Literature Review

Assessment and treatment of sleep disturbances in older adults

Article· Literature ReviewinClinical Psychology Review 20(6):783-805 · September 2000with 818 Reads 
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Abstract
Sleep disturbances are common in older adults. These disturbances are often secondary to medical illness and/or medication use or are due to specific problems such as sleep disordered breathing, periodic limb movements in sleep and circadian rhythm disturbances. The prevalence of sleep disordered breathing and periodic limb movement in sleep increases with age. The circadian rhythm tends to advance with age, causing older people to awaken early in the morning. Insomnia is often caused by pain associated with medical illness. Insomnia can also be caused by stimulating medications. In institutionalized elderly, sleep becomes even more disturbed and fragmented than in community-dwelling older adults. Accurate assessment and diagnosis is crucial since effective treatment strategies are available for these sleep disturbances. The effect, prevalence and treatment of each of these conditions is reviewed.

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  • ... Research examining whether or not older adults actually need less sleep is inconclusive (Bliwise, Ansari, Straight & Parker, 2005); however, some evidence suggests that there is a decrease in older adults' ability to initiate and maintain sleep (Martin, 2000). Changes in the ability to sleep in older adults may be caused by several factors, including specific sleep disorders such as, insomnia, sleep apnea, periodic leg movement in sleep, and restless leg syndrome, which have known to be common in an inpatient rehabilitation facility (Ouellet & Beaulieu-Bonneau, 2011). ...
    ... For example, it is important to consider that these medications may increase the medical and cognitive risks for adverse effects (e.g., falls, confusion, and increase fatigue) (Ray, Thapa & Gideon, 2000;Schneeweiss & Wang, 2005). Moreover, physiologic alteration in how older adults metabolize some of these medications may produce either a higher peak of concentration or longer duration of drug activity (Martin, 2000) leading to residual daytime sedation (Alessi et al., 2005). Withdrawals from these medications may also be associated with rebound insomnia, although the symptoms usually do not last more than 1-2 days (Roehrs, Vogel & Roth, 1990). ...
    ... Following the American Psychological Association on coding procedures, sleep restriction-sleep compression therapy and multicomponent cognitive-behavioral therapy were the two treatments found to meet evidence-based psychological treatments criteria for insomnia in older adults. Other studies identified cognitive-behavioral relaxation therapy, and sleep hygiene education (see Table 2) (Harvey, 2002;Martin, 2000;Montgomery & Dennis, 2009;Morin, 2004;Morin et al., 1999). However, only one research study has been related to treatments of disturbed sleep in IRFs (Freter & Becker, 1999). ...
    Article
    Purpose: The purpose of this article is to provide an overview of changing sleep patterns and common sleep disorders in older adults and to discuss treatment options of sleep disturbances within inpatient rehabilitation facilities (IRFs). Methods: Through extensive review of the existing literature, common sleep disorders among older adults and several key factors that may impact sleep in older adults in inpatient rehabilitation facilities, such as behavioral and environmental factors, psychosocial and emotional factors, medical conditions, and medications were identified. Findings: Current literature on the factors associated with sleep disturbance in older adults in IRFs is based on work with community-dwelling older adults and those in long-term care facilities. While interventions to address these disorders and research investigation key factors associated with sleep problems among older adults appear in the literature, there is very little work that applies these interventions within IRFs. Conclusions and clinical relevance: Research is needed to examine the impact of sleep problems on older adults in IRFs, including work that focuses on intervention trials to identify successful treatments for these problems and translate those approaches into practice.
  • ... Assessment of health status in the elderly has become a more important research priority as a result of the global increase in the life-expectancy [1]. Sleep disturbances represent a leading problem in the elderly populations (≥ 65 years), with approximately 40% of the older individuals reporting sleep impairment and dissatisfaction from sleep quality [1][2][3][4]. ...
    ... Assessment of health status in the elderly has become a more important research priority as a result of the global increase in the life-expectancy [1]. Sleep disturbances represent a leading problem in the elderly populations (≥ 65 years), with approximately 40% of the older individuals reporting sleep impairment and dissatisfaction from sleep quality [1][2][3][4]. Poor sleep quality may lead to day-time sleepiness, chronic fatigue, and increased risk of accidents and falls [5]. The prevalence of sleep disorders has been reported to increase after 30 years of age, followed by a plateau period and a subsequent additional peak after the 5 th decade of life [1,4]. ...
    ... Poor sleep quality may lead to day-time sleepiness, chronic fatigue, and increased risk of accidents and falls [5]. The prevalence of sleep disorders has been reported to increase after 30 years of age, followed by a plateau period and a subsequent additional peak after the 5 th decade of life [1,4]. In recent years, we have witnessed a growing interest in sleep disturbances in the scientific community. ...
  • ... Hypnotics are the most common therapy for insomnia in older adults. 24 Age-related differences seen in the elderly related to changes in pharmacokinetics and pharmacodynamics may alter the effects of these medications. In addition, long-acting hypnotics may cause adverse daytime effects such as excessive daytime sleepiness, poor motor coordination, and visuospatial problems, which may lead to falls and injury. ...
    ... 26 Other disadvantages related to the use of hypnotics in older patients include (1) alteration of sleep architecture with a reduction in slow-wave sleep and rapid eye movement sleep; (2) development of tolerance when used continuously, resulting in reoccurrence of insomnia symptoms unless the dosage is increased; (3) rebound insomnia and anxiety caused by withdrawal; and (4) exacerbation of coexisting medical conditions. 24 Elderly caregivers of persons with AD and their care recipients may be placed at great risk for adverse events when either the elderly caregiver or the person with AD is taking hypnotics for the relief of symptoms related to insomnia. ...
    Article
    Family caregivers of persons with dementia and their care recipients frequently experience sleep and mood disturbances throughout their caregiving and disease trajectories. Because conventional pharmacologic treatments of sleep and mood disturbances pose numerous risks and adverse effects to elderly persons, the investigation of other interventions is warranted. As older adults use complementary and alternative medicine interventions for the relief of sleep and mood disturbances, cranial electrical stimulation, an energy-based complementary and alternative medicine, may be a viable intervention. The proposed mechanism of action and studies that support cranial electrical stimulation as a modality to reduce distressing symptoms are reviewed. Directions for research are proposed.
  • ... People with Alzheimer's disease and people with Lewy Body dementia have been found to have specific changes in their circadian rhythms, which can result in significant sleep disturbance (Grace et al., 2000;Volicer et al., 2001;Cole and Richards, 2005). Most older people do wake at night because of sleeping difficulties (Martin, 2000) but the disorientation in time and space caused by the dementia means that, when people with dementia wake, they are often distressed and confused. The confusion will often mean that they mix up day and night. ...
    Article
    People with a learning difficulty are living longer. This increased longevity brings with it the conditions and illnesses of older age, such as dementia. It is known that amongst people in the general population who have dementia there is inadequate pain recognition and treatment. This report has identified similar trends in pain management amongst people with a learning difficulty and dementia. The report explores knowledge and practice in relation to pain recognition and management amongst direct support staff, members of community learning disability teams and general practitioners. It also examines the understanding and experiences of pain amongst people with a learning difficulty and dementia. It identifies the dilemmas and obstacles to effective pain management, and reports on examples of good practice. The authors make clear recommendations for practitioners and service providers. The report found that the pain experiences and management of people with a learning difficulty who have dementia mirrored findings in relation to people in the general population. It did, however, identify extra and compounding issues in relation to people with a learning difficulty. The findings in this report will be of interest to service providers and direct practitioners in health, housing, social care and social work.
  • ... Ülkemizde yap›lan araflt›rma sonuçlar› da bul-gular›m›z› destekler nitelikte olup, Fad›lo¤lu ve arkadafllar›-n›n (6) yapt›¤› çal›flmada huzurevinde yaflayan yafll›lar›n %77'sinin, Eser ve arkadafllar›n›n (21) çal›flmas›nda %61'nin bozuk uyku kalitesine sahip oldu¤u bildirilmifltir. Di¤er ülkelerde yap›lan epidemiyolojik çal›flmalar da toplumun yafl-lanmas›yla birlikte, yafll› bireylerde spesifik t›bbi ve psikolojik problemlerin yan› s›ra kötü uyku kalitesinin de yo¤unlafl-t›¤›n› do¤rulamakta (21) huzurevi gibi uzun süreli bak›mevlerinde kalan 65 yafl üstü yafll›lar›n yaklafl›k olarak üçte ikisinin uyku bozuklu¤u sorunu yaflad›klar›n› bildirmektedirler (22,23). ...
    Article
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    Introduction: This study aimed to define the sleep quality levels of the elderly living in a nursing home and to determine the relation between sleep quality and sociodemographic properties, circadien rhythm changes and daytime sleepiness in the elderly. Materials and Method: This study was implemented with a sample group of 136 people who were ≥65 and were dwelling at Gazio¤lu Nursing Homes in Kayseri. Sleep quality was assessed with Pittsburg Sleep Quality Index (PSQI), circadian rhythm with Morningness- Eveningness Questionnaire (MEQ) and daytime sleepiness with Epworth Sleepiness Scale (ESS). In the statistical analysis; percent and frequency distribution, t test and ANOVA were used. Results: The mean age of the sample was 75.05±6.96 consisting of 59.6% males. 64.7% had not received formal education, 83.1% were divorced. The mean score of PSQI was 6.01±3.17 and 55.1% of aged had a poor sleep quality. PSQI mean scores were higher for females, for illiterate (6.42±3.21), for married, and for subjects with a chronic disease. 49.3% of the aged were “close to morning type” and 47.8% indicated “intermediate type” feature. 23.0% of the group had increased daytime sleepiness. Conclusion: More than half of aged had a poor sleep quality. Gender, marital status and presence of chronic diseases significantly influence sleep quality.
  • ... Based on the results obtained from other studies conducted in our country, which supported our findings, it was reported that between 61% -77% of nursing home residents [34]. In epidemiologic studies performed in other countries, it was confirmed that, with an aging population, the incidence of poor sleep quality, as well as specific medical and psychological problems, was increased in elderly people [35]. It was reported that for people aged 65 years and over, approximately half of those who live in their own homes, and approximately two thirds of those who reside in long-term nursing homes had sleep disorders [36]. ...
    Article
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    Purpose: To define the level of quality of life in an elderly population and to investigate the effects of selected variables, such as anemia, fatigue , depression and sleep disorders, on the quality of life. Design and Methods: The study was conducted in Gazioğlu Nursing Home, located in the city center of Kayseri, on 136 subjects ≥65 in the year 2008-2009. Data were collected using the Geriatric Depression Scale (GDS), Fatigue Severity Scale (FSS), Pittsburgh Sleep Quality Index (PSQI) and the World Health Organization Quality of Life-OLD (WHOQOL-OLD) Module. In the statistical analysis mean ± standard deviation, student's t-test, ANOVA and Spearman correlation analysis were used. Results: The mean total score of quality of life was 43.45 ± 10.30. Of the residents 47.0% had a poor quality of life. Autonomy had the lowest (35.70 ± 19.96) and intimacy had the highest (48.75 ± 17.96) subdomain scores. Fatigue significantly decreased the total and autonomy, social participation and death and dying subdomain scores. Anemia had a significant adverse effect on intimacy , depression on autonomy and intimacy and sleep disorder on death and dying. There were negative correlations between fatigue with past-present-future activities and social participation , depression with social participation, intimacy , death and dying and glucose levels with social participation and intimacy. Implications: About half of the subjects had a poor quality of life. Fatigue was the sole factor to negatively affect the total score in WHOQOL-OLD. Depression , anemia and sleep disorder adversely affected the autonomy, social participation, intimacy , death and dying subdomain scores but not in all.
  • ... Com o envelhecimento, é possível notar mudanças na qualidade do sono dos idosos, considerada uma das queixas mais frequentes entre eles (3) . A literatura aponta que prejuízos significativos no funcionamento cognitivo podem advir de perturbações do sono (4) . Embora o processo do envelhecimento não seja considerado causa direta de problemas relacionados ao sono, algumas modificações são notadas, tais como: redução quantitativa dos estágios de sono profundo, redução do limiar para o despertar devido a ruídos, aumento quantitativo do sono superficial e da latência para o início do sono, redução da duração total do sono noturno, maior número de transições de um estágio para outro e para a vigília, maior frequência de distúrbios respiratórios durante o sono (5) . ...
    Article
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    This is a descriptive cross-sectional study, which aimed to identify the perception of nursing home elderly residents related to the chronological organization of their daily routines and to their sleep quality. The study was conducted with 37 elderly (14 women and 23 men, mean age of 75 years) who lived in a long term care facility located in the municipality of Campinas-SP, Brazil. The results showed that 81% of the elderlies had complaints compatible with poor sleep, but 70% of them reported that they had good sleep quality when directly questioned about it. All elderlies adequately realized the chronological organization of their routines, but this perception did not appear to contribute to the good sleep quality, as most of them had complaints compatible with poor sleep. It becomes evident that nurses should perform detailed assessment of sleep quality in order to minimize or prevent these problems and their possible consequences.
  • ... When evaluating the sleep of older adults, one should also assess for daytime symptoms as well as nighttime sleep difficulties (e.g., daytime sleepiness, low energy, napping; Martin et al., 2000). When assessing for sleep difficulties, consider potential medical and environmental causes for sleep problems. ...
    Article
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    The psychological assessment of older adults is often challenging due to the frequent co-morbidity of mental and physical health problems, multiple medications, interactions among medications, age-related sensory and cognitive deficits, and the paucity of assessment instruments with psychometric support for use with older adults. First, psychological assessment instruments for examining five important clinical areas (suicide ideation, sleep disorders, anxiety, depression, and personality) are discussed in light of the most current research regarding their psychometric properties and suitability for use with older adults. Instruments developed specifically for older adults are distinguished from instruments developed for younger adults that have some psychometric support for their use with older adults. Second, the potential sensory deficits that could compromise assessment, factors to consider in light of these deficits, and accommodations that can be made to minimize their effects are discussed.
  • ... Ip et al. [10] reported that, the prevalence of SDB increased nearly 12 folds in the 50-60 year old group, compared to 30-39 year old group. Martin et al. [11] study showed that SDB is common among elderly and a potential risk factor for mortality during sleep. The physiological changes that occur with advancing age in the form of reduction in upper airway size, with increased its collapsibility, inadequate compensatory action of upper airway dilator muscles, decreased vital capacity and altered ventilatory control contribute to occurrence of SDB in the elderly. ...
    Article
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    Background: Sleep disorders are common and the gold standard for diagnosis is through polysomnography (PSG) with standard scoring criteria. Published clinical and polysomnographic data reporting sleep disorders among Egyptian patients are lacking. Aim: To study clinical and polysomnographic characteristics in Egyptian patients with suspected sleep disorders. Patients and methods: All patients’ polysomnographic records and sleep questionnaires were reviewed from November 2006: November 2012 at the Minoufiya University Hospital Sleep Disorders Unit. Results: 421 patients were recruited among which 229 were males (54.4%); excessive daytime sleepiness and obesity were major features (ESS = 16, BMI = 33). Most of the patients were referred by a chest physician (81%). The most common symptoms were snoring (84.6%), witnessed apneas (78.6%), insomnia (70.9%) while the least was parasomnia (15.4%). 337 patients were diagnosed as having obstructive sleep apnea OSA (80%) of them, 70 (21%) had mild OSA, 75 (22%) had moderate OSA and 192 (57%) had severe OSA, The most common diseases accompanying OSA were: systemic hypertension (77%), diabetes (63%), COPD (57%), and coronary heart disease (49%). Conclusions: Sleep medicine in Egypt is still lagging behind the developed world, awareness of sleep disorders among Egyptian physicians should be increased. Diabetes, HTN, IHD and COPD are the commonest predisposing factors for OSA among Egyptians especially snorers, obese and overweight patients.
  • ... Moreover, the generalizability of the sample is limited such that future studies should include men, as sex and gender differences have been found in relation to HRV (72), insomnia (73), and depression (74). In the current study, participant age CHRONIC STRESS, HRV, SLEEP, AND DEPRESSION 18 also differed across groups and may represent an important confound as age is independently associated with both HRV and sleep disturbances (75,76). However, the associations observed in the current study were found over and above the effects of age. ...
    Article
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    Background: Disrupted sleep quality is one of the proposed mechanisms through which chronic stress may lead to depression. However, there exist significant individual differences in sleep reactivity, which is the extent to which one experiences sleep disturbances in response to stress. Purpose: The aim of the current study was to investigate whether low high-frequency heart rate variability (HRV), as a psychophysiological marker of poor emotional and physiological arousal regulation, predicts stress-related sleep disturbances associated with greater risk of depression symptoms. Methods: Using a chronic caregiving stress model, 125 mothers of adolescents with developmental disorders and 97 mothers of typically developing adolescents had their resting HRV and HRV reactivity recorded, completed a measure of depressive symptoms, as well as a seven-day sleep diary to assess their sleep quality. A moderated mediation model tested whether sleep quality mediated the association between chronic stress exposure and depressive symptoms, and whether HRV moderated this mediation. Results: After controlling for participant age, body mass index, ethnicity, socioeconomic status, and employment status, poor sleep quality mediated the association between chronic stress and depressive symptoms. Resting HRV moderated this indirect effect such that individuals with lower HRV were more likely to report poorer sleep quality in the context of chronic stressor exposure, which in turn was related to greater depressive symptoms. Conclusions: Lower HRV, a potential biomarker of increased sleep reactivity to stress, is associated with greater vulnerability to stress-related sleep disturbances, which in turn increases risk for elevated depressive symptoms in response to chronic stress.
  • ... The literature identifi es problems with sleep among older people with or without dementia. At least 50 per cent of people over the age of 65 experience diffi culty in sleeping (Martin, 2000) and sleep disturbance is common among people with dementia (Fetveit and Bjorvatn, 2002;Cole and Richards, 2005) who can experience '40 per cent of their bedtime hours awake and 14 per cent of their daytime hours asleep' (Dewing, 2003, p. 26). ...
  • ... Uyku kalitesine etki edebilecek birçok etkenin olduğu yapılan araştırmalarda görülmüştür. 1 Fiziksel aktivite, yaşlı bireylerin sağlığının korunması ve kaliteli bir yaşam için gereklidir ve birçok hastalıktan koruyucu bir faktördür. 2 Fiziksel aktivite ve egzersizin, sağlıklı yetişkinlerde daha iyi bir uyku ve daha az uyku bozukluğuyla ilişkili olduğu görülmüştür. ...
    Article
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    Purpose: The aim of this study was to determine whether there was a relationship between physical activity and sleep quality in elderly. Methods: Two hundred twenty two subjects staying in rest and care homes were included in the study. Demographic characteristics were reported by face to face interview method. Physical activity level (International Physical Activity Questionnaire), sleep quality (Pittsburgh Sleep Quality Index), and daytime sleepiness (Epworth Sleepiness Scale) were measured. Results: There were no significant difference in sleep quality among physical activity levels (p=0.33). There was a statistically significant difference in daytime sleepiness between the groups (p<0.001). A negative, weak and statistically significant relationship was found between physical activity level and daytime sleepiness (r=-0.14, p=0.03), and between sleep quality and daytime sleepiness (r=0.20, p<0.001). Conclusion: Sleep quality and physical activity level are not related in the elderly. However, daytime sleepiness is associated with subjects' physical activity level. Daytime sleepiness is among the causes of low physical activity level in the elderly and should be questioned in the evaluation of physical activity level.
  • ... Actigraphy is considered a valid measure of rest-activity rhythms (Pollak et al. 2001) and has been successfully used in healthy elderly and demented elderly patients (Huang et al. 2002;Martin et al. 2000;Van Someren et al. 1996). Traditionally, actigraphy has been recorded from the non-dominant wrist but studies that investigated different placement locations found no difference between the dominant wrist, non-dominantwrist, ankle, or trunk (Jean-Louis et al. 1997;Sadeh et al. 1994) or favored the dominant wrist when assessment of optimal variability of motor movement was of interest (Middelkoop et al. 1997). ...
  • ... Chez le sujet âgé, le sommeil s'altère naturellement en qualité [14], avec un allongement des stades d'endormissement et de sommeil lent léger, un sommeil lent profond diminué (stades 3 et 4), un peu plus d'éveils nocturnes et un sommeil paradoxal plus fragmenté [15,16]. La quantité de sommeil totale sur 24 heures n'est que peu ou pas diminuée par rapport à l'adulte jeune. ...
    Article
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    Objective: To analyze sleep of residential home patients taking hypnotic drugs. Patients and method: This prospective, observational and multicentric study was performed a given day in nursing homes. Residents over than 65, having MMSE ≥ 15 and coherence A or B (for the AGGIR scale) were included. Aphasic residents or having acute pathology were excluded. Sleep complain was expressed by the resident himself and sleep disorder was observed by care givers. Sleep qualitative (complain versus disorder, difficulty to fall asleep and night awakenings) and quantitative (sleep duration) aspects were compared to residents who take or not hypnotic treatments. Results: 635 residents were included. 28.2% of the residents expressed sleep complains whereas care givers reported that only 11.4% of resident presented real sleep disorders (p<0.001). Compared to the residents who take hypnotic drugs (55.6%), residents without such treatment had shown less sleep complaints (31.2 versus 24.8%; p<0.05), less difficulties to fall asleep (38.6 versus 26.5%; p<0.001), and less night awakenings (69.5 versus 60.9%; p<0.05). No sleep duration difference was found according to hypnotic drugs. Discussion: Institutionalized geriatric patients who take hypnotic drugs seem to have a significant lower quality of sleep.
  • ... Older adults get more light sleep but less SWS than younger adults (see Bliwise, 1993, for review; see Ohayon et al., 2004, for a meta-analysis). Not only is there nominally less SWS in older adults (even when accounting for total sleep time, i.e., examining SWS percent) but there is also an age-related decrease in the amplitude of delta waves that compose SWS (e.g., Martin, Shochat, & Ancoli-Israel, 2000). The implication of studies demonstrating changes in SWS across the life span is that SWS declines may underlie memory impairments in older adults directly by reducing consolidation of memories or indirectly by reducing the ability of the hippocampus to encode new memories. ...
    Article
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    In younger adults, recently learned episodic memories are reactivated and consolidated during slow-wave sleep (SWS). It is interesting that SWS declines across the life span, but little research has examined whether sleep-dependent memory consolidation occurs in older adults. In this study, younger adults and healthy older adults encoded word pairs in the morning or evening and then returned following a sleep or no-sleep interval. Sleep-stage scoring was obtained by using a home sleep-stage monitoring system. In the younger adult group, there was a positive correlation between word retention and amount of SWS during the retention interval. In contrast, the older adults demonstrated no significant positive correlations but one significant negative correlation between memory and SWS. These findings suggest that the link between episodic memory and SWS that is typically observed in younger adults may be weakened or otherwise changed in the healthy older adult population. (PsycINFO Database Record (c) 2012 APA, all rights reserved).
  • ... Another comparison of placebo with HT showed a reduction in the number of sleep-disordered breathing episodes and a decreased duration of hypopneas with HT [24]. Sleep difficulties in older postmenopausal women may be influenced by the emergence of coexisting medical conditions and the presence of other hormonal, physiologic , and even psychosocial factors363738. Estrogen regulates the synthesis and release of neurotransmitters and neuromodulators that affect many brain functions including mood, behavior, cognition and sleep15161721,39,40] . ...
    Article
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    Background: Sleep disturbance and insomnia are commonly reported by postmenopausal women. However, the relationship between hormone therapy (HT) and sleep disturbances in postmenopausal community-dwelling adults is understudied. Using data from the multicenter Study of Osteoporotic Fractures (SOF), we tested the relationship between HT and sleep-wake estimated from actigraphy. Methods: Sleep-wake was ascertained by wrist actigraphy in 3,123 women aged 84 +/- 4 years (range 77-99) from the Study of Osteoporotic Fractures (SOF). This sample represents 30% of the original SOF study and 64% of participants seen at this visit. Data were collected for a mean of 4 consecutive 24-hour periods. Sleep parameters measured objectively included total sleep time, sleep efficiency (SE), sleep latency, wake after sleep onset (WASO), and nap time. All analyses were adjusted for potential confounders (age, clinic site, race, BMI, cognitive function, physical activity, depression, anxiety, education, marital status, age at menopause, alcohol use, prior hysterectomy, and medical conditions). Results: Actigraphy measurements were available for 424 current, 1,289 past, and 1,410 never users of HT. Women currently using HT had a shorter WASO time (76 vs. 82 minutes, P = 0.03) and fewer long-wake (> or = 5 minutes) episodes (6.5 vs. 7.1, P = 0.004) than never users. Past HT users had longer total sleep time than never users (413 vs. 403 minutes, P = 0.002). Women who never used HT had elevated odds of SE <70% (OR,1.37;95%CI,0.98-1.92) and significantly higher odds of WASO > or = 90 minutes (OR,1.37;95%CI,1.02-1.83) and > or = 8 long-wake episodes (OR,1.58;95%CI,1.18-2.12) when compared to current HT users. Conclusions: Postmenopausal women currently using HT had improved sleep quality for two out of five objective measures: shorter WASO and fewer long-wake episodes. The mechanism behind these associations is not clear. For postmenopausal women, starting HT use should be considered carefully in balance with other risks since the vascular side-effects of hormone replacement may exceed its beneficial effects on sleep.
  • ... Les auteurs soulignent notamment l'importance d'adapter l'institution au sujet âgé et non l'inverse, en évitant de coucher les patients en début de soirée [3]. En effet, alors que les personnes âgées tendent à dormir moins que les jeunes adultes [4], il semble que les institutions les accueillant les incitent à se reposer davantage qu'il n'est nécessaire et de façon parfois inadaptée, contribuant de ce fait à l'accentuation des troubles [5]. Or il est aujourd'hui admis que la quantité et la qualité du sommeil diurne et nocturne ont un impact direct sur la qualité de vie des personnes atteintes de MA [6,7]. ...
    Article
    La maladie d’Alzheimer (MA) et les troubles apparentés sont souvent associés à une détérioration de la structure et de la distribution circadienne du sommeil. Ces troubles du sommeil sont fréquemment aggravés par l’institutionnalisation des personnes qui en sont atteintes. Dans le cadre d’une étude se rapportant à l’évaluation d’un programme d’intervention psychoenvironnementale pour les personnes atteintes de MA en unité spécifique, nous avons pu mettre en évidence l’impact de l’accompagnement de nuit sur la qualité de vie de ces personnes. Les résultats de cette étude suggèrent que la mise en oeuvre d’un accompagnement de nuit adapté des personnes atteintes de MA institutionnalisées est un préalable nécessaire à toute intervention utilisant des moyens techniques (luxthérapie, chronothérapie. . .) ciblant spécifiquement les troubles du sommeil. Alzheimer’s disease and related disorders (AD) are often associated with an alteration of the circadian structure and distribution of sleep. Moreover, sleep disorders are often worsened by the institutionalisation of people with AD. In a large study on a psychoenvironmental intervention program, we were able to enlighten the impact of nightshifts on institutionalised people with AD. Results suggest that the implementation of adapted nightshifts is an essential prerequisite to any technical intervention for sleep disorders.
  • ... ACEI, AT1 blockers, thiazide diuretics, long acting calcium channel blockers with peripheral effect Neuroleptics with better risk/benefit ratio, e.g. risperidone, pipamperone, haloperidol (in acute psychosis, short term use less than 3 days) Non-pharmacological interventions -delirium -Prevention -Avoid use of delirium related drugs -Stop delirium -multicomponent intervention -Identification of clinical changes during the prodromal phase Non-pharmacological interventions -Psychological strategies tailored to patients: music, reminiscence therapy, exposure to pets, outdoor activities, bright light exposure -In agitation and aggression try to identify the cause of the problem -can be disease, pain, medication In anxiety indication: -Short-acting benzodiazepines -less than half of the dose usually given to adults -Mirtazapine, trazodone, mianserine ➢ In hypnotic indication:In non-benzodiazepine hypnotics: zolpidem, zopiclone Valeriana Non-pharmacological interventions -anxiety -Cognitive-behavioral therapy Non-pharmacological interventions -insomnia -Sleeping hygiene -Explore the cause of sleep disorder -can be disease, medication, environment -Light therapy26,27,[58][59][60] ATC, anatomical therapeutic chemical; COPD, chronic obstructive pulmonary disease; CNS, central nervous system; ECG, electrocardiogram; MAO, monoamine oxidase inhibitors; NSAID, non-steroidal anti-inflammatory drugs; SSRI, selective serotonin reuptake inhibitors; TCA, tricyclic antidepressants. logistical constraints of busy clinical settings where there might be few financial reimbursements for the extra time spent applying the algorithm. ...
    Article
    Aim: Frail older people typically suffer several chronic diseases, receive multiple medications and are more likely to be institutionalized in residential aged care facilities. In such patients, optimizing prescribing and avoiding use of high-risk medications might prevent adverse events. The present study aimed to develop a pragmatic, easily applied algorithm for medication review to help clinicians identify and discontinue potentially inappropriate high-risk medications. Methods: The literature was searched for robust evidence of the association of adverse effects related to potentially inappropriate medications in older patients to identify high-risk medications. Prior research into the cessation of potentially inappropriate medications in older patients in different settings was synthesized into a four-step algorithm for incorporation into clinical assessment protocols for patients, particularly those in residential aged care facilities. Results: The algorithm comprises several steps leading to individualized prescribing recommendations: (i) identify a high-risk medication; (ii) ascertain the current indications for the medication and assess their validity; (iii) assess if the drug is providing ongoing symptomatic benefit; and (iv) consider withdrawing, altering or continuing medications. Decision support resources were developed to complement the algorithm in ensuring a systematic and patient-centered approach to medication discontinuation. These include a comprehensive list of high-risk medications and the reasons for inappropriateness, lists of alternative treatments, and suggested medication withdrawal protocols. Conclusions: The algorithm captures a range of different clinical scenarios in relation to potentially inappropriate medications, and offers an evidence-based approach to identifying and, if appropriate, discontinuing such medications. Studies are required to evaluate algorithm effects on prescribing decisions and patient outcomes. Geriatr Gerontol Int 2015; ●●: ●●-●●.
  • ... Further, if obstructive sleep apnea is diagnosed in persons with dementia, a trial of the use of a continuous positive pressure machine is warranted. Sources: (American Medical Directors Association, 2006; Martin, Shochat, & Ancoli-Israel, 2000; Bloom et al., 2009) Sources: (Smith, 2002; Cole & Richards, 2007; Ancoli-Israel & Ayalon, 2009; Floyd, 1999; Harris, 2009) ...
    Article
    Full-text available
    Approximately one quarter of adults with dementia experience sleep disturbances. The purpose of this article is to (a) describe and define sleep disturbances in individuals with dementia, (b) describe techniques to assess for sleep disturbances in individuals with dementia, and (c) provide nursing interventions to improve sleep in this patient population. Typical presentations of sleep disturbances in individuals with dementia are described, along with medications that may interfere with sleep. Suggestions for nursing measures that can be implemented to enhance sleep are also presented. Nurses have numerous nonpharmacological options to assist with the regulation of sleep-wake rhythms in individuals with dementia.
  • ... Инсомния характеризуется трудностью засыпания и поддержания продолжительности сна, низким каче-ством сна, вызывает нарушения работоспособности; может приводить к ухудшению настроения, депрессии, проблемам на работе и снижать качество жизни [6]. Для выявления диссомний и уточнения их причин применяются различные опросники [7,8]. У пациента необходимо выяснить: в какое время он обычно ложится спать и когда просыпается утром; часто ли у него возникают проблемы со сном; сколько раз он просыпается в течение ночи и, если просыпается, трудно ли ему заснуть снова; отмечаются ли у него нарушения дыхания (храп, нехватка воздуха или задержка дыхания), движения рук и ног во сне, сноговорение; чувствует ли он сонливость или усталость в течение дня; возникает ли у него в течение дня желание уснуть на короткое время; сколько часов сна необходимо, чтобы он чувствовал себя выспавшимся и отдохнувшим; принимает ли он снотворное. ...
    Article
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    Sleep and awakening disorders are almost obligate manifestations of Parkinson’s disease. Primary sleep and awakening disorders in Parkinson’sdisease are associated with the degeneration of serotoninergic neurons in the dorsal raphe nucleus and cholinergic neurons in the pedunculopontine nucleus. Impaired awakening maintenance with the development of hypersomnia may result from neuron degeneration in the locus coeruleus or pedunculopontine nucleus. A certain role may be played by the pathological basal ganglionic pulsation caused by striatal dopamine deficiency, which goes to both the thalamic reticular nucleus and pedunculopontine nucleus, as well as by dysfunction of the mesocortical dopaminergic pathways involved in sleep-wake cycle regulation. Synthetic melatonin (Melaxen) is one of the effective medications for the treatment of sleep disorders in Parkinson’s disease. The drug normalizes circadian rhythms and has a hypnotic effect although it is in the usual sense not a soporific agent. Melaxen has a minimum of side effects and is well tolerated by patients from different age groups.
  • ... Intriguingly, recent studies suggest that not only are the spindle frequency (sigma power) and SOs independently associated with performance improvement (Clemens et al., 2005;Gais et al., 2002;Mednick et al., 2013;Oyanedel et al., 2014;Schabus et al., 2004), but the coincidence or coupling of SOs and sigma (SO/sigma) may also be a key mechanism of long-term memory formation during sleep Staresina et al., 2015), with several studies suggesting that sigma activity during the SO up-state are optimal (Niknazar et al., 2015;Gais and Born, 2004;Mölle et al., 2009). Older adults typically show decreased amplitude of SOs (0.5-1 Hz) (Carrier et al., 1997;Martin et al. 2000). Additionally, a recent study examining coupling of sigma and SO in relation to fMRI brain activity and memory performance in older adults (Helfrich et al., 2018), reported changes in spindle/SO coupling and decreased coupling over the frontal pole with age. ...
    Article
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    Working Memory (WM), is an important factor influencing many higher-order cognitive functions that decline with age. Repetitive training appears to increase WM, yet the mechanisms underlying this improvement are not understood. Sleep has been shown to benefit long-term memory formation and may also play a role in WM enhancement in young adults. However, considering age-related decline in sleep, it is uninvestigated whether sleep will facilitate WM in older adults. In the present work, we investigated the impact of a nap, quiet wakefulness (QW) and active wakefulness (AW) on within-day training on the Operation Span (OSPAN) task in older adults. Improvement in WM was found following a nap and QW, but not active wake. Furthermore, better WM was associated with shared electrophysiological features, including slow oscillation (SO, 0.5–1 Hz) power in both the nap and QW, and greater coupling between SO and sigma (12–15 Hz) in the nap. In summary, our data suggest that WM improvement in older adults occurs opportunistically during offline periods that afford enhancement in slow oscillation power, and that further benefits may come with cross-frequency coupling of neural oscillations during sleep.
  • ... In spite of high prevalence of sleep disorders that too many doctors ignore majority of the individuals suffer from sleep disorders remain undiagnosed and untreated which ultimately results in creation of unnecessary public health and safety problems, as well as increased health care cost [9]. It is also believed that high rates of undiagnosed sleep disorders cases are due to limited knowledge of sleep medicine among health care providers [10]. ...
  • ... (see reviews: [30,31]) In general, sleep quality and quantity decline with age and the prevalence of sleep disorder increases. [32] However, our data suggest that this pattern may not hold true in PD as younger participants reported more difficulty initiating and maintaining sleep, and less overall satisfaction with their sleep. Other authors have reported a similar pattern of results (e.g. ...
    Article
    Full-text available
    Many studies have sought to describe the relationship between sleep disturbance and cognition in Parkinson’s disease (PD). The Parkinson’s Disease Sleep Scale (PDSS) and its variants (the Parkinson’s disease Sleep Scale-Revised; PDSS-R, and the Parkinson’s Disease Sleep Scale-2; PDSS-2) quantify a range of symptoms impacting sleep in only 15 items. However, data from these scales may be problematic as included items have considerable conceptual breadth, and there may be overlap in the constructs assessed. Multidimensional measurement models, accounting for the tendency for items to measure multiple constructs, may be useful more accurately to model variance than traditional confirmatory factor analysis. In the present study, we tested the hypothesis that a multidimensional model (a bifactor model) is more appropriate than traditional factor analysis for data generated by these types of scales, using data collected using the PDSS-R as an exemplar. 166 participants diagnosed with idiopathic PD participated in this study. Using PDSS-R data, we compared three models: a unidimensional model; a 3-factor model consisting of sub-factors measuring insomnia, motor symptoms and obstructive sleep apnoea (OSA) and REM sleep behaviour disorder (RBD) symptoms; and, a confirmatory bifactor model with both a general factor and the same three sub-factors. Only the confirmatory bifactor model achieved satisfactory model fit, suggesting that PDSS-R data are multidimensional. There were differential associations between factor scores and patient characteristics, suggesting that some PDSS-R items, but not others, are influenced by mood and personality in addition to sleep symptoms. Multidimensional measurement models may also be a helpful tool in the PDSS and the PDSS-2 scales and may improve the sensitivity of these instruments.
  • ... Participants who are awoken during Stage 1 sleep will sometimes contend that they were not truly asleep (though they often cannot describe what was on their mind prior to the awakening). Stage 2 of non-REM is considered to be "true" sleep (Martin et al. 2000) and is represented by slower EEG activity (<8 Hz) interleaved with bursts of thalamocortical sleep spindles. Individuals next enter into non-REM Stages 3 and 4, which are characterized by even slower EEG oscillations (<4 Hz) and are therefore collectively referred to as slow wave sleep (SWS). ...
  • ... Participants who are awoken during Stage 1 sleep will sometimes contend that they were not truly asleep (though they often cannot describe what was on their mind prior to the awakening). Stage 2 of non-REM is considered to be "true" sleep (Martin et al. 2000) and is represented by slower EEG activity (<8 Hz) interleaved with bursts of thalamocortical sleep spindles. Individuals next enter into non-REM Stages 3 and 4, which are characterized by even slower EEG oscillations (<4 Hz) and are therefore collectively referred to as slow wave sleep (SWS). ...
  • ... The range of reported PLMS prevalence is highly variable, from 4% to 47% in adults depending on the population and definitions used, 3 and PLMS are commonly comorbid with obstructive sleep apnea (OSA), 20 insomnia, 3 and advanced age. 30 Given the potential connection between PLMS and cardiovascular and cerebrovascular morbidity, the question arises as to how to best identify patients with PLMS, the majority of which do not have RLS symptoms. Such information could improve screening decisions and transform PLMS from mainly an incidental PSG finding to an actively sought aspect of clinical sleep evaluations. ...
    Article
    Full-text available
    Introduction: Periodic limb movements of sleep (PLMS) may increase cardiovascular and cerebrovascular morbidity. However, most people with PLMS are either asymptomatic or have nonspecific symptoms. Therefore, predicting elevated PLMS in the absence of restless legs syndrome remains an important clinical challenge. Methods: We undertook a retrospective analysis of demographic data, subjective symptoms, and objective polysomnography (PSG) findings in a clinical cohort with or without obstructive sleep apnea (OSA) from our laboratory (n=443 with OSA, n=209 without OSA). Correlation analysis and regression modeling were performed to determine predictors of periodic limb movement index (PLMI). Markov decision analysis with TreeAge software compared strategies to detect PLMS: in-laboratory PSG, at-home testing, and a clinical prediction tool based on the regression analysis. Results: Elevated PLMI values (>15 per hour) were observed in >25% of patients. PLMI values in No-OSA patients correlated with age, sex, self-reported nocturnal leg jerks, restless legs syndrome symptoms, and hypertension. In OSA patients, PLMI correlated only with age and self-reported psychiatric medications. Regression models indicated only a modest predictive value of demographics, symptoms, and clinical history. Decision modeling suggests that at-home testing is favored as the pretest probability of PLMS increases, given plausible assumptions regarding PLMS morbidity, costs, and assumed benefits of pharmacological therapy. Conclusion: Although elevated PLMI values were commonly observed, routinely acquired clinical information had only weak predictive utility. As the clinical importance of elevated PLMI continues to evolve, it is likely that objective measures such as PSG or at-home PLMS monitors will prove increasingly important for clinical and research endeavors.
  • Article
    Sleep is fragmented and disturbed in older adults with dementia. Their sleep problems vary according to dementia subtypes, such as Alzheimer's disease, Parkinson's disease and dementia with Lewy bodies. Multiple factors, such as neurobiologic mechanisms underlying sleep disturbances and dementia, primary sleep disorders, long-term care environments, and physical and mental health conditions are associated with sleep disturbances. In older adults with dementia, these disturbances negatively affect their health, quality of life and medical expenses. As a result, these adults may require placement in a long-term care institution, and their caregivers' health may be adversely affected. Both pharmacologic and nonpharmacologic interventions may alleviate the symptoms associated with sleep disturbances. However, nonpharmacologic interventions, particularly when combined, have been shown to be more effective than pharmacologic interventions for the treatment of sleep disturbances in older adults with dementia.
  • Article
    In 2001 gaf de Algemene Vereniging Verpleegkundigen en Verzorgenden (AVVV) de opdracht tot een evidence-based richtlijn voor slaapstoornissen.
  • Article
    Research investigating the relationship between cognitive styles and sleep quality has focused on younger adults, despite insomnia being most prevalent in older adults. Improved knowledge of the psychological factors associated with disturbed sleep may help to improve therapies. Fifty-four adults aged 60–84years reported on their sleep quality, pre-sleep arousal, dysfunctional beliefs about sleep and completed a catastrophising interview. In individual models, pre-sleep arousal, dysfunctional beliefs and the number of catastrophising steps all predicted self-reported sleep quality. Interviews revealed several worries of particular relevance to older adults, including fears about accidents, health and domestic management. These findings suggest that similar associations between cognitions and insomnia are present in older as in younger adults, but also that greater consideration should perhaps be paid to the content of the worries that are specific to this population. KeywordsSleep–Older adults–Cognitive style–Worry–Insomnia
  • Chapter
    Der Anteil der über 65-Jährigen in der Bevölkerung steigt stetig und somit auch die Anzahl an verordneten rezeptpflichtigen und frei verkäuflichen psychotropen Medikamenten für Patienten dieser Altersgruppe. Die Behandlung psychiatrischer Symptome im Alter, im Vergleich zum jüngeren Erwachsenenalter, stellt auf verschiedenen Ebenen eine Herausforderung dar. Zum einen verändern sich pharmakokinetische und pharmakodynamische Parameter der Verstoffwechslung von Medikamenten im Alter, zum anderen liegen oft Multimorbidität oder chronische Schmerzsyndrome vor. Demzufolge sollten neben psychiatrischen Grunderkrankungen auch somatische, medikamenteninduzierte oder ernährungsbedingte Syndrome als symptomverursachend oder-verstärkend in Erwägung gezogen werden. Zusätzlich können durch den Alterungsprozess auch im Symptomverlauf von langjährig bestehenden bekannten Erkrankungen und langjährig eingenommenen Medikamenten neue Symptome auftreten. Dem liegen sowohl Veränderungen in der Verstoffwechselung der Medikamente als auch Veränderungen in der Funktionsfähigkeit der Zielorgane zugrunde.
  • Article
    Epilepsy is defined as a chronic illness, diagnosed after the occurrence of two or more unprovoked seizures (seizures which occur without any obvious immediate cause) and must be differentiated from acute symptomatic seizures (which are provoked by acute illnesses) in order to avoid confusing data on dementia. Recognizing and correctly diagnosing late-onset seizures in the elderly may be challenging for various reasons: limited knowledge of seizure symptoms in this age group, multiple conditions that may mimic seizures such as transient ischemic attacks, stroke, syncope, sleep disorders and toxic or metabolic disturbances. When seizures are suspected, there is often limited access to specific diagnostic tools such as video-EEG, or an absence of witnesses so that diagnosis is not easily confirmed. Epilepsy is particularly complex in older people since they are more likely to have co-morbidities than younger individuals. Antiepileptic drugs (AEDs) should be started only after the diagnosis is clearly established, when the risk of recurrence is high and using mono-therapy whenever possible. Treatment must be adapted to the particular susceptibility of elderly subjects. Although little data are available, the newer AEDs offer significant advantages over older medications in this context.
  • Article
    The article shows that in the treatment of chronic insomnia in geriatric patients, it is recommended to use a step-by-step treatment and start with steps aimed at the elimination of somatic, environmental and psychological barriers which affect the quality of sleep. An algorithm for the evaluation of sleep disorders at a later age firstly desctibed. The specifics of the clinical and psychological evaluation of the quality of sleep in geriatric patients presented. Evidence on the effectiveness of pharmacological and non-pharmacological approaches for the treatment of chronic insomnia at a later age presented on the basis of a number of foreign studies. It is recommended to use multicomponent cognitive-behavioral psychotherapy as a first-line treatment of chronic insomnia at a later age Types, forms and structural components of cognitive-behavioral therapy of chronic insomnia in the elderly are detailed. Practical difficulties and reccomentations for the use of medical approach in the treatment of sleep disorders in the elderly are also presented.
  • Article
    Background The promotion of sleep in older adults is a significant issue in high-level residential aged care facilities, with as many as 67% of residents experiencing disruptions to their sleep patterns. Not only do health concerns such as cognitive impairment, pain and incontinence impact upon this population's sleep quality and quantity, but environmental factors including noise, light and night-time nursing care also affect sleep of those residing in institutions. In order to address the issue of sleep disruption, assessment and diagnosis of sleep problems and implementation of interventions that are effective in promoting sleep are essential.
  • Article
    Contexte La prévalence des troubles du sommeil augmente avec l'âge et concernerait entre 20 et 40 % des personnes de plus de 60 ans. Un programme d'éducation à la santé a été mis au point chez des seniors de 55 ans et plus pour répondre à cette plainte courante. Méthodes Une évaluation du sommeil a été faite pendant 9 jours à l'aide d'un agenda du sommeil et d'un actimètre de poignet. Elle a été suivie d'une journée de formation sur les comportements et l'hygiène du sommeil, accompagnée d'un compte rendu collectif et individuel des caractéristiques du sommeil de la période d'observation, et d'une nouvelle évaluation, à distance, objectivant les bénéfices obtenus. Résultats Sur les 26 participants, 17 femmes et 9 hommes âgés en moyenne de 68 ± 1 ans et ayant rempli les différents critères d'inclusion, 14 avaient une insomnie avec une durée des réveils nocturnes ≥ 1 heure et/ou une latence d'endormissement ≥ 30 min (groupe 1). Les 12 autres (groupe 2), considérés comme « non insomniaques » sur ces critères, se plaignaient aussi de la qualité de leur sommeil. Après la formation, les participants du groupe 1 ont augmenté de 24 à 33 min leur temps de sommeil, grâce à une réduction de la durée des réveils nocturnes et de la latence d'endormissement, sans modifier le temps passé au lit. Ceux du groupe 2 ont augmenté la durée de leur sommeil de 18 à 47 min, en restant au lit plus longtemps et en maintenant une efficacité du sommeil proche de 88 %. Ces effets bénéfiques étaient accompagnés par une appréciation positive de la qualité subjective de leur sommeil et une augmentation du dynamisme le matin. Conclusion Des séances de formation simples, répétées et comprenant l'analyse de données individuelles ont eu une efficacité sur la qualité objective et subjective du sommeil.
  • Article
    Normal SleepStages of SleepCircadian RhythmsSleep DiSturbances in the ElderlyTypes of Sleep DisturbancesUniversal Measures of Prevention for Sleep DisturbancesSelective Measures for the Prevention of Sleep DisturbancesPractice and Policy ImplicationsFuture DirectionsConclusion
  • Chapter
    This chapter analyzed evidence for the effectiveness of psychological interventions with older adults, the importance of ethnic diversity issues in mental health and aging within the population of dementia caregivers, and the influence of public policies on the accessibility of mental health services for older adults. The aging of the population worldwide suggests that older adults will become a larger part of the client populations for professional psychologists. Also, successive generations of American adults have higher prevalence of mental disorders, suggesting that future cohorts of older adults will have a higher need for psychological services. Older adults have more positive attitudes toward mental health services than younger adults, and rate psychological treatments as more credible and acceptable than drug therapy for the treatment of depression. The presumed widespread negativity of mental health professionals toward older adults was either exaggerated from the beginning or has changed over time.
  • The prevalence of insomnia, SDB, circadian rhythm disorders, and sleep-related movement disorders increases substantially in late-life. In addition, normal age-related changes in sleep architecture create a fragmented and light sleep pattern that sets the stage for sleep complaints in this population. Sleep disturbance in older adults may be associated with poorer quality of life, dependence on hypnotic medication, increased risk of falls, increased morbidity, impaired cognitive performance, and daytime somnolence. A thorough evaluation of a sleep complaint includes assessment of contributing medical, psychiatric, medication, behavioral, and environmental factors. Once identified, sleep disorders can be effectively treated. Treatments include medically-based interventions such as mechanical devices for SDB and medications for movement disorders as well as behavioral and environment interventions (e.g., behavioral treatments for insomnia and bright light therapy for circadian disturbances). However, more information on the application and effectiveness of these treatments specific to elderly populations is needed and will only increase in importance as the population of older adults grows. Uncited items.
  • Article
    p>Sleep disorders and sleeping difficulty are poorly-addressed problems of aging. Research has shown that as many as 50% of older adults complain about difficulty in initiating or maintaining sleep. Elderly with varieties of sleep complaints are differentially affected by 'age-related cognitive decline'. Normal developmental processes have been affected with changes in sleep, which can be further compromised by sleep disturbances secondary to medical or psychiatric diseases such as chronic pain, depression, dementia or age-related primary sleep disorders (e.g., sleep disordered breathing and periodic limb movements during sleep), or certain combinations of these high-risk factors. Sleep serves as a protective mechanism to keep the organism out of danger; therefore, it is imperative to consider sleep disorders for quality life. The evaluation of these disorders is discussed in this review. Anwer Khan Modern Medical College Journal Vol. 7, No. 1: Jan 2016, P 45-49</p
  • Research
    Full-text available
    Starting page 18, in depth look at insomnia in primary care
  • Article
    Background: The promotion of sleep in older adults is a significant issue in high-level residential aged care facilities, with as many as 67% of residents experiencing disruptions to their sleep patterns. Not only do health concerns such as cognitive impairment, pain and incontinence impact upon this population's sleep quality and quantity, but environmental factors including noise, light and night-time nursing care also affect sleep of those residing in institutions. In order to address the issue of sleep disruption, assessment and diagnosis of sleep problems and implementation of interventions that are effective in promoting sleep are essential. Objectives: The objective of this review was to determine the most effective tools for the assessment and diagnosis of sleep in older adults in high-level aged care. The review also sought to determine the most effective strategies for the promotion of sleep in this population. Outcome measures for this review were: indicators of improved sleep quality and quantity, including an improvement in daytime functioning and improved night-time sleep; reduction in use of hypnotics and sedatives; and increased satisfaction with sleep. Search strategy: A literature search was performed using the following databases for the years 1993-2003: AgeLine, APAIS Health, CINAHL, Cochrane Library, Current Contents, Dissertation Abstracts International, Embase, Medline, Proquest, PsycInfo, Science Citations Index. A second search stage was conducted through review of reference lists of studies retrieved during the first search stage. The search was limited to published and unpublished material in English language. Selection criteria: The review was limited to papers addressing sleep diagnosis, assessment and/or management in adults aged 65 or over who were residing in high-level aged care. The review included randomised controlled trials (RCTs) and, due to the limited number of RCTs available, non-RCTs, cohort and case control studies and qualitative research were also considered for inclusion. Research was included if it addressed the assessment, diagnosis or management of sleep using outcome measure of improved night-time sleep or daytime function, improvements in resident satisfaction with sleep or reduction in medication use associated with sleep. The types of interventions considered by this review were alternative therapies including massage, aromatherapy and medicinal herbs; behavioural or cognitive interventions; biochemical interventions; environmental interventions; pharmacological interventions and related nocturnal interventions such as continence care. Instruments and strategies to diagnose and assess the sleep of older high-level care residents, including objective and subjective assessment tools, were considered by this review. Data collection and analysis: All retrieved papers were critically appraised for eligibility for inclusion and methodological quality independently by two reviewers, and the same reviewers collected details of eligible research. Papers were grouped according to the type of intervention or type of assessment tool used and findings were presented in a narrative summary. Findings: Wrist actigraphy was found to be the most accurate objective sleep assessment tool for use in the population of interest, and issues surrounding its use are presented. Although no subjective sleep assessment tools were identified in this review, the evidence suggested that subjective reports of sleep quality are an important consideration in sleep assessment. Evidence suggested that behavioural observations may be an effective assessment strategy when conducted on a frequent basis. The review found no evidence on the effectiveness of any assessment tools for the diagnosis of specific sleep problems in older adults. The use of multidisciplinary strategies including reduction of environmental noise, reduction of night-time nursing care that disrupts sleep and daytime activity is likely to be the most effective strategy for the promotion of sleep in older high-level care residents. The use of sedating medications did not appear to have a substantial effect in promoting sleep, and health practitioners in high-level aged care should consider their use cautiously.
  • Chapter
    Normal ageing is associated with both structural and functional changes in the brain and spinal cord. The changes in the brain include cerebral atrophy, neuronal loss, decrease in neurotransmitters and cerebral blood flow. As age advances, there is increasing diminution in the number of motor neurons in the spinal cord. The functional and morphological changes of the peripheral nervous system are deeply affected by ageing. The structural changes in the brain and spinal cord have functional implications. Ageing influences cognition, sensory and affective processes and memory. Parkinson’s disease is caused by degeneration of the dopaminergic neurons of the substantia nigra with accumulation of alpha-synuclein in the neuronal perikarya and neuronal processes. In multisystem atrophy, the hallmark is the formation of glial cytoplasmic inclusions in the oligodendroglia and staining positive for alpha-synuclein. In amyotrophic lateral sclerosis, there is progressive degeneration and death of anterior horn cells, corticospinal tract and/or bulbar nuclei. Neuropathy is pathologically classified on the specific cell type, namely, neurons (the neuronopathies), axon (axonopathies) and demyelinating neuropathies. In myasthenia gravis, there is blockade of the binding site for acetylcholine. Included in the chapter are related disorders such as sleep disorders, headache, memory loss, chronic pain and gait disorders in the elderly.
  • Article
    Schlafstörungen stellen im Kontext der wachsenden Zahl alter Menschen mit Multimorbidität, Pflegebedürftigkeit, Heimunterbringung und Demenzsyndromen eine diagnostische und therapeutische Herausforderung dar. Schlafstörungen werden trotz ihrer hohen Prävalenz und Relevanz bei alten Menschen kaum berücksichtigt.
  • Chapter
    Use of inappropriate drugs is common among elderly. These drugs are associated with an increased risk of adverse drug reactions in older adults. Here we focus on four groups of drugs that are frequently used by older patients but should, if possible, be avoided. These groups are: benzodiazepines, antipsychotic drugs, drugs with anticholinergic effects, and non-steroidal anti-inflammatory drugs (NSAID). Benzodiazepines, anticholinergic drugs and antipsychotic drugs may cause delirium, especially in the elderly. Possible severe adverse effects from NSAIDs are e.g. gastrointestinal bleeding, renal, and heart failure. Elderly patients are more susceptible to adverse drug reactions from all these drugs due to pharmacokinetical and pharmacodynamical alterations. In most cases there are safer alternatives.
  • Article
    Sleep complaints are common among elderly persons. They are secondary to somatic or psychiatric comorbidities and iatrogenic causes but not to aging per se. The prevalence of intrinsic sleep disturbances (sleep apnea, periodic limb movement in sleep, restless legs syndrome) increases with age. Other agerelated situations such as neurodegenerative diseases, the life in the nursing home worsen sleep disturbances in older people. Psychotropic medication use therefore increases and is often chronic in this population with more risk than benefit.
Literature Review
  • Article
    Drawing on clinical experience in sleep disorder centers and laboratory-based investigations, we are continuing to develop conceptual models as well as behavioral treatment strategies for insomnia. The technique reported on here, sleep restriction therapy, has had its effectiveness confirmed in laboratory and clinical studies and is now widely used in sleep disorders centers (Spielman, Saskin, & Thorpy, 1987; Friedman, Bliwise, Yesavage, & Salom, 1991; Morin, Kowatch, & Wade, 1989; Morin, Kowatch, & O’Shanick, 1990; Rubinstein, Rothenberg, Maheswaran, Tsai, Zozula, & Spielman, 1990).
  • Article
    As part of the National Institute of Mental Health Epidemiologic Catchment Area study, 7954 respondents were questioned at baseline and 1 year later about sleep complaints and psychiatric symptoms using the Diagnostic Interview Schedule. Of this community sample, 10.2% and 3.2% noted insomnia and hypersomnia, respectively, at the first interview. Forty percent of those with insomnia and 46.5% of those with hypersomnia had a psychiatric disorder compared with 16.4% of those with no sleep complaints. The risk of developing new major depression was much higher in those who had insomnia at both interviews compared with those without insomnia (odds ratio, 39.8; 95% confidence interval, 19.8 to 80.0). The risk of developing new major depression was much less for those who had insomnia that had resolved by the second visit (odds ratio, 1.6; 95% confidence interval, 0.5 to 5.3). Further research is needed to determine if early recognition and treatment of sleep disturbances can prevent future psychiatric disorders. (JAMA. 1989;262:1479-1484)
  • Article
    The common complaint by older adults of sleep disturbance can arise from a multitude of causes.Recent literature suggests three major considerations regarding sleep disorders and aging: the recognition of the multifactorial nature of sleep disorders in elderly people; the need to, wherever possible, treat the primary illness rather than the symptom of sleep disturbance; the importance of taking a conservative approach to prescription of hypnotic drugs. Also reviewed is the emerging literature elucidating the interactions of circadian rhythms with sleep quality and suggesting a number of potentially useful therapies, particularly melatonin administration, for treating sleep disturbance based on circadian principles.
  • Article
    Seventeen healthy volunteers (10 women and 7 men, aged 29-68) were flown from London to San Francisco between 20 November 1985 and 25 January 1986 and remained there for 14 days prior to flight home. Subjects took melatonin (N = 8, 5 women, 3 men) or placebo in a double-blind design, at 18.00h local time for three days before the return flight and at bedtime (22.00-24.00h) in Great Britain for four days. For three days before departure and on days 1-7,14,15, 21 and 22 after their return subjects collected 6-hourly sequential urine samples and kept a daily sleep log. They recorded mood and oral temperature 2 hourly and performed logical reasoning and letter cancellation tests 4 hourly from 08.00h (or wake up time) to 24.00h (or bedtime) whichever was the earlier. Urine was also collected for 48 h prior to departure from the U.S.A‥ On day 7 after their return subjects rated ‘jet lag’ (10 cm visual analogue scale—VAS) from 0 (insignificant) to 100 (very bad). Melatonin significantly improved ‘jet lag’ (p= 0.009). Comparisons by ANOVA between jet-lagged placebo subjects (N = 7) and melatonin (N = 8) showed decreased sleep latency with melatonin (p= 0.0397) which correlated positively with jet lag ratings, p< 0.001. Sleep quality was significantly improved in the melatonin group and correlated negatively with jet-lag ratings (p
  • Article
    Compared the short-term treatment effects of a cognitive-behavioral therapy (CBT) and conventional pharmacotherapy (clonazepam) among 16 60-yr-old and older adults with insomnia and periodic limb movement disorder (PLMD). Ss completed baseline assessment procedures, including completion of a sleep log for 2 weeks, an ambulatory polysomnogram (APSG) and an Insomnia Symptom Questionnaire (ISQ). Ss maintained sleep logs throughout a 4-week treatment and then completed a second APSG and ISQ. Comparison of pre- and post-treatment data suggested that the 2 treatments led to equal improvements in sleep log measures of sleep-wake times and ISQ measures of subjective sleep concerns. Ss treated with CBT showed a decrease in daytime napping, whereas the clonazepam group reported increased napping. Ss treated with clonazepam showed larger declines in periodic limb movement-arousals per hour of sleep than did the CBT group. Post-treatment interviews suggest that both CBT and clonazepam therapies were generally well tolerated by Ss. It is concluded that both treatments may be useful for PLMD but that the 2 treatments may have contrasting effects across selected measures of improvement. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
  • Article
    review the available information about the effects of drugs on sleep disorders discussion of adverse effects will be limited . . . to those effects specific to sleep, sleep-related physiological function, and daytime sleepiness/alertness disorders of initiating and maintaining sleep / psychophysiological / psychiatric disorders / sleep-related respiratory disturbance / nocturnal myoclonus and restless legs syndrome drug induced [adverse effects on sleep] / CNS [central nervous system] depressants and stimulants / cardiovascular drugs disorders of excessive daytime somnolence / sleep-related respiratory impairment / narcolepsy drug induced [excessive sleepiness during sleeping hours] / stimulants and depressants / antihistamines / antihypertensives (PsycINFO Database Record (c) 2012 APA, all rights reserved)
  • Article
    Full-text available
    Periodic movements in sleep (PMS) is a sleep disorder characterized by repetitive leg kicks accompanied by arousals. In our clinical experience, many patients with PMS anecdotally report that they suffer from cold feet. This study explored whether there is an increased incidence of cold feet complaints in patients with periodic movements in sleep. Results indicated that, indeed, significantly more patients with leg kicks complain of cold feet as compared to patients without leg kicks. A case study was then conducted to determine whether foot thermal biofeedback training would alleviate symptoms of periodic movements in sleep. The number of leg kicks decreased from a mean of 536 per night before biofeedback training to a mean of 19.5 after training. These data lend support to our hypothesis that poor circulation may be contributing to the severity of periodic movements in sleep and that thermal biofeedback may afford an alternative treatment strategy.
  • Article
    For many adults, changes in sleep occur with aging. An estimated 15 million elderly, or 50% of older Americans, experience some sleep problem. The elderly complain that their sleep is more fragmented and that as they have gotten older, they experience more daytime sleepiness. Laboratory studies have confirmed these complaints. Research has shown that it is not the need for sleep that decreases with age, but rather the ability to sleep. Circadian rhythm disturbances, sleep disorders such as sleep disordered breathing and periodic movements in sleep, medical illness, medication use, and impaired cognitive functioning all contribute to poor sleep and decreased daytime alertness. In institutionalized elderly, sleep is even more disturbed and disrupted. With careful assessment, many of these problems can be addressed and treated, and sometimes cured.
  • Article
    This study compared the effectiveness of progressive relaxation, stimulus control, paradoxical intention, and a placebo control treatment for different degrees of sleep onset insomnia (mild, moderate, and severe). Results demonstrated that stimulus control was the most effective intervention regardless of severity level. Individuals with severe insomnia showed at least as much improvement as those with either mild or moderate insomnia, regardless of type of treatment. © 1983 Association for Advancement of Behavior Therapy. All rights reserved.
  • Article
    We reviewed behavioral and related nonpharmacologic treatments for insomnia, as well as salient diagnostic and assessment issues. The paper evaluates the scientific status of the existing literature, giving greater weight to the literature of the past decade, and offers practical, clinical recommendations for assessment and treatment that derive from the literature. We found that treatments for insomnia, namely relaxation, cognitive behavior therapy, stimulus control, sleep restriction, and sleep hygiene are all effective to varying degrees, and it is both practically feasible and clinically desirable to favor a tailored package treatment approach rather than relying on unitary interventions. Overall, we underscored the importance of comprehensive, developmentally tuned assessment, and we concluded that behavioral treatment of insomnia has demonstrated strong success. Promising areas for future inquiry include comparing nonpharmacologic vs. hypnotic treatments and exploring the utility of very brief and self-help interventions.
  • Article
    Background: Removable oral appliances are employed to treat obstructive sleep apnea and snoring. In this review we summarize the current state of the art of this therapy. Methods: We performed a systematic review of the medical literature on the effectiveness, side effects and practical aspects of oral appliance therapy for sleep-disordered breathing. Results: Several randomized, controlled trials demonstrate the improvement of symptoms and sleep-related breathing disturbances in obstructive sleep apnea and snoring by oral appliances that advance the mandible. Side effects are common but usually transient and rarely severe. Conclusions: Mandibular advancement devices are a valuable treatment modality for obstructive sleep apnea and snoring. Dental and medical examinations at regular intervals and polysomnographic follow-up are important during long-term treatment to avoid potential adverse effects and to assure continued effectiveness.
  • Article
    Full-text available
    The authors tested the hypothesis that evening bright light pulses would improve sleep-wake patterns and reduce agitation in patients with Alzheimer's disease who have severe sundowning (a syndrome of recurring confusion and increased agitation in the late afternoon or early evening) and sleep disorders. Ten inpatients with Alzheimer's disease on a research ward of a veterans' hospital were studied in an open clinical trial. All patients had sundowning behavior and sleep disturbances. After a week of baseline measurements, patients received 2 hours/day of exposure to bright light between 7:00 p.m. and 9:00 p.m. for 1 week. During the baseline week, the treatment week, and a posttreatment week, patients were rated by nurses for agitation, sleep-wake patterns, use of restraints, and use of prescribed-as-needed medication. On the last 2 days of each week, patients wore activity monitors. Activity counts were analyzed for circadian rhythmicity. Clinical ratings of sleep-wakefulness on the evening nursing shift improved with light treatment in eight of the 10 patients. The proportion of total daily activity occurring during the nighttime decreased during the light-treatment week. The relative amplitude of the circadian locomotor activity rhythm, a measure of its stability, increased during the light-treatment week. More severe sundowning at baseline predicted greater clinical improvement. Evening bright light pulses may ameliorate sleep-wake cycle disturbances in some patients with Alzheimer's disease. This effect may be mediated through a chronobiological mechanism.
  • Article
    We reviewed the literature on sleep in psychiatric disorders and evaluated the data by meta-analysis, a statistical method designed to combine data from different studies. A total of 177 studies with data from 7151 patients and controls were reviewed. Most psychiatric groups showed significantly reduced sleep efficiency and total sleep time, accounted for by decrements in non-rapid eye movement sleep. Rapid eye movement sleep time was relatively preserved in all groups, and percentage of rapid eye movement sleep was increased in affective disorders. Reduction in rapid eye movement sleep latency was seen in affective disorders but occurred in other categories as well. Although no single sleep variable appeared to have absolute specificity for any particular psychiatric disorder, patterns of sleep disturbances associated with categories of psychiatric illnesses were observed. Overall, findings for patients with affective disorders differed most frequently and significantly from those for normal controls.
  • Article
    The cyclical changes in heart rate and systemic blood pressure that accompany apneic events are predominantly mediated by fluctuations in the activity of the autonomic nervous system. Increased vagal efferent parasympathetic activity is responsible for the cyclical reductions in heart rate during apnea. In contrast, the cyclical elevations in systemic blood pressure are believed to result from recurrent peripheral vasoconstriction mediated by repetitive activation of the sympathetic nervous system. Maximal activation and pressures coincide with apnea termination and brief arousal from sleep. These cyclical elevations in systemic pressure during sleep increase ventricular workload and, thereby, may contribute to the development of ventricular hypertrophy. Systemic hypertension is present during wakefulness in approximately 50% of patients with OSA. Although age and obesity are the predominant risk factors for diurnal hypertension, OSA probably makes an independent contribution in younger obese men. Sinus bradycardia, Mobitz type 1 second-degree heart block, and prolonged sinus arrest have all been documented in association with the apneic events. Increased ventricular ectopy has been observed with oxyhemoglobin desaturations below 60%. Myocardial ischemia, infarction, sudden death, and stroke all demonstrate similar circadian variations in time of onset. Peak frequencies occur between 6 AM and noon, generally within several hours of awakening. Although sleep is associated with decreased frequencies of these adverse cardiovascular events in the general population, evidence exists linking REM sleep to an increased risk of myocardial ischemia. In men who habitually snore, epidemiologic data have detected an increased risk for ischemic heart disease and stroke. Habitual snoring has also been associated with an increased risk of sudden death during sleep. In patients with clinically significant OSA, there is reasonable information indicating excessive mortality in the absence of treatment. This mortality is predominantly cardiovascular and tends to occur during sleep.
  • Article
    The study was designed to investigate sleep-wake patterns in healthy elderly men and women (greater than 88 years) using ambulatory recording techniques. Cross-sectional observations on 2 consecutive days. Two consecutive 24-hour recordings were made. Each 30-second period of the recording was scored as characteristic of wakefulness, REM, and non-REM sleep (stages 1-4). Interviews and recordings were done in the home of the elderly, not interfering with the habitual routine. Among eligible members of the "Senieur" protocol, screened for wellness, seven females (88-102 years) and seven males (88-98 years) volunteered to participate. Organization of sleep, sleep structure, and daytime mapping. There was no difference between the first and second night recording. Important gender differences were observed: males had significantly less total sleep, shorter REM latency, more transitions to wake from REM, less NREM 3 sleep, and virtually no NREM 4. Daytime napping, REM amount, and distribution did not show sex differences. Although the variability in the amount of napping was considerable, it occupied less than 10 percent of the total sleep time in both women and men. Daytime napping was unrelated to sleep characteristics. Ambulatory sleep-wake recordings allow an objective and critical evaluation of sleep function in normal aging. Interesting findings include a shift of REM sleep to the first part of the sleep period an increased cycle variability, and non-correlation of night-time sleep with daytime napping. In contrast to earlier findings in elderly persons, a polygraphic and subjective first-night effect was lacking.
  • Article
    The purpose of this study was to test the phase-shifting and entraining effects of melatonin in human subjects. Five totally blind men were found in a previous study to have free-running endogenous melatonin rhythms. Their rhythms were remarkably stable, so that any deviation from the predicted phase was readily detectable. After determination of their free-running period and phase, they were given exogenous melatonin (5 mg) at bedtime (2200 hr) for 3 weeks, in a double-blind, placebo-controlled trial. The effects on the endogenous melatonin rhythm were assessed at intervals ranging from several days to 2 weeks. Exogenous administration of melatonin phase-advanced their endogenous melatonin rhythms. In three of the subjects, cortisol was shown to be phase-shifted in tandem with the melatonin rhythm. A sixth subject [one of the coauthors (JS)] was previously found to have free-running cortisol and temperature rhythms and was plagued by recurrent insomnia and daytime sleepiness. He had tried unsuccessfully to entrain his rhythms for over 10 years. After he took melatonin (7 mg at 2100 hr), his insomnia and sleepiness resolved. Determination of his endogenous melatonin rhythm after about a year of treatment demonstrated endogenous rhythms that appeared normally entrained. The treatment of blind people with free-running rhythms has many advantages for demonstrating chronobiological effects of hormones or drugs.
  • Article
    Full-text available
    This study examined the role of sleep problems in the decisions of families to institutionalize elderly relatives. Previous work on institutionalization of the elderly has given little attention to the contribution of nocturnal, sleep-related problems. Seventy-three primary caregivers of elders recently admitted to a nursing home or psychiatric hospital were asked to identify the problems the elder was having during the night and day and rate the degree to which these influenced their decision to institutionalize the elder. Seventy percent of the caregivers in each sample cited nocturnal problems in their decision to institutionalize, often because their own sleep was disrupted. The most frequent disruptive nocturnal events were micturition, pain, and complaints of sleeplessness. Sleep problems of the elderly contribute heavily to the decision to institutionalize an elder and thus to the social and economic cost of institutional care. They appear to do this largely by interfering with the sleep of caregivers. The nature, prevalence, and treatability of the sleeping problems of both elders and their caregivers need further study.
  • Article
    The prevalence of periodic limb movements in sleep (PLMS) in a randomly selected elderly sample is reported. In San Diego, 427 elderly volunteers aged 65 yr and over were recorded in their homes. Forty-five percent had a myoclonus index, MI greater than or equal to 5. Correlates of PLMS included dissatisfaction with sleep, sleeping alone and reported kicking at night. Although statistically significant, the strengths of the associations between interview variables and myoclonus indices were all small. No combination of demographic variables and symptoms allowed highly reliable prediction of PLMS.
  • Article
    Full-text available
    These are the final results of a survey of sleep-disordered breathing, which examined objective and subjective information from a large randomly selected elderly sample. We randomly selected 427 elderly people aged 65 yr and over in the city of San Diego, California. Twenty-four percent had an apnea index, AI, greater than or equal to 5 and 62% had a respiratory disturbance index, RDI, greater than or equal to 10. Correlates of sleep-disordered breathing included high relative weight and reports of snoring, breathing cessation at night, nocturnal wandering or confusion, daytime sleepiness and depression. Body mass index, falling asleep at inappropriate times, male gender, no alcohol within 2 hr of bedtime and napping were the best predictors of sleep-disordered breathing. Despite statistical significance, all of the associations between interview variables and apnea indices were small. No combination of demographic variables and symptoms allowed highly reliable prediction of AI or RDI.
  • Article
    Advanced age among the elderly has been hypothesized to be a risk factor for depression, yet extant data do not uniformly support this hypothesis. The paucity of sufficiently large and representative samples of both the young-old and old-old and the failure to control for critical variables known to confound the association between advanced age and depression have prevented testing this hypothesis. The duke EPESE (Establishment Of A Population For Epidemiologic Studies Of The Elderly) assessed 3,998 community-dwelling elders (65+)for depressive symptoms using a modified version of the ces-d and relevant control variables. Depressive symptoms were associated in bivariate analysis with increased age, being female, lower income, physical disability, cognitive impairment, and social support. In a multiple regression analysis, the association of age and depressive symptoms reversed when the above confounding variables were simultaneously controlled. The oldest old suffered fewer depressive symptoms when factors associated with both increased age and depressive symptoms were taken into account. Because many of these factors can be prevented (such as decreased income, physical disability, and social support), the uncontrolled association between age and depressive symptoms can potentially be modified.
  • Article
    This study compared differential effects of behavioral therapy and triazolam in a clinical population with sleep-onset insomnia. Triazolam was hypothesized to decrease sleep latency and frequency and duration of awakening, with some effects during the first night's administration. But at follow-up, sleep measures were predicted to return to baseline levels. Behavioral treatment was hypothesized to effect sleep after 2 or more weeks of training which persisted at follow-up. Thirty patients with average sleep latencies of 81.48 minutes, who reported chronic insomnia for an average of 2.6 years, were randomly assigned to one of two treatment groups: behavioral stimulus control/relaxation training and triazolam. Both treatments decreased sleep latency but differentially. Triazolam was effective immediately but maintained only some gains at follow-up. Behavioral treatment decreased sleep latency beginning the second week, when subjects expected no improvement, with gains maintained at follow-up. Comparisons showed that triazolam group latencies returned toward baseline, while behavioral group gains were maintained at follow-up. Triazolam treatment showed superior immediate treatment effects, while behavioral treatment showed superior treatment effects at follow-up, effects that accrued during the training period and differentially persisted at follow-up. One treatment strategy implied by these results would be to combine these two interventions concurrently. This would seem to use the immediate effects produced by the medication until the behavioral skills were learned, at which point medication would be terminated. This strategy could offer immediate relief and sustained effects at drug termination.
  • Article
    The Apnea Plus Hypopnea Index (A + HI) of 60 male positional sleep apneics was analyzed by sleep stage to determine if positional differences are limited to NREM sleep. Differences in apnea severity by sleep position were found to persist in REM sleep and to be of equal extent to those differences found in NREM sleep, despite the fact that there is also a significant increase in the frequency of apneic events associated with REM sleep. The positional effect persists in REM sleep, making treatments to control sleep posture a viable option.
  • Article
    Sleep apnea is characterized by transient hypoxemias which are thought to affect mental functioning. Accordingly, speculation and research have focussed on relationships between sleep apnea and dementia. We studied 235 nursing home (ie institutionalized) patients (152 women with a median age of 83.5; 83 men with a median age of 79.7) with portable sleep recording equipment. The Mattis Dementia Rating Scale and the Geriatric Depression Scale were given to each. Seventy percent of the patients had five or more respiratory disturbances per hour of sleep and 96 percent showed some dementia. Sleep apnea was significantly correlated with all subscales on the dementia rating scale. There were trivial differences in dementia ratings between those with mild-moderate apnea and those with no apnea. There were significant differences, however, between the latter two groups and those with severe apnea. In particular, items reflecting attention, initiation and perseveration, conceptualization, and memory tasks on the DRS distinguished between those with and without severe sleep apnea. Among those patients with no depression, all patients with severe sleep apnea were also severely demented. Our data suggest that there is a strong relationship between dementia and sleep apnea when the sleep apnea and dementia are severe. Although causality cannot be inferred from associations, our hypothesis for study is that sleep apnea causes deficits in brain function, possibly due to global effects rather than any particular cortical or subcortical structure.
  • Article
    Reviews studies on changes in sleep–wake patterns that accompany normal aging, the various sleep disorders common among the elderly, and their treatment. The disorders discussed include sleep disturbance (SD) secondary to psychiatric illness and persistent psychophysiologic insomnia. Other disorders include SD associated with drug and alcohol use, SD related to changes in circadian rhythms, and nightmares and REM-sleep behavior disorder. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
  • Article
    Highlights aspects of insomnia (INS), which may occur in transient and short-term or chronic forms. Transient INS generally occurs in people who usually have normal sleep and are experiencing acute stress and environmental disturbances. Chronic INS usually results from underlying medical or psychiatric disorders. Between one-third and two-thirds of patients with chronic INS have a recognizable psychiatric illness. Conditioned anxiety about falling asleep or the consequences of sleep loss may perpetuate INS to varying degrees in all chronic INS patients. Management of INS may include counseling and psychotherapy, behavioral and biofeedback techniques, and pharmacotherapy. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
  • Article
    Sleep patterns of aged, infirm, demented, chronically institutionalized residents of a skilled-care nursing facility were studied. The purpose of this naturalistic study was to describe sleep and wakefulness (S/W) within the limits afforded by brief behavioral observations and to examine homeostasis and diurnal rhythmicity of S/W as a function of psychoactive drug intake. Observers noted S/W every 15 min, 24 hr a day for 10 days in 24 Ss. Results indicated substantial individual variation in daytime hours. Daily and weekly variation within Ss was minimal. Sleep was least likely near sunset. Ss on psychoactive drugs showed dampened diurnal variation in S/W rhythms. In Ss not on such drugs, there was a suggestion of homeostasis of S/W between sleep during the morning and evening hours. Results are discussed methodologically (viability of approach), theoretically (age-related change in sleep), and practically (potential treatments).
  • Article
    This investigation examined the diagnostic value of polysomnography (PSG) for evaluating disorders of initiating and maintaining sleep (DIMS). The sample consisted of 100 outpatients who presented to the Duke Sleep Disorders Center with a complaint of chronic insomnia. All patients were given comprehensive medical, psychiatric, behavioral, and ambulatory PSG evaluations. Sleep disorder diagnoses were assigned using the criteria of the Association of Sleep Disorders Centers. Overall, PSG yielded important diagnostic information in 65% of the sample: 34% were given a primary sleep disorder diagnosis that was heavily dependent on PSG data [periodic movements of sleep (PMS) = 25%, apnea = 3%, and subjective insomnia = 6%]; 15% were given a secondary diagnosis of one of these three disorders; and PSG ruled out suspected PMS in 9% and sleep apnea in 7% of the sample. Patients greater than 40 years of age had a significantly higher rate of positive PSG findings than younger patients. Using only the clinical exam, two experienced sleep clinicians were able to predict only 14 of 25 PMS cases and one of three cases of sleep apnea. Based on these data, we suggest using PSG routinely with older insomniacs and with younger patients who fail initial treatment.
  • Article
    As part of the National Institute of Mental Health Epidemiologic Catchment Area study, 7954 respondents were questioned at baseline and 1 year later about sleep complaints and psychiatric symptoms using the Diagnostic Interview Schedule. Of this community sample, 10.2% and 3.2% noted insomnia and hypersomnia, respectively, at the first interview. Forty percent of those with insomnia and 46.5% of those with hypersomnia had a psychiatric disorder compared with 16.4% of those with no sleep complaints. The risk of developing new major depression was much higher in those who had insomnia at both interviews compared with those without insomnia (odds ratio, 39.8; 95% confidence interval, 19.8 to 80.0). The risk of developing new major depression was much less for those who had insomnia that had resolved by the second visit (odds ratio, 1.6; 95% confidence interval, 0.5 to 5.3). Further research is needed to determine if early recognition and treatment of sleep disturbances can prevent future psychiatric disorders.
  • Article
    Sleep-activity patterns were objectively recorded over a 24-hr period in 19 elderly nursing home residents. On average, both sleep and wake times were observed during every hour of the 24 recorded hours; however, the sleep pattern of the residents was fragmented so that they rarely experienced even a single hour of consolidated time spent sleeping. It is hypothesized that several independent factors, including compensation for lost sleep, increased total time in bed, weakening of social constraints, and deterioration of the circadian sleep-wake rhythm, are interacting to produce this increase in sleep fragmentation.
  • Article
    Full-text available
    There has been much speculation on the risk of mortality associated with sleep apnea. We followed-up 233 elderly patients in nursing homes, 70 percent of whom had five or more respiratory disturbances per hour of sleep, to determine if sleep apnea is a predictor of mortality. Cox proportional hazards survival analyses indicated a gender effect, with women having a much better survival rate than men. In women, but not in men, there was a strong association between mortality and the RDI. In addition, patients with obstructive sleep apnea had a greater tendency to die in their sleep. These results show that respiratory disturbances in sleep are an extremely significant risk factor for mortality in elderly women who are in poor health.
  • Article
    Data for this report come from a nationally representative probability sample survey of noninstitutionalized adults, aged 18 to 79 years. The survey, conducted in 1979, found that insomnia afflicts 35% of all adults during the course of a year; about half of these persons experience the problem as serious. Those with serious insomnia tend to be women and older, and they are more likely than others to display high levels of psychic distress and somatic anxiety, symptoms resembling major depression, and multiple health problems. During the year prior to the survey, 2.6% of adults had used a medically prescribed hypnotic. Typically, use occurred on brief occasions, one or two days at a time, or for short durations of regular use lasting less than two weeks. The survey also found a small group of hypnotic users (11% of all users; 0.3% of all adults) who reported using the medication regularly for a year or longer. If we include anxiolytics and antidepressants, 4.3% of adults had used a medically prescribed psychotherapeutic drug that was prescribed for sleep; 3.1% had used an over-the-counter sleeping pill. The majority of serious insomniacs (85%) were untreated by either prescribed or over-the-counter medications.
  • Article
    Full-text available
    Clonazepam (1 mg h.s.) and temazepam (30 mg h.s.) were studied in 10 patients diagnosed as having insomnia with nocturnal myoclonus. Each subject underwent two nocturnal polysomnographic recordings while drug-free, two during treatment with clonazepam, and two during treatment with temazepam. Treatment sessions were 7 days long, and recordings were done on nights 6 and 7 of the treatment sessions. A 14-day washout period separated the treatment sessions. The order of drugs used in the first and second treatment sessions was randomized. Objective and subjective sleep laboratory data showed that both drugs improved the sleep of patients with insomnia in association with nocturnal myoclonus. Neither drug significantly reduced the number of nocturnal myoclonic events. Sleep changes were consistent with those produced by sedative benzodiazepines in general. Thus, the data support clinical reports that clonazepam, a benzodiazepine marketed for the indication of seizure, is useful in improving sleep disturbances associated with nocturnal myoclonus. Temazepam, a benzodiazepine marketed for the indication of insomnia, was found to be a suitable alternative to clonazepam in the treatment of insomnia associated with nocturnal myoclonus. The present data and other studies suggest the need for a model that explains why leg movements and sleep disturbances may wax and wane independently.