Dr. Richards is a Resident Physician in Family Medicine and Psychiatry, UC Davis Health; Dr. Demartini is Chief Resident Physician in Internal Medicine, UC Davis Health, Internal Medicine and Psychiatry; and Dr. Xiong is Associate Professor, UC Davis Health, Internal Medicine and Psychiatry.
Sleep disorders are highly prevalent in the older population and frequently encountered in psychiatry and primary care. More than one-half of the elderly have at least one sleep complaint.1 Given the impact of sleep on quality of life, cognitive functioning, and health outcomes, understanding sleep disorders in older adults is vital to their overall care.
The most common sleep disorder both in the general population and in seniors is insomnia. Women tend to have a higher incidence of insomnia than men. Findings indicate that insomnia affects 31% to 38% of adults aged 18 to 64 years but 45% of those aged 65 to 79 years.2 Many factors can contribute to insomnia, including psychiatric or neurological disorders, medical conditions, polypharmacy, medication adverse effects, substance use, environmental changes (home, hospital, care home), decreased sensory input (blindness, deafness), unrealistic expectations of sleep, lifestyle changes (retirement, change in daily structure), and psychosocial stressors.
In addition to insomnia, several other sleep disorders are more often seen in older adults. Obstructive sleep apnea is especially common and affects 25% to 35% of people aged over 60 years, compared with 2% to 4% of 30- to 60-year-olds.3 Rates of sleep apnea are higher in men than women and are highest among institutionalized elderly adults (33% to 70%), particularly those with dementia.3 REM sleep behavior disorder is characterized by acting out dreams during sleep due to lack of muscle atonia and primarily affects elderly men. Additional disorders include circadian rhythm disorders (shift in the sleep-wake schedule), periodic limb movement disorder (repetitive and stereotyped limb movements during sleep), and restless legs syndrome (uncomfortable urge to move prior to sleep onset).
Changes in sleep patterns with aging
As our brains age, physiological changes alter the timing and quality of sleep. Older adults frequently report waking up at earlier times, increased sleep-onset latency (taking longer to fall asleep), more nighttime awakenings, and decreased total sleep.3 With aging, progressively more time is spent in light sleep (stages 1 and 2), and less time is spent in deep sleep (stages 3 and 4). In addition, REM sleep is decreased. As sleep becomes more fragmented, there are more frequent shifts between sleep stages and more opportunities for awakenings.
Changes in circadian rhythm can also occur, because of decreased responsiveness of the superchiasmatic nucleus (which controls our internal clock) to external cues (light). Circadian rhythm dysfunction can be exacerbated by the loss of daily structure (or typical work routines), increased daytime napping, or inconsistent exposure to light, such as in nursing homes where day and night blend together. This often leads to advanced sleep phase syndrome, a circadian shift in the sleep-wake cycle where older adults feel tired earlier and earlier each evening, and then wake up earlier and earlier each morning. These changes in sleep architecture can result in less total sleep, decreased sleep efficacy (the proportion of time asleep compared with time in bed), and early morning awakenings.
Medical disorders, substance use disorders, and medications
Older adults often have one or more medical comorbidities that can contribute to difficulty with sleep. Data from an epidemiologic study of 6800 elderly adults over 3 years showed that only 7% of the cases of insomnia were in isolation of common comorbid conditions.4 Heart disease, diabetes, and respiratory disease were all associated with long-term persistence of insomnia at the 3-year follow-up (Table 1).
Related content: 14 Medical Conditions That Contribute to Insomnia
Finding and treating the underlying cause of the sleep disturbance is critical to effective management. For example, awakenings from sleep to urinate can be triggered by nocturia from benign prostatic hyperplasia, from polyuria with diabetes, from drinking water or alcohol too close to bedtime, or from evening doses of diuretics.
Substance use is often under-reported in older adults and can adversely affect sleep, especially with metabolic changes with age. For example, caffeine can have a stimulant effect for over 8 to 14 hours in older adults, and alcohol can also take longer to metabolize, leading to disrupted sleep and nocturnal awakenings. Nicotine can also interfere with falling asleep and decrease sleep duration. These changes increase sleep fragmentation and can worsen symptoms from other sleep disorders, such as obstructive sleep apnea.
1. Foley D, Monjan A, Brown S, et al. Sleep complaints among elderly persons: an epidemiological study of three communities. Sleep. 1995;18:425-432.
2. Alessi C, Vitiello M. Clinical evidence handbook: primary insomnia in older persons. Am Fam Physician. 2013;87:280-281.
3. Roepke SK, Ancoli-Israel S. Sleep disorders in the elderly. Indian J Med Res. 2010;131:302-310.
4. Foley DJ, Monjan A, Simonsick EM, et al. Incidence and remission of insomnia among elderly adults: an epidemiologic study of 6,800 persons over three years. Sleep. 1999;22:S366-S372.
5. Ohayon MM, Roth T. What are the contributing factors for insomnia in the general population? J Psychosomatic Res. 2001;51:745-755.
6. Bernert RA, Turvey CL, Conwell Y, Joiner TE Jr. Association of poor subjective sleep quality with risk for death by suicide during a 10-year period: a longitudinal, population-based study of late life. JAMA Psychiatry. 2014;71:1129-1137.
7. Cho HJ, Lavretsky H, Olmstead R, et al. Sleep disturbance and depression recurrence in community-dwelling older adults: a prospective study. Am J Psychiatry. 2008;165:1543-1550.
8. Maher AR, Maglione M, Bagley S, et al. Efficacy and comparative effectiveness of atypical antipsychotic medications for off-label uses in adults: a systematic review and meta-analysis. JAMA. 2011;306:1359-1369.
9. Trauer JM, Qian MY, Doyle JS, et al. Cognitive behavioral therapy for chronic insomnia. Ann Intern Med. 2015;163:191-204.
10. Buysse DJ, Rush AJ, Reynolds CF. Clinical management of insomnia disorder. JAMA. 2017;318: 1973-1974.
11. Hampton LM, Daubresse M, Chang HY, et al. Emergency department visits by adults for psychiatric medication adverse events. JAMA Psychiatry. 2014;71:1006-1014.