Evidence‐Based Recommendations for the Assessment and Management of Sleep Disorders in Older Persons

Abstract

Background and SignificanceSleep-related disorders are common in the general adult population, and as the population ages, the prevalence of these disorders increases. A common misconception among clinicians and the public is that this increased prevalence is a normal and expected phenomenon of aging. However, this higher prevalence of sleep disruption is often the result of the increased presence of medical, and psychosocial comorbidities in this population. The complicated multifactorial interactions that generate sleep disorders in older individuals pose important challenges to clinicians. Furthermore, many clinicians are unaware of the seriousness and potential morbidity associated with sleep problems in older people, distinct from the morbidity of concurrent disorders. As a result, these issues are often underinvestigated, or completely ignored. 1 Because of the high prevalence, complexity, and health implications associated with sleeprelated disorders in older individuals, increasing attention is now being focused on this topic. For example, a recent publication has recommended that sleep problems be approached as a "multifactorial geriatric syndrome." 2 Of major clinical concern is the strong bidirectional relationship between sleep disorders and serious medical problems in older persons. Individuals with sleep disorders are more likely to Corresponding Author: Harrison G. Bloom, M.D., AGSF, International Longevity Center-USA, 60 East 86th Street New York, NY 10028, 212.517.1308, 212.288.5450, HarrisonB@ilcusa.org NIH-PA Author ManuscriptNIH-PA Author Manuscript NIH-PA Author Manuscript develop hypertension, depression, cardiovascular, and cerebrovascular disease. Conversely, individuals with any of these diseases are at higher than normal risk of developing sleep problems. 3,4 Older individuals consider quality sleep to be an essential part of good health. A Gallup survey of over 1000 Americans age 50 and older (43% of whom were age 65 or older) found that 80% answered "a great deal" when asked whether sleep was important for healthy aging. In the same survey, and contrary to the myth that older adults need less sleep, 45% believed they required more sleep now than when they were younger and 25% believed they had a sleep "problem." 5 The goal of this paper is not to present an exhaustive and comprehensive review of sleep and sleep disorders in older persons. Rather, we present an overview of sleep disorders and suggest appropriate evidence-based recommendations for assessing and treating sleep disorders in the older adult population. These recommendations have been developed by professionals with expertise in sleep disorders and in the clinical care of older people.As in many areas of clinical research, older persons are often poorly represented (or specifically excluded) in clinical sleep studies. Thus, there are less data available from randomized controlled trials for this population compared to the general adult population. Nevertheless, given the importance of the subject, and the opportunity for ...

Sleeping difficulties reported by patients with heart failure

“…The effects of bad sleep are cumulative. Chronic sleep loss puts individuals at risk of decreased cognitive functioning, depression, concentration difficulties, social isolation and a global reduction in quality of life (6) .…”

A Four-Session Sleep Intervention Program Improves Sleep for Older Adult Day Health Care Participants: Results of a Randomized Controlled Trial

“…A five-point Likert-like scale is used to rate each item, ranging from 0 (no problem) to 4 (very severe problem). Total scores range from 0 to 28 and are interpreted as follows: no insomnia (0-7), subthreshold insomnia (8)(9)(10)(11)(12)(13)(14), moderate insomnia (15)(16)(17)(18)(19)(20)(21), and severe insomnia (22)(23)(24)(25)(26)(27)(28).…”

“…19 On the other hand, nonpharmacological interventions, such as cognitive-behavioral therapy for insomnia (CBT-I) do not show these adverse effects. CBT-I has been shown to be as effective for older as for younger adults; 17 however, studies of older adults have typically been conducted in outpatient settings with participants who do not have significant functional impairments. [20][21][22][23] It also is not clear whether adapting CBT-I for patients with limited physical abilities will reduce potency.…”

“…15 Available studies also show that sleep problem is typically not addressed within routine clinical care of older patients, 16 and treatment of sleep issues is often limited to medications (eg, hypnotics, sedating antidepressants), which are not recommended for older adults. 17 Both untreated insomnia 18 and pharmacological treatment of insomnia can be associated with increased risk of falls and other adverse health events among older persons. 19 On the other hand, nonpharmacological interventions, such as cognitive-behavioral therapy for insomnia (CBT-I) do not show these adverse effects.…”

Hypnotics and mortality in an elderly general population: A 12-year prospective study

“…Sleep changes with advancing age; however, the high prevalence of insomnia in the older adult population is often due to associated age-related medical and psychosocial comorbidities and the frequent use of medications that may impact sleep per se [1]. Insomnia symptoms in older adults are frequently associated with daytime fatigue, excessive daytime sleepiness (EDS), and hypnotics use [2][3][4].…”