Adults spend approximately one third of their life asleep; yet, approximately 50% of older adults report sleep irregularity (Vance, Heaton, Eaves, & Fazeli, 2011). Additionally, approximately 21% of older adults report changes in cognitive functioning due to loss of sleep (Vance et al., 2011). Some factors associated with changing sleeping patterns in older adults are life-changing events such as retirement, spousal death, medication adjustments, and comorbid diseases (Vance et al., 2011). As an individual ages, changes in sleep pattern are considered part of the normal aging process. Changes in sleep patterns can increase morbidity and mortality and change the quality of life and cognitive functioning for many older adults (Crowley, 2011).
Pathophysiology of Sleep
The hypothalamus contains the sleep-wake center responsible for regulating sleep. The limbic system, reticular activating system, and thalamus are all controlled by the hypothalamus, which also influences sleep and wakefulness. A mass of several nuclei connected with portions of the nervous system, the hypothalamus is located distal to the thalamus, forming part of the walls of the third ventricle. These clusters of hypothalamic nerve cells are known as the suprachiasmatic nucleus (SCN) and are responsible for controlling the sleep-wake cycle (Moore, 2007).
Sleep is classified into two categories: (a) rapid eye movement (REM) and (b) non-REM. The majority of sleep is non-REM, accounting for 75% to 80% of the sleep cycle. The additional 20% to 25% of the sleep cycle comprises REM sleep. Sleep occurs in cycles of non-REM and REM sleep, beginning with the four stages of non-REM sleep, progressing to periods of REM sleep. Sleep cycles continue during the night, alternating between non-REM and REM sleep. There are approximately four to six cycles per night, each lasting approximately 70 to 120 minutes (Stevens, 2011).
Stage 1 of non-REM sleep is the lightest level of sleep. As the individual progresses through the next three stages, sleep progressively deepens. Stage 4 is the deepest level of sleep and is characterized by a reduction in respiratory rate, heart rate, blood pressure, and body temperature. REM sleep is characterized by an increase in brain activity and oxygen consumption, and heart and respiratory rates become irregular, as the body cannot regulate the low levels of carbon monoxide. This contributes to certain disorders such as chronic obstructive pulmonary disease (COPD), sleep apnea, and asthma (Bloom et al., 2009; Sanker, 2011; Stevens, 2011).
Sleep in Older Adults
Sleep patterns change as individuals age. There is a decrease in total sleep time, and it takes longer for the older adult to fall asleep. The older adult retires to bed earlier in the evening and tends to wake up much more frequently during the night and sometimes earlier in the morning. In addition, REM sleep decreases with age. REM sleep is particularly important for older adults. During REM sleep, neurotransmitters are replenished, helping organize the neural networks for memory, learning, problem solving, and performance. REM sleep controls memory by transferring short-term memories to the motor cortex to become long-term memories. In addition to changes in REM sleep, Stage 1 and Stage 2, the light sleep stages, are increased. Maintenance of general health, restorative, and growth-inducing properties are also functions of REM sleep (Neikrug & Ancoli-Israel, 2010; Uma Devi, Murugan, & Senapathy, 2010).
Circadian rhythms are controlled by the SCN located in the hypothalamus. Time cues and exogenous stimuli regulate the 24-hour circadian clock. With increasing age, circadian rhythms become weaker and less coordinated, disrupting the rhythm in older adults. It is believed that the external or exogenous stimuli are weakened or absent causing this disruption in the sleep-wake cycle. In addition, the endogenous changes in the production of melatonin are diminished, resulting in less sleep efficacy and further disruption of restorative sleep (Neikrug & Ancoli-Israel, 2010; Waterhouse, Fukuda, & Morita, 2012).
Changes in the sleep pattern of older adults may be correlated to changes in lifestyle or activities of daily living. Chronic disease, changes in daily routine, alteration in circadian rhythms, and sedative agent use can contribute to some of the changing sleep patterns. Cortisol levels, growth hormone, and melatonin, all of which are decreased in the older adult, also affect sleep patterns (Espiritu, 2008; Harrington & Lee-Chiong, 2007). Aging does not automatically signify that sleep disorders will occur in older adulthood; however, it increases the likelihood that older adults will seek professional help to cope with the problem (Bloom et al., 2009; Vitiello, 2009).
Medical Conditions Affecting Sleep in Older Adults
Older adults with comorbid conditions are also at risk for sleep disturbances. Some of the following conditions can contribute to sleep dysfunction in this population.
Disorders such as asthma, COPD, and respiratory illness strengthen the predisposition for diminished oxyhemoglobin desaturation. This low level of arterial oxygen irritates the central nervous system, resulting in changes of sleep quality. Individuals experience frequent arousals, poor sleep quality, hypoxia, and hypercapnia (Parish, 2009).
Gastroesophageal Reflux Disease
An incompetent lower esophageal sphincter causes gastroesophageal reflux disease (GERD). The prevalence of GERD increases with age. Individuals with GERD are frequently awakened during the night from symptoms of indigestion such as heartburn, chest discomfort, and a “sour” taste in the mouth. Clearance of heartburn/indigestion can only occur with the arousal process to produce proper acid clearance (Jung, Choung, & Talley, 2010; Parish, 2009). Individuals with GERD have difficulties with sleep latency and sleep maintenance and experience frequent nighttime awakenings (Parish, 2009).
Conditions such as reduced bladder capacity, benign prostatic hypertrophy in men, and decreased sphincter control in women make nocturia seem commonplace for many older adults. In addition, aging changes such as decreased glomerular filtration rate, vaginal atrophy, and reduced bladder capacity can contribute to frequent awakenings at night. All of these conditions result in sleep disturbance in older adults and can cause poor nighttime sleeping, difficulties falling back to sleep, and daytime fatigue (Bliwise et al., 2009).
Specific Sleep Disorders in Older Adults
The primary sleep complaint for older adults is insomnia. Insomnia is defined as difficulty falling asleep, staying asleep, or sleep that is non-restorative (Roepke & Ancoli-Israel, 2010). Insomnia is a common sleep disorder in older adults, as it is a result of changing sleep patterns affecting Stage 4 or deep sleep. Insomnia is classified as short term, lasting for days to a few weeks, or chronic, lasting for years. Short-term and chronic insomnia are usually precipitated by a stressful experience. The causes of insomnia include psychiatric issues, medical issues, medication use, and possible behavioral or environmental issues (Crowley, 2011). The 2003 National Sleep Foundation Survey, which was administered to adults older than 65, reported a positive correlation between increased sleep complaints and comorbid medical conditions (e.g., cardiac disease, respiratory disease, depression) (Foley, Ancoli-Israel, Britz, & Walsh, 2004). Older adults often experience insomnia due to chronic arthritic pain, GERD, and nocturia (Crowley, 2011).
One of the major risk factors for depression is insomnia. Daytime sleepiness, early morning awakenings, or problems falling asleep are related to depression, which may be one of the reasons that older adults with depression pursue treatment. Fatigue, concentration difficulties, and daytime sleepiness are common in people with depression (Carney, Ulmer, Edinger, Krystal, & Knauss, 2009). Data suggest that insomnia is not only a symptom of depression but in fact is a reliable predictor of insomnia (Baglioni et al., 2011). Insomnia usually is a precursor to depression. Depression is less likely to be present in those with no sleep difficulties, whereas those with sleep difficulties or insomnia have a twofold risk of developing depression (Baglioni et al., 2011). Confirming similar findings, Jaussent et al. (2011) found that insomnia is a risk factor for depression in older adults. Approximately 50% of geriatric patients with depression report insomnia (Gentili, 2012). The connection between depression and insomnia is controversial, and thoughts on the relationship between the two vary. Some believe that sleep deprivation caused by lifestyle changes can precipitate depression (Statharou & Taka, 2012). Other theories about depression and insomnia include: lack of sleep can lead to thoughts of hopelessness and helplessness leading to depression; lying in the darkness for periods of time can trigger a depressive episode; and a relationship between lack of sleep and constant state of awakeness may cause neurological alterations resulting in depression (Taylor, 2008). This link between depression and insomnia indicates individuals with altered sleep patterns should be screened for depression, as insomnia places the older adult at risk for depression.
Sleep-disordered breathing (SDB) is defined as periods of hypopnea or partial respiration to the complete cessation of respirations known as apnea. SDB is characterized by snoring, interrupted breathing, frequent nighttime arousals, and an increase in daytime sleepiness. SDB is prevalent in approximately 45% to 62% of adults older than 60 (Ancoli-Israel & Ayalon, 2006). During SDB, normal ventilation does not occur and there is a complete cessation of airflow, causing the individual to be awakened from sleep to take a deep breath. Once a normal breath is taken, the individual tries to resume sleep. This cycle of awakening and sleeping continues causing interrupted non-restorative sleep. Primary symptoms of SDB are loud snoring that can be heard throughout the house, interrupted sleep with multiple nocturnal awakenings (usually reported by a partner), daytime sleepiness causing changes in mental status, slower response time, and diminished attention span, which ultimately can affect quality of life.
Obese older adults are at risk for sleep apnea (Ancoli-Israel & Ayalon, 2006; Cooke & Ancoli-Israel, 2011). A common form of sleep apnea in the older adult is obstructive sleep apnea (OSA). OSA is prevalent across the life span but increases with age. To treat older adults experiencing insomnia related to SDB (e.g., OSA), continuous positive airway pressure (CPAP) is the treatment of choice. CPAP is the most successful treatment for OSA; there are no pharmacological therapies for the treatment of OSA. CPAP creates a pneumatic splint opening the airway. If left untreated, sleep apnea can result in cognitive dysfunction or mild cognitive impairment and cardiac irregularities (e.g., heart failure, dysthymia), which can lead to stroke and even death (Cooke & Ancoli-Israel, 2011).
Restless Leg Syndrome
Restless leg syndrome (RLS) is another cause of sleep disruption, affecting approximately 45% of older adults and approximately 20% of individuals older than 80. Women are twice as likely than men to experience RLS (Roepke & Ancoli-Israel, 2010; Rye & Trotti, 2012). Individuals with RLS have an uncontrollable need to move their legs. RLS is also accompanied by symptoms or sensations of burning, tingling/itching, or creeping/crawling. These RLS sensations increase during the night, causing sleep latency and frequent awakening (Bloom et al., 2009; Roepke, 2010).
The following criteria are specific to a diagnosis of RLS (Leschziner & Gringras, 2012):
- A strong urge to move the legs with the sensation of crawling or creeping, itching, tugging, or gnawing.
- Symptoms are exacerbated with rest.
- Leg movement offers some relief.
- Symptoms worsen at night.
Certain medications can cause RLS, such as selective serotonin reuptake inhibitors, calcium channel blockers, and lithium. In addition, withdrawal from opioid or sedative agents can cause RLS. RLS is associated with anemia, kidney disease, and lifestyle factors (e.g., caffeine consumption, tobacco use, sedentary lifestyle). Older adults subject to polypharmacy also develop RLS more frequently (Bloom et al., 2009).
Assessing Sleep in Older Adults
Clinicians should assess sleep behaviors and bedtime rituals, as this is necessary to recognize responses that can indicate possible sleep difficulties. Questions asked during the assessment should solicit descriptive responses. Bloom et al. (2009, p. 764) identified 12 questions for initially assessing sleep patterns in older adults (Table). If the clinician recognizes complaints from these questions, additional questions may be needed to further assess sleep history. Additional questions should relate to leg movement during sleep, nocturia, physical activity routines, schedule of medication administration, side effects of medication, caffeine intake patterns, use of alcohol to induce sleep, and some basic questions about affect (e.g., sadness, anxiety, recent loss) to assess for any history of psychiatric or mood disorders (Bloom et al., 2009; Gentilli, 2012). Older adults reporting signs of sleep deprivation such as sleep initiation difficulties, problems staying asleep, numerous awakenings at night, morning fatigue or grogginess, and mood or behavioral changes, may need further assessment to diagnose any underlying sleep disorder. Sleep history should also include current health problems and the use of over-the-counter (OTC) preparations. Many older adults may use OTC products containing antihistamines, which are often used to induce sleep.
Questions to Assess Sleep Patterns
A reliable and valid tool to accurately assess sleep patterns in older adults is the Epworth Sleepiness Scale (ESS). The ESS is part of the best practices in geriatric care by the Hartford Institute for Geriatric Nursing (2012). The ESS, developed by Murray Johns in 1991, is one of the most widely used tools to measure daytime sleepiness. The ESS contains eight self-reported questions on how likely it is for one to fall asleep in various situations. A score of 10 or less is considered normal, and a score of 10 or higher may require intervention by a sleep specialist. The ESS can also quantify sleep disorders in the geriatric patient (Hartford Institute for Geriatric Nursing, 2012; Johns, 1991).
Initial first-line choices of drug treatment for many patients who have some form of insomnia are OTC sleep preparations. Approximately 25% of patients use some form of OTC sleep aid (Ramakrishnan & Scheid, 2007). OTC sleep aid preparations or supplements are readily available at local pharmacies and supermarkets. Some common OTC preparations that “promote” sleep contain ingredients such as kava kava, valerian root, melatonin, chamomile, and tryptophan. Current practice does not require herbal preparations or dietary supplements to be regulated; therefore, information and outcomes of efficacy and safety may not be known (Randall, Roehrs, & Roth, 2008). Results vary regarding the efficacy of these supplements. Melatonin is not suggested for primary insomnia, but may have some beneficial effect on secondary and age-related insomnia. Tryptophan increases Stage 1 sleep and reduces Stage 2 sleep. Valerian root is beneficial in improving sleep quality and reduces the time required to fall asleep. Chamomile is shown to produce a mild sedative effect, and kava kava is effective in stress-induced insomnia (Hulisz & Duff, 2009; Randall et al., 2008). Individuals taking OTC preparations to induce sleep may delay proper medical treatment for their insomnia. A delay in treatment will have adverse effects on prompt diagnosis and treatment for concurrent disease or disorders.
Diphenhydramine, a common ingredient in many OTC antihistamine preparations, is also used to treat insomnia. Diphenhydramine’s pharmacotherapeutic action is its effect on the postsynaptic blockade of H1 receptors. H1 receptors promote the onset of sleep. Diphenhydramine is distributed and well absorbed through the central nervous system and has an elimination half-life of approximately 8 hours. As a postsynaptic H1 receptor, an additional function of diphenhydramine is its action as a postsynaptic muscarinic receptor agonist. As a result of this action, common anticholinergic side effects are often present, including dry mouth, blurry vision, urine retention, confusion, and delirium. In addition to these side effects, diphenhydramine, with its half-life of approximately 8 hours, can cause grogginess on awakening. Diphenhydramine is not recommended for use in older adults (Hulisz & Duff, 2009; Randall et al., 2008).
Sedative Hypnotic Agents—Benzodiazepine and Non-Benzodiazepine
Sedative hypnotic agents work using gamma-aminobutyric acid (GABA) neurotransmitters. Sedative hypnotic agents increase GABA activity in the brain, attaching to the receptor nerves to produce sedating hypnotic effects to induce drowsiness and expedite or maintain sleep. The primary functions of benzodiazepine agents are to accelerate sleep onset, reduce the number of nighttime awakenings, and increase sleep time. In addition, Stage 2 sleep is lengthened and there is a decrease in REM sleep. The half-life of benzodiazepine agents varies, as does their action and duration (Saddichha, 2010; Smith, 2012). Benzodiazepine agents continue to be commonly prescribed preparations for sleep; however, according to the American Geriatrics Society (AGS) 2012 Beers criteria, all benzodiazepine agents (short, long, and intermediate acting) should not be used in the treatment of insomnia for older adults. Older adults are more sensitive to benzodiazepine agents, as they metabolize drugs less efficiently. When used in the older adult, benzodiazepine agents can cause central nervous system effects such as cognitive and psychomotor impairments, falls, fractures, hangover effects, and amnesia (AGS, 2012). The Beers criteria (AGS, 2012) indicate limited use of benzodiazepine agents in REM sleep disorders, periprocedural anesthesia, benzodiazepine agent withdrawal, alcohol withdrawal, severe anxiety disorders, and end-of-life care. U.S. Food and Drug Administration (FDA)–approved benzodiazepine agents indicated for the treatment of insomnia are estazolam (Prosom®), flurazepam (Dalmane®), quazepam (Doral®), temazepam (Restoril®), and triazolam (Halcion®).
Non-benzodiazepine agents function similar to benzodiazepine agents using GABA receptor sites to produce sedative effects. Half-life for non-benzodiazepine agents is variable and similar to benzodiazepine agents (Proctor & Bianchi, 2012). Non-benzodiazepine agents are safer and less addictive than benzodiazepine agents, do not cause rebound insomnia or symptoms of withdrawal when discontinued, but must be used with caution in older adults. FDA-approved insomnia treatment with non-benzodiazepine agents include preparations such as eszopiclone (Lunesta®), zaleplon (Sonata®), and zolpidem (Ambien®) (Neikrug & Ancoli-Israel, 2010).
Non-benzodiazepine preparations are indicated for sleep initiation (zaleplon and zolpidem) and the treatment of insomnia (eszopiclone); however, these preparations should not be used for more than 90 days. In addition, when used in older adults, non-benzodiazepine agents can have detrimental effects causing changes in mental status (e.g., delirium), falls, and fractures, with only minimum improvement in sleep latency and duration (AGS, 2012). The duration of zaleplon is approximately 4 hours and is used for assistance with sleep latency, allowing the individual to awaken refreshed (Archer, Odera, Madden, & Steinvoort, 2012; Saddichha, 2010). Zolpidem is of shorter duration; however, the extended release preparation of zolpidem should be used cautiously in older adults, as this population has slower metabolic and drug elimination rates. If zolpidem is administered daily for an extended period of time, addiction may occur (Smith, 2012).
It is important to note that clinicians may see patients who have previously been prescribed or are currently taking benzodiazepine agents, and should therefore be aware of the effects these agents can produce on patients. Benzodiazepine agent use can cause changes in cognitive ability, produce changes in coordination, and slow reaction time. Additional benzodiazepine agent side effects include rebound insomnia, possible amnesia, and risk of falls and fractures. When benzodiazepine agents are used for more than 4 months, withdrawal symptoms must be considered when discontinuing the medication. Side effects of non-benzodiazepine agents include changes in mental status, fractures, and falls. In older adults, treatment duration of the non-benzodiazepine agent should be no more than 3 months. Unlike benzodiazepine agents, non-benzodiazepine agents do not cause withdrawal symptoms or rebound amnesia. Other common side effects include headaches, dizziness, and drowsiness (Gentili, 2012; Saddichha, 2010).
A limited number of antidepressant agents can be used for the treatment of insomnia in the older adult, including trazadone (Desyrel®, Oleptro®), doxepin (Silenor®), mirtazapine (Remeron®), tricyclic antidepressant agents (e.g., Aventyl®), and nefazodone (Serzone®). Low-dose doxepin (3 to 6 mg) is the only antidepressant agent approved by the FDA for use with insomnia. Higher doses of doxepin have been shown to produce anticholinergic effects and should be used cautiously in older adults (Markov & Doghramji, 2010). Primary use of these agents is indicated for individuals with comorbid depression, as these agents promote sleep, reduce sleep latency, and cause no physical dependence (Gentili, 2012; Morin & Benca, 2012). Anti-depressant agents are to be used cautiously in the geriatric population, as higher doses produce anticholinergic side effects similar to antihistamine agents (AGS, 2012; Hulisz & Duff, 2009). Common side effects of antidepressant agents are postural hypotension, confusion, and oversedation. Mirtazapine should be used cautiously in older adults due to reduced renal clearance (Gentili, 2012). Due to polypharmacy in the geriatric population, the use of antidepressant agents can produce numerous drug–drug interactions.
Selective Melatonin MT1–MT2 Receptor Agonists
In 2005, the FDA approved ramelteon (Rozerem®), a selective melatonin agonist to be used for chronic insomnia. Ramelteon acts on the MT1 and MT2 receptors in the SCN to reduce sleep latency; however, it is not effective in maintaining sleep. Ramelteon is a good choice of drug for use in the geriatric population, as it is less likely to produce confusion or memory problems compared to benzodiazepine agents. Ramelteon has lower abuse potential, less motor deficit side effects, and does not cause rebound insomnia. Ramelteon should be used with caution in individuals with hepatic dysfunction (Archer, 2012; Cardinali, Vidal, & Vigo, 2012; Johnson & Griffiths, 2006).
Nonpharmacological Interventions for Sleep
Below are some recommended nonpharmacological interventions for sleep (Bloom et al., 2009; Neikrug & Ancoli-Israel, 2010; Taibi, 2008; Vance et al., 2011).
- Developing a regular routine for sleep, such as wake times and bedtimes, can enhance circadian rhythms.
- Promote good sleep hygiene by developing relaxing conditions that are favorable to inducing sleep. Bedtime rituals (e.g., soft music, warm milk, snacks, warm bath, comfortable room temperature) are good ways to curb insomnia and supplement readiness for sleep.
- Use the bedroom for sleeping only.
- Use positioning to alleviate pain.
- Eliminate caffeinated products in the late afternoon and evenings, as caffeine promotes wakefulness.
- Limit alcohol in the evening, as alcohol can have hyperarousing effects increasing sleep latency and producing lighter sleep.
- Small, light carbohydrate snacks may help with sleep by decreasing hypoglycemia.
- Eat at regular intervals; avoid large meals or spicy foods prior to bedtime, especially patients with GERD, as this can interfere with sleep.
- Reducing or limiting fluids in the evening can reduce nighttime awakenings for nocturia.
- Napping is appropriate but should not exceed 2 hours.
- Develop a regular physical exercise regimen for those who are able; regular exercise can deepen sleep, increase daytime arousal, and decrease depression.
- Exercise should be completed during the daytime and strenuous exercise should be avoided near bedtime.
- Medications taken by older adults can affect sleep. Instruction on proper administration times and possible side effects should be reviewed.
Implications for Nurses
Sleep assessment in older adults cannot be overlooked. Nurses have a responsibility to assess sleep patterns and understand the effects of how poor sleep patterns can affect quality of life. The ability to recognize the association of sleep complaints to sleep disorders and comorbid illness is key. Nurses are the ones who frequently administer sleep medications; therefore, it is important for nurses to promote optimal sleep in patients with and without sleep disorders. In addition, nurses are often the members of the health care team evaluating sleep interventions, thus understanding the need for nonpharmacological methods, as well as understanding the current practice and use of pharmacological methods, is critical to foster positive sleep outcomes. Information and educational programs addressing sleep needs in older adults to promote positive health outcomes should be offered to nursing staff.
Sleep is usually consistent through adult life. However, for older adults, the ability to attain sufficient sleep is decreased. Many conditions such as medical problems, psychiatric issues, and insomnia can cause sleep disorders in this population. Therefore, older adults should be assessed for sleep disruption, which may be associated with increased morbidity and mortality. Proper assessment and recognition can lead to appropriate treatment.
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Questions to Assess Sleep Patterns
|1. What time do you normally go to bed at night? What time do you normally wake up in the morning?
|2. Do you often have trouble falling asleep at night?
|3. Approximately how many times do you wake up at night?
|4. If you do wake up during the night, do you usually have trouble falling back asleep?
|5. Does your bed partner say (or are you aware) that you frequently snore, gasp for air, or stop breathing?
|6. Does your bed partner say (or are you aware) that you kick or thrash?
|7. Are you aware that you ever walk, eat, punch, kick, or scream during sleep?
|8. Are you sleepy or tired during much of the day?
|9. Do you usually take one or more naps during the day?
|10. Do you usually doze off without planning to during the day?
|11. How much sleep do you need to feel alert and function well?
|12. Are you currently taking any type of medication or other preparation to help you sleep?