Elderly patients are especially vulnerable to insomnia: sleep cycle changes, medical and emotional disorders, and polypharmacy are a few factors contributing to sleep disruption in your elderly patients

Journal of Family Practice, Sept, 2004 by Roger J. Cadieux

Elderly patients are frequently dissatisfied with their sleep. Changes in the sleep cycle that occur with age are one cause. Disturbed sleep also may be a symptom that reflects a serious underlying pathology; or it may accompany physical and emotional abnormalities that are correctable or that subside with time.

Generally, elderly persons are light sleepers. Their first sleep cycle is shorter than that of children and young adults, and they have more stage 2 sleep and less of stages 3 and 4. Their sleep is less restful and not as deep as it was when they were younger. They toss and turn more, consequently experiencing more arousals as well as more frank awakenings.

Evaluating elderly patients with insomnia

Insomnia is often a symptom of another condition, either medical or psychosocial, rather than the primary disorder. When an elderly patient presents in your office complaining of insomnia, it's important to look for the underlying cause of the sleep problem and treat that condition. Try to uncover and understand what is causing the symptoms of insomnia. For example, is the patient having trouble falling asleep because he or she is itchy? Is pain from osteoarthritis disrupting sleep?

In addition to often having multiple physical conditions, elderly patients have an increase, in predisposition to emotional disorders. Both anxiety and depression are associated with insomnia. Before ordering multiple tests or prescribing medication, lend an empathic ear. Explore underlying fears and encourage appropriate ventilation of conflicts and anger. Maintain emotional support while providing psychotherapeutic insight.

Sleep hygiene

While it is important to address issues of sleep hygiene with patients of all ages who present with sleep complaints, the elderly are particularly susceptible to discomfort, neighborhood noise, anti disruptions of privacy. Some elderly patients have a habit of going to bed early in the evening, spending too much time in bed. Ironically, the more time the elderly spend in bed, the less time they spend actually asleep. Another habit common among older people is multiple daytime naps, which also can interfere with a good night's sleep.

Ask your elderly patients:

* Is the climate in your bedroom appropriate, neither too hot or cold, nor too humid or dry?

* Do you go to bed at the same time each night?

* Do you avoid the use of alcohol, which can disrupt your sleep cycle?

Appropriate medication choices

Polypharmacy and individual variability in drug metabolism due to genetic factors, concurrent disease, and dietary habits make careful selection of appropriate medication an important issue for elderly insomniacs. The elderly in general take more medications and thus have higher rates of drug interactions. We need to be careful about which medications we choose for this patient population.

The physiologic changes that accompany aging may cause different rates of drug metabolization. Too short a half-life for a hypnotic medication (< 10 hours) and elderly patients will experience rebound of their condition; a drug with too long a half-life (>50 hours) may lead to carry over effects, such as daytime sleepiness, falls, and injuries. How medications are metabolized in your elderly patients should be a concern for all drugs, especially those with sedating or hypnotic effects.

Avoid OTC sleeping aids

The use of antihistamines and over-the-counter sleeping aids is neither safe nor effective in elderly patients. They have a higher rate of anticholinergie side effects that can lead to confusion and delirium. They also can disrupt the sleep cycle and cause rebound rapid eye movement (REM), leading to nightmares or the elimination of stages 3 and 4 sleep, that is, the loss of deep sleep.

To break the cycle of insomnia, clinicians may consider a short-term course of a nonbenzodiazepine hypnotic for 7 to 10 days, after which the patient should be reevaluated. If the cycle of insomnia is broken and the underlying cause of insomnia has been treated, that's a good place to suspend treatment.

FOR MORE INFORMATION

Buysse DJ. Insomnia, depression and aging. Assessing sleep and mood interactions in older adults. Geriatrics. 2004;59(2):47-51; quiz 52.

Cadieux RJ, Woolley DC, Kales JD. Sleep disorders in the elderly. Psychiatric Med. 1986; 4(2):165-180.

Dollman WB, LeBlanc VT, Roughead EE. Managing insomnia in the elderly--what prevents us using non-drug options? J Clin Pharm Ther. 2003;28(6):485-491.

Kryger M, Monjan A, Bliwise D, Ancoli-lsrael S. Sleep, health, and aging. Bridging the gap between science and clinical practice. Geriatrics. 2004;59(1):24-6, 29-30.

Dr Cadieux is a clinical professor in the Department of Psychiatry at Pennsylvania State University College of Medicine. Hershey, PA.