Almost 80% of Americans will now live well into their CHAPTER OUTLINE LEARNING OBJECTIVES KEY TERMS. Carl J. Stepnowsky, Jr. and Kimberly A.

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1 7 Sleep and Aging Carl J. Stepnowsky, Jr. and Kimberly A. Trotter LEARNING OBJECTIVES On completion of this chapter, the reader should be able to: 1. Understand the normal aging process 2. Understand circadian rhythms in the elderly 3. Recognize sleep disorders related to aging 4. Know common medications used by the elderly and how they affect sleep 5. Appreciate age-related factors as they pertain to sleep consultation and sleep testing 6. Address sleep hygiene issues with elderly patients. KEY TERMS Age-related competencies Circadian rhythms Patient assessment Sleep hygiene Sleep patterns CHAPTER OUTLINE Circadian Rhythms Diagnosis and Management Common Sleep Disorders Sleep Disordered Breathing (SDB) Management of Sleep Apnea Periodic Limb Movement Sleep Disorder (PLMSD) Restless Leg Syndrome (RLS) Insomnia Medication Issues Sleep and Dementia Sleep Consultation and Testing Preparing the Technologist Preparing the Center References Suggested Readings Almost 80% of Americans will now live well into their late seventies. The fastest growing segment of our population is those who are over eighty-five years of age. Because of these demographics, the likelihood that you will work with elderly patients is extremely high. It is well known that elderly individuals report spending more time in bed, experience more awakenings during the night, and have increased complaints of insomnia than middle-aged adults (1). Elderly individuals often complain about insomnia or hypersomnia; these complaints are not disorders themselves but are often symptoms for another disorder. The symptoms in the elderly are more likely related to some underlying physiological problem rather than secondary to stress, as typically seen in younger adults. This is an extremely important point, so we will cover this issue first, then will review the major sleep disorders and age-related factors in the elderly. As people age, the pattern of their sleep-wake cycle changes. As was reviewed elsewhere, during the night most individuals cycle through different levels of sleep: non rapid eye movement sleep (NREM, stages 1, 2, 3, and 4) and rapid eye movement sleep (REM). Laboratory studies have shown that total sleep time during the night may decrease and the total amount of sleep during the daytime may increase as we age. However, in a twentyfour-hour period the total amount of sleep does not differ very much from that of younger adults. By the age of seventy the amount of scorable delta sleep (NREM stages 3 and 4) is greatly reduced relative to the younger years. The decrease in scorable delta waves is much more pronounced for males than for females (that is, seventyyear-old females have considerably more stage 3 and 4 sleep than do seventy-year-old males). The absolute amount of REM sleep is decreased because the nighttime 40

2 CHAPTER 7 SLEEP AND AGING 41 total sleep time is decreased, but the percentage of REM decreases only minimally. The number and duration of awakenings during the night increases in older adults and as a result, sleep efficiency (the proportion of time spent asleep relative to the time in bed) decreases. Research has attempted to determine if this decrease in sleep occurs 1) because the need for sleep has decreased with age (that is, the elderly simply need less sleep) or 2) because the ability to sleep has decreased. This is a key distinction, because if it is the need for sleep that decreases, then interventions will be of little use; however, if it is the ability to sleep that has decreased, and we can identify the cause or causes, then interventions could prove extremely useful for the elderly patient. So which is it? Since laboratory studies have determined that the elderly are sleepier during the day than younger adults, and since daytime sleepiness at any age in indicative of disturbed or insufficient sleep at night, then it is unlikely to be the case that it is the need for sleep that decreases with age. This means that sleep disturbances in the elderly are likely secondary to a decreased ability to sleep. Possible causes of this decreased ability to sleep include numerous factors including specific sleep disorders (for example, circadian rhythm disturbances, obstructive sleep apnea), medical illnesses, and/or medication use. There are many consequences of disordered sleep in the elderly, including excessive daytime sleepiness, frequent daytime napping, attention and memory problems, depressed mood, increased risk of falls, overuse of hypnotic and nonprescription medications, possible interactions with comorbid conditions, and diminished quality of life. Because of these serious consequences, assessment and treatment of sleep problems in the elderly need to focus on determining the primary cause or causes of the sleep complaint. The remainder of this chapter will review circadian rhythm disturbances and other specific sleep disorders in the elderly, how various medical conditions and medications impact sleep in the elderly, and finally, review important age-related factors in conducting a sleep consultation and sleep testing. CIRCADIAN RHYTHMS Circadian literally means about a day (from the word circa, which means about and the word dia, which means day ). Circadian rhythms refer to those cyclical changes that occur about every twenty-four hours. There are literally hundreds of circadian rhythms in the body affecting both our cellular and organ system physiology. Two examples are our temperature cycle and our sleepwake cycle. It is important to note that these sleep-wake cycles are in part intrinsically controlled (within the body), but that they are also in part under the control of external stimuli, such as light, time of day, social activities, and meals. The light-dark cycle is one of the strongest factors in our environment that synchronizes the sleep-wake cycle with the twenty-four-hour earth cycle of night and day. Specifically, the timing, duration, and brightness of daily light exposure is one of the major extrinsic (outside the body) factors that determines the onset, duration, and termination of sleep and alertness. The elderly have higher rates of visual impairment, hearing deficits, and experience social isolation, all of which can lead to decreased perception of external stimuli, including light. Research has demonstrated that community dwelling elderly are exposed to only about one hour of bright light per day (2); community dwelling Alzheimer s patients are exposed to only thirty minutes of bright light per day (3); and sadly, institutionalized elderly are exposed to less than ten minutes of bright light per day (4). The most common circadian rhythm disorder in the elderly is the advanced sleep phase syndrome. It is called advanced because the sleep-wake cycle literally is earlier than normal. For example, if the normal bedtime was 10:00 P.M. and waketime was 6:00 A.M. for an individual, it would be advanced if the bedtime was 08:00 P.M. and waketime was 3:00 A.M. These individuals typically complain of being sleepy in the early evening and of early morning awakenings. Because it is easier to stay up later, these individuals are often able to force themselves to go to bed later (after social functions are over), say about 10:00 P.M., perhaps because of a theater show or lecture, but they still wake up very early in the morning, say at 3:00 A.M. This results in a suboptimal amount of total sleep time, which leads to excessive daytime sleepiness. Circadian rhythm disturbances can also lead to increased awakenings, fragmented nighttime sleep, and the need for frequent daytime naps. We discuss this type of circadian rhythm sleep disturbance first because of its widespread occurrence, and because it often interacts with other sleep-related factors such as depression, anxiety, poor sleep habits, or specific sleep disorders. When asked directly, an individual with advanced sleep phase syndrome can often easily identify himself as a morning person. It is important to be able to identify a circadian rhythm sleep disturbance and to distinguish it from a complaint of insomnia or sleep apnea, for example, so that appropriate treatment can be prescribed. Typically, treatments for circadian rhythm disturbances are better tolerated than the treatments prescribed for insomnia or sleep apnea. Diagnosis and Management The diagnosis of a circadian rhythm disturbance can usually be made on the basis of careful questioning of the patient and clinical history alone, along with the

3 42 SECTION 2 PHYSIOLOGY OF NORMAL SLEEP aid of a sleep diary that specifically assesses bedtime, time spent asleep and awake, daytime functioning, and alertness levels throughout the day and night. Not surprisingly, the hallmarks of advanced sleep phase syndrome are complaints of drowsiness in the evening (sooner than is desired) and awakenings between midnight and 5:00 A.M., much earlier than desired. Bright light exposure is known to stabilize the circadian sleep-wake cycle. When a circadian rhythm disturbance is identified, then bright light exposure at specific times is prescribed. Typically, bright light should be obtained late in the day or in the evening. Two hours of bright light, in the evening time before sunset, or artificial bright light equivalent to at least 2,500 lux, is beneficial for healthy older adults (5,6). The 1999 American Academy of Sleep Medicine Report provides more detail on the appropriate use of light therapy (6). It is important to note that typical indoor light is insufficient and that commercially manufactured bright light boxes provide the appropriate lux level. It is also important to discuss briefly the role of melatonin in this section because of the large amount of attention in the popular press it has received recently. The circadian temperature cycle and melatonin rhythms interact with both the timing and quality of sleep in the elderly. Melatonin is a hormone secreted from the pineal gland but only during darkness. Melatonin secretion by the pineal gland is inhibited by light. Levels of melatonin have been shown to decrease with aging (7), so there is some speculation that a decrease in the level of melatonin is directly related to the decreased sleep levels seen in the elderly. However, the efficacy of exogenous melatonin (that is, melatonin produced outside of the body) on sleep in general and in the elderly in particular needs further research in regard to the proper timing and dose before it can be recommended. Importantly, the Food and Drug Administration (FDA) does not regulate melatonin, so caution needs to be taken regarding the purity and dosage of melatonin sold over the counter. COMMON SLEEP DISORDERS Sleep Disordered Breathing (SDB) In an early study of breathing during sleep, it was found that nine of twelve healthy men with an average age of fifty-four had periodic breathing with apneas (8). Since this initial observation, there have been several studies on the epidemiology of sleep-disordered breathing in the elderly. Studies agree that the prevalence of sleepdisordered breathing is higher in the elderly than in middle-aged adults (9), higher in older men than in older women (10), and higher in postmenopausal women than in premenopausal women (11). In one of the largest studies in the elderly to date, Ancoli-Israel et al. (9) found that 24% of randomly selected community-dwelling elderly had five or more apneas per hour of sleep (with a mean apnea index (AI) of thirteen) and 81% had five or more respiratory disturbances per hour of sleep (with a mean respiratory disturbance index (RDI) of thirty-eight). For comparison purposes, when more stringent criteria were used, the prevalence rates were 10% and 4% for AI greater than or equal to ten and twenty, respectively, and 44% and 24% for RDI levels greater than or equal to twenty and forty, respectively. These rates are clearly higher than those reported in middle-aged adults. Special considerations exist when understanding the significance of obstructive sleep apnea in the elderly. For example, the cardinal symptoms of sleep apnea, including daytime sleepiness and snoring, are particularly common in the elderly. There are also a large number of agedependent risk factors for SDB, including increased body weight, decreased lung capacity, increased upper airway collapsibility, increasedsleepfragmentation, and decreased slow wave sleep that all increase the likelihood of SDB in the elderly (12). As described, it is clear that the prevalence of SDB increases with age. The degree to which SDB relates to the clinical diagnosis of obstructive sleep apnea is a matter of controversy and will not be covered here [for a very good recent review of this controversy, the reader is referred to Stradling, 2004 (13)]. However, it is generally accepted that SDB should be considered clinically significant in thepresenceofsymptomsofsleepapneaorevidenceof vascular disease, including hypertension. In fact, sleep apnea is now considered a risk factor for hypertension (14). In addition to morbidity, SDB is associated with increased risk of mortality. Older people with severe SDB have shorter survival times than those with minimal SDB (15). Management of Sleep Apnea Age alone should not be the determining factor for deciding whether treatment should be initiated for sleep apnea; rather, the significance of the patient s symptoms and the severity of the disorder should influence treatment (16). Most patients should initially be started with nasal continuous positive airway pressure (CPAP) therapy or bilevel positive airway pressure (BPAP), which have both been shown to effectively manage SDB with minimal side effects. These devices blow air into the nasal passage and upper airway, thereby producing positive airway pressure that acts as a pneumatic splint to keep the airway open, counteracting the excessive negative pressure during inspiration in sleep apnea/hypopnea patients. Compliance with CPAP therapy has been shown to be fairly low at one year after commencing treatment, with less than 50% of the patients still using the machine (17). Some evidence suggests that improved education and patient follow-up can increase compliance with this therapy. It is known that compliance at one month predicts compliance at three and six months (18). Therefore, effective problem-solving during the first one month

4 CHAPTER 7 SLEEP AND AGING 43 of treatment initiation appears to be an important factor in increasing compliance (19). For individuals who cannot or will not use positive airway pressure, alternative treatments exist, including dental devices and surgery. Follow-up assessments are crucial for these treatments, as less than 50% are successfully treated, with success being defined as a 50% reduction in the number of apneas and hypopneas per hour of sleep and a respiratory disturbance index of less than fifteen apneas or hypopneas per hour of sleep. Periodic Limb Movement Sleep Disorder (PLMSD) Restless Leg Syndrome (RLS) Periodic limb movements in sleep, which cause EEG arousals and sleep disruption independent of sleep apneas or sleep hypopneas, are common in the elderly. PLMSD is characterized by repeated movements of the legs at about twenty- to forty-second intervals, typically clustered indistinct episodes. The leg movements that result in arousals from sleep, either recognized or unrecognized by the patient, are a cause for clinical concern, as they may be the direct cause of excessive daytime sleepiness. PLMSD can result in complaints of insomnia and/or excessive daytime sleepiness. Restless legs syndrome (RLS) is a clinical condition defined by the presence of four necessary conditions: 1. An irresistible urge to move the legs, accompanied by an uncomfortable sensation (such as pain, ache, tingling, vibration, or other disagreeable sensation). 2. The uncomfortable sensations and urge to move the legs are worse during periods of rest or inactivity, such as while sitting down or lying in bed prior to falling asleep. 3. The uncomfortable sensations and urge to move the legs are worse at certain times of day, such as the late afternoons, early evenings, or at bedtime and are noticeably less severe upon awakening in the morning. 4. Movement of the legs, stretching, massaging, or jerking the legs brings about transient relief. Older patients commonly have the clinical symptoms of restless legs syndrome. About 80% of RLS patients also have periodic limb movements during sleep and many have periodic limb movement sleep disorder with more than five leg jerks causing an EEG arousal per hour of sleep. Because both RLS and PLMSD can interfere with sleep, patients with RLS or PLMSD often have shorter total sleep times at night. The etiology of PLMSD and RLS is unknown, but is considered to be a neurological abnormality of motor control. PLMSD is often seen in neuropathy, in conjunction with sleep apnea/hypopnea syndrome, narcolepsy, fibromyalgia, and other disorders. PLMSD patients are often significantly older than patients without PLMSD, and the disorder becomes more severe with age. The prevalence rate of PLMSD in community dwelling elderly is approximately 45%, with no differences between men and women (20). This high prevalence rate suggests that the occurrence of repetitive movements during sleep might be considered normal, and by no means is there always a clear relationship between each patient s complaint and the finding of PLMSD in that patient (21). Thus, PLMSD can exist in a patient with symptoms, might not exist in patients with symptoms, or may be clearly related to symptoms. There are certain medical conditions that cause or exacerbate RLS in patients, including iron-deficiency anemia, uremia, and peripheral neuropathy. These conditions should be ruled out before proceeding with symptomatic treatment. These conditions are best treated with one of three classes of medications: benzodiazepines, opiates, or dopaminergic agents. Insomnia Insomnia is typically divided into three patterns: difficulty initiating sleep (sleep-onset insomnia), difficulty maintaining sleep (sleep-maintenance insomnia) or early morning awakening (terminal insomnia). Specific characterization of the insomnia pattern is important because there are different diagnostic and treatment considerations for each. In one of the largest studies to date, the National Institute on Aging s multi-site study called Established Populations for Epidemiologic Studies of the Elderly (EPESE) looked at the most common sleep complaints of over nine-thousand participants over the age of sixtyfive (22). Less than 20% rarely or never had any sleep complaints, including trouble falling asleep, waking up often during the night, awaking too early in the morning, not feeling rested upon arising, and needing to nap during the day. Importantly, over 50% of elderly patients reported experiencing at least one of these complaints most of the time. Women reported both more trouble falling asleep and more nighttime complaints than men; however, men were more likely to nap during the day. Clearly, insomnia complaints are common in the elderly. Etiology There are a number of factors that can contribute to the complaint of insomnia. Insomnia can occur as a result of circadian rhythm disturbances, sleep disorders such as SDB or PLMSD/RLS, medical illnesses, medications and alcohol, psychiatric conditions, or behavioral dysfunction. Some of these factors tend to be more pronounced in the elderly. It is estimated that 90% of the elderly take at least one prescription medication and most are taking two, with many medications prescribed by more than one physician. Since many medications have stimulating or sedating effects, physicians must consider all possible effects of medications on sleep. Unfortunately, it is not always easy to tell if a medication is causing insomnia, and it is not always easy to simply discontinue or change a medication. We will review the effect of medications on sleep in the elderly in more detail in a later section.

5 44 SECTION 2 PHYSIOLOGY OF NORMAL SLEEP The elderly sometimes use or abuse alcohol at bedtime to aid sleep onset. Many believe that a serving of alcohol before bedtime will promote sleep. While it is true that alcohol promotes sleep initially because it is a central nervous system depressant, alcohol actually causes arousals and awakenings from sleep later during the night as alcohol is metabolized and blood levels fall during the night. In addition, with nightly intake of alcohol, tolerance can develop and patients can have frequent awakenings and marked sleep fragmentation during alcohol withdrawal. One very common sleep disrupter is the need to void. Nearly two out of three older adults get up to use the bathroom at least a few nights per week. Nocturia and nocturnal incontinence may be symptoms of SDB, which we have seen is prevalent in the elderly. Also, chronic renal disease is prevalent in the elderly, and individuals with this disorder commonly experience nocturia and neurogenic bladder. Importantly, nocturia doesn t only contribute to disrupted sleep, but may lead to an increased risk of falling when getting up to use the restroom as well. Postmenopausal women have a higher incidence of insomnia and report more frequent awakenings during the night compared to premenopausal women. Menopause has been associated with objective changes in sleep including increased sleep latency, decreased REM sleep, and shorter total sleep time. Treatment with supplemental estrogens may help to alleviate some sleep disturbances associated with menopause. If the cause of a patient s insomnia complaint is recognized to be secondary to a specific sleep disorder, then the sleep disorder can be treated first and the insomnia will likely lessen. This is true for sleep apnea, PLMSD, RLS, and the circadian rhythm sleep disorders. In addition, depression must be considered and treated when appropriate. Depression is common in the elderly; insomnia is often a prominent symptom, especially early morning awakening insomnia (also called terminal insomnia). Missing a diagnosis of depression can be harmful. Treatment As discussed above, identification of the specific cause or causes of insomnia can lead to appropriate treatment of the underlying disorder. In addition, any patient with a complaint of insomnia should be taught good sleep habits, often referred to as good sleep hygiene. These suggestions, while non-specific, can often improve insomnia by implementing them alone, and are necessary components of other treatments for insomnia. Table 7-1 lists some of the most common components of good sleep hygiene. One of the most important good sleep habits is the maintenance of a regular morning wake-up time. By waking up at the same time every day, the circadian rhythm is stabilized. Patients with insomnia should avoid daytime naps or limit naps to no more than thirty minutes. This is especially important in the elderly because they Table 7-1 Sleep Hygiene Rules for the Elderly 1. Decrease time in bed awake. 2. Arise at the same time every day. 3. Exercise daily (but not close to bedtime). 4. Eat a light snack before bedtime. 5. Avoid caffeine, alcohol, and tobacco, particularly after lunch. 6. Avoid frequent use of sedative-hypnotics. 7. Get out of bed if not able to sleep, especially if feeling tense, angry, or frustrated. 8. Limit any naps to thirty minutes in the early afternoon. 9. Spend more time outdoors to increase light exposure, particularly later in the day. have more leisure time during the day to take either planned or unplanned naps. Unfortunately, daytime sleep can lead to disturbed sleep at night, further exacerbating the insomnia complaint. Although many patients find it counterintuitive, those with insomnia should minimize their time in bed to about the actual number of hours they desire to sleep (typically seven to eight hours per night). Curtailing time in bed helps to consolidate sleep. If patients are in bed but not asleep within a few minutes, they should get out of bed to avoid becoming tense and anxious about not being able to sleep. Exercise is important, but generally should be performed on a daily basis sometime during the day, not immediately before bedtime, as this can be arousing. Older people can be more sensitive to the effects of caffeine, and because caffeine is long lasting, even caffeine taken early in the afternoon can affect sleep at night. It is important to remind older patients that caffeine can be found in tea, chocolate, soda, and some prescription and over-the-counter medications in addition to coffee. In addition, two behavioral techniques are highly effective in the management of primary insomnia in the elderly. They are stimulus-control therapy and sleep restriction therapy. It should be noted, however, that there are modifications to each that are specific to the elderly. In stimulus control therapy, the elderly patient 1) may allow up to twenty minutes, rather than ten, to fall asleep before getting out of bed (to accommodate the normal increase in sleep latency in this population) and 2) may nap for up to thirty minutes at the same time each day (as some patients may find it extremely difficult not to nap during the day). In sleep restriction therapy, the sleep efficiency index can be lowered by 5% from 85% to 80% as the cutoff point, indicating that a patient should spend less time in bed to account for the poorer quality sleep typically experienced by the elderly. These are guidelines, however,

6 CHAPTER 7 SLEEP AND AGING 45 and the specifics of treatment should be determined for each individual patient. MEDICATION ISSUES The sleep disorders center should have a section of the sleep questionnaire that specifically assesses medications, and medications taken on the day of the study. The sleep physician should review this section prior to ordering the sleep study and the sleep technologists should be aware of the medications the patient is taking. Some medications that may inhibit sleep may need to be reevaluated before ordering the study. Timing of medication can also be an issue. Some medications may make the patient sleepy, and others may make the patient alert. The sleep physician should instruct the patient regarding the timing of the medications to be taken. Table 7-2 lists the most common types of medications and their effects on sleep. Antidepressants can be divided into three categories: tricyclics, MAOIs (monoamine oxidase inhibitors), and SSRIs (selective serotonin reuptake inhibitors). Tricyclics can cause REM suppression, increase periodic limb movements, and increase TST (total sleep time). MAOIs, like tricylics, can cause REM suppression; however, it can also cause decreased TST and increase wake time after sleep onset (WASO). SSRIs can reduce slow wave sleep (SWS), increase WASO and may worsen both PLMSD and RLS (restless legs syndrome). Pain medications may cause drowsiness and confusion in elderly patients. These medications may also cause a decrease in SWS. Hypnotics can be divided into three categories: barbiturates, benzodiazepines, and non-benzodiazepines. Barbiturates may increase TST, suppress REM, and increase sleep spindles and SWS. It may also decrease WASO. Benzodiazepines may decrease WASO, increase TST, stages 1 and 2, and sleep spindles, but decrease SWS. Nonbenzodiazepines have a short half-life, and have the least effects on sleep architecture. With all of these hypnotics, however, it should be noted that patients experience side effect at different degrees, and if the patient awakens early from the sleep study, he/she should be evaluated to see if he/she is alert enough to leave on their own. Diuretics may cause the patient to have excessive urination during the sleep study. OTCs (over the counter medications) include melatonin. Some patients may have taken melatonin when they Table 7-2 Effects of Medications on Sleep Effect on Sleep Medication TST WASO SWS REM PLMS SL Antidepressants Tricyclics MAOIs SSRIs Pain medications Hypnotics Barbituates Benzodiazapines Nonbenzodiazapines Minimal Effects Hypertensives Excessive urination OTCs Antihistamines Stimulants Melatonin Alcohol TST: Total sleep time; WASO: Wake after sleep onset; SWS: Slow wave sleep; REM: Rapid eye movement; PLMS: Periodic limb movements while sleeping; SL: Sleep latency. MAOI: Monoamine oxidase inhibitor; SSRI: Serotonin selective reuptake inhibitor; OTC: Over-the-counter medications.

7 46 SECTION 2 PHYSIOLOGY OF NORMAL SLEEP come for the sleep study. Melatonin may decrease sleep latency and WASO. Antihistamines can cause drowsiness, shorten sleep latency and suppress REM sleep. Stimulants include decongestants, nicotine, and caffeine. These can cause delayed sleep onset, fragmented sleep, and decreased SWS. Alcohol can shorten sleep latency, decrease REM sleep, and increase WASO, especially during the second half of the night. The technologist should be aware of all medications taken, whether prescribed or over the counter. This is very important, especially with hypnotics. If a patient leaves the lab while still under the influence of these medications, there may be serious consequences. Accurate assessments is very important from a risk liability perspective. SLEEP AND DEMENTIA As the American population continues to age, both the numbers of patients with dementia and those who require institutionalization will increase. Dementia refers to the loss of cognitive functioning due to changes in the brain caused by disease or trauma. While some types of dementia are reversible (typically caused by some sort of trauma), dementia due to aging and related to Alzheimer s disease is irreversible, eventually reducing the ability for self-care. Five to eight percent of those over age sixty-five have some form of dementia, and the number doubles every 5 years after the age of sixty-five. It has been estimated that 5.3 million elderly will require nursing home care by the year Patients with dementia have disturbed sleep at night, night wandering (typically with confusion and agitation), excessive sleepiness during the day, and possibly problems with sundowning [for a recent review, see (23)]. Sundowning refers to a diurnal pattern of agitated behavior, with worsening in the late afternoon or early evening. Performing laboratory-based studies of sleep in patients with dementia is particularly challenging, both because of the difficulty in obtaining a full night s recording and because of changes in the EEG patterns, which can make distinguishing wake from sleep (as well as staging sleep in general) troublesome (24). Studies show that patients with dementia have decreased sleep efficiency, total sleep time, and delta sleep, and that they have increased sleep fragmentation and sleep onset latency (25). Despite the best attempts of nursing homes to provide structure and routine, sleep in institutionalized patients is extremely fragmented. One study has shown that patients on average were never fully asleep, nor fully awake, for a complete hour throughout the twenty-four-hour day (26). Essentially, it is thought that fragmented nighttime sleep leads to increased napping during the day, which results in disorganization of the circadian system. Key factors leading to this circadian system disorganization include: chronic, excessive time in bed; lack of activity; and lack of exposure to bright light. In fact, it has been shown that nursing home patients are exposed to less than ten minutes of bright light (defined as more than one thousand lux) each day (27); the mean amount of light exposure in this group was only sixty-three lux. It should also be mentioned that nursing home patients have higher rates of obstructive sleep apnea (OSA) than those elderly living independently in the community, with estimates as high as 42% (28). As is well known, OSA can lead to sleep fragmentation as well. Better recognition and treatment of underlying sleep disturbances, such as insomnia or obstructive sleep apnea, in community dwelling elderly may enable caregivers to delay institutionalization, thereby helping to maintain the quality of life of their loved ones and perhaps even helping to save healthcare dollars. SLEEP CONSULTATION AND TESTING Sleep testing for the geriatric population can be very challenging. The sleep disorders center must be prepared for geriatric patients in every aspect of testing. Preparing the Technologist It is important that the sleep technologist has gone through age-specific competencies in order to understand the aging milestones of humans and interact appropriately with geriatric patients. Geriatric patients may have certain physical limitations. The patient may be frail, weak, or unsteady. The technologist must evaluate the patient s physical limitations, and stay with the patient, guiding them so they do not lose their balance and fall. Falls are a major risk in the geriatric population, and the technologist must be vigilant in assuring that falls are avoided. Another physical consideration is pain. As we age, pain from a variety of sources becomes more prevalent. The technologist needs to evaluate for pain and make sure that the patient is comfortable at all times. If the lab has an adjustable bed, the geriatric patient may be best suited for this bed. Make sure the patient is in a comfortable position for setup, and continue to ask the patient if they are comfortable. Do whatever is necessary to keep the patient as comfortable as possible. Another consideration in the geriatric population is the senses. Patients should be evaluated for sight and hearing deficiencies. Many patients lose some of their sight and/or hearing as they age. Speak clearly and slowly and make sure the patient can understand you. If the print on the sleep questionnaire is too small, read the instructions for the patient. Technologists must also take

8 CHAPTER 7 SLEEP AND AGING 47 the necessary steps to be sure that the patient can contact them for assistance during nighttime awakenings. Preparing the Center Make sure the center has a geriatric-based sleep questionnaire. If this is not available, at least make sure the center s sleep questionnaire is in larger print for the geriatric patients. Some geriatric-based questions might include: Specific items and an appropriate amount of space to list medications taken and medications taken day of study A sleep diary, as many geriatric patients have DIMS (difficulty initiating and maintaining sleep) An appropriate amount of space to list medical conditions, and perhaps some specific questions regarding pain, movement, balance, sight and hearing that will help the sleep technologist evaluate the patient s condition prior to arrival, as well as give the sleep physician more information During the sleep consultation, the physician should find out if the patient has difficulty with confusion at night. Many times, the patient will seem fine during the sleep consultation with the physician during the day, but at night, they will present with confusion, dementia, and agitation, (sundowning). Should this be the case, be sure a provider needs to accompany the patient to the sleep study. The sleep technologist is typically not trained to deal with demented patients. The geriatric patient should also bring a care provider if they have special needs, such as incontinence, inability to ambulate, or others that the sleep technologist is not trained to provide and would stand in the way of obtaining a good sleep study. REFERENCES 1. National Sleep Foundation: 2003 Sleep in American Poll. Washington, DC, Espiritu RC, et al.: Low illumination experienced by San Diego adults: Association with atypical depressive symptoms. Biol Psychiatry 35(6): pp , Campbell SS, et al.: Exposure to light in healthy elderly subjects and Alzheimer s patients. Physiol Behav 42(2):pp , Pat-Horenczyk R, et al.: Hourly profiles of sleep and wakefulness in severely versus mild-moderately demented nursing home patients. Aging (Milano) 10(4): p , Campbell SS, et al.: Light treatment for sleep disorders: Consensus report: V. Age-related disturbances. 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9 48 SECTION 2 PHYSIOLOGY OF NORMAL SLEEP 28. Ancoli-Israel S, et al.: Sleep apnea in female patients in a nursing home: Increased risk of mortality. Chest 96(5):1054 8, SUGGESTED READINGS Bliwise DL: Normal aging. In: Kryger MH, Roth T, Dement WC (eds), Principles and Practice of Sleep Medicine Philadelphia, WB Saunders, (pp , 2000). Chesson AL, Jr., Littner M,Davila D, Anderson WM, Grigg- Damberger M, Hartse, K, Johnson S, Wise M: Practice parameters for the use of light therapy in the treatment of sleep disorders. Standards of Practice Committee, American Academy of Sleep Medicine. Sleep, 22(5), , 1999.