pii: jc-17- 00295 http://dx.doi.org/10.5664/jcsm.

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RE V I EW A R T IC L ES

Insomnia in the Elderly: A Review

Dhaval Patel, MD; Joel Steinberg, MD; Pragnesh Patel, MD
Department of Geriatrics, Wayne State University School of Medicine, Detroit, Michigan

Background: Insomnia remains one of the most common sleep disorders encountered in the geriatric clinic population, frequently characterized by the
subjective complaint of difficulty falling or maintaining sleep, or nonrestorative sleep, producing significant daytime symptoms including difficulty concentrating
and mood disturbances.
Methods: A search of the literature was conducted to review the epidemiology, definition, and age-related changes in sleep, as well as factors contributing
to late-life insomnia and scales utilized for the assessment of insomnia in older people. The aim is to summarize recent diagnostic guidelines and both
nonpharmacological and pharmacological strategies for the management of insomnia in the older population.
Results: Insomnia remains a clinical diagnosis. There are several demographic, psychosocial, biologic, and behavioral factors that can contribute to late-life
insomnia. Older adults are at higher risk for the medical and psychiatric effects of insomnia.
Conclusions: The most important aspect in evaluation of insomnia is detailed history taking and thorough physical examination. Nonpharmacological
treatment options have favorable and enduring benefits compared to pharmacological therapy.
Keywords: cognitive behavioral therapy, elderly, insomnia, pharmacological treatment
Citation: Patel D, Steinberg J, Patel P. Insomnia in the elderly: a review. J Clin Sleep Med. 2018;14(6):1017–1024.

SCO PE O F T H E PRO B LE M awakenings or problems returning to sleep after awaken-

ings, and (3) early-morning awakening with inability to return
The population of older adults continues to expand rapidly to sleep.14 The fifth edition of the Diagnostic and Statistical
from the current 205 million persons aged 60 years or older, Manual for Mental Disorders (DSM-5) emphasizes that a sleep
to a projected 2 billion by 2050.1 One of the most common disturbance causes clinically significant distress or functional
sleep disturbances in the older population is insomnia.2–4 As impairment, and occurs at least 3 nights a week for at least
many as 50% of older adults complain about difficulty initiat- 3 months despite adequate opportunity to sleep, whereas the
ing or maintaining sleep.5 Prevalence of insomnia is higher in International Statistical Classification of Diseases and Related
older individuals than in the younger population.6 The overall Health Problems, 10th revision (ICD-10) requires at least 1
prevalence of insomnia symptoms ranges from 30% to 48% month of symptoms not explained by another sleep-wake dis-
in the elderly,5,7,8 whereas the prevalence of insomnia disor- order, illicit substance use, or coexisting medical and psychi-
der ranges from 12% to 20%.9 Insomnia is often classified by atric disorders. The term “nonrestorative sleep” is no longer
the predominant symptom of either difficulty in sleep onset an accepted diagnostic symptom for the DSM-5; however, it
or sleep maintenance. Sleep maintenance symptoms are most still remains in the ICD-10 criteria. The pathophysiology of
prevalent among individuals with insomnia (50% to 70%), fol- insomnia disorder induces a state of hyperarousal during sleep
lowed by difficulty in initiating sleep (35% to 60%) and non- and wakefulness. Hyperarousal is manifested as an elevated
restorative sleep (20% to 25%).10 A study of 6,800 older adults whole-body metabolic rate during sleep and wakefulness, el-
(age 65 years or older) observed an incidence rate for insomnia evated cortisol and adrenocorticotropic hormone during the
symptoms of 5% per year,11 with a yearly incidence of 7.97% early sleep period, and reduced parasympathetic tone in heart
at 1-year follow-up.12 Approximately 50% of the patients with rate variability.15 An important change with respect to diag-
symptoms of insomnia will have a remission during the follow- nostic classifications was defined in the DSM-5 and the third
up period, with higher remission rates among older males rela- edition of the International Classification of Sleep Disorders
tive to females.12,13 (ICSD-3). Insomnia in the ICSD-3 is defined as a complaint of
trouble initiating or maintaining sleep that is associated with
daytime consequences and is not attributable to environmen-
D E FI N I T I O N tal circumstances or inadequate opportunity to sleep. This re-
places earlier categories of primary and secondary forms of
Insomnia is broadly defined as dissatisfaction with sleep ei- insomnia in favor of a broad category for insomnia disorder
ther qualitatively or quantitatively. This is usually associated when insomnia is comorbid with medical or psychiatric condi-
with one or more of the following: (1) difficulty initiating sleep, tions.16 In a study of 6,800 elderly patients (older than 65 years),
(2) difficulty maintaining sleep, characterized by frequent Foley et al. demonstrated that 93% have one or more comorbid

Journal of Clinical Sleep Medicine, Vol. 14, No. 6 1017 June 15, 2018
D Patel, J Steinberg and P Patel Insomnia in the Elderly: A Review

conditions and other factors, most commonly depression, CH A N G ES I N S LE E P W I T H AG I N G

chronic pain, cancer, chronic obstructive pulmonary disease,
cardiovascular diseases, medication use, and factors associ- Along with many physiologic changes seen with aging, signifi-
ated with aging (retirement, inactivity, or caregiving).11,17–20 cant changes also occur in sleep and circadian rhythm across
The increased prevalence of chronic conditions in later life the lifespan. Differentiated by waveforms on electroencephalo-
may explain most insomnia symptoms in the older population; gram and other physiologic signals, sleep is currently classified
1% to 7% of insomnia in later life occurs independently of into four stages. The first three are non-rapid eye movement
chronic conditions.20,21 Reduced mobility, retirement, and re- (NREM) stages: stage N1, N2, and N3 sleep. Rapid eye move-
duced social interaction are sources of sleep disturbances.22–24 ment (REM) sleep occurs in the fourth stage, stage R sleep.29
Caregiving may be responsible for ruminations and anxiety Stage N1 sleep is the lightest stage and it accounts for 18%
while trying to sleep. Women who are caregivers are found to of older adults’ sleep time.30 In stage N2 sleep, brain waves
have increased prevalence of sleep complaints.18,25 Women are slow, body temperature begins to drop, and heart rate slows as
more often the primary caregivers for their children, parents, sleep deepens, accounting for 48% of sleep time. Sleep further
or partner, in addition to working outside of the home, affect- deepens in stage N3 sleep, characterized by very slow brain
ing their total sleep time. Women are also more likely than men waves referred to as delta or slow wave sleep. This stage ac-
to complain of sleep problems and see a general practitioner for counts for 16% of sleep.30 Stage R sleep is “paradoxical sleep”
those complains. because brain activity is similar to that in awake state with
increased sympathetic tone characterized by rise in blood pres-
sure and heart rate but with muscle atonia.31 Dreaming occurs
FAC TO RS CAUS I N G I N S O M N I A in this stage of sleep and accounts for 18% of sleep time in
older adults.30 Total sleep time decreases considerably from 10
Spielman and colleagues demonstrated a three-factor model to 14 hours a night in the pediatric age range, to 6.5 to 8.5 hours
for understanding the etiology and persistence of insomnia. a night as a young adult, then decreases at a slower rate in the
This model identifies predisposing, precipitating, and perpetu- older age range to 5 to 7 hours a night, and plateaus at about
ating factors that combine to raise the likelihood of insomnia 60 years of age.32 The natural shortening of their total sleep
above the insomnia threshold.26 time in some older adults may generate unrealistic expecta-
tions about sleep duration, producing anxiety that could cause
Predisposing Factors or worsen insomnia.
These include demographic, biologic, psychological, and social Beginning in middle age, adults spend less time in slow
characteristics. Women older than 45 years are 1.7 times more wave sleep and REM sleep. Sleep efficiency continues to de-
likely to have insomnia than men.7 Those divorced, separated, crease past age 60 years. There is a prominent increase in
or widowed are also more likely to have insomnia than married wakefulness after sleep onset, but no change is observed in
individuals.7 Lower levels of education or income may contrib- sleep latency.32 It is common for healthy older adults to ex-
ute to insomnia in some cases.7,27 Smoking, alcohol use, and re- hibit a temporally advanced sleep phase (falling asleep early
duced physical activity are other factors associated with higher and waking up early).5 However, this may not be true for older
rates of insomnia in older adults.7,18 adults with insomnia symptoms, who have a delayed circadian
phase.33 These individuals tend to have circadian dispersion
Precipitating Factors and lack of synchronization compared to healthy subjects.33
These factors generally include stressful life events or medical Early awakenings may result in frequent daytime naps, which
conditions that may disrupt sleep. Older adults with respira- further accentuates the problem of insomnia during the night.34
tory symptoms, physical disability, and fair to poor perceived Important time cues (zeitgebers) for circadian rhythm may
health are at increased risk of insomnia.11 Medications such as erode as one ages; for example, elderly individuals may lack
beta blockers, glucocorticoids, nonsteroidal anti-inflammatory fixed work schedules or meal times due to retirement, which
drugs, decongestants, and antiandrogens may be one of the further contributes to insomnia. Healthy elderly individuals
factors contributing to insomnia. Several studies have demon- sleep as well as younger subjects according to an epidemio-
strated that patients with depression and generalized anxiety logical study done by Ohayon.7 Research shows that older indi-
disorder have higher rates of insomnia.11,13,28 viduals may be more tolerant of sleep deprivation than younger
ones. A study on psychomotor vigilance task performance af-
Perpetuating Factors ter several nights of sleep deprivation in women aged 20 to
These factors often consist of behavioral or cognitive 30 years compared to older women aged 55 to 65 years found
changes that arise as a result of acute insomnia. An acute ep- younger women had more prominent impairments with sleep
isode of insomnia will not necessarily develop into chronic deprivation compared to an older age group.35 The American
insomnia without these provoking behavioral and cognitive Insomnia Survey of 10,094 individuals 18 years and older
events. Examples include spending excessive time in bed, noted self-reported complaints of insomnia rates were lower
frequent naps, and conditioning (increased anxiety before in older adults (older than 65 years) compared to the younger
sleep onset due to fear of spending another sleepless night). group (18 to 64 years). This highlights the importance of ap-
Nonpharmacological treatment options often target these proaching any complaint of insomnia in the older population
perpetuating factors. with more vigilance.9

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D Patel, J Steinberg and P Patel Insomnia in the Elderly: A Review

M O R B I D I T Y AS S O C I AT E D W I T H I N S O M N I A Environmental factors including bedroom temperature, light

intensity, sound level, and sleep patterns of the partner should
Insomnia is associated with significant morbidity if left un- also be assessed. The clinician should also inquire about symp-
treated. The strongest level of evidence is for mental illness. toms generated by other sleep disorders including obstructive
Older individuals with insomnia have a 23% increase in risk of sleep apnea (snoring, breathing pauses), restless leg syndrome
development of depression symptoms.36 Several studies have (urge to move the extremities), parasomnias (unusual sleep
documented an increased risk of depression in older patients behaviors), and circadian rhythm disorders (unusual sleep
with persistent insomnia.37–39 A recent study noted 44% of older timings). Determining the use of alcohol, caffeinated drinks,
patients with persistent insomnia continued to have depression cigarettes, and any other substance that can adversely affect the
6 months later as compared to only 16% of those without in- quality of sleep is also very important. An insomnia evalua-
somnia.39 Insomnia and mental disorders such as depression tion should also include a history and physical examination re-
and anxiety have a bidirectional relationship.40 Additionally, lated to medical and psychiatric disorders that can exacerbate
insomnia also confers an increased risk of suicidal tedencies.41 insomnia. Neurological disorders (stroke, migraine), chronic
A meta-analysis of insomnia symptoms and its association with pain, endocrine disorders (hypothyroidism/hyperthyroidism),
heart disease, after adjusting for age and other cardiovascular chronic obstructive pulmonary disease, asthma, gastroesopha-
risk factors, identified that risk ratios for heart disease from geal reflux, and congestive heart failure can lead to or worsen
insomnia symptoms ranged from 1.47 to 3.90.42 Sleep loss and insomnia. The clinician should also ask about depression, bi-
insomnia are associated with hypertension, myocardial infarc- polar disorder, and anxiety disorders. Medication use should
tion, and perhaps stroke.43–46 In the Sleep Heart Health Study, a be reviewed, as sedatives, antidepressants, antihypertensives,
community-based cohort, adults (middle-aged and older) who steroids, and antihistamines can interfere with sleep.
reported 5 hours of sleep or less were 2.5 times more likely to
have diabetes, compared with those who slept 7 to 8 hours per Modalities That Assist the Clinician in the Evaluation
night.47 Another study has also demonstrated that people with of Insomnia
insomnia are at greater risk for metabolic syndrome.48 Recent
Wrist Actigraphy
research also demonstrates that insomnia symptoms may lead
to increased rates of cancer such as prostate cancer.49 Long- Wrist actigraphy, which monitors and stores movement data
term insomnia symptoms are also associated with greater risk for up to 28 days, can be used to monitor treatment response
of developing cognitive impairment.50,51 A cross-sectional cor- and to screen for other circadian disorders.57–59
relation between poor sleep quality and cortical atrophy has
Polysomnography
been shown in community-dwelling older adults.52 Insomnia is
regarded as an independent risk factor for work disability, sick Polysomnography is not recommended for the evaluation for
leave, and reduced work performance.53 Economically driven insomnia, but contributes to the evaluation of sleep apnea or
analyses conclude that insomnia is associated with high direct parasomnias.60
and indirect costs for the health care system and society.54
Insomnia Rating Scales
Numerous insomnia rating scales record symptoms and moni-
D I AG N O S I S tor the response to treatment.
The Insomnia Severity Index measures the subjective symp-
The evaluation and diagnosis of insomnia is a clinical one, toms and negative outcomes of insomnia over the previous 2
based on a thorough clinical history of the sleep problems and weeks. On this scale, scores higher than 14 suggest “clinical in-
relevant comorbidities obtained from the patients, their part- somnia.”61 The Pittsburgh Sleep Quality Index, a 19-item ques-
ners, and/or caregivers. Evaluation of insomnia symptoms tionnaire, measures 7 domains of sleep over the prior month.
presents challenges as they may occur as a primary disorder Global scores higher than 5 indicate clinically significant sleep
or result from other comorbid conditions. The clinician should disturbances.62
evaluate the nature, frequency, evolution, and duration of
Imaging Studies
symptoms, as well as the response to treatment. Using vari-
ous sleep diaries and questionnaires, a thorough assessment Daytime imaging studies are not needed for diagnosis of in-
of insomnia can be achieved. A Consensus Sleep Diary that somnia; however, if performed, MRI studies detect gray mat-
includes detailed questions can assist in obtaining additional ter reduction in the frontal lobes of the brain63–65 and reduced
sleep history.55 The temporal aspects of sleep (time at which hippocampal volume.66–68
a patient goes to bed, attempts at sleep, wake-up time, and fi-
nal time out of bed), quantitative aspects (sleep onset latency,
number and duration of awakenings, wakefulness after sleep T R E AT M E N T
onset, total sleep time), and qualitative aspects (subjective
sleep quality, satisfaction) should be noted. Behavioral fac- If left untreated, insomnia can have multiple medical and
tors, such as the use of electronic devices before going to bed, psychological consequences, emphasizing the importance
should also be addressed because these can suppress bedtime of insomnia at any age. Treatment can be divided into non-
melatonin production, adversely affecting circadian rhythm.56 pharmacological and pharmacological options.16,24,25,69 Aging

Journal of Clinical Sleep Medicine, Vol. 14, No. 6 1019 June 15, 2018
D Patel, J Steinberg and P Patel Insomnia in the Elderly: A Review

increases body fat, and reduces total body water and plasma populations.80 Multicomponent cognitive behavioral therapy
proteins, resulting in increased drug elimination half-life and that involves sleep hygiene measures, relaxation techniques,
the potential risk of adverse effects. Older adults should there- sleep restriction, and stimulus control is also as effective in
fore be treated with nonpharmacological options prior to phar- older adults as a stand-alone treatment.81,82
macological options.16,70
Pharmacological
Nonpharmacological There are several pharmacological options available for use in
There are several nonpharmacological options for the treat- older patients with insomnia. Pharmacological treatments are
ment of insomnia, including relaxation techniques, improving primarily classified as benzodiazepine sedatives, nonbenzo-
sleep hygiene, and cognitive behavioral therapy. These options diazepine sedatives, melatonin receptor agonists, antidepres-
are effective in managing insomnia for extended periods of sants, and orexin receptor antagonists. Recently published
time, even in patients with cognitive impairment.71 clinical practice guidelines of the American Academy of Sleep
Medicine for the pharmacological treatment of chronic insom-
Sleep Hygiene Education nia represent an evidence-based review of each class of drug
Education regarding sleep hygiene consists of several inter- commonly used in the treatment of insomnia.83
ventions that promote healthy stable sleep and a nondisrup-
Benzodiazepines and Nonbenzodiazepine Sedatives
tive sleep environment. These include avoiding daytime naps,
maintaining a regular sleep schedule, limiting substances such Both benzodiazepines and nonbenzodiazepine receptor ago-
as caffeinated beverages, nicotine, and alcohol that adversely nists have a common mechanism of action. They work by bind-
affect sleep, and exercising at least 6 hours before bedtime.72,73 ing to a specific receptor site on gamma-aminobutyric acid type
A receptors, with the difference being nonbenzodiazepines are
Cognitive Behavioral Therapy for Insomnia more selective for the alpha-1 subclass of receptors, which
When sleep hygiene is not effective, Cognitive Behavioral while causing sedation has minimal anxiolytic, amnesic, and
Therapy for Insomnia (CBT-I), effective in older adults, should anticonvulsant effects compared to that of benzodiazepines.84
be attempted.73–75 The American College of Physicians recom- Both classes of drugs effectively treat insomnia-related param-
mends CBT-I as first-line management for insomnia in adults.76 eters such as sleep onset latency, number of nighttime awaken-
It consists of 6 to 10 sessions with a trained therapist that focus ings, total sleep time, and sleep quality in the short term, but
on cognitive beliefs and counterproductive behaviors that in- not with chronic use.85–87
terfere with sleep. Prolonged use of these drugs can lead to tolerance, depen-
dence, rebound insomnia, residual daytime sedation, motor
Sleep Restriction Therapy incoordination, cognitive impairment, and increased risk of
This therapy involves restricting time in bed to the number of falls in institutionalized older individuals.88 These drugs can
hours of actual sleep, until sleep efficiency improves. If after 10 have additive effects if taken together. Because of these ad-
days sleep efficiency remains lower than 85%, sleep time in bed verse effects, and the equivalent or superior response seen with
should be restricted by 15 to 30 minutes until sleep efficiency CBT-I for longer duration therapy, use of these drugs should
improves. Time in bed is gradually advanced by 15 to 30 minutes be avoided in older individuals. The recent 2015 Beers criteria
when the time spent asleep exceeds 85% of total time in bed.77 strongly advise avoiding these drugs in the elderly.89
Pharmacokinetic properties of these drugs dictate the differ-
Stimulus Control Therapy ences between the drug effects on sleep parameters. Zolpidem
This therapy attempts to reassociate use of the bed and the de- has a shorter half-life (2 to 3 hours) and so may have less poten-
sired bedtime to sleep only. This includes going to bed only tial for residual daytime adverse events than zopiclone, which
when one feels tired, not using bed for reading, working, or has a longer half-life (5 to 6 hours). However, the shorter half-
lounging, leaving the bed if unable to sleep in 15 to 20 minutes, life of zolpidem renders it less useful in treating sleep mainte-
and maintaining a constant wake-up time each morning.78 nance insomnia. These drugs have a faster onset of action and
therefore can be used in treating sleep onset insomnia (reduce
Relaxation Techniques sleep onset latency).84
These include progressive muscle tensing and relaxing, guided Although the benefits outweigh the harms, there have been
imagery, paced diaphragmatic breathing, or meditation.25 reports of impairment in daytime concentration tasks, such as
driving while on zopiclone.90,91 In women, in whom zolpidem
Brief Behavioral Therapy for Insomnia clearance occurs more slowly than in men, morning blood lev-
Due to financial constraints and lack of psychological re- els following the recommended previous bedtime dose could
sources needed for CBT-I, a shorter form of therapy known be considerably higher, affecting psychomotor performance.92
as brief behavioral therapy for insomnia is also available and In 2013, this led the United States Food and Drug Administra-
involves core techniques from CBT-I, directed at improving tion (FDA) to require the manufacturers of zolpidem to lower
circadian regulation of sleep in more than two sessions. It has the recommended dose, particularly for women, from 10 mg to
been found to be effective in the geriatric population, with ben- 5 mg for immediate-release preparations, and 12.5 mg to 6.5
efits persisting for 6 months and beyond.79 Internet-based be- mg for extended-release forms. It also required manufacturers
havioral therapies have also been found to be effective in older to lower the recommended doses for men.

Journal of Clinical Sleep Medicine, Vol. 14, No. 6 1020 June 15, 2018
D Patel, J Steinberg and P Patel Insomnia in the Elderly: A Review

Antidepressants age 55 years and older based on decline in melatonin produc-

Various antidepressants, including phenylpiperazine com- tion seen with age.101 Treatment has been shown to be effec-
pounds (trazodone), tricyclic antidepressants (doxepin), and tive for primary insomnia in some studies; however, formal
serotonergic antidepressant (mirtazapine), have sedating prop- recommendations for the use of melatonin in the treatment of
erties and are often used for the treatment of insomnia. insomnia requires further research.83,101,102
Trazodone: It is widely prescribed for insomnia in doses of 25
Orexin Receptor Antagonists
to 100 mg. A study on trazodone comparing its effect with zol-
pidem in 21 to 65 year olds showed it has similar efficacy for Suvorexant: It is the first FDA-approved dual orexin recep-
sleep latency and sleep efficiency, with these effects dissipating tor antagonist and may be prescribed up to a 20-mg dose. It
after the first week.93 Adverse events such as dizziness, cardiac targets wakefulness-promoting neuropeptides that regulate
arrhythmias, orthostatic hypotension, and potential priapism the sleep-wake cycle, demonstrating its efficacy in decreasing
can be significant in the elderly population.94 Clinical practice sleep latency and in increasing total sleep time. Suvorexant has
guidelines from the American Academy of Sleep Medicine been studied in both elderly (age 65 years or older) and non-
suggest that clinicians not use trazodone for sleep onset or elderly (age 18 to 64 years) patients, identifying no significant
maintenance insomnia because its harms outweigh benefits.83 efficacy or safety differences between these two groups.103 Al-
though it is well tolerated by older adults, long-term data are
Doxepin: Of all the antidepressants, only doxepin is FDA ap- still lacking.103–105
proved for insomnia at doses of 3 to 6 mg. It is selective for
histamine 1 receptors. Studies of men and women age 65 years
and older with doses of 1 mg and 3 mg have shown that doxepin CO N CLUS I O N S
1 mg and 3 mg significantly improved measures of sleep on-
set (patient reported), sleep duration, sleep quality, and global Insomnia is very prevalent in older adults. Using the history
treatment outcomes over the 12-week study period.95 Higher and physical examination along with insomnia scales, clini-
doses of doxepin 3 mg and 6 mg to adults (18 to 64 years) with cians can evaluate and treat insomnia in our rapidly aging
chronic primary insomnia has also been reported to lead to population. Behavioral and cognitive behavioral therapies offer
significant and sustained improvements in sleep maintenance very effective longer duration treatment and are recommended
and early morning awakenings.96 as first-line treatment options for insomnia compared to hyp-
notic medications in older adults.
Mirtazapine: This antidepressant with strong 5-HT2 antago-
nism may also improve insomnia. In a study of adults age 18
to 75 years old with mean age of 40.9 years, the mirtazapine A B B R E V I AT I O N S
group had significant improvement in sleep latency, sleep ef-
ficiency, and awakenings after sleep onset after only 2 weeks CBT-I, cognitive behavioral therapy for insomnia
of treatment.97 It may be preferred over other drugs as it pro- DSM, Diagnostic and Statistical Manual for Mental Disorders
duces sedative effects solely through histamine receptor antag- FDA, United States Food and Drug Administration
onism.97 Because of conflicting evidence and habituation to its ICD, International Statistical Classification of Diseases and
sedative effects, it should not be used to treat insomnia in the Related Health Problems
absence of depression. ICSD, International Classification of Sleep Disorders
NREM, non-rapid eye movement
Melatonin Receptor Agonists REM, rapid eye movement
Ramelteon: It is also FDA approved for treatment of insom-
nia. In a study of older adults (age 65 years or older), treatment
with ramelteon significantly reduced patient reports of sleep R E FE R E N CES
latency over 5 weeks of treatment with no significant rebound
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Wayne State University School of Medicine, 5C University Health Center, 4201
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D I SCLO S U R E S TAT E M E N T
All authors have seen and approved the manuscript. The authors report no conflicts
of interest.

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