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(PSYCHIATRIC TIMES) - Psychiatric Times - Category 1 Credit
o earn AMA PRA Category 1 Credit(s)™:
Read the article "Sleep Disorders in the Elderly" from the April 2008 issue of Psychiatric Times, complete the posttest and the evaluation. (Note: A score of at least 70% must be achieved in order to be awarded credit.)

The posttest will be scored instantly and results will be shown onscreen. Please make a copy of your test results for your continuing education records. After submitting the activity evaluation, you may then print a Statement of Credit for your records.

You must keep your own records of this activity. Copy this information and include it in your continuing education file for reporting purposes.

CME LLC is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

CME LLC designates this educational activity for a maximum of 1.5 AMA PRA Category 1 Credits™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

CME LLC is approved by the California Board of Registered Nursing, Provider No. CEP12748, and designates this educational activity for 1.5 contact hours for nurses.

The American Nurses Credentialing Center (ANCC) accepts AMA PRA Category 1 Credits™ toward recertification requirements.

The American Academy of Physician Assistants (AAPA) accepts AMA PRA Category 1 Credits™ from organizations accredited by the ACCME.

Educational Objectives

After reading this article, you will be familiar with:

* The effects of aging on sleep.
* How the various sleep disorders impact older adults.
* How to diagnose each of the sleep disorders that can develop in older adults.
* Optimum treatments for each of the sleep disorders.

Who will benefit from reading this article?

Psychiatrists, primary care physicians, neurologists, nurse practitioners, and other health care professionals. Continuing medical education credit is available for most specialists. To determine whether this article meets the continuing education requirements of your specialty, please contact your state licensing board.

Dr Cooke is clinical instructor in the division of pulmonary and critical care medicine at the University of California, San Diego, School of Medicine; she is also staff physician at the Veterans Administration San Diego Healthcare System. She reports no conflicts of interest concerning the subject matter of this article.

Aging is often associated with complaints of difficulties with sleep, as evidenced by reports that up to 50% of older US adults complain of chronic trouble with sleep.1 Research has found that a number of normal changes in sleep occur with aging, which may explain some of these complaints.2 However, there are a variety of conditions that may account for the sleep difficulties experienced by many older adults, including specific sleep disorders, circadian rhythm disturbances, and medical and psychiatric comorbidities.

With age, it is normal for a number of changes to occur in sleep architecture and sleep patterns. Compared with younger adults, older adults sleep less despite spending more time in bed, spend more time awake during the night, wake up earlier in the morning, nap more, and take longer to fall asleep. Findings from a meta-analysis that included more than 3500 participants showed that after age 60, sleep efficiency (defined as the ratio of total sleep time to nocturnal time in bed, normally defined as 85% or greater), which is considered a measure of sleep continuity, decreases with further increases in age.2 Older adults experience more fragmented sleep, as evidenced by an increase in the number of sleep stage shifts, arousals, and awakenings.2

Older adults' need for sleep does not decrease with age. Their actual ability to sleep, however, does.3 When tested for daytime sleepiness (considered one marker of insufficient sleep), older adults were sleepier than their young counterparts, which may in part be due to their difficulty in obtaining enough sleep at night.

Insufficient sleep is associated with significant morbidity and increased mortality. Increased symptoms of depression and anxiety and decreased quality of life have been reported in patients who experience difficulty in sleeping. Sleep problems in older adults are associated with an increased risk of falls and difficulty with ambulation, balance, and vision—even after controlling for medication use.4 Chronic sleep difficulties and lack of sleep can lead to deficits in attention, response times, short-term memory, and performance level. Poorly maintained sleep, as reflected in low sleep efficiency, is also associated with increased mortality; a longitudinal study of healthy older adults reported that lower sleep efficiency (less than 80%) nearly doubled the risk of all-cause mortality.5

Insomnia is the most commonly reported sleep disturbance in older adults and is defined as the inability to initiate or maintain sleep resulting in daytime consequences. Complaints, which are more common in older women than in older men, can vary from difficulty in falling asleep to difficulty in maintaining sleep to frequent arousals from sleep and early morning awakenings. In a study of more than 9000 older adults (older than 65 years), 42% had difficulty in falling asleep and staying asleep.6 Three years later, insomnia complaints had resolved in 15% of the patients, although there was a 5% incidence of new sleep complaints.6

Insomnia may be a primary sleep disorder. In the older adult, however, it is important to recognize that complaints of insomnia may coexist with many chronic medical and/or psychiatric conditions including depression, chronic pain, cancer, chronic obstructive pulmonary disease, congestive heart failure, and stroke. In a survey of insomnia, 28% of older adults complained of chronic insomnia, but fewer than 10% of the new cases occurred in the absence of one of these related conditions.6 In addition to any underlying medical/ psychiatric condition, a number of medications used in the treatment of these conditions, including β-blockers, bronchodilators, corticosteroids, decongestants, diuretics, and antidepressants, can contribute to or even cause sleep difficulties.

Research has found that behavioral therapy, specifically cognitive-behavioral therapy (CBT), is as effective as or more effective than medications for insomnia. Based on head-to-head trials of CBT versus medications, the 2005 NIH State-of-the-Science Conference on Insomnia concluded that CBT is as effective as prescription medications for the treatment of chronic insomnia in older adults.7 A variety of medications have been used to treat insomnia in older adults but, as concluded by the conference, there is no systematic evidence for the effectiveness of the following classes of medications in the treatment of insomnia: antihistamines, antidepressants, antipsychotics, and anticonvulsants.7 Furthermore, the panel of experts stated that the risks associated with the use of these medications, especially among the elderly, largely outweigh any benefits.

Sedative-hypnotic medications are effective and appropriate at times for the management of insomnia. Studies have shown, however, that these medications should be accompanied by behavioral therapy and should no longer be considered first-line agents in the treatment of insomnia.7 To use this class of medications effectively and safely, clinicians must select the sedative-hypnotic that best fits the specific type of insomnia (eg, an agent with a long onset of action is not appropriate for a patient with sleep-onset insomnia).

New medications with different mechanisms of action are now available and should be consid-ered the first-line agents for the treatment of insomnia (Table 1). The selective short-acting nonbenzodiazepines, including eszopiclone, zaleplon, zolpidem, and zolpidem MR, are safe and effective for older adults. The melatonin agonist, ramelteon, is the only sleep-related medication not controlled by the Drug Enforcement Administration, and it is safe and effective in the treatment of sleep-onset insomnia in the elderly. In general, both pharmacological and behavioral treatments should be combined for the most effective treatment of insomnia. Patients should receive short-term relief with medications while learning the techniques of CBT, which should provide long-term treatment of insomnia.

Circadian rhythm sleep disorders
The sleep-wake cycle in humans is controlled by an endogenous clock located in the suprachiasmatic nucleus of the hypothalamus, which generates a circadian rhythm that is synchronized by external time cues (zeitgebers). The light-dark cycle is the major cue in humans. Circadian rhythm sleep disorders may develop if a lack of synchrony occurs between the endogenous clock and external environmental zeitgebers.

A number of factors associated with aging may contribute to the development of circadian rhythm sleep disorders. The circadian pacemaker itself degenerates with age, which may result in a weaker rhythm. Melatonin is important in the sleep-wake cycle, but its nocturnal secretion decreases with age, which may contribute to disrupted or weakened circadian rhythms. In addition, the environmental cues needed to synchronize the circadian rhythm of sleep-wake (ie, daily exposure to light) may be absent or weak in older patients. A study found that daily bright light exposure averaged 60 minutes for healthy elderly persons, 30 min-utes for patients with Alzheimer disease living at home, and no exposure for nursing home patients.8,9

Advanced sleep phase syndrome is by far the most common circadian rhythm sleep disorder, and its prevalence increases with age. Advanced sleep phase syndrome is characterized by routine and involuntary sleep and wake times that are several hours earlier than societal norms. Individuals with advanced sleep phase syndrome feel sleepy in the early evening and wake up in the early morning. Sleep architecture itself is normal and if patients follow their natural rhythms, they do not typically complain of daytime sleepiness. However, as these individuals experience an early morning wake time regardless of what time they go to sleep, delays in sleep onset often result in insufficient sleep time and complaints of excessive daytime sleepiness. A careful and detailed sleep history, sleep diaries, and activity monitoring with wrist actigraphy can be useful in making the diagnosis.

Patients with advanced sleep phase syndrome should be reassured that this condition is not a medical disorder, does not require treatment, and is a natural, often expected shift in circadian rhythm. If patients are happy with their sleep/wake times and are getting enough sleep, treatment is not necessary. For those patients who prefer a more "normal" sleep/wake time, however, therapy to delay circadian rhythm should be offered.

Treatment of advanced sleep phase syndrome focuses on strengthening and synchronizing the sleep-wake cycle; because bright light is the strongest cue for circadian entrainment, it is the most common and the most effective treatment. Exposure to bright light in the evening strengthens the sleep-wake cycle and delays circadian rhythms in patients with advanced sleep phase syndrome, including those who reside in nursing homes. Patients with advanced sleep phase syndrome should be advised to avoid bright light during the morning and should be educated on sleep hygiene practices, including maintaining a regular sleep schedule. Supplemental exogenous melatonin administered in the morning could, in theory, result in a phase delay in older adults with advanced sleep phase syndrome. The effectiveness and safety of this therapy has not been well studied in advanced sleep phase syndrome, however, and the sedating properties of melatonin may limit its clinical utility.

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