythm disturbances experience a disparity between their endogenous sleep/wake systems and the sleep/wake schedules they desire or are required to follow (Morin and Edinger, 2003). Examples of circadian rhythm disturbances include those resulting from frequent changes in schedules and alterations of daily routines, such as from jet lag or shift work. Circadian rhythm disturbances also affect individuals who demonstrate a persistent advance or delay in the endogenous rhythm relative to the desired sleep schedule as well as individuals who obtain their daily sleep complement by means of multiple nap periods throughout the 24-h day. Individuals presenting with circadian rhythm

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disturbances may complain that their sleep does not occur at a desirable time for them or that their sleep is disrupted. They may also complain of insomnia, excessive sleepiness, and general daytime dysfunction (Myers and Badia, 1995). Given age-associated biologic, environmental, and psychosocial changes, older adults are particularly vulnerable to advanced sleep phase syndrome, jet leg, and irregular sleep/wake schedule disorders. Available data suggest that older adults’ sleep/wake schedules are phase advanced approximately 90 mins (Neylan et al., 1996). This phase advance causes older adults to become sleepy much earlier (e.g., between 6:00 and 9:00 p.m.) and to waken much earlier (e.g., between 2:00 and 5:00 a.m.) than desired or required. In addition, older adults are relatively intolerant of shifts in their sleep/wake schedules as might occur during a trip across several time zones (Bliwise, 1993; Neylan et al., 1996). Finally, an irregular sleep/wake schedule, characterized by random sleep throughout the 24-h day in place of a single consolidated overnight sleep period, can emerge due to an absence of daytime structure.

4.4. Sleep-related movement disorders 4.4.1. Restless legs syndrome (RLS) The RLS is characterized by unpleasant sensations, typically in the lower limbs, leading to an almost irresistible urge to move (Feinsilver, 2003). Movement tends to momentarily relieve the sensations, but difficulty with sleep initiation is often present. There is an increased incidence of RLS in older adults due to the higher prevalence of medical disorders and medication use that can aggravate or cause the condition. Medical conditions that are associated with RLS include anemia, renal failure, and diabetic peripheral neuropathy (Milligan and Chesson, 2002). Medications and substances that exacerbate RLS include antidepressants, caffeine, diuretics, antihistamines, and bronchodilators (Bliwise, 1993; Chokroverty, 1994a; Neubauer, 1999).

4.4.2. Periodic limb movement disorder (PLMD) Most individuals with RLS (85%) also suffer from periodic limb movement disorder (Milligan and Chesson, 2002). The PLMD is characterized by periodic and stereotypic leg movements during sleep approximately every 20–40 s (Ancoli-Israel, 1997; White and Mitler, 1997). These repetitive leg movements are often associated with arousals from sleep. Individuals often are unaware of these repetitive twitches during sleep, but they may complain of excessive daytime sleepiness or unrefreshing sleep. The higher incidence of PLMDs in older adults appears to be related to metabolic, vascular, and neurological factors (Prinz et al., 1990). Proposed causal factors for PLMD include venous insufficiency in the lower limbs, cycles in arterial blood pressure, deficits in central dopaminergic transmission, and osteoarthritic changes (Bliwise, 1993, 2000b; Chokroverty, 1994b).

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4.4.3. REM behavior disorder (RBD) The RBD is characterized by restoration of muscle tone and elaborate activity during REM sleep (e.g., kicking, punching, jumping out of bed, talking) representing dream enactment (Espie, 2000). Sleep disruption is often less of a concern than injury to self or bed partners during these nocturnal events (Mahowald and Schenck, 2000). Arousals from these episodes are usually rapid with full dream recall and no resulting confusion (Mahowald and Schenck, 2000). Acute forms of RBD are associated with alcohol intoxication/withdrawal, excessive caffeine intake, or use of tricyclic antidepressants and monoamine oxidase inhibitors. Chronic and late onset RBD are associated with organic brain factors and may herald the onset of Parkinson’s disease (Mahowald and Schenck, 2000). Chronic RBD is much more prevalent in males, suggesting that hormonal influences may be a contributing factor to this disorder (Mahowald and Schenck, 2000). 4.5. Secondary sleep disturbances 4.5.1. Sleep disturbance secondary to medical disorders Many age-dependent medical conditions have the capacity to impair sleep, such as nocturia, gastrointestinal disturbance, chronic pain, menopause, cerebrovascular disease, diabetes, pulmonary disease, rheumatoid arthritis, renal disorders, and osterarthritis (Bliwise, 1993). Sleep disturbances can arise from the physiological mechanisms of the disease itself, from symptoms associated with the disease, from treatment of the medical disorder, and/or the resulting psychological stress produced (Lichstein, 2000). In addition, the sleep disturbance itself can have a negative impact on the course of the medical illness (Chokroverty, 1994a). Most patients with sleep disturbances secondary to a medical condition present with insomnia but may have a mixture of insomnia and hypersomnia (Chokroverty, 1994a). 4.5.2. Sleep disturbance secondary to medications and/or substance use Individuals with substance-induced or medication-induced sleep disorders present with complaints of insomnia, hypersomnia, parasomnias, or a mixture of these symptoms (Morin and Edinger, 2003). Common substances that impair sleep include alcohol, caffeine, and nicotine. Although the use and abuse of alcohol declines with age, alcohol is frequently used by older adults to address their sleep problems (Prinz et al., 1990; Espie, 2000). This self-medication is problematic since alcohol can increase the severity of SDB, cause fragmented sleep, and lead to sleep disruption when discontinued (Chokroverty, 1994b). In addition to alcohol, older adults may use stimulants such as caffeine or nicotine that increase sleep onset latency, interfere with sleep maintenance, and increase sleep fragmentation (Ancoli-Israel, 1997). Polypharmacy is especially prevalent in older adults. The number of medications ingested is positively related to the severity of reported sleep disturbances in older adults (Bliwise, 1997; Bliwise and Breus, 2000). Sleep disruption may be due to direct effects on sleep architecture or to side effects of the medications

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(Bliwise and Breus, 2000). A higher risk of sleep disturbance is not only due to the increased utilization of prescription medication in this population, but also to reduced drug metabolism, absorption, distribution, and elimination rates in older adults (Lichstein, 2000). The main classes of prescription drugs that can cause sleep disruption are antidepressants (particularly SSRIs), decongestants, antihypertensives, bronchodilators, diuretics, beta-blockers, and corticosteroids (Neubauer, 1999; Lichstein, 2000). Additionally, sedative-hypnotic use is especially prevalent in older adults and, as discussed later, is associated with a number of adverse side effects. 4.5.3. Sleep disturbance secondary to psychiatric disorders Common psychiatric disorders in older adults that affect sleep include adjustment disorders, depression, bereavement, anxiety, dementia, and delirium (Bliwise, 2000b). Adjustment disorders can be caused by retirement, institutionalization, relocation, financial strain, health concerns, and holocaust trauma (Bliwise, 2000b). Bereavement and depression usually involve some form of sleep disturbance, and sleep disturbance is a major risk factor for the subsequent development of depression (Reynolds, 1996). Changes in sleep architecture caused by depression include reduced total sleep time, sleep efficiency, and slow-wave sleep and increased awakenings and REM density (Wooten, 1994). Additionally, anxiety disorders can increase sleep latency and lead to insomnia complaints. Psychosocial factors, such as social isolation, boredom, and inactivity, can negatively impact sleep as well. Dementia and delirium increase in prevalence in older age groups. Although Parkinson’s disease, Huntington’s disease, and vascular dementia are all common causes of dementia in old age, 70% of dementias result from Alzheimer’s disease (Bliwise, 1993). Sleep in Alzheimer’s dementia shows a progressive deterioration in sleep architecture and circadian rhythm as the disease progresses (Reynolds, 1996). Sleep is marked by increased frequency and duration of awakenings, decreased slow-wave sleep, randomly-distributed sleep over a 24-h period, and increased daytime napping (Prinz et al., 1990; Wauquier, 1993). ‘‘Sundowning,’’ frequently seen in the middle to late stages of dementing disorders, reflects the onset or exacerbation of delirium during the night. It involves behaviors such as reduced responsiveness to external stimuli, agitation and restlessness, disruptiveness, emotional and perceptual disturbances, and disorganized thinking and speech (Prinz et al., 1990; Neylan et al., 1996). 5. Assessment and diagnosis of sleep problems in older adults Because many factors can contribute to sleep disturbances in older adults, a thorough assessment of a sleep complaint addresses environmental, behavioral, medical, psychological, and pharmacological factors (Morin and Edinger, 2003). In addition to a comprehensive clinical interview, assessment procedures may involve a physical examination, a psychological evaluation, patient self-monitoring, and/or sleep laboratory testing to assist in diagnostic clarification.

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5.1. Clinical interview The initial assessment interview should elicit information about the duration, course, severity, and frequency of the sleep problem. It is also important to ascertain an understanding of contributing and alleviating factors, daytime consequences/ impairment, and responses to previous treatment. Assessment of poor sleep habits, disruptive environmental influences on sleep, sleep schedules, beliefs about sleep, and family history of sleep disturbance should routinely be assessed (Reynolds, 1996; White and Mitler, 1997). Inquiry about life events, medical illness, psychiatric disturbance, and medication or substance use that coincided with the onset of the sleep difficulty can assist in determining etiological factors. Because individuals are often unaware of sleep behaviors such as snoring, breathing cessation, or nocturnal movements, interviewing the bed partner can contribute greatly to diagnostic decision-making. Medical history should include a review of systems most commonly associated with sleep difficulties, such as rheumatologic (e.g., arthritis, fibromyalgia) pulmonary (e.g., asthma, COPD), cardiac (e.g., heart disease), gastrointestinal (e.g., reflux, peptic ulcer disease), neurological (e.g., seizure disorder), endocrine (e.g., hyperthyroidism), and chronic pain disorders. Results of a medical history and exam may uncover the need for laboratory testing (e.g., thyroid function, ferritin levels in suspected sleep movement disorders). As mentioned previously, numerous medications and substances cause or exacerbate sleep complaints. Current medication usage and use of illicit substances also should be evaluated. Additionally, some individuals may resort to self-help remedies (e.g., melatonin, alcohol, antihistamines) to promote sleep. Finally, inquiry regarding psychiatric symptoms and history can help determine the influence of psychological factors on the sleep complaint and the need for further psychological assessment (discussed next). 5.2. Psychological assessment Because of the elevated prevalence of anxiety and depression among older adults and the association between psychopathological symptoms and sleep disturbance, assessment of psychological functioning is important in assessing sleep complaints. Brief psychological screening measures such as the Beck Depression Inventory (Beck et al., 1979) and the State-Trait Anxiety Inventories (Spielberger, 1983) are easily administered and may provide important supplemental information not apparent from the clinical interview. A mental status exam also can be easily administered and may be useful to screen for deficits in cognitive functioning. In some cases, a more thorough psychological assessment with instruments such as the Minnesota Multiphasic Personality Inventory-2 (MMPI-2) may be warranted. The MMPI-2 is an extensive psychological questionnaire that produces personality profiles for a wide range of psychopathology in addition to information on response biases such as attempts to deny or exaggerate symptoms (Butcher et al., 1989). However, it is a lengthy questionnaire that requires interpretation by a trained psychologist.

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Other psychometric assessment instruments developed specifically for use with sleep-disordered patients can provide useful collateral information. A variety of self-report sleep questionnaires have been developed to measure hyperarousal, daytime sleepiness, sleep hygiene behaviors, sleep quality, satisfaction with sleep, functional impairment, sleep-related beliefs and attitudes, and insomnia severity (Sateia et al., 2000; Savard and Morin, 2002). These questionnaires are not immune to subjective biases inherent in self-report methodology, but their utility may be maximized when combined with other methods such as sleep logs or actigraphy. 5.3. Sleep logs Sleep logs provide a practical, simple, and non-intrusive measure of an individual’s perceived sleep pattern over an extended period of time. A typical sleep log contains questions about bed and wake times, number and duration of nighttime awakenings and daytime naps, sleep latency, use of sedatives or alcohol, and ratings of sleep quality and restorativeness (see Fig. 2). This information easily can be gathered over several weeks to provide information about the variability in sleep/ wake patterns, severity of sleep disturbance, and subjective measures of sleep quantity and quality. Its main applications are in individuals with insomnia and circadian rhythm disorders, as it may reveal important diagnostic issues such as circadian changes, insufficient sleep, or perpetuating factors (Savard and Morin, 2002). Sleep logs have been used successfully in older adult populations and also provide a reliable measurement of treatment outcome (Espie, 2000). 5.4. Actigraphy The actigraph is a portable behavioral assessment device that derives estimates of sleep and wakefulness from limb movement activity. It consists of a recording device that is usually worn on the non-dominant wrist in a manner similar to a wristwatch. Microprocessors contained in the device enable the storing and downloading of data into a computer software program that then estimates common sleep/wake parameters. Actigraphy can be used to inexpensively and unobtrusively collect sleep/ wake data in the home environment over extended periods of time. Current standards of practice recommend a minimum recording period of three days with concurrent use of a sleep log to assist in determining sleep periods (Standards of Practice Committee of the American Academy of Sleep Medicine, 2003). When combined with information from a clinical interview and sleep log, actigraphy contributes additional objective data regarding sleep phase changes and variability of sleep patterns over time. This information can assist in diagnosis, document severity of the sleep problem, measure treatment outcome, and monitor patient compliance to treatment recommendations (Ancoli-Israel et al., 2003a; Standards of Practice Committee of the American Academy of Sleep Medicine, 2003). Actigraphy has been used successfully in older adults and nursing home patients; in these populations actigraphy may be particularly useful in documenting the nature

MONDAY

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WEDNESDAY

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DAY OF THE WEEK Calendar Date Yesterday I napped from ___ to ___ (note time of all naps). Last night I took __ mg of ____ or ____ of alcohol. Last night I turned off the lights and attempted to fall asleep at _____a.m./p.m. After turning off the lights, it took me about ___ minutes to fall asleep.

My awakenings lasted ____ minutes. (List each awakening separately) Today I woke up at ____a.m./p.m. NOTE: This is your final awakening. Today I got out of bed at ____a.m./p.m. I would rate the quality of last night’s sleep as: 1 = very poor 4 = good 2 = poor 5 = excellent 3 = fair When I awoke today I felt: 1 = not at all rested 4 = rested 2 = slightly rested 5 = well rested 3 = somewhat rested

Fig. 2. Sample Sleep Log.

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I woke from sleep ___ times. (Do not count your final awakening here)

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of the nocturnal sleep disturbance, assessing the 24 h sleep/wake activity pattern, and identifying unreported daytime napping (Ancoli-Israel et al., 2003a; Standards of Practice Committee of the American Academy of Sleep Medicine, 2003). 5.5. Polysomnography (PSG) The PSG is a ‘‘gold standard’’ objective test of diagnostic sleep assessment. This typically includes physiological measurements of EEG, electro-oculography, chin electromyography, electrocardiography, respiration, oxygen saturation, and leg muscle activity obtained during an individual’s normal sleep period. Recordings are usually conducted in a sleep laboratory environment, although portable recorders now allow for physiological data collection to occur in other settings. This PSG is essential in appropriately diagnosing SDB and is usually indicated to diagnose PLMD and RBD (American Sleep Disorders Association Standards of Practice Committee, 1997). However, PSG is not recommended for routine diagnosis of RLS, insomnia, and circadian rhythm disturbances (American Sleep Disorders Association Standards of Practice Committee, 1997; Chesson et al., 2000). These disorders usually can be diagnosed appropriately on the basis of clinical information; however, PSG may be considered in these cases if there is evidence of underlying sleep pathologies (e.g., SDB, periodic limb movements) or a failure to respond to treatment. Due to the extensive nature of this assessment method, PSG may be difficult to conduct in demented patients (Janssens et al., 2000). 5.6. Multiple sleep latency test (MSLT) The MSLT is a laboratory-based objective assessment test to evaluate daytime sleepiness (Carskadon and Dement, 1977). During this procedure, the patient is offered approximately five separate 20-min nap periods every two hours throughout the day. Sleep latency for each nap opportunity is recorded including the presence or absence of any REM periods. A mean sleep latency  5 min is indicative of excessive daytime sleepiness, whereas latencies of  10 min are considered normal. The MSLT testing may have clinical utility in documenting sleepiness associated with SDB, PLMD, insomnia, and circadian rhythm disorders (Thorpy, 1992) but is not considered a necessary part of the diagnostic evaluation in these disorders. 6. Treatment of sleep disturbances in older adults 6.1. Sleep-disordered breathing Treatments for SDB include symptom-focused interventions designed to maintain airway patency during sleep (positive pressure devices and oral appliances) and treatments to reduce the severity of apneic events (surgical and behavioral

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interventions). These treatments are reviewed briefly here and discussed in more detail in Chapter 6. 6.2. Positive pressure devices Positive pressure devices such as positive airway pressure (PAP) are the treatment of choice for SDB. By delivering air pressure via a nasal mask, PAP prevents airway obstruction during sleep and restores normal sleep and breathing patterns. Because many patients use PAP only partially or are unable to use it long-term, compliance with this treatment is a critical issue (Grunstein and Sullivan, 2000). Preliminary studies in older adults with SDB suggest that a brief educational intervention can enhance PAP use and that higher compliance is associated with greater improvements in cognitive functioning (Aloia et al., 2001, 2003). 6.2.1. Oral appliances Oral appliances include a variety of devices designed to enlarge and maintain airway space by repositioning the mandible and/or advancing the tongue (Lowe, 2000). They are generally indicated for patients with mild SDB or those with more severe SDB who have failed PAP (Thorpy et al., 1995). Because sufficient dentition is needed to fit most of these devices, use in older adults with dentures or otherwise poor dentition is limited (Lowe, 2000). 6.2.2. Surgical interventions A number of surgical techniques that attempt to treat SDB by correcting anatomical abnormalities or removing upper airway tissue have been developed (Riley et al., 2000). However, because older adults in general have a greater risk of surgical complications and because data regarding the effectiveness of surgical treatments for SDB in this age group are lacking, surgery is usually not considered in this age group (Janssens et al., 2000). 6.2.3. Behavioral interventions Behavioral interventions such as weight loss and sleep position training are often used as adjunctive therapy to PAP or in cases where SDB is of mild severity (Sanders, 2000; Cartwright, 2003). Because SDB is often more severe when the individual is sleeping in a supine position, sleep position training encompasses a variety of techniques designed to encourage non-supine sleep (Sanders, 2000; Cartwright, 2003). Sleeping on a wedge or elevating the head of the bed can help maintain an open airway during sleep. Positional retraining can be achieved by use of a position alarm that signals and awakens the patient after movement to the supine position, or by ‘‘tennis ball therapy,’’ sewing a vertical pocket on the back of a T-shirt and filling it with tennis balls to keep the patient from rolling over on his/her back at night.

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6.3. Primary insomnia The main approaches to treating insomnia are pharmacological and behavioral interventions. Pharmacological treatments include medications that provide symptomatic relief to the sleep problem. Behavioral treatments, however, are designed to reestablish normal sleep/wake functioning, with the goal of eradicating the behavioral and conditioning factors that perpetuate insomnia. This section reviews the most common behavioral and pharmacological interventions used to treat insomnia in older adults. 6.3.1. Behavioral treatments 6.3.1.1. Stimulus control therapy (SCT) The SCT is a structured behavioral regimen based on the assumption that both the timing (bedtime) and setting (bed/bedroom) are associated with repeated unsuccessful sleep attempts and over time become conditioned cues that perpetuate insomnia (Bootzin, 1972). The goal of SCT is to re-associate the bed/bedroom with successful sleep attempts by curtailing sleep-incompatible activities that occur in the bedroom and by enforcing a consistent sleep/wake schedule. Patients are instructed to go to bed only when sleepy, establish a standard wake-up time, get out of bed whenever awake for extended periods, refrain from napping, and avoid sleep-incompatible behaviors (e.g., reading, watching TV, eating, worrying) in the bed and bedroom. 6.3.1.2. Sleep restriction therapy (SRT) The SRT reduces sleep disturbance by restricting time in bed each night to match the patient’s actual sleep requirement (Spielman et al., 1987). Spending too much time in bed fragments the sleep pattern and creates excessive time awake each night. By restricting time in bed, mild sleep deprivation may be induced; subsequently, sleep drive is increased, wakefulness is reduced, and the sleep pattern is consolidated. 6.3.1.3. Sleep hygiene This approach involves education about healthy sleep behaviors and promotion of sleep-conducive environmental conditions and habits (Hauri, 1991). Patients are encouraged to exercise daily, eliminate the use of caffeine, alcohol, and nicotine, eat a light snack at bedtime, and ensure that the sleeping environment is quiet, dark, and comfortable. Sleep hygiene is seldom used as a primary intervention, but is often included with other interventions such as SC or SRT. 6.3.1.4. Relaxation therapies A variety of relaxation strategies (e.g., progressive muscle relaxation, passive relaxation, autogenic training, biofeedback, imagery training, meditation) have been used to treat insomnia (Stepanski, 2000; McCrae and Lichstein, 2001). The goal of these therapies is to reduce or eliminate the physiological arousal (e.g., muscle

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tension) and/or cognitive arousal (e.g., racing thoughts) associated with insomnia. Treatment typically entails specific therapeutic exercises and relaxation skills training. Once the patient gains mastery of relaxation skills, these techniques can be used to facilitate sleep initiation by reducing sleep-related performance anxiety and bedtime arousal. 6.3.1.5. Cognitive-behavioral therapy (CBT) The CBT is a multi-component treatment approach combining cognitive therapy strategies with behavioral therapies such as SC, SRT, and sleep hygiene (Morin, 1993). The cognitive component addresses sleep-related misconceptions and dysfunctional beliefs about sleep, whereas the behavioral component targets the behavioral and conditioning mechanisms that perpetuate insomnia. 6.3.1.6. Sleep education Although not a formal intervention strategy, sleep education may be beneficial to older adults who develop unrealistic expectations about sleep. Some retired older adults believe that since they are retired, they should be able to sleep as long as they wish. Older adults also may mistakenly believe that they should be obtaining a certain number of hours of sleep per night, with minimal or no awakenings. In these cases, it is usually helpful to provide education about the range of human sleep requirements and the negative effects of too much time in bed. These patients should be advised that several brief nighttime awakenings are normal and are not likely to affect their daytime functioning. 6.3.1.7. Effectiveness of behavioral therapies Behavioral treatments for older adults with insomnia produce significant improvements in sleep patterns that are durable over time (Pallesen et al., 1998; Martin et al., 2000; Stepanski et al., 2003). Many older adults prefer behavioral treatment to pharmacotherapy because it is perceived to have greater benefits and less side effects (Morin et al., 1992). 6.3.2. Pharmacotherapy 6.3.2.1. Sedative-hypnotic medications Pharmacological approaches for insomnia typically include benzodiazepine receptor agonists (e.g., temazepam, zolpidem, zaleplon), sedating antidepressants (e.g., trazodone, amitriptyline, mirtazapine), or antihistamines (e.g., diphenhydramine). Although these medications effectively treat sleep disturbance, older adults are at increased risk for drug interaction, accumulation, and toxicity due to polypharmacy and age-related changes in pharmacokinetics and pharmacodynamics (Gottlieb, 1990; Monane, 1992; Buysse and Reynolds, 2000). Thus, older adults are particularly susceptible to the adverse effects of these medications, which may include daytime sedation, respiratory depression, increased risk of falls, and impairments in memory, cognition, and psychomotor functioning (Buysse and Reynolds, 2000; Roehrs and Roth, 2000; Petrovic et al., 2003). Long-term use of

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benzodiazepines may result in such iatrogenic effects as drug tolerance, dependence, hangover, amnesia, and rebound insomnia upon discontinuation (Roehrs and Roth, 2000; Petrovic et al., 2003). Furthermore, there are limited data demonstrating the efficacy and safety of long-term benzodiazepine use. For these reasons, treatment is rarely recommended for extended periods (Buysse and Reynolds, 2000; Petrovic et al., 2003). Although sleep medications may be helpful in treating short-term or intermittent insomnia, they often provide little lasting benefit to patients with chronic sleep disturbances. Unlike behavioral treatments that address underlying mechanisms that ostensively cause and sustain insomnia, sedative-hypnotic medications provide only symptomatic relief. 6.3.2.2. Melatonin Melatonin is an endogenous hormone produced by the pineal gland. Released in a circadian pattern during dark cycles, it functions to synchronize circadian rhythms. Because older adults show age-related reductions in melatonin levels, melatonin replacement has been tested as a treatment for insomnia. Although melatonin supplementation in older adults with sleep complaints may improve sleep measures (Buysse and Reynolds, 2000; Olde Rikkert and Rigaud, 2001) it is seldom recommended as a long-term treatment for sleep difficulties. The FDA does not regulate the purity, quality, and exact dosage of over-the-counter melatonin preparations, and little information exists concerning the safety, side effects, and long-term use of this substance (Buysse and Reynolds, 2000; Martin et al., 2000). 6.4. Secondary insomnia The treatment of older adults with sleep disturbance secondary to medical or psychiatric disorders or medication/substance use is of particular importance, given the prevalence and severity of secondary insomnia in this population (Lichstein, 2000). The primary treatment approach should address the causative disorder. However, once the primary disorder is successfully treated, insomnia may fail to remit as it becomes perpetuated by behavioral and conditioning factors. Secondary insomnia has been successfully treated in older adults using behavioral treatments described above (Lichstein et al., 1998, 2000). 6.5. Circadian rhythm disorders 6.5.1. Bright light therapy Bright light therapy delivered via a specially designed ‘‘light box’’ shifts desynchronized circadian rhythms by exposing the individual to light of a specified intensity and duration. Bright light (  2500 lux) for a few hours in the evening over a number of days advances the circadian phase. This therapy is beneficial in treating advanced sleep phase syndrome and sleep maintenance insomnia in older adults (Campbell et al., 1993; Murphy and Campbell, 1996; Chesson et al., 1999a;

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Van Someren, 2000). Bright therapy also has been associated with cognitive performance improvements in older adults (Murphy and Campbell, 1996).

6.5.2. Other circadian modulators Manipulation of other circadian modulators such as body temperature and physical activity may be beneficial in improving sleep patterns in older adults. Warm baths prior to bedtime have been shown to improve sleep continuity and quality in older adults (Dorsey et al., 1996, 1999; Liao, 2002). Similarly, physical activity has been associated with a reduction in sleep fragmentation (Van Someren et al., 1997), improvements in subjective sleep quality (King et al., 1997), and increased slow wave sleep (Naylor et al., 2000). The precise mechanisms of how these treatments influence circadian systems are unknown. In general, these interventions have not been rigorously tested, and more information concerning their effectiveness and application are needed.

6.6. Sleep-related movement disorders 6.6.1. Periodic limb movement disorder (PLMD) and restless legs syndrome (RLS) Studies show PLMD and RLS are typically treated pharmacologically with medications designed to reduce movement activity and/or improve sleep quality. Dopaminergic agents (e.g., levodopa, pergolide, pramipexole) are the most successful treatments (Chesson, et al., 1999b; Edinger, 2003). Other agents that have shown treatment efficacy include opioids (e.g., oxycodone, propoxyphene), benzodiazepines (e.g., clonazepam), and anticonvulsants (e.g., carbamazepine, gabapentin). Iron supplementation can effectively treat RLS secondary to iron deficiency (Chesson et al., 1999b). Effective therapeutic management may also include treatment of contributing medical disorders or discontinuation of medications such as antidepressants that can exacerbate movement disorders.

6.6.2. REM behavior disorder (RBD) Clonazepam, a long-acting benzodiazepine, is the primary treatment for RBD. Other agents that affect the seroternergic or dopaminergic systems may be beneficial, although some antidepressants can aggravate REM motor activity (Mahowald and Schenck, 2000). Recently, some data suggest that melatonin may effectively treat RBD (Boeve et al., 2003). Due to the association between RBD and neurodegenerative processes, brain imaging is indicated if there is evidence of neurological dysfunction (Mahowald and Schenck, 2000). Adjunctive treatment strategies should include avoidance of sleep deprivation and environmental manipulations to increase safety in the bedroom (e.g., removing dangerous objects, surrounding the bed with cushions, placing the mattress on the floor, protecting windows) (Mahowald and Schenck, 2000; Stepanski et al., 2003).

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6.7. Sleep in institutionalized older adults Older adults living in supervised care facilities are particularly susceptible to suffering sleep disruption for a variety of reasons. First, sleep/wake dysregulation is characteristic of dementing illnesses (Bliwise, 2000a). Second, institutionalized individuals are likely to take multiple medications and suffer from a number of medical, neurological, and psychological disorders that disrupt sleep. Finally, environmental factors such as low daytime light levels, long periods of time in bed, inactivity, daytime napping, and noise often perpetuate sleep disturbances in institutional settings (Bliwise and Breus, 2000). Although much more research is needed to determine successful treatments for sleep disturbance in institutionalized elderly, a number of experts have made recommendations to maximize sleep potential in these patients (Bliwise, 2000a; Bliwise and Breus, 2000; Martin et al., 2000). One of the easiest and most effective interventions is the provision of daytime light exposure to strengthen the circadian rhythm, prevent napping, and improve sleep patterns (Bliwise and Breus, 2000; Martin et al., 2000; Fetveit et al., 2003). Other recommended interventions include increasing physical activity, adjusting medications, providing stimulating daytime activities to prevent napping, limiting time spent in bed during the day, encouraging routines for meals and activities, matching roommates with similar schedules, providing an activity time period during the night to reduce disruption to other residents, and minimizing nighttime noise and light (Bliwise, 2000a; Bliwise and Breus, 2000; Martin et al., 2000).

7. Summary The prevalence of insomnia, SDB, circadian rhythm disorders, and sleep-related movement disorders increases substantially in late-life. In addition, normal agerelated changes in sleep architecture create a fragmented and light sleep pattern that sets the stage for sleep complaints in this population. Sleep disturbance in older adults may be associated with poorer quality of life, dependence on hypnotic medication, increased risk of falls, increased morbidity, impaired cognitive performance, and daytime somnolence. A thorough evaluation of a sleep complaint includes assessment of contributing medical, psychiatric, medication, behavioral, and environmental factors. Once identified, sleep disorders can be effectively treated. Treatments include medically-based interventions such as mechanical devices for SDB and medications for movement disorders as well as behavioral and environment interventions (e.g., behavioral treatments for insomnia and bright light therapy for circadian disturbances). However, more information on the application and effectiveness of these treatments specific to elderly populations is needed and will only increase in importance as the population of older adults grows.

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