Sleep in the A ging

Population
Brienne Miner, MD, MHSa,*, Meir H. Kryger, MD, FRCP(C)a,b

KEYWORDS
 Aging  Insomnia  Sleep disorders  Multimorbidity  Polypharmacy  Geriatric syndromes

KEY POINTS
 Changes to sleep architecture with normal aging include decreases in total sleep time, sleep effi-
ciency, slow wave sleep, and REM sleep, and an increase in wake after sleep onset.
 Although sleep disturbance is common with aging, it is not an inherent part of the aging process;
medical, psychiatric, and psychosocial factors overshadow age as risk factors.
 Sleep disturbance in older adults is associated with increased morbidity and mortality.
 The evaluation and management of sleep disturbances in older adults is best approached as a
multifactorial geriatric health condition, arising from impairments in multiple domains.

INTRODUCTION disturbance. The increasing prevalence of multi-

morbidity (ie, having at least 2 concurrent diseases
Sleep is an important component for health and in the same individual)3 among older adults means
wellness across the lifespan. The number of peo- that sleep disorders might arise from multiple
ple in the United States who are 65 years or older different domains. Thus, sleep disturbance in this
is steadily increasing, and is expected to double age group should be considered a multifactorial
over the next 25 years to about 72 million. By geriatric health condition (previously referred to
2030, roughly 1 in 5 people in this country will be as a geriatric syndrome),4 requiring consideration
over the age of 65.1 Sleep complaints are common of multiple risk factors and a comprehensive treat-
among older adults, and as this segment of the ment approach.
population grows, so too will the prevalence of
sleep disturbances. However, sleep problems NORMAL AGE-RELATED CHANGES TO
are not an inherent part of the aging process. SLEEP–WAKE PHYSIOLOGY
There are changes to sleep architecture over the
lifespan that are not, in themselves, pathologic, Physicians addressing sleep complaints in older
but can be viewed as making older adults more adults are commonly asked about how much sleep
vulnerable to sleep disturbances.2 It is the conse- is enough. The National Sleep Foundation recom-
quences of aging, in the form of medical and psy- mends 7 to 8 hours of sleep for adults aged 65
chiatric comorbidity, medication and substance and older.5 This recommendation is supported by
use, psychosocial factors, and primary sleep dis- evidence that older adults sleeping anywhere
orders that put older adults at risk for sleep from 6 to 9 hours have better cognition, mental

Funding Sources: Dr B. Miner is supported by T32AG1934, the John A. Hartford Center of Excellence at Yale
and the Yale Claude D. Pepper Older Americans Independence Center (P30AG021342).
sleep.theclinics.com

Disclosure Statement: Drs B. Miner and M.H. Kryger have no commercial or financial conflicts of interest to
disclose.
a
Department of Internal Medicine, Yale School of Medicine, 333 Cedar Street, New Haven, CT 06520, USA;
b
VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT 06516, USA
* Corresponding author.
E-mail address: [email protected]

Sleep Med Clin - (2016) -–-

http://dx.doi.org/10.1016/j.jsmc.2016.10.008
1556-407X/16/Ó 2016 Elsevier Inc. All rights reserved.
2 Miner & Kryger

and physical health, and quality of life compared potentially protective effects of napping in later
with older adults with shorter or longer sleep dura- life, whereas others show it to be a risk factor for
tions. Thus, the need for sleep is not reduced in morbidity and mortality.11 There is some evidence
older adults, but the ability to get the required sleep to suggest that naps are protective for mortality if
may be decreased owing to normal changes in nighttime sleep duration is short, but are associ-
sleep architecture through the lifespan.6 ated with increased mortality risk if nighttime sleep
Age-related changes in sleep physiology have duration is longer than 9 hours.12
been well-documented using polysomnography
(Table 1). Most age-dependent changes in SLEEP COMPLAINTS IN OLDER ADULTS
sleep parameters occur by age 60 years,7 with Epidemiology
the exception of sleep efficiency. Sleep effi-
ciency (percentage of time spent asleep while Major sleep complaints include insomnia and
in bed), in contrast, continues to show an age- drowsiness. Symptoms of insomnia consist of dif-
dependent decrease beyond age 90 years. ficulties with initiating or maintaining sleep
Older adults also have a decrease in total sleep (including early morning awakening).13 Drowsi-
time, with corresponding decreases in the per- ness has to do with the propensity for sleep and
centage of time in slow wave sleep and REM is often established by napping behavior.14 Many
sleep.7 Slow wave sleep and REM sleep are large studies documenting the epidemiology of
thought to promote metabolic and cognitive re- sleep complaints in older adults have shown that
covery, and to enhance learning and memory, insomnia symptoms and drowsiness are common
respectively.2 Older adults also have an in- in this age group. The Established Populations for
crease in time awake after sleep onset.7 Epidemiologic Studies of the Elderly included 9282
Although the number of arousals from sleep in- community-dwelling adults aged 65 and older, and
creases in healthy older adults, evidence sug- found that 43% of participants reported difficulty
gests they do not have greater difficulty falling with sleep onset or maintenance, and 25% re-
back to sleep.8 There is an increase in sleep la- ported napping.15 The National Sleep Founda-
tency (the time it takes to fall asleep) up to age tion’s 2003 Sleep in America Poll confirmed the
60, with no clear age effect beyond that point.7 prevalence of these symptoms, stating that 46%
Circadian rhythms also change over the lifespan. of community-dwelling adults aged 65 to 74 re-
These rhythms are 24-hour intrinsic physiologic ported insomnia symptoms, and 39% of people
cycles that are involved in control of sleep-wake in this age group reported napping. These preva-
and many other physiologic processes (eg, blood lence rates increased to 50% and 46%, respec-
pressure, bone remodeling, release of certain tively, in participants aged 75 to 84 years.16 It is
hormones).9 Aging is associated with a phase estimated that 40% to 70% of older adults have
advance, resulting in an earlier onset of sleepiness chronic sleep problems, and up to 50% of cases
in the evening and earlier morning awakening.10 are undiagnosed.6
Daytime wakefulness is affected by phase The major sleep complaint depends on the
advance, with older adults being more alert in the cause of the sleep disturbance. Symptoms of
morning and more somnolent in the evening. insomnia are common in people using activating
Although napping is common in older adults, re- medications or substances, in those with comor-
sults with regard to the benefit or harm of this prac- bid medical or psychiatric illness, or in those with
tice are mixed. Some studies show beneficial and restless leg syndrome (RLS). Daytime drowsiness
can result from sedating medications, chronic
medical illness, or obstructive sleep apnea
(OSA). With respect to OSA, whereas drowsiness
Table 1
Age-related changes in sleep architecture
and snoring are the most common complaints,
older adults may also complain of choking or
Decreased Increased gasping on awakening, observed apneas, morning
headache, nocturia, wandering, or confusion.17,18
Sleep  Total sleep  Time awake
parameter time after sleep Consequences of Poor Sleep
 Sleep onset
efficiency  Number of Sleep complaints, whether related to insomnia
 Slow wave arousals symptoms or drowsiness, have important conse-
sleep from sleep quences in older adults. Beyond being distressing
 Rapid eye  Sleep for the subject, these symptoms predict poor
movement latency
physical and mental health-related quality of
sleep
life.19 In longitudinal studies, insomnia complaints
 Sleep in the Aging Population 3

have been associated with many different detri- cooccurring disease with respect to an index dis-
mental outcomes, including poor self-reported ease) to multimorbidity. Multimorbidity refers to
health status, cognitive decline, depression, the coexistence of 2 or more chronic medical con-
disability in basic activities of daily living, poorer ditions in the same person.25 However, a more
quality of life, and a greater risk of institutionaliza- nuanced definition takes into account the both
tion.2,17 Insomnia is also associated with impaired number and the severity of conditions, and
physical function and an increased risk for considers the link between multimorbidity and
falls.11,17 Daytime drowsiness has also been asso- cognitive and physical dysfunction, as well as psy-
ciated with harmful outcomes in longitudinal chosocial factors.3
studies, including cardiovascular disease, falls, With an increasing number of health problems,
and death.2 Healthy older adults who have sleep the likelihood of sleep complaints increases. This
latencies of greater than 30 minutes, sleep effi- was demonstrated in the 2003 National Sleep
ciencies of less than 80%, or REM sleep percent- Foundation survey, which showed that, among
age of less than 16% or greater than 25% of total people aged 65 years and older without comorbid
sleep are at increased mortality risk, even after illness, 36% reported a sleep problem. This per-
controlling for age, gender, and baseline medical centage increased to 52% among people with 1
burden.20 to 3 comorbid conditions, and to 69% among peo-
ple with 4 or more comorbid conditions.16 The cu-
mulative effects of multiple chronic conditions on
PATHOLOGIC AND PSYCHOSOCIAL FACTORS
sleep complaints is not surprising, considering
AFFECTING SLEEP IN THE AGING
that single diseases are known to affect sleep
POPULATION
quality in older adults; if one is bad, more than
Pathologic Factors
one is likely to be worse.
Although aging per se does not lead to sleep
pathology, the aging process is associated
Medications and Substance Use
commonly with multiple pathologic problems that
can affect sleep. Older adults commonly suffer Medication use is another factor that may increase
from pain syndromes, arthritis, digestive disease, risk for sleep disturbances in older adults. The use
heart disease, lung disease, renal and urologic dis- of prescription medications, over-the-counter
eases, and cancer, all of which can contribute to medications, and dietary supplements is increasing
sleep disturbance through specific symptoms or in this age group. A recent study of a nationally
because of complications or anxiety associated representative sample of community-dwelling
with these diseases.21 Psychiatric illness is as adults aged 62 to 85 years found that 88% used
important as medical comorbidity in its effect on at least 1 prescription medication, 38% used
sleep, and has long been recognized to signifi- over-the-counter medications, and 64% used die-
cantly and independently increase the risk for tary supplements.26
insomnia in older adults.21,22 Sleep disruption fea- Different classes of medications commonly
tures prominently in many psychiatric conditions, used in older adults can impact sleep directly
including depression and anxiety, which are com- through multiple mechanisms. One such effect
mon in older adults.21 Sleep disturbance and is increased daytime drowsiness, as can be
depression are intertwined, as insomnia may be seen with antihistamines, anticholinergic and anti-
a result of depression but also increases the risk convulsant medications, and opiates. Medica-
of developing depression in older adults.23 tions can be activating or stimulating, as is the
More so than the impact that a single condition case with pseudoephedrine, beta agonists, corti-
has on sleep problems, one of the major issues costeroids, certain antidepressants, methylpheni-
leading to a higher risk of sleep problems in older date, or selegiline. Other medications can
adults is the accumulation of comorbidities. More exacerbate primary sleep disorders or directly in-
than 1 in 4 Americans is living with 2 or more fluence sleep architecture. For example, RLS and
chronic conditions, and the prevalence of multiple periodic limb movements of sleep (PLMS) can
chronic conditions increases with age.24 A recent worsen with the use of certain antidepressants,
report of fee-for-service Medicare beneficiaries and sleep disordered breathing can worsen with
found that the rate of 2 or more chronic conditions the use of opiates or benzodiazepines.21 With
was 62% for those aged 65 to 74 years and respect to sleep architecture, certain beta-
increased to 82% for those aged 85 years and blockers have been shown to suppress melatonin
older.25 In fact, this situation has become so com- secretion and increase sleep fragmentation.
mon that there has been a shift from looking at co- Others can worsen parasomnias, induce REM
morbidity (which focuses on the effect of a single sleep behavior disorder (RBD), or change the
4 Miner & Kryger

amount of time spent in REM sleep.21 A final fac- and erratic schedules, all of which may contribute
tor to consider is whether a medication might be to diminished sleep quality and disruptions in
interfering with sleep by worsening other condi- normal sleep patterns. In addition, caregiving is
tions or causing sleep-disruptive symptoms. associated with depressed mood as well as
Several examples of such effects include medica- erosion of physical health in the caregiver, further
tions that worsen heart failure, have diuretic ef- increasing the risk for sleep disturbance.31,32 This
fects, create bothersome coughing, or cause can be a vicious cycle, because poor sleep can
nocturnal hypoglycemia. further erode physical health. Poor overnight
Polypharmacy may also contribute to height- sleep in caregivers has also been associated
ened risk for sleep disturbance in older adults. with reduced quality of life and increased inflam-
Although it is generally defined as the use of mul- matory markers,32 and is one of the strongest fac-
tiple medications, there is no consensus definition tors leading to institutionalization of a care
about the number of medications that constitutes recipient with dementia.33
polypharmacy.27 In epidemiologic studies, poly- Rates of social isolation increase after retirement
pharmacy is frequently defined as taking 5 or and because 28.3% of adults aged 65 and older live
more medications. A 2003 survey of Medicare alone.34 Isolation can impact sleep through its ef-
beneficiaries found that 46% of those surveyed fect on sleep hygiene and zeitgebers (see below).
met this definition for polypharmacy.28 This condi- Sleep hygiene refers to a set of behavioral and envi-
tion is increasingly common as age-related ronmental recommendations that are intended to
comorbidities increase, putting older adults at promote sleep. These recommendations include
risk for drug–drug and drug–disease interac- avoiding caffeine or alcohol, getting regular exer-
tions.26,29 Polypharmacy may be compounded cise, and maintaining a regular sleep schedule
by the cascade effect, which refers to the use of while avoiding daytime naps.35 However, the loss
medications to treat side effects caused by other of a regular schedule and decreased social contact
medications.21 can lead to loneliness, inactivity, and boredom,
Substance use merits consideration in the older potentially promoting behaviors like napping and
adult with sleep disruption, especially with respect irregular bedtimes that are counter to the promo-
to alcohol, caffeine, and tobacco consumption. tion of healthy sleep. Zeitgebers are cues from
Although acute consumption of alcohol may the environment that entrain circadian rhythms to
decrease sleep latency, it can increase arousal, a 24-hour cycle length, promoting normal sleep–
leading to sleep that is of poorer quality and wake habits. Zeitgebers may be light based, but
shorter duration. Alcohol can also exacerbate also include exercise, scheduled meals, and other
sleep-disordered breathing by decreasing pharyn- social cues.36 For socially isolated older adults,
geal muscle tone.21 The stimulating effects of there may be inadequate exposure to zeitgebers,
caffeine can increase sleep latency and number leading to irregular sleep–wake patterns. Previous
of arousals, leading to a shorter sleep duration.21 evidence has shown that reports of insomnia and
Tobacco consumption has been associated with drowsiness were greater in older adults who felt so-
insomnia in several studies. Nicotine is a potential cially isolated,16 whereas activity and satisfaction
mediator of this effect, because it may promote with social life protected those aged 65 and older
wakefulness via an effect on acetylcholine trans- against insomnia symptoms.37
mission in the central nervous system.21 However, Loss of physical function is common among
a causal relationship has not been established.30 older adults. In 2009, 30% of Medicare enrollees
aged 65 and older reported needing assistance
with basic activities of daily living.38 Although this
Psychosocial Factors
loss has many implications for the health of older
Psychosocial factors can impact sleep in older adults, it also affects their level of activity and
adults in multiple ways. Particularly relevant are exposure to zeitgebers. Thus, its effects on sleep
the effects of caregiving, social isolation, loss of are similar to those described for social isolation.
physical function, and bereavement. In a National Sleep Foundation survey, older adults
Caregiving is common to the process of aging. with decreased physical function (defined as diffi-
Recent evidence from the National Alliance for culty walking one-half mile without help and/or dif-
Caregiving indicates that 43.5 million adults in ficulty walking a flight of stairs without help) were
the United States provided unpaid care to an more likely to report insomnia symptoms (66%
adult or child in the prior year, and that approxi- vs 44%) and daytime sleepiness (28% vs
mately 1 in 5 of these caregivers was 65 years 12%).16 Loss of physical function has also been
of age or older.31 Providing intensive assistance associated significantly with the development of
can result in psychological stress, physical strain, insomnia symptoms.15
 Sleep in the Aging Population 5

Bereavement, the experience of losing a look at insomnia diagnosis but use different diag-
loved one to death,39 is another factor that may nostic criteria. It is widely accepted that insomnia
contribute to sleep disturbance in older adults. A symptoms increase with advancing age, with
recent study found that more than 70% of older prevalence rates approaching 50% in adults
adults experienced bereavement over a 2.5-year aged 65 and older.13 The annual incidence rates
period.40 Bereavement is experienced more often for insomnia symptoms have been estimated to
in older adults because the loss of a spouse, sib- be 3% to 5%,15,22 and remission rates may be
lings, or friends is common in this age group.40,41 as high as 50% over 3 years.15 With respect to
The grief experienced from such a loss has been an insomnia diagnosis, the prevalence has been
associated with worsening health and functional estimated to be around 5%.46 It is thought that
impairment in older adults,41 as well as an prevalence of insomnia diagnosis increases after
increased risk for the development of mood and 45 years of age, but may remain the same in indi-
anxiety disorders and substance abuse.39 Impor- viduals after 65 years of age.13 There are different
tantly, bereavement in older adults has also been theories about why the discrepancy between
associated with increased loneliness and social insomnia symptoms and diagnosis exists. Some
isolation.41 Thus, as with the other psychosocial authors have postulated that insomnia symptoms
factors mentioned, worsening health, psychiatric may be better tolerated or the daily demands
illness, and social isolation play a role in increasing less for older adults.47 Others point to a “paradox
the risk for sleep disturbance in bereavement. Mul- of well-being” bias in questionnaires, in which
tiple studies have shown an association between older adults are less likely to report dissatisfaction
bereavement and sleep disturbance.15,42,43 Older or distress because their actual state of health ex-
adults are at higher risk for complicated grief after ceeds the expected level.11,48
bereavement, a condition in which grief symptoms
are more severe and prolonged. The physical and
Obstructive Sleep Apnea
mental health consequences of complicated grief
are more severe than those associated with acute OSA increases with advancing age, with preva-
grief, and sleep impairment may be worse in these lence estimates differing depending on the defini-
individuals.41 tion used. Using a definition of 10 or more apneas
and/or hypopneas per hour of sleep, OSA preva-
lence estimates in older adults may be as high as
SLEEP DISORDERS IN OLDER ADULTS
70% in men and 56% in women. This is in contrast
Insomnia
with prevalence estimates in the general adult
A diagnosis of insomnia disorder is made clinically population of 15% in men and 5% in women.17
via a complaint of dissatisfaction with sleep quality Although it is more common, this condition
and/or quantity, difficulty initiating or maintaining frequently goes undiagnosed because the pheno-
sleep, waking up too early, and/or nonrestorative type of OSA can look very different in older adults.
or poor sleep, with a negative impact on daytime After the age of 60, the prevalence of OSA is equiv-
functioning and occurring at least 3 nights a alent in males and females, obesity is no longer a
week for more than 3 months.44 The majority of significant risk factor, and witnessed apneas and
insomnia diagnoses in older adults result from “co- snoring are not reported as frequently.49 Older
morbid insomnia.”45 This designation emphasizes adults are also more likely to present with more
the coexistence of insomnia with other medical sleep-related complaints, including daytime sleep-
and psychiatric comorbidities, and acknowledges iness and nocturia.50
that it may not be possible to determine whether Older adults are at risk for OSA for several rea-
insomnia is a cause or consequence of coexisting sons. With aging, there is loss of tissue elasticity
illnesses. As described, multimorbidity, polyphar- as well as sarcopenic muscle wasting.11,49 There
macy and substance use, and psychosocial fac- are also structural changes to the upper airway,
tors are common with the aging process and put including lengthening of soft palate and upper
older adults at risk for a diagnosis of insomnia. airway fat pad deposition.11 These age-related
The epidemiology of insomnia in older adults changes increase the tendency for oropharyngeal
has been the subject of many studies, but summa- collapse. In addition, ventilatory control instability
rizing the results is difficult because insomnia is may predispose older adults to apneic events.11
defined differently in these studies. Some look The negative consequences of OSA in older
only at insomnia symptoms (eg, difficulty initiating adults include excessive daytime sleepiness,
or maintaining sleep, complaints of nonrestorative decreased quality of life, neurocognitive impair-
sleep) with or without inclusion of criteria on fre- ment, nocturia, and worsening of cardiovascular
quency or severity of symptoms, whereas others disease, particularly hypertension, heart failure,
6 Miner & Kryger

and stroke. Diabetes mellitus and depression have geriatric health condition.2,4 The implication of
also been found to be more common in older this designation is that evaluation of sleep distur-
adults with OSA. The impact of untreated OSA in bance requires consideration of multiple risk
older adults on mortality is not clear.17 However, factors and a multifaceted treatment approach.
older adults have similar adherence rates to treat- Similar approaches have been used in other multi-
ment,17,49 so there is no clear reason not to treat factorial geriatric health conditions, including falls
older adults with OSA. and delirium, and have successfully decreased
occurrence of these events.53,54
Restless Leg Syndrome and Periodic Limb
Movements of Sleep SUMMARY
RLS and PLMS increase in prevalence and There are normal changes to sleep architecture
severity with advancing age and have the potential throughout the lifespan. There is not, however, a
to cause sleep complaints. RLS is a sensorimotor decreased need for sleep and sleep disturbance
disorder characterized by unpleasant sensations is not an inherent part of the aging process. Sleep
in the limbs that cause an urge to move, especially disturbance is common in older adults because
in the evening. PLMS is a disorder characterized aging is associated with an increasing prevalence
by repetitive episodes of stereotypic limb move- of multimorbidity, polypharmacy, psychosocial
ments caused by muscle contractions during factors affecting sleep, and certain primary sleep
sleep.17 In epidemiologic studies, the prevalence disorders. It is also associated with morbidity
of RLS in older adults ranges from 9% to 20%, and mortality, making evaluation and management
and PLMS is estimated to be present in 4% to of sleep disturbance in older adults an important
11% of older adults.51 Of persons with RLS, 80% focus. Because many older adults will have several
will have PLMS. However, PLMS occurs in the factors from different domains affecting their
absence of RLS approximately 70% of the time.2 sleep, these complaints are best approached as
These disorders can contribute to insomnia com- a multifactorial geriatric health condition, necessi-
plaints through disruption of sleep onset or main- tating a multifaceted treatment approach.
tenance, as well as contributing to daytime
drowsiness.
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