Sleep Disorders in

Older Adults

Dr. Shano Thiyagalingam, Geriatrician

Assistant Professor of Medicine
September 22nd, 2021
Disclosure
• I have no actual or potential con ict of interest in relation to this
presentation

• I have no nancial interests or relationships to disclose

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Objectives

• Recognize the aging e ects on sleep

• Identify the causes of impaired sleep

• Understand nonpharmacologic sleep strategies

• Apply current trends in pharmacologic therapies

https://www.mayoclinic.org/tests-procedures/awake-brain-surgery/about/pac-20384913
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What is it?
• Insomnia:

• dissatisfaction with sleep quality or quantity

• Insomnia disorder:

• di culty initiating or maintaining sleep or awakening

• >3 nights and >3 months

• signi cant distress or impairment in function

Patel, D., et al. (2018). Journal of Clinical Sleep Medicine

Lopez, M. American Psychological Association.

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Signs/Symptoms
• commonest complaint:

• di culty falling asleep

• nighttime awakenings

• early morning awakenings

• daytime sleepiness

• Leads to

• fatigue, poor concentration, poor memory, depression, anxiety

Patel, D. et al. (2018). Journal of Clinical Sleep Medicine

Alessi, C (2021). GRS Review Syllabus

Gomez, R., et al. (2021). Ferri’s Clinical Advisor

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Why Does it Matter?

• prevalence: 30-48% in older adults vs 10% in younger adults

• F>M

• increased hospitalization, readmission, ER visits

• if untreated, increased risk for:

• depression (23% increased risk)

• heart disease (1.47-3.90x)

• diabetes (2.5x)

• myocardial infarction

• hypertension

• cognitive impairment
• falls

• hip fracture

Patel, D. et al. (2018). Journal of Clinical Sleep Medicine

Lou, B., Oks, M. (2021). Clinics in Geriatric Medicine

Physiology of Sleep
• Neurotransmitters:

• Sleep promoting

• GABA

• Wake promoting

• orexin, Ach, NE, histamine,

DA, 5-HT

• Circadian rhythm

• melatonin (maintains/
synchronize rhythm)

• 2 receptors (MT1, MT2)

Lou, B., Oks, M. (2021). Clinics in Geriatric Medicine

Bertisch, S. (2020). Harvard Geriatrics Review

Aging and Sleep

Alessi, C (2021). GRS Review Syllabus

Causes

Kryger MH et al. (2017). Principles and practice of sleep medicine

Causes

Mansukhani, M. et al. (2021). Conn’s Current Therap

y

Causes

Reynolds, M., et al. (2018). Journal for Nurse Practitioners

Insomnia: Secondary vs Comorbid

Bertisch, S. (2020). Harvard Geriatrics Review

Evaluation
• Clinical diagnosis

• di culty staying or falling asleep?

• unusual behaviours at night?
• partner/caregiver collateral history

• medications

• day naps?
• previous treatment history

• Apneas: snoring, daytime sleepiness, gasping for air

• Restless legs: evening or nighttime urge to move leg

• Parasomnias: kicking or walking while asleep

• Circadian rhythm disorders: timing of sleep (too early or

delayed)

Gomez, R., et al. (2021). Ferri’s Clinical Advisor

Alessi, C (2021). GRS Review Syllabus

Patel, D. et al. (2018). Journal of Clinical Sleep Medicine

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Diagnostic Tools
• Sleep log

• sleep time, rest time, bed time, # of awakenings

• meds before sleep, subjective sleep quality/satisfaction

• Devices

• Polysomnography (sleep apnea, leg movement, pain, parasomnias)

• Wrist actigraphy

• Insomnia Rating Scales (optional)

• Insomnia Severity Index

• Pittsburg Sleep Quality Index

• Epworth Sleepiness Scale

Patel, D. et al. (2018). Journal of Clinical Sleep Medicine

Gomez, R. et al. (2021). Ferri’s Clinical Advisor

Univ of Hong Kong. Sleep Research Clinic and Laboratory

Sleep in Dementia
• frequent nighttime awakenings/wandering, more NREM, less REM

• circadian rhythm sleep disorder (daytime sleeping, night-time wakefulness)

• tx: light therapy; melatonin not e ective alone; combination better

• AchEI

• can exacerbate insomnia, vivid dreams

• change timing to morning

Alessi, C (2021). GRS Review Syllabus

Uddin MS., et al. (2020). Ageing Research Review

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Question 1
An 82 year old woman presents to the office with difficulty staying sleep, she also
has frequent day naps. She has a history of moderate Alzheimer’s dementia. She
sleeps around 10pm, wakes up every few hours (atleast 3 times nightly) until wake
up time at 6am. Each awakening lasts around 60 minutes. She sleeps after
breakfast and lunch for 3 hours.

Which of the following is the best treatment option?

a) melatonin
b) trazodone
c) zolpidem
d) bright light exposure during the daytime

Adapted from Geriatric Review Syllabus, 10th ed.

 Sleep Disturbance in The Hospital

• Causes

• multifactorial

• illness, meds, change from usual routine, disruptive environment

• Treatment

• sleep protocol

• exible medication time, less checks at night, less noise, getting out of
bed to chair in mornings

• daytime bright light exposure

• di cult to adhere in acute hospital setting

• melatonin (some evidence of e ectiveness)

• use lowest e ective dose medication

• PAP machine in OSA/CSA patients

Alessi, C (2021). GRS Review Syllabu Freeman, L. (2016). Birmingham Medical News
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Management of Insomnia
•Nonpharmacologic

•sleep hygiene (‘necessary but not enough’)

• keep sleep and wake time consistent

• stay active, daytime exercises

• avoid uids before sleep

• avoid or limit naps (to less than 30 minutes; avoid nap after 3pm)

• avoid or limit ca eine, alcohol, don’t use nicotine

• avoid personal electronic devices

• only use for sleep or sex
• bedtime relaxing (ie: meditation, relax music, warm shower, reading)

• treat pain

• sleep only when tired

Alessi, C (2021). GRS Review Syllabus

Gomez, R. et al. (2021). Ferri’s Clinical Advisor

Patel, D. et al. (2018). Journal of Clinical Sleep Medicine

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Management of Insomnia
• Acute Insomnia (transient stressor or illness)

• sleep hygiene, pharmacologic

• Chronic Insomnia

• sleep hygiene, therapy (ie: CBT-I), pharmacologic

Gomez, R. et al. (2021). Ferri’s Clinical Adviso

Quaseem, A. et al. (2016). Ann Intern Me

d

 Management of Insomnia

• risk for falls, hip fracture, daytime drowsiness, dependence

• sleep onset vs sleep maintenance

• benzo (FDA approved 1960s); NBRA (FDA approved 1992)

Alessi, C (2021). GRS Review Syllabu

s

 Non-benzodiazepine
• structurally unrelated to benzodiazepines

• selectively bind GABA type A alpha-1 subclass receptor

• minimal anxiolytic, amnestic, anticonvulsant e ects

• relatively well tolerated in older adults though similar concerns

as benzodiazepines

• females clear drug less than males

• rapid onset

Alessi, C (2021). GRS Review Syllabus

Patel, D. et al. (2018). Journal of Clinical Sleep Medicine

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Question 2
A 65 year old man complains of sleep difficulties. He sleeps about an hour
then wakes up 3 hours later every night. Some nights he falls back to light,
interrupted sleep after an hour. The remainder of the night he is awake. The
awakenings are not related to sleep apneas. He goes to bed at 10pm and
wakes up at 7am. He was diagnosed with insomnia disorder 30 years ago
and has been treated with cognitive behavioural therapy and intermittently
zolpidem. Denies depression. Vitals are normal.

Whats the best initial drug recommendation?

a) sovurexant
b) trazodone
c) zaleplon
d) zolpidem

Adapted from Geriatric Review Syllabus, 10th ed.

 Management of Insomnia

Alessi, C (2021). GRS Review Syllabu

s

• improved sleep latency and maintenance compared to placebo and

zolpidem
 • improved sleep latency

• start at 1-3mg; higher dose for circadian rhythm disorder or REM

sleep disorder
Lou, B., Oks, M. (2021). Clinics in Geriatric Medicine
 Management of Insomnia

Alessi, C (2021). GRS Review Syllabu

s

• adverse e ects:

• dizzy, cognitive decline, confusion, urinary retention, constipation

• tolerances in just 3 days to diphenhydramine

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• insu cient evidence for routine use of cannabinoids for insomnia
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 Management of Insomnia
•Nonpharmacologic

•behavioural therapy

•sleep restriction- restrict sleep then gradually increase

•stimulus control- recondition maladaptive behaviours

•Sleep hygiene education- reduce abnormal behaviours

•Cognitive Behavioral Therapy- restructure maladaptive beliefs

•Relaxation techniques- recognize/relief tension and anxiety

•Bright light therapy- correct circadian rhythm disorder

•improved sleep e ciency, decreased nighttime wakefulness, greater

satisfaction with sleep, reduced hypnotic use

Alessi, C (2021). GRS Review Syllabus

Gomez, R. et al. (2021). Ferri’s Clinical Advisor

Patel, D. et al. (2018). Journal of Clinical Sleep Medicine

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 Other Sleep Disorder Treatments
• Circadian rhythm sleep-wake disorder

Barion and Zee. (2007). Sleep Med

Other Sleep Disorder Treatments

• REM Behaviour Disorder

• dream reenactment, no loss of muscle tone

• occurs later in sleep

• acute:

• may indicate toxic metabolic changes, drug/alcohol withdrawal or

intoxication; medications (ie: TCA, MAOI, uoxetine, AchEI,
venlafaxine)

• chronic:

• may indicate neurodegenerative conditions

• dx:

• polysomnography

• tx:

• clonazepam, melatonin, environmental safety modi cations

Alessi, C (2021). GRS Review Syllabu

s

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Other Sleep Disorder Treatments
• Restless Leg Syndrome

• while awake
• idiopathic or associated with comorbid condition (ie: neuropathy, uremia,
thyroid disease)

• medications (antiemetics, antipsychotics, SSRI, SNRI, TCA,

diphenhydramine)

• tx:

• dopamine agonist, iron if low; treat comorbid condition if iron is normal

• others include gabapentin, benzodiazepines, opioids

• Periodic Limb Movement Disorder

• while asleep (NREM)

• dx: polysomnography

Alessi, C (2021). GRS Review Syllabu

s

 Question 3
An 80 year old woman presents with worsening symptoms of her Restless Leg
Syndrome (RLS). Her depression worsened after her husband was found primary
lung adenocarcinoma. Past Medical History - MDD, CKD stage 4, RLS. Her
medications include pramipexole 0.25mg at bedtime for the past 3 years.
Which of the following is least likely to worsen her RLS?

a) sertraline
b) venlafaxine
c) buproprion
d) mirtazapine

Adapted from Geriatric Review Syllabus, 10th ed.

 Other Sleep Disorder Treatments

• Sleep Apnea (obstructive vs central)

• daytime sleepiness/fatigue, snoring

• dx:

• polysomnography

• tx:

• CPAP therapy, BPAP,

• oral appliance (if mild or intol PAP)

• upper airway surgery, implanted nerve stimulator

Alessi, C (2021). GRS Review Syllabus

 https://www.medpagetoday.com/resource-
centers/excessive-sleepiness-and-associated-
risks-with-obstructive-sleep-apnea/osa-role-
https://www.mayoclinic.org/diseases- hypoglossal-nerve-stimulation/2720
conditions/obstructive-sleep-apnea/
symptoms-causes/syc-20352090
 Conclusion
• insomnia often multifactorial

• sleep changes with age: less deep sleep, more awakenings

• untreated can lead to increased morbidity and mortality

• current drug therapy side e ects a challenge in older adults

• drug metabolism a ected by age, liver/renal impairment, drug

interactions in older adults; start low and go slow

• many clinical trials; more research needed for lower side e ect
pro le drugs
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