What are the management options for sleep disorders in older adults?

Sleep Disorders in Older Adults and Management

Common Sleep Disorders in Older Adults

Older adults experience several distinct sleep disorders that require specific diagnostic and therapeutic approaches, with insomnia being the most prevalent, followed by sleep-disordered breathing, circadian rhythm disorders, parasomnias (particularly REM Behavior Disorder), and hypersomnias of central origin. 1, 2

Primary Sleep Disorders Include:

• Chronic insomnia - characterized by difficulty initiating or maintaining sleep, affecting quality of life and increasing healthcare costs 1, 2
• Sleep-disordered breathing (obstructive sleep apnea) - increases with aging and must be treated before diagnosing other sleep disorders 1, 2
• REM Behavior Disorder (RBD) - loss of normal muscle atonia during REM sleep leading to violent, complex behaviors that can cause injury 1
• Hypersomnias of central origin - including narcolepsy and idiopathic hypersomnia, characterized by excessive daytime sleepiness not caused by disturbed nocturnal sleep 1
• Circadian rhythm sleep-wake disorders - often exacerbated by limited bright light exposure and physical inactivity 1, 2
• Restless legs syndrome and periodic limb movements - common movement disorders disrupting sleep 2

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Assessment Approach

Key History Elements to Obtain:

• Medication review - identify drugs causing or exacerbating insomnia: β-blockers, bronchodilators, corticosteroids, decongestants, diuretics, SSRIs, SNRIs, cholinesterase inhibitors taken near bedtime, and sedating medications taken during the day 1, 3
• Medical comorbidities - pain, paresthesias, nighttime cough/dyspnea, gastroesophageal reflux, nocturia, dementia, Parkinson's disease 1
• Sleep-impairing behaviors - frequent daytime napping, excessive time in bed, insufficient daytime activities, late evening exercise, insufficient bright light exposure, excess caffeine, evening alcohol, smoking in evening, late heavy dinner, watching television at night, anxiety about sleep, clock watching 1, 3
• Environmental factors - room temperature, noise, light, pets in bedroom, active bed partners 1

Diagnostic Tools:

• Sleep diaries for 2 weeks - essential baseline data before initiating treatment 1, 4
• Pittsburgh Sleep Quality Index - most frequently used validated assessment tool 5, 4
• Polysomnography - NOT routine; reserved for suspected RBD (to document lack of REM atonia), sleep-disordered breathing, or when treatment fails 1, 2

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Management of Insomnia (Most Common Disorder)

First-Line Treatment: Cognitive Behavioral Therapy for Insomnia (CBT-I)

The American College of Physicians and American Geriatrics Society recommend CBT-I as first-line treatment for chronic insomnia in older adults, with effects sustained for up to 2 years and superior long-term outcomes compared to pharmacotherapy. 3, 6

CBT-I Components (Use in Combination):

• Sleep restriction/compression therapy - limit time in bed to match actual sleep time based on 2-week sleep logs; if sleeping 5.5 hours but spending 8.5 hours in bed, restrict to 5.5-6 hours; gradually increase by 15-20 minutes every 5 days as sleep efficiency improves 1, 3

  • Sleep compression (gradual reduction) is better tolerated than immediate restriction in elderly 3

• Stimulus control - strengthen bedroom-sleep association: use bedroom only for sleep and sex, leave bedroom if unable to sleep within 20 minutes, maintain consistent sleep/wake times, avoid daytime napping 1, 3

• Sleep hygiene education - address modifiable factors but insufficient alone; must combine with other modalities 1, 3, 6

• Cognitive restructuring - address unhelpful beliefs and anxiety about sleep 1, 6

• Relaxation techniques - progressive muscle relaxation, guided imagery, diaphragmatic breathing 3, 7

Second-Line Treatment: Pharmacotherapy

Medications should only be used when CBT-I has failed, using shared decision-making, starting at the lowest available dose, and limiting to short-term use whenever possible. 3, 6

Medication Selection by Symptom Pattern:

For sleep onset insomnia:

• Ramelteon (melatonin receptor agonist) - preferred option 3, 6
• Short-acting Z-drugs (zolpidem immediate-release) - alternative 3, 6

For sleep maintenance insomnia:

• Low-dose doxepin (3-6 mg) - effective with minimal side effects 3, 6
• Suvorexant (orexin receptor antagonist) - newer option with favorable safety profile 3, 6, 5

For both onset and maintenance:

• Eszopiclone - demonstrated efficacy up to 6 months in elderly at 1-2 mg doses 3, 8
• Extended-release zolpidem - at lowest effective dose 3, 9

Critical Medication Pitfalls to Avoid:

• AVOID benzodiazepines - higher risk of falls, cognitive impairment, dependence in elderly 3, 6
• AVOID over-the-counter antihistamines (diphenhydramine) - anticholinergic effects particularly dangerous in elderly 3, 6
• AVOID sedating antidepressants (trazodone, amitriptyline, mirtazapine) unless comorbid depression/anxiety exists; no systematic evidence for primary insomnia and risks outweigh benefits 3
• AVOID barbiturates as first-line agents 3
• AVOID herbal supplements (valerian, melatonin) - lack of efficacy and safety data in elderly 3

Monitoring and Follow-up:

• Follow every few weeks initially to assess effectiveness and side effects 3
• Use lowest effective maintenance dosage and taper when conditions allow 3
• Be aware of next-day residual effects - eszopiclone 3 mg causes psychomotor and memory impairment up to 11.5 hours post-dose, even when patients don't perceive sedation 8
• For chronic use - may administer nightly, intermittent (three nights/week), or as-needed with consistent follow-up 3

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Management of REM Behavior Disorder

Clonazepam 0.5-1 mg at bedtime is the most effective treatment for RBD, controlling violent behaviors in 90% of cases within the first week, though mild limb movements may persist. 1

Treatment Approach:

• Pharmacologic: Clonazepam 0.5-1 mg at bedtime (may take 1-2 hours before bedtime if morning drowsiness occurs); alternatives include levodopa, dopamine agonists 1
• Melatonin should NOT be used in older patients due to poor FDA regulation and lack of quality control 1
• Environmental safety measures (mandatory): remove dangerous objects, pad hard/sharp surfaces around bed, heavy draperies on windows, consider placing mattress on floor 1
• Medication review: discontinue or reduce TCAs, MAOIs, SSRIs if possible, as these can induce/exacerbate RBD 1
• Neurologic evaluation: obtain brain MRI if abnormal neurologic findings, as RBD associates with Parkinson's disease, multiple system atrophy, brainstem lesions 1

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Management of Hypersomnias of Central Origin

Refer to sleep specialist when narcolepsy or idiopathic hypersomnia is suspected; primary care should not manage these complex disorders independently. 1

Treatment Considerations:

• Rule out other causes first: ensure sleep-disordered breathing is adequately treated before diagnosing hypersomnia 1
• Pharmacologic options: modafinil improves but does not eliminate sleepiness; stimulants require monitoring for hypertension, arrhythmias, irritability, psychosis 1
• Monitor with Epworth Sleepiness Scale at each visit to assess treatment response 1
• Long-term management required: most hypersomnias are lifelong disorders needing ongoing treatment 1

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Special Considerations for Nursing Home Residents

Nursing home residents face unique challenges including limited bright light exposure, extended time in bed, physical inactivity, nighttime noise/light interruptions, and multiple medications that disrupt sleep-wake cycles. 1

Interventions:

• Increase bright light exposure during daytime to coordinate circadian rhythms 1
• Reduce time in bed and increase daytime physical activity 1
• Minimize nighttime interruptions from noise and light 1
• Review and optimize medication timing - avoid diuretics, stimulating agents, anti-Parkinsonian agents, cholinesterase inhibitors near bedtime; avoid sedating medications during day 1